Test Bank for Foundations and Adult Health Nursing 9th Edition Cooper Chapter 1 - 58 Updated
Test Bank for Foundations and Adult
Health Nursing 9th Edition Cooper
Chapter 1 - 58 Updated
Chapter 01: The Evolution of Nursing
Cooper: Foundations and Adult Health Nursing, 9th Edition
MULTIPLE
CHOICES
1.
What is a nursing program considered when certified by a state agency?
a.
Accredited
b.
Approved
c.
Provisional
d.
Exemplified
ANS: B
Approved means certified by a state agency for having met minimum standards;
accredited means certified by the NLN for having met more complex standards.
Provisional and exemplified are not terms used in regard to nursing program
certification.
DIF: Cognitive Level: Knowledge
REF:
p. 10
OBJ: 5 TOP:
Nursing programs
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
2.
Which of the following must the nurse recognize regarding the health care delivery
system?
Test Bank
a.
It includes all states.
b.
It affects the illness of patients.
c.
Insurance companies are not involved.
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Test Bank for Foundations and Adult Health Nursing 9th Edition Cooper Chapter 1 - 58 Updated
d.
The major goal is to achieve optimal levels of health care.
ANS: D
The nurse must recognize that in the health care delivery system, the major goal is to
achieve optimal levels of health care. The health care system consists of a network of
agencies, facilities, and providers involved with health care in a specified geographic
area. Insurance companies do have involvement in the health care system. The illness
of patients is not necessarily affected by the health care system.
DIF: Cognitive Level: Comprehension REF:
p. 12
OBJ: 7 TOP: Health
care systems
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
3.
What is required by the health care team to identify the needs of a patient and to design
care to meet those needs?
a.
The Kardex
b.
The health care provider‘s order sheet
c.
An individualized care plan
d.
The nurse‘s notes
ANS: C
An individualized care plan involves all health care workers and outlines care to meet
the needs of the individual patient. The Kardex, health care provider‘s order sheet, and
nurse‘s notes do not identify the needs of the patient nor are they designed to assist all
members of the health care team to meet those needs.
DIF:
Cognitive Level: Comprehension REF: p. 13
TOP: Care plan
OBJ: 8 | 9
KEY: Nursing Process Step: Planning
MSC:
NCLEX: N/A
4.
Patient care emphasis on wellness, rather than illness, begins as a result of:
a.
increased education concerning causes of illness.
b.
improved insurance payments.
c.
decentralized care centers.
d.
increased number of health care givers.
ANS: A
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Test Bank for Foundations and Adult Health Nursing 9th Edition Cooper Chapter 1 - 58 Updated
The acute awareness of preventive medicine has resulted in today‘s emphasis on
education about issues such as smoking, heart disease, drug and alcohol abuse, weight
control, and mental health and wellness promotion activities. This preventive
education has resulted in an emphasis on wellness, rather than illness. Improved
insurance payments, decentralized care centers, and increased numbers of health care
givers did not influence an emphasis on wellness.
DIF:
Cognitive Level: Comprehension REF: p. 12
TOP: Wellness
OBJ: 4 | 8
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
5.
What is the most effective process to ensure that the care plan is meeting the needs of the
patient?
a.
Documentation
b.
Communication
c.
Evaluation
d.
Planning
ANS: B
Communication is the primary essential component among the health care team to
evaluate and modify the care plan. Documentation, evaluation, and planning are not
primary essential components to ensure the care plan is meeting the needs of the
patient.
DIF: Cognitive Level: Comprehension REF:
p. 17
OBJ: 8 TOP:
Communication
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
6.
How does an interdisciplinary approach to patient treatment enhance care?
a.
By improving efficiency of care
b.
By reducing the number of caregivers
c.
By preventing the fragmentation of patient care
d.
By shortening hospital stay
ANS: C
An interdisciplinary approach prevents fragmentation of care. An interdisciplinary
approach does not improve the efficiency of care, reduce the number of caregivers,
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Test Bank for Foundations and Adult Health Nursing 9th Edition Cooper Chapter 1 - 58 Updated
or shorten hospital stay.
DIF:
Cognitive Level: Comprehension
REF: p. 16
OBJ: 8 | 9 TOP:
Interdisciplinary approach KEY:
Nursing
Process Step: N/A MSC: NCLEX: N/A
7.
How may a newly licensed LPN/LVN practice?
a.
Independently in a hospital setting
b.
With an experienced LPN/LVN
c.
Under the supervision of a health care provider or RN
d.
As a sole health care provider in a clinic setting
ANS: C
An LPN/LVN practices under the supervision of a health care provider, dentist, OD, or
RN.
DIF: Cognitive Level: Knowledge
REF:
p. 11
OBJ: 11 TOP:
Vocational nursing
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
8.
Whose influence on nursing practice in the 19th century was related to improvement
of patient environment as a method of health promotion?
a.
Clara Barton
b.
Linda Richards
c.
Dorothea Dix
d.
Florence Nightingale
ANS: D
The influence of Florence Nightingale was highly significant in the 19th century as she
fought for sanitary conditions, fresh air, and general improvement in the patient
environment. Clara Barton developed the American Red Cross in 1881. Linda
Richards is known as the first trained nurse in America, was responsible for the
development of the first nursing and hospital records, and is credited with the
development of our present-day documentation system. Dorothea Dix was the pioneer
crusader for elevation of standards of care for the mentally ill and superintendent of
female nurses of the Union Army.
Test Bank
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Test Bank for Foundations and Adult Health Nursing 9th Edition Cooper Chapter 1 - 58 Updated
DIF: Cognitive Level: Knowledge
REF:
p. 17
OBJ: 2 | 4 TOP:
Nursing leaders
KEY:
Nursing
Process Step: N/A MSC: NCLEX: N/A
9.
What document identifies the roles and responsibilities of the LPN/LVN?
a.
NLN Accreditation Standards
b.
Nurse Practice Act
c.
NAPNE Code
d.
American Nurses‘ Association Code
ANS: B
The LPN/LVN functions under the Nurse Practice Act. NLN Accreditation
Standards, the NAPNE Code, and the American Nurses‘ Association Code do not
identify the roles and responsibilities of the LPN/LVN.
DIF:
Cognitive Level: Knowledge
p. 12 | p. 14
REF:
OBJ: 11 TOP:
Roles and responsibilities KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
10.
What is a cost-effective delivery of care used by many hospitals that allows the
LPN/LVN to work with the RN to meet the needs of patients?
a.
Focused nursing
b.
Team nursing
c.
Case management
d.
Primary nursing
ANS: C
Case management is a cost-effective method of care. Focused nursing, team
nursing, and primary nursing are not cost-effective methods of delivering care that
allow the LPN/LVN to work with the RN to meet patient needs.
DIF:
REF: p. 15
Cognitive Level: Comprehension
OBJ: 7 | 9 TOP:
Patient care delivery systems
KEY:
Nursing Process Step: N/A MSC: NCLEX: N/A
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Test Bank for Foundations and Adult Health Nursing 9th Edition Cooper Chapter 1 - 58 Updated
11.
What is the title of the American Hospital Association‘s 1972 document that outlines
the patient‘s expectations to be treated with dignity and compassion?
a.
Code of Ethics
b.
Patient‘s Bill of Rights
c.
OBRA
d.
Advance directives
ANS: B
Patient expectations are outlined by the Patient‘s Bill of Rights. Patient expectations
are not outlined in the Code of Ethics, OBRA, or advance directives.
DIF: Cognitive Level: Knowledge
REF:
p. 16
OBJ: 4 | 8 TOP:
Patient‘s rights
KEY:
Nursing
Process Step: N/A MSC: NCLEX: N/A
12.
The relationships among nursing, patients, health, and the environment are the basis for:
a.
care plans.
b.
nursing models.
c.
health care provider‘s orders.
d.
evaluation of patient care.
ANS: B
Nursing models are theories based on the relationship between nursing, patients,
health, and environment. Care plans, health care provider‘s orders, and evaluation of
patient care are not based on the relationships among nursing, patients, health, and
environment.
DIF: Cognitive Level: Comprehension REF:
p. 17
OBJ: 1 TOP:
Nursing models
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
13.
Test Bank
What system reduces the number of employees but still provides quality care for patients?
a.
Team nursing
b.
Cross-training
c.
Use of critical pathways
d.
Case management
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Test Bank for Foundations and Adult Health Nursing 9th Edition Cooper Chapter 1 - 58 Updated
ANS: B
Cross-training reduces the number of employees but does not alter the quality of
patient care. Team nursing, use of critical pathways, and case management do not
reduce the number of employees while continuing to provide quality care for patients.
DIF: Cognitive Level: Comprehension REF: p. 15
TOP: Patient care
OBJ: 8
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
14.
What is the purpose of licensing laws for LPN/LVNs?
a.
To limit the number of LPN/LVNs
b.
Prevention of malpractice
c.
Protection of the public from unqualified people
d.
To increase revenue for the state board of nursing
ANS: C
The purpose of licensing laws for LPN/LVNs is to protect the public from
unqualified health care providers. Licensing laws‘ purpose is not to limit the
number of LPNs/LVNs, prevent malpractice, or increase revenue for the state
board of nursing.
DIF:
Cognitive Level: Comprehension REF: p. 11
OBJ:
4 | 9 | 10 TOP: Licensure
KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
15.
What premise is Maslow‘s hierarchy of needs based on?
a.
All needs are equally important.
b.
Basic needs must be met before the next level of needs can be met.
c.
Self-actualization is a primary need.
d.
Individuals prioritize needs the same way.
ANS: B
Maslow‘s hierarchy of needs is based on the premise that basic needs must be met first. It
is not based on all needs being equally important or that individuals prioritize needs the
same way. Self-actualization is not a primary need according to Maslow.
DIF:
Test Bank
Cognitive Level: Comprehension REF:
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Test Bank for Foundations and Adult Health Nursing 9th Edition Cooper Chapter 1 - 58 Updated
p. 12 | p. 13
OBJ: 8 TOP:
Maslow‘s Hierarchy of Needs
KEY:
Nursing Process Step: N/A MSC: NCLEX: N/A
16.
What must the nurse realize when assessing physical and social environmental factors
affecting health and illness?
a.
They affect one another.
b.
They cause illness.
c.
They cause patients to react similarly.
d.
They can be separated.
ANS: A
Physical and social factors affect each other, cannot be separated, and cause each patient
to react in a unique manner. They do not necessarily cause illness or cause patients to
react similarly, and they cannot be separated.
DIF:
Cognitive Level: Comprehension REF: p. 14
OBJ: 4 | 8
TOP: Environmental factors KEY: Nursing Process
Step: Assessment MSC: NCLEX: Health Promotion
and Maintenance
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Test Bank for Foundations and Adult Health Nursing 9th Edition Cooper Chapter 1 - 58 Updated
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17.
What organization, established during World War II, provided nursing education and
training?
a.
Nightingale school
b.
Cadet Nurse Corps
c.
Public health department
d.
Frontier Nursing Service
ANS: B
The Cadet Nurse Corps was established during World War II to provide nursing
education and training. The Nightingale school, public health department, and
Frontier Nursing Service are not organizations established during World War II to
provide nursing education and training.
DIF: Cognitive Level: Knowledge
REF:
p. 5
OBJ: 1 | 4 TOP:
Nursing education
KEY:
Nursing
Process Step: N/A MSC: NCLEX: N/A
18.
What is a modern educational advancement program for the LPN/LVN to enter RN
education?
a.
Repetition
b.
Exclusion
c.
Articulation
d.
Coexistence
ANS: C
Most states have some type of articulation program in which the LPN/LVN can
achieve advanced standing in an RN program without having to enroll in the entire
curriculum. Repetition, exclusion, and coexistence do not refer to educational
advancement.
DIF: Cognitive Level: Knowledge
REF:
p. 10
OBJ: 1 | 9 TOP:
Nursing education
KEY:
Nursing
Process Step: N/A MSC: NCLEX: N/A
19.
Where did Florence Nightingale‘s original nursing education take place?
a.
Saint Thomas
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b.
Kings College Hospital
c.
Crimean Hospital
d.
Kaiserswerth School
ANS: D
Florence Nightingale trained at Kaiserswerth School. Florence Nightingale‘s original
training was not at Saint Thomas, Kings College Hospital, or Crimean Hospital.
DIF: Cognitive Level: Knowledge
REF:
p. 2
OBJ: 2 TOP:
Nursing programs
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
20.
What system of comprehensive patient care considers the physical, emotional, and
social environment and spiritual needs of a person?
a.
Interdependent care
b.
Holistic health care
c.
Illness prevention care
d.
Health promotion care
ANS: B
Holistic health care encompasses the physical, emotional, social, and spiritual aspects of
the patient.
DIF: Cognitive Level: Comprehension REF: p. 12
TOP: Health care
OBJ: 8
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
21.
What official agency exists exclusively for LPN/LVN membership and promotes standards
for the LPN/LVN?
a.
NFLPN
b.
ANA
c.
NLN
d.
NAPNES
ANS: A
The NFLPN exists solely for the LPN/LVN. The other options have membership that
includes RNs and the lay public.
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DIF: Cognitive Level: Knowledge
REF:
p. 10
OBJ: 5 | 6 | 9 TOP:
Nursing organizations
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
22.
What score does the graduate practical nurse require to be issued a license upon
completion of the computerized examination?
a.
70% or better
b.
This is defined and set by each state
c.
Designated as ―pass‖
d.
Within the 75th percentile
ANS: C
Currently graduates of an approved vocational school are eligible to take the licensing
examination and be awarded a license with a score of ―pass‖ that is recognized by all
states.
DIF: Cognitive Level: Knowledge
REF:
p. 12
OBJ: 3 TOP:
Licensure examination
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
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23.
What document, published in 1965 by the ANA, clearly defined two levels of nursing
practice?
a.
Licensing standards
b.
Position paper
c.
Smith-Hughes Act
d.
Nurse practice act
ANS: B
The ANA‘s position paper of 1965 defined two levels of nursing: registered nurse
and technical nurse. Licensing standards, the Smith-Hughes Act, and the nurse
practice act were not documents defining two levels of nursing practice published
in 1965.
DIF:
Cognitive Level: Knowledge
REF:
p. 11
OBJ: 3 | 4 | 9 TOP:
Position paper
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
24.
What is the wellness/illness continuum defined as?
a.
A concept that never changes
b.
The range of a person‘s total health
c.
A continuum influenced only by one‘s physical condition
d.
An idea that focuses strictly on an individual‘s social well-being
ANS: B
The wellness/illness continuum is defined as the range of a person‘s total health. This
continuum is ever changing, and it is influenced by the individual‘s physical condition,
mental condition, and social well-being.
DIF: Cognitive Level: Comprehension REF:
p. 12
OBJ: 8 TOP:
Wellness/illness continuum KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
25.
According to Maslow‘s hierarchy of needs, what is an individual‘s most basic need?
a.
Safety and security
b.
Love/belongingness
c.
Physiologic
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d.
Self-actualization
e.
Esteem
ANS: C
Abraham Maslow believed that an individual‘s behavior is formed by the
individual‘s attempts to meet essential human needs, which he identified as
physiologic, safety and security, love and belongingness, and esteem and selfactualization.
DIF:
Cognitive Level: Comprehension REF:
p. 12 | p. 13
OBJ: 8 TOP:
Maslow‘s Hierarchy of Needs
KEY:
Nursing Process Step: N/A MSC: NCLEX: N/A
MULTIPLE RESPONSE
1.
Florence Nightingale established a nursing school at Saint Thomas Hospital in
London. What was it characterized by? (Select all that apply.)
a.
Allowing all applicants who applied to be enrolled
b.
Offering formal and practical educational experiences
c.
Keeping records of students‘ progress
d.
Focusing on sanitation and hygiene
e.
Retaining a registry of all graduates
ANS: B, C, D, E
The nursing school established by Florence Nightingale rigorously screened its
applicants. The curriculum, which included both formal education and practical
experiences, was focused on hygiene and sanitation. The school kept records of the
students‘ progress during their school years, and also kept a registry of the graduates.
DIF:
Cognitive Level: Comprehension REF: p. 3
OBJ: 1 | 2
TOP: School established by Florence Nightingale KEY:
Nursing Process Step: N/A MSC: NCLEX: N/A
COMPLETION
1.
Primitive medical interventions were based on the belief that illness was caused by the
presence of
spirits.
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ANS:
evil
Illness was thought to be caused by the inhabitation of the body by evil spirits. Medical
interventions were designed to drive out the evil spirits by introducing good spirits.
DIF: Cognitive Level: Comprehension REF:
p. 1
OBJ: 1 TOP:
Primitive health care
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
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2.
During early civilization
men performed witchcraft and rituals to induce the bad
spirits to leave the body of the ailing person.
ANS:
medicine
Medicine men performed witchcraft and rituals to induce the bad spirits to leave the
body of the ailing person during early civilization.
DIF: Cognitive Level: Knowledge
REF:
p. 2
OBJ: 1 TOP:
Primitive health care
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
3.
The National Council of State Boards of Nursing (NCSBN) performs a job analysis
every
years to determine
the scope of practice of LPN/LVNs.
ANS:
3
three
The National Council of State Boards of Nursing performs a job analysis every 3 years
to measure the scope of practice for LPN/LVNs.
DIF: Cognitive Level: Knowledge
p. 18
REF:
OBJ: 6 | 9 TOP:
National Council analysis KEY:
Nursing
Process Step: N/A MSC: NCLEX: N/A
4.
Graduates of the first school for training the practical nurse were referred to as
nurses.
ANS:
attendant
The first school for training the practical nurse started in Brooklyn, New York, in
1892 and was conducted under the auspices of the Young Women‘s Christian
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Association (YWCA). The Ballard School, as it was known, was approximately 3
months in duration and trained its students to care for the chronically ill, invalids,
children, and the elderly. The main emphasis was on home care and included cooking,
nutrition, basic science, and basic procedures. Graduates of this program were referred
to as attendant nurses.
DIF: Cognitive Level: Knowledge
REF:
p. 9
OBJ: 1 TOP:
Attendant nurses
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
5.
In 1949, the National Federation of Licensed Practical Nurses (NFLPN) was founded by
Lillian
.
ANS:
Kuster
In 1949, the National Federation of Licensed Practical Nurses (NFLPN) was founded
by Lillian Kuster. This association is the official membership organization for licensed
practical nurses/licensed vocational nurses (LPN/LVNs), and membership is limited to
LPNs and LVNs.
DIF: Cognitive Level: Knowledge
REF: p. 10
OBJ: 2
TOP: National Federation of Licensed Practical Nurses
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
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Chapter 02: Legal and Ethical Aspects of Nursing
Cooper: Foundations and Adult Health Nursing, 9th Edition
MULTIPLE
CHOICE
1.
When a nurse becomes involved in a legal action, the first step to occur is that a
document is filed in an appropriate court. What is this document called?
a.
Deposition
b.
Appeal
c.
Complaint
d.
Summons
ANS: C
A document called a complaint is filed in an appropriate court as the first step in
litigation. A deposition is when witnesses are required to undergo questioning by the
attorneys. An appeal is a request for a review of a decision by a higher court. A
summons is a court order that notifies the defendant of the legal action.
DIF: Cognitive Level: Knowledge
REF: p. 24
TOP: Legal KEY: Nursing Process Step: N/A
2.
OBJ: 1
MSC: NCLEX: N/A
The nurse caring for a patient in the acute care setting assumes responsibility for a
patient‘s care. What is this legally binding situation?
a.
Nurse-patient relationship
b.
Accountability
c.
Advocacy
d.
Standard of care
ANS: A
When the nurse assumes responsibility for a patient‘s care, the nurse-patient
relationship is formed. This is a legally binding ―contract‖ for which the nurse must
take responsibility. Accountability is being responsible for one‘s own actions. An
advocate is one who defends or pleads a cause or issue on behalf of another.
Standards of care define acts whose performance is required, permitted, or
prohibited.
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DIF: Cognitive Level: Comprehension REF: p. 24
TOP: Legal KEY: Nursing Process Step: N/A
3.
OBJ: 3
MSC: NCLEX: N/A
What are the universal guidelines that define appropriate measures for all nursing
interventions?
a.
Scope of practice
b.
Advocacy
c.
Standard of care
d.
Prudent practice
ANS: C
Standards of care define actions that are permitted or prohibited in most nursing
interventions. These standards are accepted as legal guidelines for appropriateness of
performance. The laws that formally define and limit the scope of nursing practice are
called nurse practice acts. An advocate is one who defends or pleads a cause or issue
on behalf of another. Prudent is a term that refers to careful and/or wise practice.
DIF: Cognitive Level: Knowledge
REF: p. 22
TOP: Legal KEY: Nursing Process Step: N/A
4.
OBJ: 4
MSC: NCLEX: N/A
An LPN/LVN is asked by the RN to administer an IV chemotherapeutic agent to a
patient in the acute care setting. What law should this nurse refer to before
initiating this intervention?
a.
Standards of care
b.
Regulation of practice
c.
American Nurses‘ Association Code
d.
Nurse practice act
ANS: D
It is the nurse‘s responsibility to know the nurse practice act in his or her state. Standards
of care, regulation of practice, and the American Nurses‘ code are not laws that the nurse
should refer to before initiating this treatment.
DIF: Cognitive Level: Application
REF: p. 26
TOP: Legal KEY: Nursing Process Step: N/A
5.
OBJ: 5
MSC: NCLEX: N/A
A nurse fails to irrigate a feeding tube as ordered, resulting in harm to the patient. This
nurse could be found guilty of:
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a.
malpractice.
b.
harm to the patient.
c.
negligence.
d.
failure to follow the nurse practice act.
ANS: A
The nurse can be held liable for malpractice for acts of omission. Failure to meet a legal
duty, thus causing harm to another, is malpractice. The nurse practice act has general
guidelines that can support the charge of malpractice.
DIF: Cognitive Level: Application
REF: p. 24
TOP: Legal KEY: Nursing Process Step: N/A
OBJ: 2
MSC: NCLEX: N/A
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6.
Patients have expectations regarding the health care services they receive. To protect
these expectations, which of the following has become law?
a.
American Hospital Association‘s Patient‘s Bill of Rights
b.
Self-Determination Act
c.
American Hospital Association‘s Standards of Care
d.
The Joint Commission‘s rights and responsibilities of patients
ANS: A
Patients have expectations regarding the health care services they receive. In 1972, the
American Hospital Association ( AHA) developed the Patient‘s Bill of Rights. The SelfDetermination Act, American Hospital Association‘s Standards of Care, and The Joint
Commission‘s rights and responsibilities do not address patients‘ expectations
regarding health care.
DIF: Cognitive Level: Comprehension REF: p. 27
TOP: Legal KEY: Nursing Process Step: N/A
7.
OBJ: 3 | 4
MSC: NCLEX: N/A
The nurse is preparing the patient for a thoracentesis. What must be completed before the
procedure may be performed?
a.
Physical assessment
b.
Interview
c.
Informed consent
d.
Surgical checklist
ANS: C
The doctrine of informed consent refers to full disclosure of the facts the patient needs
to make an intelligent (informed) decision before any invasive treatment or procedure
is performed. A physical assessment, interview, and surgical checklist are not
required before this procedure.
DIF: Cognitive Level: Application
REF: p. 27
TOP: Legal KEY: Nursing Process Step: N/A
8.
OBJ: 8
MSC: NCLEX: N/A
When a nurse protects the information in a patient‘s record, what ethical responsibility is
the nurse fulfilling?
a.
Privacy
b.
Disclosure
c.
Confidentiality
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d.
Absolute secrecy
ANS: C
The nurse has an ethical and legal duty to protect information about a patient and
preserve confidentiality. Some disclosures are legal and anticipated, and may not be
subject to the rules of confidentiality. None of the information in a chart is considered
secret.
DIF: Cognitive Level: Comprehension REF:
pp. 29-30
OBJ: 9 TOP:
Confidentiality
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
9.
An older adult is admitted to the hospital with numerous bodily bruises, and the
nurse suspects elder abuse. What is the best nursing action?
a.
Cover the bruises with bandages.
b.
Take photographs of the bruises.
c.
Ask the patient if anyone has hit her.
d.
Report the bruises to the charge nurse.
ANS: D
The law stipulates that the health care professional is required to report certain
information to the appropriate authorities. The report should be given to a
supervisor or directly to the police, according to agency policy. When acting in
good faith to report mandated information (e.g., certain communicable diseases or
gunshot wounds), the health care professional is protected from liability.
DIF: Cognitive Level: Application
REF: p. 31
OBJ: 9
TOP: Elder abuse
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
10.
What is the best way for a nurse to avoid a lawsuit?
a.
Carry malpractice insurance.
b.
Spend time with the patient.
c.
Provide compassionate, competent care.
d.
Answer all call lights quickly.
ANS: C
The best defense against a lawsuit is to provide compassionate and competent
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nursing care. Carrying malpractice insurance is prudent, but it will not avoid a
lawsuit. Spending time with patients and answering call lights quickly will not
necessarily help avoid a lawsuit.
DIF: Cognitive Level: Comprehension REF:
p. 29
OBJ: 8 TOP:
Avoiding a lawsuit
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
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11.
The nurse is caring for a patient with a do-not-resuscitate (DNR) order. Although the
nurse may disagree with this order, what is his or her legal obligation?
a.
To question the health care provider
b.
To seek advice from the family
c.
To discuss it with the patient
d.
To follow the order
ANS: D
When a DNR order is written in the chart, the nurse has a duty to follow the order.
Questioning the health care provider, seeking advice from the family, and discussing it
with the patient are not legal obligations of the nurse.
DIF:
Cognitive Level: Application
REF: p. 37
TOP: Legal KEY: Nursing Process Step: N/A
12.
OBJ: 10 | 14
MSC: NCLEX: N/A
The nurse has strong moral convictions that abortions are wrong. When assigned
to assist with an abortion, what is the most appropriate action for the nurse to
take?
a.
Ask for another assignment.
b.
Leave work.
c.
Transfer to another floor.
d.
Protest to the supervisor.
ANS: A
The nurse should not abandon the patient, but ask for another assignment.
DIF:
Cognitive Level: Application
REF: p. 37
TOP: Ethics KEY: Nursing Process Step: N/A
13.
OBJ: 9 | 16
MSC: NCLEX: N/A
The new LPN/LVN is concerned regarding what should or should not be done for
patients. What resource will best provide this information?
a.
Nurse practice act
b.
Standards of care
c.
Scope of nursing practice
d.
Professional organizations
ANS: B
Standards of care define what should or should not be done for patients. The nurse
practice act, scope of nursing practice, and professional organizations do not provide the
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best information as to what should or should not be done for patients.
DIF: Cognitive Level: Comprehension REF:
p. 24
OBJ: 5 TOP:
Standards of care
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
14.
What role is the nurse who diligently works for the protection of patients‘ interests
playing?
a.
Caregiver
b.
Health care administrator
c.
Advocate
d.
Health care evaluator
ANS: C
A nurse accepts the role of advocate when, in addition to general care, the nurse
protects the patient‘s interests. Caregiver, health care administrator, and health care
evaluator are not terms for the nurse who diligently works for the protection of
patients.
DIF:
Cognitive Level: Comprehension REF: p. 25
TOP: Advocate
OBJ: 9 | 12
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
15.
When asked to perform a procedure that the nurse has never done before, what
should the nurse do to legally protect himself or herself?
a.
Go ahead and do it.
b.
Refuse to perform it, citing lack of knowledge.
c.
Discuss it with the charge nurse, asking for direction.
d.
Ask another nurse who has performed the procedure.
ANS: C
The nurse cannot use ignorance as an excuse for nonperformance. The nurse should
ask for direction from the charge nurse, explaining she has never performed the
procedure independently.
DIF: Cognitive Level: Application
REF: p. 26
TOP: Legal KEY: Nursing Process Step: N/A
OBJ: 8
MSC: NCLEX: N/A
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16.
The nurse is assisting a patient to clarify values by encouraging the expression of
feelings and thoughts related to the situation. What is the most appropriate action
for the nurse?
a.
Compare values with those of the patient.
b.
Make a judgment.
c.
Withhold an opinion.
d.
Give advice.
ANS: C
The nurse can assist the patient in values clarification without giving an opinion.
DIF: Cognitive Level: Application
REF:
p. 35
OBJ: 3 | 8 TOP:
Values clarification
KEY:
Nursing
Process Step: N/A MSC: NCLEX: N/A
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17.
What fundamental principle must the nurse first observe when confronted with an ethical
decision?
a.
Autonomy
b.
Beneficence
c.
Respect for people
d.
Nonmaleficence
ANS: C
The first fundamental principle is respect for people. Autonomy, beneficence, and
nonmaleficence are not the first fundamental principles to observe when confronted
with an ethical decision.
DIF:
Cognitive Level: Comprehension REF: p. 36
TOP: Ethics KEY: Nursing Process Step: N/A
18.
OBJ: 13 | 15
MSC: NCLEX: N/A
A nurse working on an acute care medical surgical unit is aware that his or her
first duty is to the patient‘s health, safety, and well-being. Given this knowledge,
which of the following is most necessary for the nurse to report?
a.
Unethical behavior of other staff members
b.
A worker who arrives late
c.
Favoritism shown by nursing administration
d.
Arguments among the staff
ANS: A
A member of the nursing profession must report behavior that does not meet
established standards. Unethical behavior involves failing to perform the duties of a
competent caring nurse.
DIF: Cognitive Level: Application
REF:
p. 36
OBJ: 13 TOP:
Unethical behavior
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
19.
A nurse is considering purchasing malpractice insurance. What should the nurse
be aware of regarding malpractice insurance provided by the hospital?
a.
Only offers protection while on duty.
b.
Is limited in the amount of coverage.
c.
Is difficult to renew.
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d.
Can be terminated at any time.
ANS: A
Most institutional insurance only provides liability coverage if the nurse is on duty at that
facility.
DIF: Cognitive Level: Comprehension REF:
p. 32
OBJ: 2 TOP:
Malpractice insurance
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
20.
Which is a nursing care error that violates the Health Insurance Portability and
Accountability Act (HIPAA)?
a.
Administering a stronger dose of drug than was ordered
b.
Refusing to give a patient‘s daughter information over the phone
c.
Informing the patient‘s medical power of attorney of a medication change
d.
Leaving a copy of the patient‘s history and physical in the photocopier
ANS: D
Leaving the document in the photocopier could expose it to the public. Inappropriate
drug administration is possible malpractice. Sharing information with the power of
attorney is legal. Refusing to give a patient‘s daughter information over the phone is
appropriate practice.
DIF: Cognitive Level: Comprehension
REF: p. 27
OBJ: 7 TOP:
Health Insurance Portability and
Accountability Act (HIPAA) KEY: Nursing
Process Step: N/A
MSC: NCLEX:
N/A
21.
Which of the following could cause a nurse to be cited for malpractice?
a.
Refusing to give 60 mg of morphine as ordered
b.
Giving prochlorperazine (Compazine) to a patient allergic to phenothiazines
c.
Dragging an injured motorist off the highway and causing further injury
d.
Informing a visitor about a patient‘s condition
ANS: B
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Standards of care dictate that a nurse must be aware of all the properties of drugs
administered. Prochlorperazine (Compazine) is a phenothiazine. Providing
confidential information or refusing to give an excessively large narcotic dose is not
considered malpractice. Good Samaritan laws generally protect a person giving aid to
an injured motorist.
DIF: Cognitive Level: Application
REF: p. 26
OBJ: 2
TOP: Malpractice
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
22.
A lumbar puncture was performed on a patient without a signed informed consent form.
This patient might sue for:
a.
punitive damages.
b.
civil battery.
c.
assault.
d.
nothing; no violation has occurred.
ANS: B
Civil battery charges can be brought against someone performing an invasive procedure
without the patient‘s informed consent legally documented. This patient could not sue
for punitive damages or an assault.
DIF:
Cognitive Level: Comprehension
REF: p. 27
OBJ: 6 | 8 TOP:
Informed consent
KEY:
Nursing
Process Step: N/A MSC: NCLEX: N/A
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23.
A health care provider instructs the nurse to bladder train a patient. The nurse clamps
the patient‘s indwelling urinary catheter but forgets to unclamp it. The patient
develops a urinary tract infection. What do the nurse‘s actions exemplify?
a.
Malpractice
b.
Battery
c.
Assault
d.
Neglect of duty
ANS: A
A nurse is liable for acts of commission (doing an act) and omission (not doing an act)
performed in the course of their professional duty. A charge of malpractice is likely when
a duty exists, there is a breach of that duty, and harm has occurred to the patient.
DIF: Cognitive Level: Application
REF: p. 25
OBJ: 2
TOP: Malpractice
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
24.
What is true about nurse practice acts?
a.
They informally define the scope of nursing practice.
b.
They provide for unlimited scope of nursing practice.
c.
Only some states have adopted a nurse practice act.
d.
The nurse must know the nurse practice act within his or her state.
ANS: D
The laws formally defining and limiting the scope of nursing practice are called nurse
practice acts. All state, provincial, and territorial legislatures in the United States and
Canada have adopted nurse practice acts, although the specifics they contain often
vary. It is the nurse‘s responsibility to know the nurse practice act that is in effect for
her geographic region.
DIF: Cognitive Level: Comprehension REF:
p. 26
OBJ: 5 TOP: Nurse
practice acts
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
MULTIPLE
RESPONSE
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1.
How can the medical record be used in litigation? (Select all that apply.)
a.
Public record
b.
Proof of adherence to standards
c.
Evidence of omission of care
d.
Documentation of time lapses
e.
Evidence by only the plaintiff
ANS: A, B, C, D
The information when used in court becomes a public record. The information can be
used as proof of adherence to standards, omission of care, and documentation of time
lapses. Both plaintiff and defendant can use the document.
DIF:
Cognitive Level: Comprehension
REF: p. 24
OBJ: 1
| 4 TOP: Legal properties of medical record
KEY:
Nursing
Process
Step:
N/A
MSC:
NCLEX: N/A
2.
During a lunch break, an emergency department (ED) nurse truthfully tells another
nurse about the condition of a patient who came to the ED last night. What is the ED
nurse guilty of? (Select all that apply.)
a.
HIPAA violation
b.
Slander
c.
Libel
d.
Invasion of privacy
e.
Defamation
ANS: A, D
The disclosure is an invasion of privacy and a violation of HIPAA. Because the
information is true and verbal, it cannot be considered slander or libel.
DIF: Cognitive Level: Application
p. 30
REF:
OBJ: 7 TOP:
Disclosure of information KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
3.
A nurse failed to monitor a patient‘s respiratory status after medicating the patient
with a narcotic analgesic. The patient‘s respiratory status worsened, requiring
intubation. The patient‘s family claimed the nurse committed malpractice. What
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must be present for the nurse to be held liable? (Select all that apply.)
a.
A nurse-patient relationship exists.
b.
The nurse failed to perform in a reasonable manner.
c.
There was harm to the patient.
d.
The nurse was prudent in her performance.
e.
The nurse did not cause the patient harm.
f.
Duty does not exist.
ANS: A, B, C
For the court to uphold the charge of malpractice, and to find the nurse liable, the
following elements must be present: duty exists, there is a breach of duty, and harm
must have occurred.
DIF: Cognitive Level: Application
REF: p. 24
OBJ: 2
TOP: Malpractice
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
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COMPLETION
1.
Personal beliefs about the worth of an object, idea, custom, or attitude that influence
a person‘s behavior in a given situation are referred to as
.
ANS:
values
Values are personal beliefs about the worth of an object, an idea, a custom, or an
attitude. Values vary among people and cultures; they develop over time and undergo
change in response to changing circumstances and necessity. Each of us adopts a value
system that will govern what we feel is right or wrong (or good and bad) and will
influence our behavior in a given situation.
DIF: Cognitive Level: Knowledge
REF: p. 34
OBJ: 11 | 12
TOP: Values
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
2.
Acts whose performance is required, permitted, or prohibited are defined by
of care.
ANS:
standards
Standards of care define acts whose performance is required, permitted, or prohibited.
DIF: Cognitive Level: Knowledge
REF:
p. 26
OBJ: 4 TOP:
Standards of care
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
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Chapter 03: Documentation
Cooper: Foundations and Adult Health Nursing, 9th Edition
MULTIPLE
CHOICE
1.
What does documentation of type of care, time of care, and signature of the person prove?
a.
The person who signed the documentation did all the work noted.
b.
No litigation can be brought against the person who signed.
c.
Interventions were implemented to meet the patient‘s needs.
d.
The patient‘s response to the intervention was positive.
ANS: C
Documenting type of care, time of care, and signature of the person results in
recording the interventions that are implemented to meet the patient‘s needs. Many
charting entries include health care provider‘s visits, presence of family, or
interventions by other departments. Patient response to some interventions is not
always positive.
DIF: Cognitive Level: Comprehension REF: p. 40
TOP: Documentation
OBJ: 1
KEY: Nursing Process Step:
Implementation MSC: NCLEX: N/A
2.
Why is documentation especially significant in managed care?
a.
The hospital needs to show that employees care for patients.
b.
Institutions are reimbursed only for patient care that is documented.
c.
Patients might bring lawsuits if care was not given.
d.
Documents may become part of a lawsuit.
ANS: B
Cost reimbursement rates by government plans (Medicare, Medicaid) are based on the
prospective payment system of
diagnosis-related groups (DRGs): a system that classifies patients by age, diagnosis,
surgical procedure, and other information with hundreds of different categories to
predict the use of hospital resources, including length of stay, resulting in a fixed
payment amount.
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DIF: Cognitive Level: Comprehension REF:
p. 41
OBJ: 1 TOP:
Documentation
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
3.
The nurse charts only additional treatments done, changes in patient condition,
and new concerns. What is this system of documentation?
a.
SOAP
b.
Block
c.
CBE
d.
Focus
ANS: C
Charting additional treatments done, changes in a patient‘s condition, and new
concerns during the shift is charting by exception (CBE).
DIF:
Cognitive Level: Comprehension REF:
pp. 47-48
OBJ: 1 | 5 | 7 TOP:
Documentation
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
4.
What form explains the lapse when events are not consistent with facility or national
standards of expected care?
a.
Subjective data
b.
Focus chart
c.
Incident report
d.
Nursing assessment
ANS: C
An incident report is completed when patient care was not consistent with facility or
national standards. The form explains the event, time, extent of injury, and who was
notified.
DIF: Cognitive Level: Knowledge
REF:
p. 49
OBJ: 1 | 7 TOP:
Documentation
KEY:
Nursing
Process Step: N/A MSC: NCLEX: N/A
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5.
The staff from all disciplines is developing integrated care plans for a projected
length of stay for patients of a specific case type. This is known as a:
a.
nursing order.
b.
Kardex.
c.
nursing care plan.
d.
critical pathway.
ANS: D
Critical pathways allow staff from all disciplines to develop integrated care plans for a
projected length of stay for patients of a specific case type.
DIF: Cognitive Level: Knowledge
TOP: Documentation
REF: p. 41
OBJ: 8
KEY: Nursing Process Step:
Implementation MSC: NCLEX: N/A
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6.
What makes home health care documentation unique?
a.
Some charting is retained at the hospital.
b.
The health care provider‘s office needs separate charting.
c.
Different health care providers need access.
d.
The health care provider is the pivotal person in the charting.
ANS: C
Home health care documentation has unique problems because of the need for
different health care workers to access the medical record.
DIF: Cognitive Level: Comprehension REF:
p. 55
OBJ: 9 TOP:
Documentation
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
7.
What regulates standards for long-term care documentation?
a.
OBRA
b.
Title XXII
c.
Patient problems
d.
The care plan
ANS: A
OBRA (Omnibus Budget Reconciliation Act) was a significant Medicare and Medicaid
legislation for long-term health care documentation.
DIF: Cognitive Level: Knowledge
REF:
p. 55
OBJ: 10 TOP:
Documentation
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
8.
What is the nurse required to do to adhere to the concept of confidentiality for the
patient‘s medical record?
a.
Provide information only to another nurse.
b.
Provide information only to an attorney.
c.
Share information only with the family.
d.
Have a clinical reason for reading the record.
ANS: D
The nurse should not read the patient‘s medical record unless there is a clinical reason for
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doing so.
DIF: Cognitive Level: Comprehension REF:
p. 56
OBJ: 4 TOP:
Confidentiality
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
9.
Documentation is necessary for the evaluation of patient care. Which of the following
phases of the nursing process is necessary for the evaluation of patient care?
a.
Assessment
b.
Planning
c.
Implementation
d.
Evaluation
ANS: C
Documentation is part of the implementation phase of the nursing process.
DIF:
Cognitive Level: Comprehension
REF: p. 40
OBJ: 1 | 4 TOP:
Documentation
KEY:
Nursing
Process Step: N/A MSC: NCLEX: N/A
10.
What does the nurse use as a basis for documentation in focus charting?
a.
Problem list
b.
Nursing orders
c.
Patient problems
d.
Evaluation
ANS: C
In focus charting, instead of using the problem list, modified patient problems are used as
an index for nursing documentation.
DIF: Cognitive Level: Knowledge
REF:
p. 47
OBJ: 7 TOP:
Documentation
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
11.
What is the purpose of QA (quality assurance)?
a.
To screen employment applications
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b.
To evaluate care results against accepted standards
c.
To conduct in-services for ―quality documentation‖
d.
To report deviation from standards to the state health department
ANS: B
QA is an in-house department that evaluates care services and results against accepted
standards.
DIF: Cognitive Level: Comprehension REF:
p. 41
OBJ: 1 TOP:
Documentation
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
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12.
What is the process used to appraise the practice of an individual nurse known as?
a.
Quality assurance
b.
Incident reporting
c.
OBRA
d.
Peer review
ANS: D
Peer review is an in-house department study that may appraise the nursing practice of
individual nurses.
DIF: Cognitive Level: Knowledge
REF: p. 41
OBJ: 4
TOP: Peer review
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
13.
What is the documentation format that uses the acronym SOAPE?
a.
Problem-oriented
b.
Focused
c.
Traditional
d.
Crisis
ANS: A
The problem-oriented medical record uses the acronym SOAPE to format and for focus
charting on a list of patient problems.
DIF: Cognitive Level: Comprehension REF: p. 46
OBJ: 7
TOP: Problem-oriented medical record (POMR) KEY:
Nursing Process Step: N/A MSC: NCLEX: N/A
14.
Who is the legal owner of the patient‘s medical record?
a.
Patient
b.
Health care provider
c.
Institution
d.
State
ANS: C
Ownership of a medical record belongs to the institution in the case of a hospitalized
patient, or the health care provider in the case of private office visits.
DIF: Cognitive Level: Knowledge
REF: p. 56
OBJ: 4
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TOP: Legal ownership
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
15.
When using electronic (or computerized) documentation, which process should
the nurse use to ensure that no one alters the information the nurse has entered?
a.
Charting in code
b.
Logging off
c.
Charting in privacy
d.
Signing on with a password
ANS: B
Logging off closes the computer file that was opened with the nurse‘s password. Any
other data entry will require that person to sign on with their password.
DIF: Cognitive Level: Comprehension REF:
p. 57
OBJ: 2 TOP:
Computer documentation
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
16.
What is the system that classifies patients by age, diagnosis, and surgical procedure,
and produces 300 different categories used for predicting the use of hospital
resources?
a.
Quality assurance
b.
Resource assessment
c.
Quality improvement
d.
Diagnosis-related groups
ANS: D
Cost reimbursement rates under government plans are based on diagnosis-related
groups (DRGs), which is a system that classifies patients by age, diagnosis, and
surgical procedure, producing 300 different categories used in predicting the use of
hospital resources, including length of stay.
DIF: Cognitive Level: Knowledge
pp. 41-42
REF:
OBJ: 5 TOP:
Diagnostic-related groups KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
17.
A nurse is using the data, action, response, education (DARE) system of charting, and
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is completing the data portion. What data are the nurse‘s focus?
a.
Planning
b.
Assessment
c.
Implementation
d.
Patient teaching
ANS: B
DARE is the acronym for four different aspects of charting using the focus format. Data
(D) is both subjective and objective and is equivalent to the assessment step of the nursing
process. Action (A) is a combination of planning and implementation. Response
(R) of the patient is the same as evaluation of effectiveness. Some facilities include
education/patient teaching (E).
DIF: Cognitive Level: Comprehension REF: p. 47
OBJ: 7
TOP: Charting KEY: Nursing Process Step: Assessment
MSC: NCLEX: N/A
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18.
A new patient is being admitted to a long-term care facility. Who has primary
responsibility for each patient‘s initial admission nursing history, physical
assessment, and development of the care plan based on the patient problem
identified?
a.
Health care provider
b.
Registered nurse
c.
Unlicensed assistive personnel
d.
Licensed practical nurse/licensed vocational nurse
ANS: B
The registered nurse (RN) has primary responsibility for each patient‘s initial admission
nursing history, physical assessment, and development of the care plan based on the
patient problem identified.
DIF:
Cognitive Level: Comprehension REF:
p. 43
OBJ: 4 | 10 TOP:
Scope of practice
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
19.
Which of the following will the nurse implement when an error is made when
documenting in a patient‘s chart?
a.
Scratch out the error.
b.
Apply correction fluid.
c.
Erase the error completely.
d.
Draw a single line through the error.
ANS: D
A nurse should not erase, apply correction fluid, or scratch out errors made while
recording in a patient‘s chart. Instead, the nurse should draw a single line through the
error, write the word ―error‖ above it, and sign her name or initials.
DIF: Cognitive Level: Application
REF:
p. 45
OBJ: 6 TOP:
Documentation
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
20.
What should the nurse be sure to do when documenting in a patient‘s chart?
a.
Include speculation.
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b.
Chart consecutively.
c.
Leave blank spaces.
d.
Include retaliatory comments.
ANS: B
A nurse should not write retaliatory or critical comments about a patient or care by
other health care professionals. The nurse should not leave blank spaces in the nurse‘s
notes. The nurse should be certain the entry is factual and not speculate or guess. The
nurse should chart consecutively, line by line.
DIF: Cognitive Level: Application
REF:
p. 45
OBJ: 6 TOP:
Documentation
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
21.
A nurse is receiving a telephone order from a health care provider. The nurse uses a
safety measure of preventing errors that is recognized by The Joint Commission as
one method of meeting National Patient Safety Goals. What is the second step of
this method?
a.
Read back
b.
Background
c.
Recommendation
d.
Situation
e.
Assessment
ANS: B
SBAR (Situation, Background, Assessment, and Recommendation) is a method of
communication among health care workers and a part of documentation (Kaiser
Permanente, 2007). SBAR is considered a safety measure in preventing errors from
poor communication during ―hand-off‖ or ―handover‖ interactions, the communication
that occurs from one shift to the next or when a nurse phones a health care provider
with information about a patient. An additional ―R‖ is added. The additional ―R‖
(SBARR) represents ―read back‖ when the nurse reads back the order for clarification.
DIF: Cognitive Level: Application
REF: p. 43
OBJ: 3
TOP: SBARR
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
MULTIPLE RESPONSE
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1.
What are categories of inadequate documentation that may lead to a malpractice claim?
(Select all that apply.)
a.
Incorrectly recording the time of an event
b.
Failing to record verbal orders
c.
Charting events in advance
d.
Documenting an incorrect date
e.
Marking out and initialing charting errors
ANS: A, B, C, D
Marking out with a single line and initialing is an acceptable method to indicate a
charting error.
DIF: Cognitive Level: Application
p. 45
REF:
OBJ: 4 TOP:
Inadequate documentation KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
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2.
What are some problems associated with electronic (or computerized) charting? (Select
all that apply.)
a.
Security
b.
Expense of training staff
c.
Legibility
d.
Easy retrieval
e.
New terminology
ANS: A, B, E
Security, expensive staff training, and learning new terminology are all problems of
electronic charting. Legibility and easy retrieval are advantages.
DIF:
Cognitive Level: Comprehension REF:
pp. 42-43
OBJ: 1 TOP:
Computer charting
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
3.
What are the basic purposes of written patient records? (Select all that apply.)
a.
Teaching
b.
Legal record of care
c.
Written communication
d.
Research and data collection
e.
Permanent record for accountability
f.
Temporary record of hospitalization
ANS: A, B, C, D, E
There are five basic purposes for written patient records: (1) written communication,
(2) permanent record for accountability, (3) legal record of care, (4) teaching, and (5)
research and data collection.
DIF: Cognitive Level: Comprehension REF:
p. 41
OBJ: 1 TOP:
Medical record
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
4.
What should a medical record provide for all health care providers? (Select all that
apply.)
a.
Care given to the patient
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b.
Care planned for the patient
c.
A patient‘s nursing problems
d.
A patient‘s medical problems
e.
Details about any incident reports
f.
The patient‘s response to treatment
ANS: A, B, C, D, F
A medical record should furnish all health care providers with a concise, accurate,
written picture of a patient‘s medical and nursing problems, care planned and given,
and the patient‘s response to treatments.
DIF: Cognitive Level: Comprehension REF:
p. 43
OBJ: 1 TOP:
Medical record
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
COMPLETION
1.
The best defense against malpractice claims associated with nursing care is accurate
.
ANS:
documentation
Accurate documentation can guard against malpractice claims because it should describe
when, what, and how events occurred.
DIF:
Cognitive Level: Comprehension REF:
p. 41 | p. 42
OBJ: 4 TOP:
Documentation
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
2.
Twenty-four-hour charting is designed to establish
levels to help determine staffing
needs.
ANS:
acuity
Patient acuity, which is reflected in 24-hour charting compilation, can dictate staffing
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needs.
DIF: Cognitive Level: Comprehension REF:
p. 49
OBJ: 7 TOP: 24-
hour charting
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
3.
Documentation using the DARE format (Data, Action, Response, Education)
includes elements of the
charting system.
ANS:
focused
Focused charting uses the acronym DARE to direct and formalize charting.
DIF: Cognitive Level: Comprehension REF:
p. 47
OBJ: 7 TOP:
Focused charting
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
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4.
A health care audit that evaluates services provided and the results achieved compared
with accepted standards is known as
.
ANS:
quality
assurance
quality
assessment
quality
improvement
Quality assurance/assessment/improvement is an audit in health care that evaluates
services provided and the results achieved compared with accepted standards.
DIF: Cognitive Level: Knowledge
REF:
p. 41
OBJ: 1 TOP:
Quality assurance
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
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Chapter 04: Communication
Cooper: Foundations and Adult Health Nursing, 9th Edition
MULTIPLE
CHOICE
1.
Although the patient denies pain, the nurse observes the patient breathing rapidly with
clenched fists and facial grimacing. What is the nurse‘s best response to these
observations?
a.
―I am glad you are feeling better and have no discomfort.‖
b.
―Where do you hurt?‖
c.
―What you are saying and what I am observing don‘t seem to match.‖
d.
―It makes me uncomfortable when you are not honest with me.‖
ANS: C
The nonverbal communication should be clarified to prevent miscommunication.
DIF: Cognitive Level: Application
TOP: Communication
REF: p. 69
OBJ: 2 | 3
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
2.
The nurse considers the feelings and needs of a patient by stating, ―I know you are
concerned about your surgery tomorrow. How can I help you?‖ What type of
communication is this?
a.
Intrusive
b.
Aggressive
c.
Closed
d.
Assertive
ANS: D
Assertive communication takes a patient‘s feelings and needs into account, yet honors the
patient‘s rights as an individual.
DIF: Cognitive Level: Comprehension REF: p. 63
TOP: Communication
OBJ: 4
KEY: Nursing Process Step:
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Implementation MSC: NCLEX: Psychosocial Integrity
3.
What does therapeutic communication accomplish?
a.
Facilitates the formation of a positive nurse-patient relationship.
b.
Manipulates the patient.
c.
Assigns the patient a passive role.
d.
Requires the patient to accept what the nurse says.
ANS: A
A positive nurse-patient relationship is facilitated by therapeutic communication.
DIF: Cognitive Level: Comprehension REF:
p. 64
OBJ: 10 TOP:
Communication
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
4.
The nurse is sitting in a chair near the patient‘s bed, leaning forward to hear what the
patient is saying, and does not interrupt. What is the nurse demonstrating?
a.
Support
b.
Caring
c.
Active listening
d.
Interest
ANS: C
When demonstrating active listening, the nurse must give his or her full attention and
make an effort to understand both the verbal and nonverbal message.
DIF: Cognitive Level: Comprehension REF: p. 65
TOP: Communication
OBJ: 5
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
5.
What therapeutic communication technique requires a great deal of skill and is not
used as frequently as other communication techniques?
a.
Touch
b.
Silence
c.
Listening
d.
Summarizing
ANS: B
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Silence is an extremely effective therapeutic communication skill that is frequently
underused because the nurse feels uncomfortable applying it.
DIF: Cognitive Level: Comprehension REF:
p. 65
OBJ: 5 TOP:
Communication
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
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6.
A patient does not speak English; therefore, the nurse cannot use words to provide
comfort during a painful procedure. What is another intervention that may provide
comfort to this patient?
a.
Silence
b.
Listening
c.
Touch
d.
Restating
ANS: C
Holding the hand of a non–English-speaking patient is effective and comforting.
DIF: Cognitive Level: Application
TOP: Communication
REF: p. 76
OBJ: 9
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
7.
A patient states, ―I do cocaine when I feel things are out of my control.‖ The nurse
responds by asking, ―What else does cocaine do for you?‖ What communication skill
does this exemplify?
a.
Summarization
b.
Restating
c.
Showing acceptance
d.
Stating observations
ANS: C
Acceptance is the willingness to listen and respond to what the patient is saying without
passing judgment.
DIF: Cognitive Level: Application
TOP: Communication
REF: p. 66
OBJ: 5
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
8.
A patient states, ―I‘m really strung out about this pregnancy.‖ The nurse responds by
asking, ―What about this pregnancy worries you?‖ What communication technique is
this?
a.
Closed inquiry
b.
Restating
c.
Open-ended question
d.
Minimal encouraging
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ANS: C
Open-ended questions convey interest and do not require a specific response.
DIF: Cognitive Level: Application
TOP: Communication
REF: p. 68
OBJ: 5
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
9.
A grieving young widow cries out, ―Why was my husband killed? Why wasn‘t it me?‖
What is the nurse‘s best response?
a.
Stating ―You need to be strong for your children.‖
b.
Silently placing her hand on the widow‘s arm.
c.
Asking if there is anyone the widow needs to have notified.
d.
Stating ―You are feeling overwhelmed about your husband‘s death.‖
ANS: B
The ability to listen and assist those who are newly grieving through the use of silence
and a quiet presence is very effective. Stating ―You need to be strong for your
children‖ is a cliché. Asking if there is anyone the widow needs to have notified and
stating ―You are feeling overwhelmed about your husband‘s death‖ are not therapeutic
in this immediate grieving time.
DIF: Cognitive Level: Application
TOP: Communication
REF: p. 73
OBJ: 5
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
10.
A nurse is assessing a patient with a patient problem of impaired verbal
communication. What is the lowest number of defining characteristics for this
diagnosis?
a.
One
b.
Two
c.
Three
d.
Four
ANS: A
If one or more of the defining characteristics is present, a patient problem of impaired
verbal communication can be determined.
DIF: Cognitive Level: Comprehension REF: p. 74
TOP: Communication
OBJ: 9
KEY: Nursing Process
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Step: Assessment MSC: NCLEX: Psychosocial
Integrity
11.
What communication technique should the nurse use when communicating with an
unresponsive patient?
a.
Avoid speaking directly to the patient.
b.
Assume verbal stimuli are heard.
c.
Speak in a loud voice.
d.
Use simple words.
ANS: B
A person interacting with an unresponsive patient should assume all sounds and verbal
stimuli have the potential of being heard by the patient.
DIF: Cognitive Level: Application
TOP: Communication
REF: p. 76
OBJ: 10
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
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12.
The patient states, ―I am upset about all this lab work.‖ The nurse responds ―You‘re
upset?‖ This response is an example of:
a.
An open-ended question
b.
Reflecting
c.
Restating
d.
Paraphrasing
ANS: C
Restating is one of the most effective methods of therapeutic communication to
encourage the patient to offer more information.
DIF: Cognitive Level: Application
TOP: Communication
REF: p. 69
OBJ: 5
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
13.
What is one of the main characteristics of therapeutic communication?
a.
It allows the patient a passive role.
b.
It uses only verbal communication.
c.
It involves the patient as a person.
d.
It is directive.
ANS: C
Therapeutic communication actively involves the patient in all areas of the nursing
process.
DIF: Cognitive Level: Comprehension REF:
p. 64
OBJ: 1 TOP:
Communication
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
14.
A nurse actively avoids the use of one-way communication. What is the major problem
with one-way communication?
a.
The receiver is in control.
b.
Feedback is provided to the sender.
c.
Participation is not equal.
d.
The communication is unstructured.
ANS: C
One-way communication is seldom effective because the sender is in control and gets
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very little feedback from the receiver.
DIF: Cognitive Level: Comprehension REF: p. 61
TOP: Communication
OBJ: 7
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
15.
A nurse must violate the personal space of a patient to perform an invasive procedure.
How can the nurse reduce the discomfort of the patient?
a.
By approaching the interaction in a professional manner
b.
By distracting the patient with jokes and humor
c.
By asking another nurse to be present at the bedside
d.
By assuring the patient that all people dislike invasion of personal space
ANS: A
The intimate zone can cause uneasiness for both patient and nurse; therefore, approach
the interaction in a professional manner.
DIF: Cognitive Level: Application
TOP: Communication
REF: p. 70
OBJ: 6
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
16.
What would be the best method for a literate, English-speaking patient on a ventilator to
communicate his or her needs?
a.
Eye blinking for ―yes‖ and ―no‖
b.
Magic slate or paper and pencil
c.
Computer
d.
Message board or cards
ANS: B
Writing devices are preferred as they do not limit the patient‘s messages compared
to a message board or cards. Eye blinks are tiring and time-consuming. Computers
require space and the ability to type.
DIF: Cognitive Level: Application
TOP: Communication
REF: p. 76
OBJ: 10
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
17.
A patient roughly asks the nurse to bring him some ice cream. What would be considered
an assertive response by the nurse?
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a.
―You are hungry and want a snack.‖
b.
―I can do that in 10 minutes when I finish my rounds.‖
c.
―Maybe I can get one of the aides to bring you something in a while.‖
d.
―Call the nurses‘ station and ask them to have the
kitchen bring whatever you want.‖
ANS: B
Assertiveness is the most effective style of communication to be responsive to the patient
and set limits.
DIF: Cognitive Level: Application
TOP: Communication
REF: p. 63
OBJ: 4
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
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18.
A nurse tells a patient, ―This PM you are going for an abdominal A&P, an H&H, as
well as an IV pyelogram. Please sign these consent forms.‖ What may this use of
medical jargon cause?
a.
Understanding
b.
Speed in communication
c.
Misinterpretation
d.
Clarity in the message
ANS: C
Jargon is terminology unique to people in a special type of work and is not understood by
everyone. Although jargon does speed communication and is clear to those who know it,
it may be misinterpreted and not understood by all people.
DIF: Cognitive Level: Comprehension REF: p. 61
TOP: Communication
OBJ: 7
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
19.
During a complete assessment, which type of questioning is not usually conducive to
fostering communication?
a.
Open-ended
b.
Focused
c.
Closed
d.
Clarifying
ANS: C
Closed questions are types of questions that the nurse may choose to use that are not
usually conducive to fostering communication.
DIF: Cognitive Level: Comprehension REF: p. 67
TOP: Communication
OBJ: 7
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
20.
A patient states, ―My husband has told me how he feels about my having a
mastectomy.‖ The nurse nods and says, ―Go on.‖ This is an example of:
a.
clarifying.
b.
restating.
c.
focusing.
d.
minimal encouraging.
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ANS: D
The nurse uses minimal encouragement to lead the patient to provide more information.
DIF: Cognitive Level: Application
TOP: Communication
REF: p. 66
OBJ: 5
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
21.
A nurse is communicating with an older adult. How might the nurse enhance
communication?
a.
Speak in a rapid manner to accommodate the patient‘s short attention span.
b.
Speak in a lower voice tone to accommodate hearing loss.
c.
Speak in a simple manner as if speaking to a child.
d.
Speak in a loud voice directly at ear level.
ANS: B
Older adults lose their ability to hear higher frequency sound. Speaking in a lower
tone enhances communication. Speaking overly loud and as if to a child may be
irritating and demeaning. Rapid speech may be difficult for older adults to
understand.
DIF: Cognitive Level: Application
REF: p. 73
OBJ: 6 TOP:
Physiologic factors affecting communication
KEY: Nursing Process Step:
Implementation MSC:
NCLEX: Psychosocial
Integrity
22.
What does maintaining eye contact for 2 to 6 seconds during communication with a
patient do?
a.
Keeps the nurse‘s attention on the conversation
b.
Counteracts shyness in the patient
c.
Indicates continuous focused attention
d.
Assesses if the patient is involved in the conversation
ANS: C
Maintaining eye contact for 2 to 6 seconds involves the person in what is being said,
is indicative of continued interest, and conveys to the patient an accepting attitude.
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DIF: Cognitive Level: Comprehension REF: p. 62
TOP: Communication
OBJ: 2
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
23.
The nurse recognizes that a patient experiencing stress feels vulnerable. What would
be the most appropriate way for the nurse to intervene?
a.
Use technical language.
b.
Direct the conversation.
c.
Modify communication methods.
d.
Offer all the information.
ANS: C
When the patient is experiencing stress, the nurse should modify communication
methods.
DIF: Cognitive Level: Application
TOP: Communication
REF: p. 73
OBJ: 6
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
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24.
A nurse communicates with a patient by maintaining eye contact and through the
use of touch. What type of communication technique is the nurse demonstrating?
a.
Verbal
b.
Persuasive
c.
Directive
d.
Nonverbal
ANS: D
Messages transmitted without the use of words (either oral or written) constitute
nonverbal communication. Nonverbal cues include tone and rate of voice, volume of
speech, eye contact, physical appearance, and use of touch.
DIF: Cognitive Level: Comprehension REF: p. 61
TOP: Communication
OBJ: 5
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
25.
A nurse frequently looks at her watch when giving a patient a bed bath. What
message is most likely conveyed to the patient from the nurse?
a.
She desires to spend more time with the patient.
b.
She is anxious to listen to the patient‘s concerns.
c.
She is feeling hurried.
d.
She likes her watch.
ANS: C
Frequently looking at one‘s watch while interacting with a patient conveys to the
patient that the nurse is in a hurry and really has no desire to spend time with him or
her.
DIF:
Cognitive Level: Application
REF: p. 62 | p. 66
OBJ: 8 TOP: Gestures
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Psychosocial Integrity
26.
When listening to a patient, what action by the nurse demonstrates disinterest and
coldness?
a.
Tightly crossing her arms
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b.
Uncrossing her arms
c.
Uncrossing her legs
d.
Facing the patient
ANS: A
The way that an individual sits, stands, and moves is called posture. Posture has the
potential to convey warmth and acceptance, or distance and disinterest. An open
posture is demonstrated with a relaxed stance with uncrossed arms and legs while
facing the other individual. A slight shift in body position toward an individual, a
smile, and direct eye contact are all consistent with open posturing and convey
warmth and caring. Closed posture is a more formal, distant stance, generally with the
arms, and possibly the legs, tightly crossed. A person will often interpret closed
posture as disinterest, coldness, and even nonacceptance.
DIF:
Cognitive Level: Comprehension REF:
p. 62
OBJ: 1 | 7 | 8 TOP: Posture KEY:
Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
27.
How can the nurse demonstrate warmth and acceptance when listening to a patient?
a.
Tightly crossing her arms
b.
Uncrossing her arms
c.
Tightly crossing her legs
d.
Facing away from the patient
ANS: B
The way that an individual sits, stands, and moves is called posture. Posture has the
potential to convey warmth and acceptance, or distance and disinterest. An open
posture is demonstrated with a relaxed stance with uncrossed arms and legs while
facing the other individual. A slight shift in body position toward an individual, a
smile, and direct eye contact are all consistent with open posturing and convey
warmth and caring. Closed posture is a more formal, distant stance, generally with the
arms, and possibly the legs, tightly crossed. A person will often interpret closed
posture as disinterest, coldness, and even nonacceptance.
DIF:
p. 62
Cognitive Level: Application
REF:
OBJ: 1 | 5 | 8 TOP: Posture KEY:
Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
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28.
How may a nurse caring for a pediatric patient best be perceived as nonthreatening?
a.
Tightly crossing her arms
b.
Maintaining an open posture
c.
Maintaining a tense posture
d.
Standing at the bedside
ANS: B
Standing at the bedside looking down at the patient in the bed places the nurse in a
position of authority and control. The patient is likely to experience this as intimidating
and condescending. Whenever possible, the nurse should be level with the patient; this
is especially important with pediatric patients. Sitting at the bedside in a relaxed and
open posture is one example.
DIF:
Cognitive Level: Application
pp. 62-63
OBJ: 1 | 5 TOP: Posture
REF:
KEY:
Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
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29.
A nurse is caring for a patient who is experiencing excruciating pain and requires
frequent administration of analgesics. What statement would be an example of the
nurse demonstrating aggressive communication?
a.
―Please let me know when you start to have pain.‖
b.
―Let‘s practice some guided imagery.‖
c.
―Let‘s try repositioning you.‖
d.
―I will only medicate you every 4 hours.‖
ANS: D
Aggressive communication is when a person interacts with another in an
overpowering and forceful manner to meet his or her own personal needs at the
expense of the other. By only medicating a patient every 4 hours for excruciating pain,
the nurse meets his or her own needs at the expense of the patient.
DIF: Cognitive Level: Application
TOP: Communication
REF: p. 63
OBJ: 7
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
30.
A nurse is caring for a newly admitted diabetic patient and is performing the initial
assessment. What statement made by the nurse demonstrates the use of a closed
question?
a.
―What time do you take your insulin?‖
b.
―How do you feel about taking insulin?‖
c.
―Tell me about your support system.‖
d.
―How do you feel about having diabetes?‖
ANS: A
Much of the information gathered from a patient comes from questioning them
directly. A closed question is focused and seeks a particular answer. For example,
when interviewing a newly admitted patient with diabetes, the nurse asks, ―What time
do you take your insulin?‖ A specific question with a specific answer is a typical
closed question, which generally requires only one or two words in response.
DIF: Cognitive Level: Application
REF: p. 67
OBJ: 7
TOP: Closed questioning KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
31.
A nurse is caring for a patient experiencing respiratory distress. The health care
provider places an endotracheal tube. What is the most appropriate patient problem
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for this patient?
a.
Ineffective coping
b.
Risk for infection
c.
Altered nutrition: less than body requirements
d.
Impaired verbal communication
ANS: D
Because of the placement of an endotracheal tube, the patient is unable to speak. The
patient problem of impaired verbal communication is most appropriate.
DIF: Cognitive Level: Application
TOP: Patient problem
REF: p. 74
OBJ: 9
KEY: Nursing Process
Step: Diagnosis MSC: NCLEX: Psychosocial
Integrity
32.
A nurse examines whether patient interventions have been appropriate and
expected outcomes have been met. The nurse is demonstrating which step in the
nursing process?
a.
Assessment
b.
Planning
c.
Implementation
d.
Evaluation
ANS: D
A nurse evaluates the effectiveness of interventions based on the patient‘s ability to meet
established goals and outcomes.
DIF: Cognitive Level: Application
TOP: Nursing process
REF: p. 74
OBJ: 9
KEY: Nursing Process
Step: Evaluation MSC: NCLEX: Evaluation
33.
Which question below is open-ended?
a.
―Are you going to Europe this fall?‖
b.
―Are you sailing to Europe?‖
c.
―What are you most looking forward to in Europe?‖
d.
―Have you been to Europe before?‖
e.
―Where in Europe are you going?‖
ANS: C
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Only the question ―What are you most looking forward to in Europe?‖ allows an
unlimited answer.
DIF: Cognitive Level: Comprehension REF:
p. 67
OBJ: 5 TOP: Open-
ended communication
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
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MULTIPLE
RESPONSE
1.
Which are true regarding communicating while using eye contact? (Select all that apply.)
a.
Eye contact is responsible for much communication.
b.
Eye contact is responsible for much miscommunication.
c.
Making eye contact generally indicates an intention to interact.
d.
Eye contact always results in a positive outcome.
e.
Extended eye contact can imply aggression.
f.
Extended eye contact can lead to heightened anxiety.
ANS: A, B, C, E, F
Eye contact is responsible for much communication and much miscommunication.
Generally, making eye contact communicates an intention to interact. However, the nature
of the interaction and the results of eye contact are not necessarily always positive.
Extended eye contact sometimes implies aggression and arouses anxiety.
DIF: Cognitive Level: Comprehension
REF: p. 61 OBJ: 3 TOP: Eye
contact
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Psychosocial Integrity
2.
Which are examples of passive listening? (Select all that apply.)
a.
The nurse nods frequently while the patient speaks.
b.
The nurse maintains eye contact while listening to the patient.
c.
The nurse occasionally interjects, ―I see,‖ when listening to the patient.
d.
The nurse gives verbal feedback to the patient.
e.
The nurse verbally interprets the meaning of what the patient has said.
ANS: A, B, C, D
Listening is sometimes active and sometimes passive. Active listening requires full
attention to what the patient is saying. The message is heard, its meaning is
interpreted, and the patient is given feedback, indicating understanding of the message.
Verbally interpreting the meaning of what the patient has said is an example of active
listening. In passive listening, the nurse indicates that they are listening to what the
patient is saying either nonverbally, through eye contact and nodding, or verbally
through encouraging phrases such as ―Uh-huh‖ and ―I see.‖ All of the other options
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are examples of passive listening.
DIF: Cognitive Level: Comprehension
REF: p. 65 OBJ: 5 TOP:
Listening
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Psychosocial Integrity
3.
What is true about the use of touch in therapeutic communication? (Select all that apply.)
a.
Touch is a form of nonverbal communication.
b.
Touch is a form of verbal communication.
c.
Touch should be used with indiscretion.
d.
Touch can convey warmth and caring.
e.
Touch can convey support and understanding.
f.
Touch should be used sincerely and genuinely.
ANS: A, D, E, F
Touch is a form of nonverbal communication that is inherent in the practice of
nursing. Nearly every nursing intervention for the purpose of providing physical care
calls for touch. Touch is frequently highly personal or of an intimate nature (e.g.,
giving a bed bath, assisting a patient on or off a bedpan, inserting a urinary catheter).
Because of the intimate nature of touch in the nursing context, it is necessary to use it
with great discretion to fit into sociocultural norms and guidelines. Some nurses are
uncomfortable with touch because of a fear of it seeming inappropriate or being
misinterpreted. When a nurse feels comfortable with physical contact with a patient,
touch has great potential for conveying warmth, caring, support, and understanding.
For the nurse to convey warmth, it is absolutely necessary for the nature of their touch
to be sincere and genuine.
DIF:
Cognitive Level: Comprehension
REF: pp. 65-66
OBJ: 5 TOP: Touch
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Psychosocial Integrity
4.
When speaking to a person of a different culture, how should the nurse consider
modifying his or her communication style? (Select all that apply.)
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a.
Speak slowly and with increased volume
b.
Use of touch
c.
Use of eye contact
d.
Reference of address
e.
Meaning of gestures
ANS: B, C, D, E
Use of touch, eye contact, reference of address, and meaning of gestures all may have
cultural significance and connotation. Slow, loud speech would not assist with
speaking to a person of a different culture.
DIF: Cognitive Level: Application
REF: p. 66 OBJ: 7 TOP:
Culture
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Psychosocial Integrity
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5.
Which defining characteristics support the patient problem of impaired verbal
communication? (Select all that apply.)
a.
Aphasia
b.
Geriatric patients
c.
Profoundly deaf
d.
Legally blind
e.
Severe COPD
ANS: A, C, D, E
Difficulty speaking, attending, disorientation, dyspnea, and sensory deficits are all
defining characteristics that warrant a diagnosis of impaired verbal communication.
Being a geriatric patient does not necessarily support the patient problem of impaired
verbal communication.
DIF: Cognitive Level: Application
TOP: Impaired communication
REF: p. 73
OBJ: 9
KEY: Nursing
Process Step: Assessment MSC: NCLEX:
Psychosocial Integrity
6.
What is true about the use of silence in therapeutic communication? (Select all that
apply.)
a.
Maintaining silence is an effective therapeutic communication technique.
b.
Maintaining silence is generally overused in therapeutic communication.
c.
The sender often becomes uncomfortable when using silence.
d.
The ability to use silence effectively requires skill and timing.
e.
Prolonged periods of misunderstood silence can cause tension.
f.
Purposeful use of silence often conveys lack of respect.
ANS: A, C, D, E
Maintaining silence is an extremely effective therapeutic communication technique,
and yet tends to be quite underused. Because silence often feels awkward in American
society, people tend to feel the need to ―fill‖ it. This impulse does not always allow the
people involved in an interaction time to organize their thoughts sufficiently to
communicate what they would like. It is common for a person to need several seconds
after hearing a verbal message to interpret what has been stated and to formulate the
most appropriate response. Unfortunately, the receiver often does not get this amount
of time before a response is necessary. In many cases, the sender becomes
uncomfortable with the silence and begins speaking again before the receiver has had
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an opportunity to formulate a response and is really ready to deliver it. The ability to
use silence effectively requires skill and timing. It is easy for prolonged periods of
misunderstood silence to cause uneasiness and tension. However, in many cases,
purposeful use of silence conveys respect, understanding, caring, and support, and it is
often used in conjunction with therapeutic touch.
DIF: Cognitive Level: Comprehension
REF: p. 65 OBJ: 5 TOP:
Silence
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Psychosocial Integrity
COMPLETION
1.
The nurse explains to a patient that based on the description of ―personal space,‖ the
area within 18 in of the patient is designated as the
zone.
ANS:
intimate
Personal space zones: 0 to 18 in = intimate, 18 in to 4 ft = personal zone, 4 to 12 ft =
social zone, more than 12 ft = public zone.
DIF: Cognitive Level: Knowledge
REF: p. 70
OBJ: 8
TOP: Space and territoriality KEY: Nursing Process
Step: Implementation MSC: NCLEX: Psychosocial
Integrity
2.
A patient with aphasia who cannot understand a spoken or written message is said to have
aphasia.
ANS:
receptive
Aphasic patients who do not understand verbal exchanges are classified as receptive
aphasics.
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DIF: Cognitive Level: Comprehension REF: p. 76
TOP: Aphasia
OBJ: 7
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
3.
The term that describes an individual‘s perception or understanding of a particular word
or phrase is
.
ANS:
connotation
Connotation is the meaning an individual applies to a word or phrase.
DIF: Cognitive Level: Knowledge
TOP: Connotation
REF: p. 61
OBJ: 2
KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
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4.
When a nurse lectures to a large group, the method of communication is usually in the
form of
communication.
ANS:
one-way
One-way communication allows the sender to be in control with little expectation of or
desire for feedback.
DIF: Cognitive Level: Comprehension REF:
p. 61
OBJ: 5 TOP:
Communication
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
5.
As the nurse listens to a supervisor, the nurse has a smile on her face but has crossed
her arms in front of her chest and has crossed her legs. This is an example of a
posture.
ANS:
closed
A posture with crossed limbs frequently is indicative of nonacceptance.
DIF:
Cognitive Level: Comprehension REF: p. 62
TOP: Posture
OBJ: 6 | 7
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
is described as the exchange of information.
6.
ANS:
Communication
Communication is described as the exchange of information.
DIF: Cognitive Level: Knowledge
REF:
p. 60
OBJ: 1 TOP:
Communication
KEY: Nursing
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Process Step: N/A MSC: NCLEX: N/A
7.
The
is the person conveying the message, whereas the receiver is the
individual or individuals to whom the message is conveyed.
ANS:
sender
For communication to occur, a sender and a receiver of a message are both necessary.
The sender is the person conveying the message, whereas the receiver is the individual
or individuals to whom the message is conveyed.
DIF: Cognitive Level: Knowledge
REF:
p. 60
OBJ: 1 TOP:
Communication
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
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Chapter 05: Nursing Process and Critical Thinking
Cooper: Foundations and Adult Health Nursing, 9th Edition
MULTIPLE
CHOICE
What best defines the nursing process?
1.
a.
A method to ensure that the health care
provider‘s orders are implemented correctly.
b.
A series of assessments that isolate a patient‘s health problem.
c.
A framework for the organization of individualized nursing care.
d.
A preset formula for the design of nursing care.
ANS: C
The nursing process is a framework by which to organize individualized nursing care.
DIF: Cognitive Level: Comprehension REF:
p. 80
OBJ: 1 TOP:
Nursing process
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
2.
All of the following patients have been admitted to the acute care setting. On
admission, which patient should receive a focused assessment?
a.
53-year-old admitted with a perforated ulcer
b.
5-year-old admitted for the implant of grommets in the middle ear
c.
76-year-old admitted for a knee replacement
d.
40-year-old admitted for possible bowel obstruction
ANS: A
A patient with a perforated ulcer is considered to be critically ill. Therefore, this patient
should receive a focused assessment. The remaining options are not considered critical
illnesses.
DIF:
Cognitive Level: Application
REF: p. 81 | p. 82
OBJ: 2 TOP: Assessment
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KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
3.
What subjective data does the nurse record following a head-to-toe examination?
a.
Rash on back
b.
Prolonged nausea
c.
Blood pressure of 190/100
d.
White blood cell count of 19,000
ANS: B
Another term for subjective data is symptoms, which cannot be observed or measured.
This data must come from the patient.
DIF: Cognitive Level: Application
TOP: Subjective data
REF: p. 82
OBJ: 3
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
4.
What objective data should the nurse include after a patient assessment?
a.
Headache of 3 days‘ duration
b.
Severe stomach cramps
c.
Flatulence
d.
Anxiety
ANS: C
Objective data are observable and measurable by people other than the patient.
DIF: Cognitive Level: Application
TOP: Objective data
REF: p. 82
OBJ: 3
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
5.
When the nurse is prioritizing care during the planning phase of the nursing process, what
is the guiding framework?
a.
Primary
b.
Secondary
c.
Unreliable
d. Biased
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ANS: B
Secondary sources include family members.
DIF: Cognitive Level: Comprehension REF: p. 82
TOP: Assessment
6.
OBJ: 3
KEY: Nursing Process Step: Assessment
MSC: NCLEX: N/A
What are the two primary methods used to collect data?
a.
Written report by patient and family
b.
Review of the chart and the nurse‘s notes
c.
Interview and physical examination
d.
Review of the health care provider‘s orders and the Kardex
ANS: C
The two primary methods of collecting data are interviewing and physical examination.
DIF: Cognitive Level: Comprehension REF: p. 82
TOP: Assessment
OBJ: 3
KEY: Nursing Process Step: Assessment
MSC: NCLEX: N/A
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7.
The nurse writes two patient problems: (1) inadequate nutritional intake related to
vomiting as manifested by a 3-lb weight loss and
(2) risk for impaired skin integrity related to inadequate nutrition. What is the major
difference between these diagnoses?
a.
The second diagnosis needs no defined nursing interventions.
b.
The second diagnosis needs medical intervention.
c.
The second diagnosis will not need to be evaluated.
d.
The second diagnosis reflects a problem that does not yet exist.
ANS: D
The actual patient problem represents a condition that is currently present. ―Risk for‖
diagnoses are those that the patient is susceptible to, but not yet troubled by.
DIF: Cognitive Level: Comprehension REF: p. 84
TOP: Patient problem
OBJ: 4
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
8.
What framework does the establishment of priorities of care during the planning phase of
the nursing process often use?
a.
Erikson‘s developmental tasks
b.
Piaget‘s cognitive table
c.
Maslow‘s hierarchy of needs
d.
Freud‘s classifications
ANS: C
A useful framework to guide prioritization is Maslow‘s hierarchy of needs.
DIF: Cognitive Level: Comprehension REF: p. 86
TOP: Priorities of care
OBJ: 9
KEY: Nursing Process
Step: Planning MSC: NCLEX: Physiological
Integrity
9.
What is an appropriate outcome statement for a patient with a patient problem of
ineffective airway clearance related to thick secretions?
a.
The patient will increase intake to 1000 mL daily to liquefy secretions.
b.
The patient will cough more frequently within 3 days.
c.
The patient will breathe better within 3 days.
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d.
The patient will perform deep-breathing exercises four times daily.
ANS: A
The patient goal would be to improve airway clearance. Coughing more frequently within
3 days and performing deep-breathing exercises four times daily do not directly relate to
the problem of thick secretions. Breathing better within 3 days is too vague.
DIF: Cognitive Level: Comprehension REF: p. 90
TOP: Patient problem
OBJ: 6
KEY: Nursing Process
Step: Planning MSC: NCLEX: Physiological
Integrity
10.
What is the primary purpose of nursing interventions?
a.
To support health care provider‘s orders
b.
To provide direction for all caregivers
c.
To provide broad, general statements
d.
To clarify nursing principles
ANS: B
Nursing orders are necessary to provide instructions for all caregivers.
DIF:
Cognitive Level: Comprehension REF: p. 87 | p. 88
OBJ: 7
TOP: Nursing interventions KEY: Nursing
Process Step: Planning MSC: NCLEX: N/A
11.
What documentation reflects implementation?
a.
―Patient selected low-sugar snacks independently.‖
b.
―Patient was medicated with Tylenol 500 mg PO for pain.‖
c.
―Patient was ambulated for 15 minutes after lunch.‖
d.
―Patient participated in group therapy session without reminder.‖
ANS: C
Implementation is the nurse carrying out nursing orders to promote outcome
achievement.
DIF: Cognitive Level: Comprehension REF: p. 89
TOP: Implementation
OBJ: 2
KEY: Nursing Process Step:
Implementation MSC: NCLEX: N/A
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12.
Which nursing intervention is complete and correct?
a.
―May 10: Unlicensed assistive personnel will ambulate patient. A. Nurse‖
b.
―Day nurse will cleanse wound and change
dressings every day. May 10, A. Nurse‖
c.
―Unlicensed assistive personnel will serve 8 oz glass of juice at each meal, 5/10.‖
d.
―P.M. nurse will ensure that heel protectors are in place before bedtime.‖
ANS: B
Nursing orders must be signed, dated, and have specific designation as to who will
perform intervention and specifics about time or frequency of the intervention.
DIF:
Cognitive Level: Application
REF: p. 87 | p. 88
OBJ: 7
TOP: Nursing interventions KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological
Integrity
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13.
A patient with a urinary tract infection is assessed using a clinical pathway.
When a projected outcome is not met by a predetermined date, it is
determined that what has occurred?
a.
Omission
b.
Variance
c.
Failure
d.
Error
ANS: B
A variance occurs when a projected outcome is not met.
DIF: Cognitive Level: Comprehension REF: p.
91
OBJ: 8 | 11 TOP:
Critical pathways
KEY: Nursing Process
Step: Evaluation MSC: NCLEX: Physiological
Integrity
14.
During a physical examination, the nurse discovers that the patient demonstrates
signs of flushed, dry, hot skin; dry oral mucous membranes; and temperature
elevation. The nurse should treat this data as the basis of a patient problem plan. What
does this data represent?
a.
Symptoms
b.
Data clustering
c.
Signs of fluid overload
d.
Urinary retention
ANS: B
The nurse organizes data, and those that are related are referred to as clustering. These are
also signs of fluid overload.
DIF: Cognitive Level: Comprehension REF:
p. 82
OBJ: 3 | 12 TOP: Assessment
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
15.
What type of assessment is performed continuously throughout nurse-patient contact?
a.
Complete
b. Body systems
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c.
Focused
d.
Subjective
ANS: C
Focused assessments are performed continuously throughout nurse-patient contact based on
the nursing care plan.
DIF: Cognitive Level: Comprehension REF: pp. 81-82
TOP: Assessment
16.
OBJ: 1
KEY: Nursing Process Step: Assessment
MSC: NCLEX: N/A
What assists the nurse in the identification of patient problems?
a.
Objective data
b.
Subjective data
c.
Data clustering
d.
Validated data
ANS: C
Data clustering assists the nurse in determining patient problems.
DIF: Cognitive Level: Comprehension REF: p. 82
TOP: Patient problem
OBJ: 4
KEY: Nursing Process
Step: Assessment MSC: NCLEX: N/A
17.
What organized approach might the nurse use when performing a complete physical
examination?
a.
Maslow‘s hierarchy of needs
b.
A head-to-toe assessment
c.
Subjective data collection
d.
Objective data collection
ANS: B
A head-to-toe format provides a systematic approach.
DIF: Cognitive Level: Application
TOP: Assessment
18.
REF: p. 82
OBJ: 3
KEY: Nursing Process Step: Assessment
MSC: NCLEX: N/A
Who is the person responsible for analyzing and interpreting data to arrive at a patient
problem?
a.
Health care provider
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b.
LPN/LVN
c.
RN
d.
Technician
ANS: C
The RN is responsible for analyzing and interpreting data.
DIF: Cognitive Level: Knowledge
REF:
p. 81
OBJ: 4 TOP: Role
responsibility
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
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19.
What is the basis for designing and selecting nursing interventions to meet patient needs?
a.
Patient problem
b.
Care plan
c.
Health care provider‘s orders
d.
Nurse‘s notes
ANS: A
The patient problem is the basis for developing nursing interventions.
DIF: Cognitive Level: Knowledge
TOP: Patient problem
REF: p. 87
OBJ: 4
KEY: Nursing Process
Step: Planning MSC: NCLEX: N/A
20.
The patient is confined to bed rest, which contributes to immobility. What is bed rest
considered in this situation?
a.
Contributing to the patient‘s recovery
b.
A risk factor
c.
Difficult to maintain
d.
A nursing responsibility
ANS: B
Risk factors are those that increase the susceptibility of a patient to a problem.
DIF: Cognitive Level: Application
REF: p. 84 OBJ: 5 TOP: Risk
factors
KEY: Nursing Process Step:
Evaluation
MSC: NCLEX: Physiological Integrity
21.
What is a patient problem considered when a problem is suspected but data to support it
are lacking?
a.
A syndrome patient problem
b.
An actual patient problem
c.
A ―risk for‖ diagnosis
d.
A possible patient problem
ANS: D
A possible patient problem requires additional data to confirm a problem or to
complete a data cluster so that it can be related to a NANDA-I label.
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DIF:
Cognitive Level: Comprehension REF: p. 81 | p. 86
TOP: Patient problem
OBJ: 4 | 10
KEY: Nursing Process
Step: Assessment MSC: NCLEX: N/A
22.
In which phase of the nursing process does the nurse select interventions to assist the
patient to meet the needs demonstrated?
a.
Assessment
b.
Planning
c.
Implementation
d.
Evaluation
ANS: B
During the planning phase, the nurse connects nursing interventions to nursing orders.
DIF: Cognitive Level: Comprehension REF: p. 86
TOP: Nursing process
OBJ: 2
KEY: Nursing Process
Step: Planning MSC: NCLEX: N/A
23.
What is an important consideration when developing the care plan?
a.
Ensure the number of interventions is limited.
b.
Ensure the patient is involved in the process.
c.
Ensure interventions will be easy to implement.
d.
Ensure evaluation of the patient problems is possible.
ANS: B
Plans are more effective when the patient is involved in the process. The care plan is not
limited in terms of the number of interventions, nor do they have to be easy. The patient
problems are not evaluated; the patient‘s progress toward the outcome is.
DIF:
Cognitive Level: Comprehension REF: p. 86
TOP: Care plan
OBJ: 6 | 9
KEY: Nursing Process Step: Planning
MSC:
NCLEX: N/A
24.
From where are the ―risk for‖ patient problems identified?
a.
The care plan
b.
The interventions
c.
The assessment
d. The evaluation
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ANS: C
Patient problems should be identified from the assessment.
DIF: Cognitive Level: Knowledge
TOP: Nursing process
REF: pp. 80-81
OBJ: 2
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
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25.
What expected outcome exemplifies accepted criteria?
a.
Nurse will assess vital signs every day
b.
Resident will observe safety guidelines while smoking
c.
Resident will take part in one activity daily for the next 90 days
d.
Nurse will monitor O2 saturation to maintain at greater than 90%
ANS: C
Expected outcomes must be patient-centered, measurable, and refer to a time frame.
DIF: Cognitive Level: Application
TOP: Nursing process
REF: p. 85
OBJ: 6
KEY: Nursing Process
Step: Planning MSC: NCLEX: Physiological
Integrity
26.
During an admission assessment, the nurse collects objective and subjective data. What is
an example of subjective data?
a.
The patient complains of nausea.
b.
The patient is vomiting.
c.
The patient experiences tachycardia.
d.
The patent is pacing the halls.
ANS: A
Subjective data are the verbal statements provided by the patient. Statements about
nausea and descriptions of pain, fatigue, and anxiety are examples of subjective data.
Complaining of nausea is an example of subjective data. All other options are examples
of objective data.
DIF: Cognitive Level: Application
TOP: Subjective data
REF: p. 82
OBJ: 1 | 3
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
27.
During an admission assessment, the nurse collects objective and subjective data. What is
an example of subjective data?
a.
The patient is asleep.
b.
The patient is tearful.
c.
The patient has facial grimacing.
d.
The patient states, ―I hurt all over.‖
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ANS: D
Subjective data are the verbal statements provided by the patient. Statements about
nausea and descriptions of pain, fatigue, and anxiety are examples of subjective data.
Stating ―I hurt all over‖ is an example of subjective data. All other options are examples
of objective data.
DIF: Cognitive Level: Application
REF: p.
82
OBJ: 1 | 3 TOP:
Nursing process
KEY: Nursing Process
Step: Planning MSC: NCLEX: Physiological
Integrity
28.
During an admission assessment, the nurse collects objective and subjective data. What is
an example of subjective data?
a.
The patient is coughing.
b.
The patient has cyanosis of the lips.
c.
The patient experiences tachypnea.
d.
The patient complains of generalized discomfort.
ANS: D
Subjective data are the verbal statements provided by the patient. Statements about
nausea and descriptions of pain, fatigue, and anxiety are examples of subjective data.
Complaining of generalized discomfort is an example of subjective data. All other
options are examples of objective data.
DIF: Cognitive Level: Application
TOP: Subjective data
REF: p. 82
OBJ: 1 | 3
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
29.
During an admission assessment, the nurse collects objective and subjective data. What is
an example of objective data?
a.
The patient complains of chest pain.
b.
The patient states, ―I feel nauseous.‖
c.
The patient complains of feeling faint.
d.
The patient is short of breath on exertion.
ANS: D
Objective data are observable and measurable signs. Objective data can be recorded. A
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camera can record a rash, a skin lesion, or puffy eyes. A tape recorder can give
evidence of crying or slurred speech. A thermometer can record a temperature
elevation. Other terms for objective data are signs and objective cues. Shortness of
breath on exertion is an example of objective data. All other options are examples of
subjective data.
DIF: Cognitive Level: Application
TOP: Objective data
REF: p. 82
OBJ: 1 | 3
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
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30.
During an admission assessment, the nurse collects objective and subjective data. What is
an example of objective data?
a.
The patient is jaundiced.
b.
The patient states, ―I am nervous.‖
c.
The patient complains of palpitations.
d.
The patient denies dizziness when ambulating.
ANS: A
Objective data are observable and measurable signs. Objective data can be recorded. A
camera can record a rash, a skin lesion, or puffy eyes. A tape recorder can give
evidence of crying or slurred speech. A thermometer can record a temperature
elevation. Other terms for objective data are signs and objective cues. The patient is
jaundiced is an example of objective data. All other options are examples of subjective
data.
DIF: Cognitive Level: Application
TOP: Objective data
REF: p. 82
OBJ: 1 | 3
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
31.
During an admission assessment, the nurse collects objective and subjective data. What is
an example of objective data?
a.
The patient complains of feeling depressed.
b.
The patient states, ―I hear voices in my head.‖
c.
The patient complains of auditory hallucinations.
d.
The patient is pacing back and forth while chanting.
ANS: D
Objective data are observable and measurable signs. Objective data can be recorded. A
camera can record a rash, a skin lesion, or puffy eyes. A tape recorder can give
evidence of crying or slurred speech. A thermometer can record a temperature
elevation. Other terms for objective data are signs and objective cues. Pacing back and
forth while chanting is an example of objective data. All other options are examples
of subjective data.
DIF: Cognitive Level: Application
TOP: Objective data
REF: p. 82
OBJ: 1 | 3
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
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32.
What is an example of an appropriate Patient problem?
a.
Impaired skin integrity
b.
Skin breakdown noted
c.
Turn patient every 2 hours
d.
The patient has scabies on his back
ANS: A
―Impaired skin integrity‖ is an example of a patient problem. ―Skin breakdown noted‖
is an example of a charting entry, ―turn patient every 2 hours‖ is a nursing
intervention, and ―scabies‖ is a medical diagnosis.
DIF:
Cognitive Level: Comprehension REF: p. 81 | p. 83
TOP: Patient problem
OBJ: 4
KEY: Nursing Process
Step: Diagnosis MSC: NCLEX: Physiological
Integrity
33.
What is an example of an appropriate patient problem?
a.
Constipation
b.
Patient complains of constipation
c.
Need for laxatives
d.
Patient has a duodenal ulcer
ANS: A
Constipation is an example of a patient problem, a patient complaining of constipation is
an example of a charting entry, a need for laxatives is an example of a patient need, and a
patient has a duodenal ulcer is an example of a medical diagnosis.
DIF: Cognitive Level: Comprehension REF: p. 84
TOP: Patient problem
OBJ: 4
KEY: Nursing Process
Step: Diagnosis MSC: NCLEX: Physiological
Integrity
34.
A nurse is formulating a patient problem. What is an example of an appropriately written
patient problem?
a.
Risk for impaired skin integrity related to physical immobilization
b.
Physical immobilization secondary to risk for impaired skin integrity
c.
Risk for impaired skin integrity related to diagnosis of decubitus ulcers
d. Physical immobilization
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ANS: A
Risk for impaired skin integrity related to physical immobilization is the only
appropriately written patient problem. All other options are not listed as NANDA-I
approved patient problems.
DIF: Cognitive Level: Application
TOP: Patient problem
REF: pp. 83-85
OBJ: 4
KEY: Nursing Process
Step: Diagnosis MSC: NCLEX: Physiological
Integrity
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35.
Which is an example of a patient problem?
a.
Pneumonia
b.
Diabetes mellitus
c.
Impaired skin integrity
d.
Congestive heart failure
ANS: C
Impaired skin integrity is the only example of a patient problem; all other options are
examples of medical diagnoses.
DIF:
Cognitive Level: Comprehension REF: pp. 83-85
TOP: Patient problem
OBJ: 4
KEY: Nursing Process
Step: Diagnosis MSC: NCLEX: Physiological
Integrity
36.
Which is an example of a medical diagnosis?
a.
Constipation
b.
Diabetes mellitus
c.
Impaired skin integrity
d.
Altered nutrition: less than body requirements
ANS: B
Diabetes mellitus is the only example of a medical diagnosis; all other options are
examples of patient problems.
DIF: Cognitive Level: Comprehension REF: p. 85
TOP: Medical diagnosis
OBJ: 4
KEY: Nursing Process
Step: Diagnosis MSC: NCLEX: Physiological
Integrity
37.
Which is an example of a medical diagnosis?
a.
Pain
b.
Anxiety
c.
Pneumonia
d.
Impaired skin integrity
ANS: C
Pneumonia is the only example of a medical diagnosis; all other options are examples of
patient problems.
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DIF: Cognitive Level: Comprehension REF: p. 85
TOP: Medical diagnosis
OBJ: 4
KEY: Nursing Process
Step: Diagnosis MSC: NCLEX: Physiological
Integrity
MULTIPLE
RESPONSE
1.
Which are acceptable secondary sources for data? (Select all that apply.)
a.
Patient
b.
Family members
c.
Other health professionals
d.
Diagnostic reports
e.
Textbooks
ANS: B, C, D, E
A patient is not a secondary source. The patient is the primary data source.
DIF: Cognitive Level: Comprehension REF: p. 82
OBJ: 3
TOP: Data sources KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
2.
Which are official categories of patient problems? (Select all that apply.)
a.
Actual
b.
Risk
c.
Wellness
d.
Syndrome
e.
Potential
ANS: A, B, C, D
Actual, risk, wellness, and syndrome are the four categories of patient problems.
DIF:
Cognitive Level: Comprehension REF:
NIT
OBJ: 4 TOP:
Patient problem
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
3.
Which are considered phases of the nursing process? (Select all that apply.)
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a.
Diagnosis
b.
Prediction
c.
Assessment
d.
Evaluation
e.
Implementation
f.
Outcome identification
ANS: A, C, D, E, F
The nursing process consists of six dynamic and interrelated phases: diagnosis, assessment,
outcome identification, planning, implementation, and evaluation. Prediction is not a
phase of the nursing process.
DIF: Cognitive Level: Comprehension REF:
p. 89
OBJ: 2 TOP:
Nursing process
KEY: Nursing
Process Step: All MSC: NCLEX: N/A
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COMPLETION
1.
NANDA International meets to reorganize diagnosis labels and language every 2 .
ANS:
years
NANDA International meets every two years to revise language, form, and diagnosis
labels.
DIF: Cognitive Level: Knowledge
REF: p. 83
OBJ: 10
TOP: NANDA
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
2.
The standards that name and measure patient
are referred to as NOC (Nursing
Outcome Classification).
ANS:
outcomes
NOC sets up outcome criteria based on a patient problem.
DIF: Cognitive Level: Knowledge
REF: p. 90
TOP: NOC KEY: Nursing Process Step: N/A
3.
The document that outlines a
OBJ: 10
MSC: NCLEX: N/A
plan for care interventions over a specified time
frame is called a clinical pathway, critical path, action plan, or care map.
ANS:
multidisciplinary
A clinical pathway is an organized multidisciplinary plan over a specified time frame,
which outlines aspects of patient care. They are also called critical paths, action plans,
and care maps.
DIF: Cognitive Level: Knowledge
p. 91
REF:
OBJ: 11 TOP:
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Clinical pathways
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
4.
A systematic method by which nurses plan and provide care for patients is known as the
nursing
.
ANS:
process
The nursing process serves as the organizational framework for the practice of nursing.
It is a systematic method by which nurses plan and provide care for patients.
DIF: Cognitive Level: Knowledge
REF:
p. 80
OBJ: 2 TOP:
Nursing process
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
5.
A systemic, dynamic way to collect and analyze data about a patient that includes
physiologic data as well as psychological, sociocultural, spiritual, economic, and
lifestyle factors is known as
.
ANS:
assessment
The American Nurses Association (ANA) defines assessment as ―a systematic,
dynamic way to collect and analyze data about a patient, the first step in delivering
nursing care. Assessment includes not only physiologic data, but also
psychological, sociocultural, spiritual, economic, and lifestyle factors as well.‖
DIF: Cognitive Level: Knowledge
TOP: Nursing process
REF: p. 80
OBJ: 2
KEY: Nursing Process
Step: Assessment MSC: NCLEX: N/A
6.
Any health care condition that requires diagnostic, therapeutic, or educational actions is
known as a
.
ANS:
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problem
A problem is any health care condition that requires diagnostic, therapeutic, or
educational actions.
DIF: Cognitive Level: Knowledge
REF: p. 83
OBJ: 2
TOP: A problem
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
7.
A clinical judgment concerning a human response to health conditions/life
processes, or a vulnerability for that response, by an individual, family, group or
community is known as a nursing
.
ANS:
diagnosis
A patient problem is a clinical judgment concerning a human response to health
conditions/life processes, or a vulnerability for that response, by an individual, family,
group or community.
DIF: Cognitive Level: Knowledge
TOP: Patient problem
REF: p. 83
OBJ: 4
KEY: Nursing Process
Step: Diagnosis MSC: NCLEX: N/A
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8.
The human responses to health conditions/life processes that exist in an individual,
family, or community are known as a(n)
patient problem.
ANS:
actual
An actual patient problem is described as the human responses to health conditions/life
processes that exist in an individual, family, or community.
DIF: Cognitive Level: Knowledge
REF: p. 84
OBJ: 4
TOP: Actual patient problem KEY: Nursing
Process Step: Diagnosis MSC: NCLEX: N/A
9.
Human responses to health conditions and life processes that may develop in a
vulnerable individual, family, or community are known as a(n)
patient
problem.
ANS:
risk
A risk patient problem is defined as the human responses to health conditions/life
processes that may develop in a vulnerable individual, family, or community.
DIF: Cognitive Level: Knowledge
TOP: Risk patient problem
REF: p. 84
OBJ: 4
KEY: Nursing
Process Step: Diagnosis MSC: NCLEX: N/A
10.
Human responses to levels of wellness in an individual, family, or community that
have a readiness for enhancement are known as a patient problem
ANS:
wellness
A wellness patient problem is defined as human responses to levels of wellness in an
individual, family, or community that have a readiness for enhancement.
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DIF: Cognitive Level: Knowledge
TOP: Wellness patient problem
REF: p. 83
OBJ: 4
KEY: Nursing
Process Step: Diagnosis MSC: NCLEX: N/A
11.
The identification of a disease or condition by a scientific evaluation of physical
signs, symptoms, history, laboratory tests, and procedures is known as a
diagnosis.
ANS:
medical
A medical diagnosis is the identification of a disease or condition by a scientific
evaluation of physical signs, symptoms, history, laboratory tests, and procedures.
DIF: Cognitive Level: Knowledge
REF:
p. 85
OBJ: 4 TOP:
Medical diagnosis
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
12.
A health care system that provides control over health care services for a specific
group of individuals in an attempt to control cost is known as care.
ANS:
managed
Managed care is a health care system that provides control over health care services
for a specific group of individuals in attempts to control cost.
DIF: Cognitive Level: Knowledge
REF:
p. 91
OBJ: 6 | 11 TOP:
Risk managed care
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
13.
A multidisciplinary plan that schedules clinical over an anticipated time frame for
high-risk, high-volume, and high-cost types of cases is known as a critical
pathway.
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ANS:
interventions
A critical pathway is a multidisciplinary plan that schedules clinical interventions
over an anticipated time frame for high-risk, high-volume, and high-cost types of
cases.
DIF: Cognitive Level: Knowledge
REF:
p. 91
OBJ: 11 TOP:
Clinical pathways
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
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Chapter 06: Cultural and Ethnic Considerations
Cooper: Foundations and Adult Health Nursing, 9th Edition
MULTIPLE
CHOICE
1.
Culture varies from patient to patient. Why is it important that the nurse understand and
accept each person as an individual?
a.
To develop a plan of care
b.
To provide holistic care
c.
To identify differences
d.
To support each patient
ANS: B
Accepting each person as an individual is the first step in providing holistic care.
DIF: Cognitive Level: Comprehension REF: p. 95
TOP: Culture
OBJ: 2
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
2.
What is a fixed concept that describes how all members of an ethnic group act or think?
a.
Variations within a cultural group
b.
Identical practices
c.
Holistic nursing
d.
Ethnic stereotypes
ANS: D
Ethnic stereotypes are fixed concepts of how all members of an ethnic group act or think.
DIF: Cognitive Level: Knowledge
REF: p. 96
OBJ: 4
TOP: Culture
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
3.
All nurses should work to provide culturally appropriate nursing care. What is the
integration of cultural knowledge into all aspects of care?
a.
Cultural competence
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b.
Transcultural nursing
c.
Nursing process
d.
Team nursing
ANS: B
All nurses should provide transcultural nursing, which is the integration of cultural
knowledge into all aspects of care.
DIF: Cognitive Level: Knowledge
REF: p. 96
OBJ: 1 | 2
TOP: Culture
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
4.
What is the term for when members of a particular ethnic group believe that their beliefs
and practices are the best?
a.
Prejudice
b.
Separatism
c.
Ethnocentrism
d.
Bias
ANS: C
When members of a particular ethnic group believe that their practices and beliefs are the
best, it is referred to as ethnocentrism.
DIF: Cognitive Level: Knowledge
REF: p. 96
OBJ: 4
TOP: Culture
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
5.
What is the term used to describe cultures in which women make decisions about
health care and provide the care and discipline to the children?
a.
Biological
b.
Matriarchal
c.
Cultural
d.
Patriarchal
ANS: B
In a matriarchal society, women make the decisions about health care. In patriarchal
society, the men make decisions about health care. There is no such thing as biological
or cultural cultures.
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DIF: Cognitive Level: Knowledge
REF: p. 101
OBJ: 4
TOP: Culture
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
6.
What basic philosophy in the United States is relevant to health care?
a.
Folk remedies
b.
Biomedical therapy
c.
Holistic therapy
d.
Spiritual intervention
ANS: B
Most people in the United States believe biomedical therapy is the best way to treat
disease.
DIF: Cognitive Level: Comprehension REF: p. 106
TOP: Culture
OBJ: 4
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
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7.
What is a set of learned values, beliefs, customs, and practices shared by a group?
a.
Race
b.
Ethnicity
c.
Culture
d.
Religion
ANS: C
Culture is a set of learned values, beliefs, customs, and practices shared by a group.
DIF: Cognitive Level: Knowledge
REF: p. 95
OBJ: 4
TOP: Culture
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
8.
A nurse is American-born and works in a large hospital with patients from many
cultures. What must this nurse develop to provide the best care?
a.
Another language
b.
Assessment skills
c.
Cultural competence
d.
Care planning ability
ANS: C
To provide care to patients from different cultures, the nurse must develop cultural
competence.
DIF: Cognitive Level: Comprehension REF: p. 96
TOP: Culture
OBJ: 3
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
9.
The nurse from New York City is caring for a patient from Atlanta, Georgia. What
difference between the nurse and patient may cause them to experience difficulty in
communicating?
a.
Race
b.
Subculture
c.
Ethnic group
d.
Culture
ANS: B
Subcultures have characteristic patterns that distinguish them from the rest of the culture.
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DIF: Cognitive Level: Comprehension REF: p. 95
TOP: Subculture
OBJ: 2
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
10.
The father of an American Indian has just died. What should the nurse do immediately
after death?
a.
Provide privacy so that the family may touch and kiss the deceased goodbye
b.
Ask about providing help with the death ceremony
c.
Carefully wrap the deceased‘s clothing for the family to take home
d.
Mention the deceased by name frequently
ANS: B
In the American Indian culture it is taboo to touch the deceased or any of the
belongings of the deceased. After death, the name of the deceased is not spoken.
DIF:
Cognitive Level: Application
TOP: American Indian
REF: p. 113
OBJ: 1 | 4 | 6
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
11.
What is the term for a generalization about a form of behavior, an individual, or a group?
a.
Dialect
b.
Religion
c.
Ethnicity
d.
Stereotype
ANS: D
A stereotype is a generalization about a form of behavior, an individual, or a group.
DIF: Cognitive Level: Knowledge
REF: p. 96 OBJ: 4 TOP:
Stereotype
KEY: Nursing Process Step:
N/A
MSC: NCLEX: Psychosocial Integrity
12.
What is the term for a group of people who share biological physical characteristics?
a.
Race
b.
Culture
c.
Religion
d. Social organization
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ANS: A
A race is a group of people who share biological physical characteristics.
DIF: Cognitive Level: Knowledge
REF: pp. 96-97
OBJ: 4 TOP: Race
KEY: Nursing Process Step:
N/A
MSC: NCLEX: Psychosocial Integrity
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13.
What is the term for a group of people who share a common social and cultural
heritage based on shared traditions, national origin, and physical and biological
characteristics?
a.
Race
b.
Culture
c.
Religion
d.
Ethnicity
ANS: D
Ethnicity refers to a group of people who share a common social and cultural heritage
based on shared traditions, national origin, and physical and biological characteristics.
DIF: Cognitive Level: Knowledge
REF: pp. 96-97
OBJ: 4 TOP: Ethnicity
KEY: Nursing Process Step:
N/A
MSC: NCLEX: Psychosocial Integrity
14.
A nurse is caring for a neonate born to observant Orthodox Jewish parents. Who can the
nurse anticipate will name the neonate?
a.
Father
b.
Mother
c.
Grandfather
d.
Grandmother
ANS: A
For observant Jews, babies are named by the father.
DIF: Cognitive Level: Knowledge
REF:
p. 104
OBJ: 2 | 3 TOP:
Religious practices
KEY:
Nursing
Process Step: N/A MSC: NCLEX: Psychosocial
Integrity
15.
A nurse is caring for a male neonate born to observant Orthodox Jewish parents. Who
will the nurse anticipate will circumcise the neonate?
a.
A bishop
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b.
A mohel
c.
His father
d.
His health care provider
ANS: B
Male children are named 8 days after birth, when ritual circumcision is done. A mohel
performs the circumcision.
DIF: Cognitive Level: Knowledge
REF:
p. 104
OBJ: 2 | 4 TOP:
Religious practices
KEY:
Nursing
Process Step: N/A MSC: NCLEX: Psychosocial
Integrity
16.
A nurse is caring for a female neonate born to observant Orthodox Jewish parents.
What book does the nurse know will be used when naming this neonate?
a.
Bible
b.
Koran
c.
Holy Torah
d.
Book of Mormon
ANS: C
For observant Jews, female babies are usually named during a reading of the Holy Torah.
DIF: Cognitive Level: Knowledge
REF:
p. 104
OBJ: 2 | 4 TOP:
Religious practices
KEY:
Nursing
Process Step: N/A MSC: NCLEX: Psychosocial
Integrity
17.
A nurse is caring for an Orthodox Jewish woman immediately after she has given
birth. What can the nurse expect regarding the spouse‘s participation in his wife‘s
care?
a.
He will share a bed with the patient.
b.
He will ask to bathe with the patient.
c.
He will touch the patient frequently.
d.
He will avoid physical contact with the patient.
ANS: D
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For observant Jews, a woman is considered to be in a ritual state of impurity
whenever blood is coming from her uterus, such as during menstrual periods and after
the birth of a child. During this time, her husband will not have physical contact with
her. When this time is completed, she will bathe herself in a pool called a mikvah.
Nurses need to be aware of this practice and be sensitive to the husband and wife
because the husband will not touch his wife.
DIF:
Cognitive Level: Comprehension
REF: p. 104
OBJ: 4 | 5 TOP:
Religious practices
KEY:
Nursing
Process Step: N/A MSC: NCLEX: Psychosocial
Integrity
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18.
A nurse is caring for an Orthodox Jewish patient. What is the most appropriate dietary
requirement for the nurse to implement?
a.
Mixing of milk and meat at a meal
b.
Use of separate cooking utensils for meat and milk products
c.
Use of one set of cooking utensils for meat and milk products
d.
Consumption of food not slaughtered in accordance with Jewish law
ANS: B
For observant Jews, Kosher dietary laws include the following: no mixing of milk
and meat at a meal; no consumption of food or any derivative thereof from animals
not slaughtered in accordance with Jewish law; use of separate cooking utensils for
meat and milk products; if a patient requires milk and meat products for a meal, the
dairy foods should be served first, followed later by the meat.
DIF: Cognitive Level: Application
REF:
p. 104
OBJ: 4 TOP:
Religious practices
KEY: Nursing
Process Step: N/A MSC: NCLEX: Psychosocial
Integrity
19.
The nurse is preparing an Orthodox Jewish patient‘s tray during Passover. What
intervention is appropriate for this patient?
a.
Avoid fish dishes.
b.
Encourage time for prayer.
c.
Offer the patient leavened products.
d.
Encourage the use of loud music in celebration.
ANS: B
Orthodox Jews say prayers over the bread and wine before meals. Time and a quiet
environment should be provided for this. During Passover, no leavened products are
eaten.
DIF: Cognitive Level: Application
REF:
p. 104
OBJ: 4 TOP:
Religious practices
KEY: Nursing
Process Step: N/A MSC: NCLEX: Psychosocial
Integrity
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20.
A nurse is preparing to discuss birth control options for a Roman Catholic patient.
What is the most appropriate method for the nurse to discuss with this patient?
a.
Abstinence
b.
Vasectomy
c.
Tubal ligation
d.
Oral contraceptives
ANS: A
Birth control for Roman Catholics is prohibited except for abstinence or natural family
planning. Referral to a priest for questions about this can be of great help. Nurses can
teach the techniques of natural family planning if they are familiar with them;
otherwise, this should be referred to the health care provider or to a support group of
the Church that instructs couples in this method of birth control. Sterilization is
prohibited unless there is an overriding medical reason.
DIF:
Cognitive Level: Application
REF:
p. 104
OBJ: 3 | 5 | 7 TOP:
Religious practices
KEY: Nursing
Process Step: N/A MSC: NCLEX: Psychosocial
Integrity
21.
A nurse is preparing a meal tray for a patient who is a Latter-Day Saint. What beverage
should the nurse prepare?
a.
Tea with all meals
b.
Coffee each morning
c.
Cola beverages
d.
Fruit juice
ANS: D
For observant Latter-Day Saints, beverages with caffeine such as cola, coffee, and tea;
alcohol; and other substances are considered injurious.
DIF:
Cognitive Level: Application
REF:
p. 102
OBJ: 4 | 7 TOP:
Religious practices
KEY:
Nursing
Process Step: N/A MSC: NCLEX: Psychosocial
Integrity
22.
A nurse is caring for a patient who is a Latter-Day Saint. The nurse is aware members
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of this faith may wear sacred undergarments. What intervention is appropriate for the
nurse caring for this patient?
a.
Instruct the patient to remove the undergarments.
b.
Allow the patient to wear the undergarments only at night.
c.
Allow the patient to wear the undergarments only during the day.
d.
Remove the undergarments in emergency situations only.
ANS: D
For observant Latter-Day Saints, a sacred undergarment may be worn at all times
and should be removed only in emergency situations.
DIF:
Cognitive Level: Application
REF:
p. 102
OBJ: 4 | 5 TOP:
Religious practices
KEY:
Nursing
Process Step: N/A MSC: NCLEX: Psychosocial
Integrity
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23.
Which statement about the biomedical health belief system is true?
a.
Life processes can be manipulated by humans by mechanical interventions.
b.
Life processes cannot be manipulated by humans by mechanical interventions.
c.
Disease has a nonspecific cause, onset, course, and treatment.
d.
Disease is only caused by failure of body parts and chemical imbalances.
ANS: A
Characteristic of the biomedical health belief system includes the beliefs that life is
regulated by biomedical and physical processes. Life processes can be manipulated by
humans by mechanical interventions. Health is the absence of disease or signs and
symptoms of disease. Disease is an alteration of the structure and function of the
body. Disease has a specific cause, onset, course, and treatment. It is caused by
trauma, pathogens, chemical imbalances, or failure of body parts. Treatment focuses
on the use of physical and chemical treatments.
DIF:
Cognitive Level: Comprehension
pp. 106-108
REF:
OBJ: 4 TOP: Health belief
systems
KEY: Nursing
Process Step: N/A MSC: NCLEX: Psychosocial
Integrity
24.
Which health belief system is commonly referred to as ―third-world‖ beliefs and
practices?
a.
Folk health belief system
b.
Holistic health belief system
c.
Biomedical health belief system
d.
Alternative/complementary belief system
ANS: A
The folk health belief system is commonly referred to as ―third-world‖ beliefs and
practices. It is often called strange or weird by nurses and other health professionals
who are unfamiliar with folk medicine beliefs.
DIF: Cognitive Level: Knowledge
REF:
p. 108
OBJ: 4 TOP: Health
belief systems
KEY: Nursing
Process Step: N/A MSC: NCLEX: Psychosocial
Integrity
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25.
Which health belief system includes a belief of a supernatural force exerting influence to
cause health or illness?
a.
Folk
b.
Holistic
c.
Biomedical
d.
Alternative/complementary
ANS: A
The folk health belief system is commonly referred to as ―third-world‖ beliefs and
practices. It is often called strange by nurses and other health professionals who are
unfamiliar with folk medicine beliefs.
DIF: Cognitive Level: Knowledge
REF:
p. 108
OBJ: 4 TOP: Health
belief systems
KEY: Nursing
Process Step: N/A MSC: NCLEX: Psychosocial
Integrity
26.
Which health belief system focuses on restoring balance with physical, social, and
metaphysical worlds?
a.
Folk health belief system
b.
Holistic health belief system
c.
Biomedical health belief system
d.
Alternative/complementary belief system
ANS: B
The treatment based on the holistic health belief system is designed to restore
balance with physical, social, and metaphysical worlds.
DIF: Cognitive Level: Knowledge
REF:
p. 108
OBJ: 4 TOP: Health
belief systems
KEY: Nursing
Process Step: N/A MSC: NCLEX: Psychosocial
Integrity
27.
The nurse is caring for a patient who fasts during daylight hours during Ramadan. The
nurse recognizes that the patient is adhering to the cultural beliefs of which culture?
a.
Muslims
b.
African Americans
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c.
Chinese Americans
d.
Mexican Americans
ANS: A
Muslims practice fasting during daylight hours during Ramadan.
DIF:
Cognitive Level: Knowledge REF: p. 103 | p. 113 | p. 114
OBJ: 4 | 5
TOP: Health belief systems KEY: Nursing
Process Step: N/A MSC: NCLEX: Psychosocial Integrity
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28.
The nurse is caring for a Muslim patient. What dietary selection should the nurse serve to
this patient?
a.
Bacon, eggs, and toast
b.
Pork fried rice
c.
Ham and cheese sandwich
d.
Chicken and rice
ANS: D
Muslims practice avoidance of foods that include pork products. Bacon, pork, and ham
are all pork products. Only the chicken and rice meal does not include a pork product.
DIF:
Cognitive Level: Application
REF:
p. 114
OBJ: 1 | 2 | 4 TOP:
Health belief systems
KEY: Nursing
Process Step: N/A MSC: NCLEX: Psychosocial
Integrity
29.
A patient requests a consultation between the health care provider and a religious
leader known as an Imam. What is this patient‘s cultural belief?
a.
Muslim
b.
African American
c.
Chinese American
d.
Mexican American
ANS: A
Muslims may wish to have their health care provider consult with an Imam, a religious
leader.
DIF: Cognitive Level: Comprehension REF:
p. 111
OBJ: 4 TOP: Health
belief systems
KEY: Nursing
Process Step: N/A MSC: NCLEX: Psychosocial
Integrity
30.
The nurse is delivering a meal tray to a female Muslim patient. What intervention is most
appropriate for this patient?
a.
Offering her a ham and cheese sandwich
b.
Providing her with a male nurse
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c.
Providing her with a female nurse
d.
Offering her bacon and eggs
ANS: C
When caring for Muslims, same-sex health care providers should be used if at all
possible. Ham and bacon are not appropriate items to offer a Muslim patient, since
they do not consume pork products.
DIF: Cognitive Level: Application
REF:
p. 111
OBJ: 4 TOP: Health
belief systems
KEY: Nursing
Process Step: N/A MSC: NCLEX: Psychosocial
Integrity
31.
The nurse is caring for a Chinese American patient. How should this nurse demonstrate
cultural awareness?
a.
Maintain eye contact with the patient.
b.
Hold the patient‘s hand while conversing.
c.
Touch the patient‘s arm when speaking to the patient.
d.
Sit side-to-side when speaking with the patient.
ANS: D
Chinese Americans view maintaining eye contact as ill-mannered and disrespectful. They
are uncomfortable when face-to-face, and prefer to sit side-to-side or at a right angle to
carry on conversation. Touching is not usual during conversation; it is regarded as
disrespectful or impolite.
DIF:
Cognitive Level: Application
REF:
p. 112
OBJ: 4 | 5 TOP:
Health belief systems
KEY:
Nursing
Process Step: N/A MSC: NCLEX: Psychosocial
Integrity
32.
The nurse is caring for a Mexican American patient. What nursing intervention would
best demonstrate cultural sensitivity?
a.
Encouraging consultation of male members of the
family regarding health care decisions
b.
Discouraging consultation of male members of the
family regarding health care decisions
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c.
Insisting on providing all personal care required by the patient
d.
Asking only female family members about health care decisions
ANS: A
When caring for Mexican Americans, families may expect to help care for the patient.
Male family members usually are consulted before health care decisions are made.
DIF:
Cognitive Level: Application
REF:
p. 112
OBJ: 4 | 5 | 7 TOP:
Health belief systems
KEY: Nursing
Process Step: N/A MSC: NCLEX: Psychosocial
Integrity
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33.
The nurse is caring for an African-American patient. Who would the nurse expect to
be the primary decision maker in the patient‘s family?
a.
Men
b.
Women
c.
Clergy
d.
Grandparents
ANS: B
When caring for African Americans, women are primarily the decision makers in the
family and are frequently the head of the household.
DIF:
Cognitive Level: Comprehension
REF: p. 112
OBJ: 1 | 4 TOP:
Health belief systems
KEY:
Nursing
Process Step: N/A MSC: NCLEX: Psychosocial
Integrity
34.
The nurse is caring for a Mexican American patient who is in labor. How can this nurse
best demonstrate cultural sensitivity?
a.
Encouraging female family members to be present for the delivery
b.
Encouraging the patient‘s spouse to be present for the delivery
c.
Asking the patient‘s spouse to see his baby before cutting the umbilical cord
d.
Asking the patient‘s spouse to hold the neonate before bathing the neonate
ANS: A
When caring for Mexican Americans, it is considered inappropriate for the husband to
be present during birth. The father is not expected to see his wife or baby until both are
cleaned and dressed.
DIF: Cognitive Level: Application
REF:
p. 113
OBJ: 4 TOP: Health
belief systems
KEY: Nursing
Process Step: N/A MSC: NCLEX: Psychosocial
Integrity
35.
The nurse is caring for a postpartum patient who requests to dry and bury the
umbilical cord near an object or in a place that symbolizes what the parents want for
the child‘s future. Which cultural beliefs does the nurse recognize this patient
adhering to?
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a.
American Indian
b.
African American
c.
Chinese American
d.
Mexican American
ANS: A
After delivery, American Indians practice taking the umbilical cord from the newborn,
drying and burying it near an object or place that symbolizes what the parents want for
the child‘s future.
DIF: Cognitive Level: Comprehension REF:
p. 113
OBJ: 4 TOP: Health
belief systems
KEY: Nursing
Process Step: N/A MSC: NCLEX: Psychosocial
Integrity
MULTIPLE RESPONSE
1.
What are some characteristics that cultures have in common? (Select all that apply.)
a.
Economic practices
b.
Survival modes
c.
Transportation systems
d.
Language
e.
Family systems
ANS: A, B, C, E
Language may differ within cultures; the rest are shared characteristics.
DIF:
Cognitive Level: Comprehension
REF: p. 97
OBJ: 1 | 4 TOP:
Common traits
KEY:
Nursing
Process Step: N/A MSC: NCLEX: N/A
2.
What should the culturally sensitive nurse do for a Muslim woman being treated in the
hospital? (Select all that apply.)
a.
Assign only female staff to care for her.
b.
Keep her head and extremities covered as much as possible.
c.
Arrange for family to bring specially prepared pork dishes.
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d.
Let her make decisions relative to her care.
e.
Allow privacy for prayer.
ANS: A, B, E
Muslim women are not accustomed to making decisions, leaving it to the head of the
house or the family as a whole. Muslims do not eat pork.
DIF:
Cognitive Level: Application REF: pp.
111-114
OBJ: 4 | 5 TOP: Muslims
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Psychosocial Integrity
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3.
A nurse working in a long-term care facility is admitting an 85-year-old resident of
Hispanic descent diagnosed with Alzheimer‘s disease. What should this nurse take
into consideration when caring for the resident? (Select all that apply.)
a.
Cultural background has an important role in determining the resident‘s status
b.
The resident will be culturally sensitive to caregivers
c.
Home remedies may have value even if harmful
d.
The resident will have a strong sense of trust for health care workers
e.
Communication should involve gesturing whenever possible
ANS: A, C
Cultural background has an impact on family dynamics and plays an important role in
determining the role and the status of the older person. Some older adults are less
tolerant of other cultures as a result of influences or experiences early in their lives,
which raises the possibility of misunderstandings and distrust when the caregiver is of
a cultural group different than that of the older person. Communication should suit the
individual needs of the resident and does not necessarily involve gesturing.
DIF: Cognitive Level: Application
REF: p. 98 OBJ: 6 TOP:
Older adult
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Psychosocial Integrity
COMPLETION
1.
The nurse should not maintain eye contact with a Korean patient because many Asians
believe prolonged eye contact is
or rude.
ANS:
impolite
Many Asians avoid eye contact, believing it to be impolite or rude.
DIF:
p. 112
Cognitive Level: Comprehension REF:
OBJ: 2 | 4 TOP: Asians
KEY:
Nursing Process Step: Implementation
MSC: NCLEX: N/A
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2.
The cultural characteristic of unwillingness to leave a current activity—which may result
in late or missed appointments—is called
.
ANS:
elasticity
Elasticity is the ethnic characteristic of being late or missing an appointment
altogether because of involvement in a current activity.
DIF: Cognitive Level: Knowledge
REF: p. 101
OBJ: 4
TOP: Elasticity
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
3.
Following the death of a Presbyterian infant, the nurse should help arrange for
.
ANS:
baptism
Presbyterians believe in infant baptism.
DIF: Cognitive Level: Application
TOP: Infant baptism
REF: p. 105
OBJ: 4
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
4.
While caring for a Mexican American family in the home, the home health nurse
recognizes that the family may also consult the curandero or
for health advice.
ANS:
folk healer
The curandero or folk healer is an important figure in the health care of Mexican
Americans.
DIF: Cognitive Level: Application
REF: p. 109
OBJ: 4
TOP: Mexican Americans KEY: Nursing Process Step:
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Implementation MSC: NCLEX: Psychosocial Integrity
5.
A nation, community, or broad group of people who establish particular aims, beliefs,
or standards of living and conduct is known as a .
ANS:
society
A society is a nation, community, or broad group of people who establish particular
aims, beliefs, or standards of living and conduct.
DIF: Cognitive Level: Knowledge
REF: p. 95
OBJ: 4
TOP: Society
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
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6.
A set of learned values, beliefs, customs, and practices that are shared by a group and
are passed from one generation to another is known as .
ANS:
culture
Culture is a set of learned values, beliefs, customs, and practices that are shared by a
group and are passed from one generation to another.
DIF: Cognitive Level: Knowledge
REF: p. 96
OBJ: 4
TOP: Culture
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
7.
A generalization about a form of behavior, an individual, or a group is known as a .
ANS:
stereotype
A stereotype is a generalization about a form of behavior, an individual, or a group.
DIF: Cognitive Level: Knowledge
REF: p. 96
OBJ: 4
TOP: Stereotype
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
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Chapter 07: Asepsis and Infection Control
Cooper: Foundations and Adult Health Nursing, 9th Edition
MULTIPLE
CHOICE
1.
Which is true regarding surgical asepsis?
a.
It inhibits growth of pathogenic organisms.
b.
It is known as a cleaning technique.
c.
It includes hand hygiene.
d.
It is known as a sterile technique.
ANS: D
Surgical asepsis is known as a sterile technique.
DIF: Cognitive Level: Knowledge
REF: p. 118
OBJ: 1
TOP: Infection
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
2.
What action exemplifies a nurse practicing medical asepsis in performing daily care?
a.
Lifting a sterile swab from a sterile field
b.
Using disposable sterile gowns
c.
Washing hands for 5 minutes between patients
d.
Keeping bed linens off the floor
ANS: D
Keeping the bed linens off the floor is an example of medical asepsis; all other options are
examples of surgical asepsis.
DIF:
Cognitive Level: Comprehension REF:
p. 123
OBJ: 1 | 2 TOP: Infection KEY:
Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment
3.
What bacteria can lie dormant when conditions for growth are not favorable?
a.
Residue
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b.
Capsules
c.
Spores
d.
Flagella
ANS: C
Spore formation occurs when conditions are unfavorable, causing the bacteria to take a
dormant form.
DIF:
Cognitive Level: Comprehension REF:
p. 119
OBJ: 2 | 4 TOP: Bacteria
KEY:
Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment
4.
A patient with a respiratory infection reports that he is not yet on an antibiotic. The
nurse explains that the health care provider is waiting on the results of the culture and
sensitivity. What does this test determine?
a.
What media the bacteria requires to grow
b.
How fast the bacteria grow
c.
Which antibiotics stop bacterial growth
d.
When the bacteria colonize
ANS: C
Sensitivity tests are done to determine which antibiotics will stop growth.
DIF: Cognitive Level: Comprehension REF: p. 119
TOP: Laboratory tests
OBJ: 6
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
5.
What bacterium is responsible for more diseases than any other organism?
a.
Staphylococcus
b.
Pseudomonas aeruginosa
c.
Haemophilus influenzae
d.
Streptococcus
ANS: D
The Streptococcus bacterium is responsible for more diseases than any other organism.
DIF: Cognitive Level: Knowledge
REF: p. 137 OBJ: 3 TOP:
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Bacteria
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Safe, Effective Care Environment
6.
What additional complication does a disease caused by a virus have compared to a
disease caused by bacteria?
a.
Multiplies rapidly.
b.
Returns frequently.
c.
Is not killed by antibiotics.
d.
Is unable to be cultured.
ANS: C
Antibiotics do not alter the course of a disease caused by a virus.
DIF: Cognitive Level: Comprehension
REF: p. 121 OBJ: 3 TOP:
Virus
KEY: Nursing Process Step:
N/A
MSC: NCLEX: Physiological Integrity
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7.
What should the nurse be diligent in to provide a safe environment for the patient?
a.
Keeping a light on at night to prevent falls
b.
Hand hygiene between patient contacts
c.
Regulating the temperature to avoid drafts
d.
Changing the bed linen to diminish microorganisms
ANS: B
One of the most important actions is hand hygiene before caring for another patient.
DIF:
Cognitive Level: Application
TOP: Safe environment
REF: p. 122
OBJ: 5 | 8 | 9
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Safe, Effective Care
Environment
8.
What does the nurse describe when giving an example of a fomite vehicle?
a.
Rabid dog
b.
Person with AIDS
c.
Contaminated stethoscope
d.
Infected wound
ANS: C
If a vehicle is an inanimate (nonliving) object, it is called a fomite.
DIF: Cognitive Level: Application
REF: p. 123 OBJ: 2 TOP:
Infection
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Safe, Effective Care Environment
9.
The nurse is concerned when a patient admitted with a diagnosis of pneumonia
suddenly develops a urinary tract infection (UTI). What type of infection is this UTI
considered?
a.
Viral infection
b.
Bacterial infection
c.
Health care–associated infection
d.
Spore infection
ANS: C
More than 40 million people are admitted to hospitals each year and as many as 10%
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of them acquire a health care–associated infection while there. Criteria for health care–
associated infections require that the infection manifest at least 48 hours after
hospitalization or contact with another health agency.
DIF: Cognitive Level: Comprehension REF: p. 125
TOP: Health care–associated infection
OBJ: 2
KEY:
Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
10.
The nurse prioritizes the care of four patients. Which patient has a systemic infection?
a.
14-year-old with acute appendicitis
b.
80-year-old with a urinary tract infection
c.
40-year-old with AIDS
d.
50-year-old with arthritis
ANS: C
AIDS is a systemic viral infection. Acute appendicitis and urinary tract infections are
local infections. Arthritis is not an infection.
DIF:
Cognitive Level: Application
REF: p. 124 | p. 125 OBJ:
6
TOP: Systemic infection
KEY: Nursing Process Step: Assessment
11.
MSC: NCLEX: Physiological Integrity
What assessment does the nurse recognize as an inflammatory response in a surgical
wound on the leg of a patient?
a.
A foul drainage is coming from the wound.
b.
The affected leg is cooler than the other leg.
c.
There are raised, red, pruritic welts on the leg.
d.
Rubor and edema appear around the wound.
ANS: D
Rubor and edema are two of the cardinal signs of an inflammatory response. Foul
drainage suggests infection, the affected leg being cooler than the other leg suggests
circulatory disorder, and raised, red, pruritic welts on the leg suggest allergy.
DIF: Cognitive Level: Application
REF: p. 125
OBJ: 7
TOP: Inflammatory response KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
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Integrity
12.
The infection control health care provider plans an in-service on control of health
care–associated infections. What should be the focus of this program?
a.
Observing nurses caring for patients
b.
Screening patients who are admitted to the hospital
c.
Educating hospital personnel about aseptic practices
d.
Discharging infectious patients from the hospital
ANS: C
Duties of the infection control health care provider include staff education on infection
control.
DIF:
p. 126
Cognitive Level: Application
REF:
OBJ: 5 | 13 TOP: Infection KEY:
Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment
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13.
A health care worker is stuck by a needle left on the patient‘s bedside table. The staff
member appropriately reports the needlestick. What will the indicated treatment be
combatting?
a.
Hepatitis B
b.
Streptococcal infections
c.
Staphylococcal infections
d.
Influenza
ANS: A
Workers who have had a needlestick need to complete an injury report and seek treatment
in the event of exposure to hepatitis B.
DIF:
Cognitive Level: Comprehension REF: p. 126
OBJ: 3 | 5
TOP: Needlesticks KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
14.
What technique should the nurse use when disposing of linens contaminated with feces?
a.
Don gown, gloves, and mask
b.
Wash hands for 5 minutes after disposal
c.
Don gloves only
d.
Double-bag the sheets
ANS: C
All health care workers should follow Standard Precautions to prevent infection from
pathogens. Standard Precautions for the disposal of ordinary feces require only that the
nurse don gloves.
DIF: Cognitive Level: Application
TOP: Standard precautions
REF: p. 131
OBJ: 13
KEY: Nursing
Process Step: Analysis MSC: NCLEX: Safe,
Effective Care Environment
15.
The nurse is instructing a patient about the most important preventive technique for
breaking the chain of infection. What technique is the patient learning about?
a.
Sterilization
b.
Standard Precautions
c.
Hand hygiene
d.
Medical asepsis
ANS: C
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Hand hygiene is the most important preventive measure for interrupting the infection
process.
DIF:
Cognitive Level: Comprehension REF:
p. 118
OBJ: 2 | 9 TOP: Infection KEY:
Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment
16.
A nurse is observing isolation precautions by wearing a mask while performing
complex patient care. How often should the nurse change masks?
a.
5 to 10 minutes
b.
10 to 20 minutes
c.
20 to 30 minutes
d.
30 to 40 minutes
ANS: C
The mask should be changed every 20 to 30 minutes.
DIF: Cognitive Level: Comprehension
REF: p. 133 OBJ: 8 TOP:
Mask
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Safe, Effective Care Environment
17.
A major threat to health care workers is blood-contaminated sharps. What should the
nurse use to discard the used syringe?
a.
Wastebasket
b.
Sink
c.
Puncture-proof container
d.
Disinfecting soap
ANS: C
All patient care areas where sharps are used require puncture-proof containers.
DIF:
Cognitive Level: Comprehension
OBJ: 8
REF: p. 122 | p. 136
TOP: Sharps KEY: Nursing Process Step:
Implementation MSC: NCLEX: Safe, Effective Care
Environment
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18.
The nurse is transporting a patient in respiratory isolation to the radiology
department. What intervention should the nurse implement?
a.
Cover the patient with a sheet.
b.
Take the patient down the service elevator.
c.
Apply a mask to the patient.
d.
Call x-ray to come and get the patient.
ANS: C
If a patient requiring respiratory isolation must be transported to another area, the patient
must don a mask.
DIF:
Cognitive Level: Application REF: p. 133 | p. 135
OBJ: 5 | 8
TOP: Isolation KEY: Nursing Process
Step: Implementation MSC: NCLEX: Safe, Effective
Care Environment
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19.
The patient in isolation may experience psychological or emotional deprivation.
What should the nurse do to help minimize these feelings?
a.
Be cheerful.
b.
Spend extra time with the patient.
c.
Protect the patient from additional infection.
d.
Answer the call light quickly.
ANS: B
To minimize feelings of psychological or emotional deprivation, the nurse should spend
extra time with the patient.
DIF: Cognitive Level: Application
REF:
p. 138
KEY:
OBJ: 13 TOP: Isolation
Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
20.
The infection control officer is observing hospital staff for appropriate use of aseptic
technique. What observation demonstrates the need for more instruction on surgical
asepsis?
a.
Facing the sterile field
b.
Placing a sterile dressing on a sterile field
c.
Touching the edges of the sterile field with sterile gloves
d.
Keeping gloved hands above the waist
ANS: C
The edges of a sterile field are not considered sterile.
DIF: Cognitive Level: Application
TOP: Sterile technique
REF: p. 143
OBJ: 1
KEY: Nursing Process
Step: Evaluation MSC: NCLEX: Safe, Effective
Care Environment
21.
The nurse is pouring a sterile solution from a bottle. What direction should the label on
the bottle be in for appropriate technique?
a.
Facing outward
b.
Covered
c.
Facing downward
d.
In the palm of the hand
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ANS: D
The bottle should be held with the label in the palm of the hand.
DIF:
Cognitive Level: Application
TOP: Sterile technique
REF: p. 147
OBJ: 11 | 12
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Safe, Effective Care
Environment
22.
What is a method used to kill all microorganisms, including spores?
a.
Disinfecting
b.
Using an antiseptic
c.
Using chlorine bleach
d.
Sterilizing
ANS: D
Sterilization refers to methods used to kill all microorganisms and spores.
DIF:
Cognitive Level: Knowledge REF: p. 142 | p. 143
OBJ: 12
TOP: Pathogens
KEY:
Nursing Process Step: N/A MSC: NCLEX: N/A
23.
The nurse accidently spills blood from a specimen container. The first action the
nurse takes is to don gloves. What should the nurse then spray the fluid with?
a.
Liquid detergent
b.
20% bleach solution
c.
10% bleach solution
d.
Warm soapy water
ANS: C
Any accidental body fluid spill should be cleaned up as soon as possible. The person
cleaning the spill should wear gloves. One cup of bleach diluted with 10 cups of water
should be used as a disinfectant to spray over the spill and clean up with paper towels.
The paper towels should then be placed in the plastic-lined waste container.
DIF: Cognitive Level: Knowledge
p. 153
REF:
OBJ: 12 TOP: Body fluids KEY:
Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment
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24.
When assessing a patient for signs of an infection, the nurse recognizes which laboratory
result as indicative of an infection?
a.
Lowered red blood cell count
b.
Increased white blood cell count
c.
Lowered white blood cell count
d.
Increased red blood cell count
ANS: B
Increased white blood cell count may indicate an infection.
DIF:
Cognitive Level: Application
p. 155
REF:
OBJ: 3 | 4 TOP: Lab results
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
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25.
What can result from the nurse consistently performing hand hygiene and using
sterile supplies when caring for patients in the hospital setting?
a.
Hospital stay is shortened
b.
Sense of self-worth is improved
c.
Risk of infection is reduced
d.
Nursing care needed is reduced
ANS: C
Hand hygiene is the most important measure for interrupting the infectious process.
DIF: Cognitive Level: Comprehension
REF: p. 118 OBJ: 5 TOP:
Infection
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Safe, Effective Care Environment
26.
Recognizing the stages of an infection assists the nurse in identifying the
progression of an infection. What is the nonspecific to specific symptom stage of an
infection?
a.
Convalescent
b.
Illness
c.
Prodromal
d.
Incubation
ANS: C
The prodromal stage progresses from onset of nonspecific signs and symptoms to more
specific signs and symptoms.
DIF: Cognitive Level: Knowledge
p. 125
REF:
OBJ: 4 | 6 TOP: Infection KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
27.
What is the most dependable and practical method to use when sterilizing instruments for
the operating room?
a.
Chemical solution
b.
Boiling water
c.
Steam under pressure
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d.
Dry heat
ANS: C
Steam under pressure is the most practical and dependable method for destruction of all
microorganisms.
DIF: Cognitive Level: Comprehension REF: p. 153
TOP: Sterilization
28.
OBJ: 12
KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
What contribution did Joseph Lister introduce to medical practice?
a.
Isolation of infected patients
b.
Iodine and alcohol use as disinfectants
c.
The autoclave
d.
Aseptic technique
ANS: D
Joseph Lister contributed to medical practice through the introduction of the aseptic
technique.
DIF: Cognitive Level: Knowledge
REF:
p. 117
OBJ: 1 TOP:
Joseph Lister
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
29.
The nurse is providing instruction to an anxious mother of a child with Rocky
Mountain spotted fever. When discussing this diagnosis, what information will
the nurse relay about this disease?
a.
It is extremely contagious among humans.
b.
It is contracted from handling unvaccinated animals.
c.
It is a hemolytic B Streptococcus infection spread by droplet transmission.
d.
It is a serious disease contracted from the bite of a tick.
ANS: D
Rocky Mountain spotted fever is contracted through the bite of a tick vector. It is not
contagious among humans.
DIF:
Cognitive Level: Comprehension REF: p. 120
OBJ: 2 | 3
TOP: Vector transmission KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
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30.
The emergency department nurse is assessing a puncture wound of the foot. What
is the most likely type of infection in this wound?
a.
Aerobic bacterial infection
b.
Anaerobic bacterial infection
c.
Viral infection
d.
Fungal infection
ANS: B
An anaerobic bacterial infection is one that grows in an oxygenated environment.
DIF: Cognitive Level: Comprehension REF: p. 119
TOP: Anaerobic infections
OBJ: 6
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
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31.
The nurse is instructing a bioterrorism class regarding anthrax. How can anthrax be
transmitted?
a.
From person to person
b.
Through microscopic skin punctures
c.
Through inhalation of the spores
d.
By exposure to animals that have anthrax
ANS: C
Anthrax is contracted by inhaling the spores.
DIF:
Cognitive Level: Comprehension
OBJ: 3
REF: p. 119 | p. 120
TOP: Anthrax KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological
Integrity
32.
The nurse is providing teaching to elementary students regarding vectors. What
example will the nurse provide as an example of a vector?
a.
Child with measles giving it to his sister
b.
Tick whose bite causes Lyme disease
c.
Woman with syphilis infecting her partner
d.
Dog whose bite causes rabies
ANS: B
A vector is a person or animal not sick with the disease harboring an organism that is
contagious.
DIF: Cognitive Level: Comprehension
REF: p. 122 OBJ: 3 TOP:
Vector
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
33.
What type of organism causes malaria?
a.
Bacterium
b.
Virus
c.
Protozoan
d.
Fungus
ANS: C
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Malaria is caused by the introduction of protozoa from the bite of a mosquito.
DIF: Cognitive Level: Knowledge
REF: p. 122
OBJ: 4
TOP: Protozoan infections KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
34.
A nurse is performing an admission assessment on a patient with suspected
tuberculosis. What assessment findings by the nurse are consistent with tuberculosis?
a.
Hemoptysis
b.
Weight gain
c.
Night terrors
d.
Hypothermia
ANS: A
Suspicious symptoms consistent with tuberculosis include fatigue, unexplained weight loss,
dyspnea, fever, night sweats, and hemoptysis (a cough that can be productive of blood).
DIF: Cognitive Level: Comprehension
REF: p. 138
OBJ: 6 TOP:
Tuberculosis KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
35.
A nurse is performing an admission assessment on a patient with suspected
tuberculosis. What is the greatest risk of exposure to tuberculosis?
a.
After a diagnosis is made
b.
Before a diagnosis is made
c.
After the patient has begun medication therapy
d.
After implementation of isolation precautions
ANS: B
The risk of exposure to tuberculosis is greatest before a diagnosis is made and isolation
precautions are implemented.
DIF: Cognitive Level: Comprehension
REF: p. 139
OBJ: 8 TOP:
Tuberculosis KEY: Nursing Process Step:
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Assessment
MSC: NCLEX: Physiological Integrity
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MULTIPLE RESPONSE
1.
A person can spread a bacterial infection by which actions? (Select all that apply.)
a.
Kissing others
b.
Sneezing at work
c.
Donating blood
d.
Coming in contact with blood products
e.
Leaving used tissue on the lavatory
ANS: A, B, E
Bacteria can be spread by direct, indirect, or airborne transmission.
DIF:
Cognitive Level: Comprehension
REF: p. 122 | p. 155 OBJ:
14
TOP: Bacterial
transmission
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
2.
What are some characteristics of microorganisms? (Select all that apply.)
a.
Involved in a life process of their own.
b.
Pathogens that cause disease.
c.
Nonpathologic organisms that cause disease.
d.
May be infectious.
e.
Can enter the body via skin, air, or blood.
ANS: A, B, D, E
Microorganisms are involved in a life process of their own, pathogens cause disease,
may be infectious, and can enter the body via skin, air, or blood. Nonpathologic
organisms do not cause disease.
DIF:
Cognitive Level: Comprehension
TOP: Characteristics of microorganisms
REF: pp. 122-126
OBJ: 3
KEY:
Nursing Process Step: Implementation MSC: NCLEX:
Safe, Effective Care Environment
COMPLETION
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1.
A patient is distressed that an antibiotic has not been effective for the control of the
infection. The nurse explains that some bacteria are capable of defending against
antibiotics by the formation of a
.
ANS:
capsule
Some bacteria can protect themselves by the formation of a capsule of sticky protein that
prevents antibiotics from entering the cell.
DIF: Cognitive Level: Comprehension REF: p. 119
TOP: Bacterial capsules
OBJ: 4
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
2.
The nurse reminds a group of nursing students that the type of asepsis that destroys all
microorganisms and their spores is
asepsis.
ANS:
surgical
Surgical asepsis destroys all microorganisms and their spores.
DIF: Cognitive Level: Comprehension REF: p. 118
TOP: Surgical asepsis
OBJ: 1
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Safe, Effective Care
Environment
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Chapter 08: Body Mechanics and Patient Mobility
Cooper: Foundations and Adult Health Nursing, 9th Edition
MULTIPLE
CHOICE
1.
The nurse instructs an unlicensed assistive personnel to use large muscle groups
when lifting. What is the rationale for this instruction?
a.
Workers‘ compensation claims will be prevented.
b.
Big muscles work more effectively.
c.
It guarantees no muscle strain.
d.
It distributes workload more evenly.
ANS: D
Proper body mechanics provide for even distribution of workload.
DIF:
Cognitive Level: Comprehension REF: p. 161
TOP: Body mechanics
OBJ: 1 | 2
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Safe, Effective Care
Environment
2.
What should the nurse do to reduce the effort of moving a heavy object?
a.
Bring the feet close together and flex the knees.
b.
Keep the back straight and bend at the waist.
c.
Widen the base of support in the direction of movement.
d.
Broaden the base of support and twist toward the direction of movement.
ANS: C
The base of support should be broadened in the direction of movement.
DIF:
Cognitive Level: Application
TOP: Body mechanics
REF: p. 161
OBJ: 1 | 2
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Safe, Effective Care
Environment
3.
What should the nurse do to protect his or her back when lifting or moving a patient?
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a.
Lowering the height of the bed
b.
Holding the back straight with locked knees
c.
Bending knees and hips
d.
Getting the patient to the side of the bed
ANS: C
The nurse‘s back can be well protected when he or she bends knees and hips.
DIF: Cognitive Level: Application
TOP: Body mechanics
REF: p. 161
OBJ: 11
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Safe, Effective Care
Environment
4.
Where should the nurse place the load when carrying heavy objects?
a.
In a low position
b.
To the side of the body
c.
Close to the body midline
d.
With another‘s assistance
ANS: C
The nurse should carry objects close to the midline of the body.
DIF: Cognitive Level: Comprehension REF: p. 163
TOP: Body mechanics
OBJ: 11
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Safe, Effective Care
Environment
5.
The nurse is educating a patient on ways to regain the ability to perform ADLs and
maintain normal physiologic activities. What will the nurse relay as a requirement?
a.
Strength
b.
Wellness
c.
Alertness
d.
Mobility
ANS: D
The purpose of mobility is completing ADLs and maintaining physiologic activities.
DIF: Cognitive Level: Comprehension
REF: p. 167 OBJ: 4 TOP:
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Mobility
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
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6.
The nurse counsels the immobilized patient in regard to prevention of muscle atrophy
and contractures. What will the nurse be sure to include when counseling this patient?
a.
The need for additional calcium
b.
The need for additional protein
c.
The need for some type of exercise
d.
The need for a special protective bed
ANS: C
The immobilized patient must receive some type of exercise to prevent atrophy and
contractures.
DIF: Cognitive Level: Application
REF: p. 171 OBJ: 6 TOP:
Immobility
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
7.
What is the term for range of motion (ROM) when it is performed by the patient?
a.
Assisted
b.
Passive
c.
Active
d.
Coordinated
ANS: C
ROM performed actively by the patient is designated as active ROM.
DIF: Cognitive Level: Knowledge
TOP: Range of motion (ROM)
REF: p. 183
OBJ: 9
KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity
8.
The nurse is performing passive range of motion (ROM) for the patient. How will the
nurse move the joint through ROM?
a.
The fullest extent.
b.
Place the joint in normal position.
c.
The point of pain.
d.
Relax the patient.
ANS: C
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The joints are moved to the point of resistance or pain.
DIF: Cognitive Level: Application
TOP: Range of motion (ROM)
REF: p. 171
OBJ: 9
KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity
9.
How should the nurse assist the patient with moving when pain is anticipated?
a.
Be supportive.
b.
Apply heat before moving them.
c.
Administer medication before ambulation.
d.
Obtain assistance if the patient is heavy.
ANS: C
The nurse may want to administer medication before an activity that may be painful.
DIF: Cognitive Level: Application
TOP: Body mechanics
REF: p. 180
OBJ: 6
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
10.
The 125-lb nurse is preparing to lift a heavy object. What is the maximum amount of
weight considered safe for the nurse to lift?
a.
75 lb
b.
50 lb
c.
100 lb
d.
125 lb
ANS: B
The suggested maximum weight considered safe to lift by a single person is 50 lb.
DIF: Cognitive Level: Knowledge
TOP: Body mechanics
REF: p. 163
OBJ: 11
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Safe, Effective Care
Environment
11.
What is the site of the most common strain injury acquired by the nurse when working?
a.
Trapezius muscle group
b.
Thoracic muscle group
c. Lumbar muscle group
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d.
Thigh muscle group
ANS: C
The most common back injury is strain of the lumbar muscle group.
DIF:
Cognitive Level: Knowledge REF: p. 163 | p. 164
OBJ: 2
TOP: Body mechanics
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
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12.
What implementation might the nurse use to improve safety during a transfer?
a.
Weighing the patient first
b.
Using a transfer belt
c.
Putting shoes on the patient
d.
Supporting a flaccid arm
ANS: B
As a general rule, the nurse should use a transfer belt.
DIF: Cognitive Level: Application
TOP: Body mechanics
REF: p. 178
OBJ: 5
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Safe, Effective Care
Environment
13.
What is considered to be the minimum number of hours of daily activity
necessary to prevent the negative consequences of immobility?
a.
2 hours
b.
4 hours
c.
6 hours
d.
8 hours
ANS: A
The amount of exercise required to prevent physical disuse syndrome is 2 hours in 24
hours.
DIF:
Cognitive Level: Knowledge REF: p. 167 | p. 183
OBJ: 6
TOP: Immobility
KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity
14.
The nurse is performing passive range-of-motion exercises on a patient following a
traumatic injury. What is the number of times the nurse should move each joint when
performing passive range-of-motion (ROM) exercises?
a.
Three
b.
Four
c.
Five
d.
Six
ANS: C
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Each movement should be repeated five times.
DIF: Cognitive Level: Application
TOP: Range of motion (ROM)
REF: p. 174
OBJ: 6
KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity
15.
What profession has the highest workers‘ compensation claim rates of any occupation or
industry?
a.
Firefighters
b.
Truck drivers
c.
Law enforcement
d.
Nursing personnel
ANS: D
Studies of workers‘ compensation claims show that nursing personnel have the highest
claim rates of any occupation or industry.
DIF: Cognitive Level: Knowledge
REF:
p. 161
OBJ: 2 TOP:
Workers‘ compensation
KEY: Nursing
Process Step: N/A MSC: NCLEX: Physiological
Integrity
16.
A nurse instructs an unlicensed assistive personnel about moving older adult patients in
bed. When should the nurse intervene when observing the unlicensed assistive
personnel perform a return demonstration?
a.
The unlicensed assistive personnel is using simple language.
b.
The unlicensed assistive personnel is avoiding jerky movements.
c.
The unlicensed assistive personnel is avoiding sudden movements.
d.
The unlicensed assistive personnel is pulling the patient across bed linens.
ANS: D
The skin of older adults is more fragile and susceptible to injury. When moving or
transferring older adults, it is essential to avoid pulling them across bed linens because
this may cause shearing or tearing of the skin. The nurse should explain each step in
simple language and avoid jerky, sudden movements.
DIF:
Cognitive Level: Application
REF: p. 162
OBJ: 10 | 11
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TOP: Moving patients
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
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17.
The LPN/LVN assists a patient into the semi-Fowler‘s position per health care
provider order. What would indicate that this patient is in the correct position?
a.
Patient is leaning over the bedside table
b.
Head of bed is at a 30-degree angle
c.
Knee is drawn toward the chest
d.
Arms are flexed toward the head
ANS: B
The semi-Fowler‘s position is when the head of the bed is raised approximately 30
degrees. Orthopneic position is when the patient is leaning over the bedside table. Sims
position is when the knee is drawn toward the chest. Arms are not flexed toward the
head in the semi-Fowler‘s position.
DIF: Cognitive Level: Comprehension REF: p. 165
OBJ: 7
TOP: Positioning patients KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1.
A newly hired group of graduate practical/vocational nurses are attending orientation
at a long-term care facility. What information will be included regarding
considerations of mobility and the older adult? (Select all that apply.)
a.
The skin of older adults is more fragile and susceptible to injury.
b.
Always support older adults under the soft tissue when moving them in bed.
c.
Weakness and hypertension are common signs and
symptoms noted in an older adult on bed rest.
d.
Aging tends to result in loss of flexibility and joint mobility.
e.
Older adults sometimes become fearful when hydraulic lifts are used for transfers.
ANS: A, D, E
The skin of older adults is more fragile and susceptible to injury. Aging tends to
result in the loss of flexibility and joint mobility and older adults sometimes do
become fearful with use of hydraulic lifts. Older adults should be supported under
the joints when moving in bed. Weakness and hypotension are common signs and
symptoms noted in an older adult on bed rest.
DIF: Cognitive Level: Comprehension
REF: p. 162 OBJ: 3 TOP:
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Older adult
KEY: Nursing Process Step:
N/A
MSC: NCLEX: Physiological Integrity
2.
The nurse receives a patient from the recovery room following total hip replacement
surgery. What will the nurse include when assessing neurovascular status on this
patient? (Select all that apply.)
a.
Pupils
b.
Pain
c.
Sensation
d.
Color
e.
Skin temperature
ANS: B, C, D, E
One of the responsibilities of the nurse is to frequently monitor the patient‘s
neurovascular function, or circulation, movement, and sensation (CMS) assessment.
The LPN/LVN checks for skin color, temperature, movement, sensation, pulses,
capillary refill, and pain. Pupil assessment is part of a neurologic assessment.
DIF:
Cognitive Level: Comprehension
TOP: Neurovascular function
REF: pp. 168-169
OBJ: 8 | 13
KEY: Nursing
Process Step: Assessment MSC: NCLEX:
Physiological Integrity
COMPLETION
1.
The most common cause of musculoskeletal disorders in nurses involves a movement
that requires the nurse to
and
lift at the same time.
ANS:
twist
The motion of twisting and lifting at the same time frequently strains the muscles of the
lower back.
DIF:
Cognitive Level: Comprehension
OBJ: 1 | 2
TOP: Muscle strain
REF: p. 161 | p. 162
KEY: Nursing
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Process Step: N/A MSC: NCLEX: N/A
2.
To maintain a wide base of support, the nurse should stand with the feet separated by the
distance of
width apart.
ANS:
shoulder
Actions to promote proper body mechanics include positioning feet shoulder width apart
to create a wide base of support.
DIF: Cognitive Level: Knowledge
TOP: Base of support
REF: p. 161
OBJ: 1
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Safe, Effective Care
Environment
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3.
When a fall occurs, the nurse should document the incident and initiate a(n)
report.
ANS:
incident
The nurse must initiate an incident report describing the events of a patient‘s fall.
DIF: Cognitive Level: Knowledge
TOP: Incident report
REF: p. 168
OBJ: 6
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Safe, Effective Care
Environment
4.
Continuous
motion machines flex and extend joints to mobilize them
passively without the strain of active exercises.
ANS:
passive
Continuous passive motion (CPM) machines flex and extend joints to mobilize them
passively without the strain of active exercises. It is imperative that the CPM machine
be set according to the health care provider‘s orders for the degree and the speed of
flexion and extension for each individual patient to prevent damage to the joint or
surgical site.
DIF: Cognitive Level: Knowledge
p. 174
REF:
OBJ: 12 TOP:
Continuous passive motion machines
KEY: Nursing Process Step:
Implementation MSC:
NCLEX: Physiological
Integrity
5.
Acute
syndrome occurs in the extremities, especially the legs, where a
sheath of inelastic fascia partitions blood vessel, nerve, and muscle tissue.
ANS:
compartment
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Acute compartment syndrome occurs in the extremities, especially the legs, where
a sheath of inelastic fascia partitions blood vessel, nerve, and muscle tissue.
DIF: Cognitive Level: Knowledge
TOP: Compartment syndrome
REF: p. 169
OBJ: 8
KEY: Nursing
Process Step: Assessment MSC: NCLEX:
Physiological Integrity
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Chapter 09: Hygiene and Care of the Patient’s
Environment Cooper: Foundations and Adult
Health Nursing, 9th Edition
MULTIPLE
CHOICE
1.
The nurse is preparing to bathe a patient. What should the room temperature be set at?
a.
No warmer than 67°F (19.4°C)
b.
No cooler than 68°F (20°C)
c.
No cooler than 70°F (21.1°C)
d.
75°F or warmer (23.8°C)
ANS: B
The recommended room temperature is 68° to 74°F (20° to 23.3°C).
DIF:
Cognitive Level: Application
REF: p. 188
OBJ: 1 | 2 | 4
TOP: Patient's environment KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological
Integrity
2.
The nurse explains that the purpose of a sitz bath is to reduce inflammation in the
perineal and anal area. What is the least amount of time the nurse will instruct for a
sitz bath? (The wording of this is unclear)
a.
10 to 15 minutes
b.
20 to 30 minutes
c.
30 to 40 minutes
d.
1 hour
ANS: B
The sitz bath should last 20 to 30 minutes.
DIF:
Cognitive Level: Application
TOP: Therapeutic baths
REF: p. 192
OBJ: 2 | 3
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
3.
A patient is recovering from a hemorrhoidectomy and experiences dizziness within 5
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minutes when taking a sitz bath. What action should the nurse implement?
a.
Cover the patient to prevent chilling.
b.
Stay with the patient until the full time for the bath has elapsed.
c.
Remove the patient from the sitz bath and return to bed.
d.
Assess vital signs every 5 minutes during the remainder of the sitz bath.
ANS: C
The patient may become dizzy during a sitz bath due to dilation of the large vessels
in the abdomen. If this occurs, the patient should be removed from the site bath and
returned to bed. Vital signs should be assessed until they return to normal.
DIF: Cognitive Level: Application
REF: p. 193 OBJ: 3 TOP: Sitz
bath
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
4.
What should the water temperature be when preparing a tepid bath for a patient?
a.
98.6°F (37°C)
b.
100.2°F (37.8°C)
c.
104.8°F (40.4°C)
d.
110.4°F (43.5°C)
ANS: A
The tepid bath is taken in water that is 98.6°F (37°C).
DIF: Cognitive Level: Knowledge
REF: p. 193 OBJ: 4 TOP:
Tepid bath
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
5.
The nurse is assessing a patient‘s skin for signs of impaired skin integrity. Which
finding by the nurse is considered a major manifestation?
a.
Burn
b.
Laceration
c.
Pressure injury
d.
Infection
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ANS: C
A major manifestation of impaired skin integrity is a pressure injury.
DIF: Cognitive Level: Comprehension REF: p. 202
TOP: Pressure injuries
OBJ: 5
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
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6.
A nurse assesses an area of sustained redness on the coccyx area of a resident in
long-term care. What is the most likely cause of this pressure area?
a.
Heat from pressure
b.
Collapse of blood vessels
c.
Friction from pressure
d.
Collapse of skin tissue
ANS: B
A pressure injury occurs when there is sufficient pressure to collapse the blood vessels.
DIF: Cognitive Level: Comprehension REF: p. 202
TOP: Pressure injuries
OBJ: 5
KEY: Nursing Process
Step: Evaluation MSC: NCLEX: Physiological
Integrity
7.
The nurse is caring for an unconscious patient with a risk for skin impairment. How
often will the nurse plan to change the position of this patient?
a.
Every 30 minutes
b.
Every 60 minutes
c.
Every 120 minutes
d.
Every 180 minutes
ANS: C
The bedfast patient should have a position change every 2 hours (120 minutes) because
skin compromise can occur if there is unrelieved pressure during that amount of time.
DIF: Cognitive Level: Application
TOP: Pressure injuries
REF: p. 231
OBJ: 5
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
8.
The nurse assesses a red blister over the right superior iliac area of a patient. What stage
is this decubitus injury?
a.
1
b.
2
c.
3
d.
4
ANS: B
A pressure injury demonstrating blisters is a stage 2 decubitus injury.
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DIF: Cognitive Level: Application
TOP: Pressure injuries
REF: p. 203
OBJ: 5
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
9.
The nursing assessment of a pressure injury includes size, depth, pain, odor, and color of
tissue. What does this evaluate?
a.
Treatment needed
b.
Effectiveness of implementation
c.
Whether improvement is occurring
d.
Need for additional interventions
ANS: C
Ongoing assessment of a pressure injury will evaluate whether improvement is occurring.
DIF:
Cognitive Level: Comprehension
REF: p. 202 | p. 203 OBJ:
5
TOP: Pressure injuries
KEY: Nursing Process Step: Assessment
10.
MSC: NCLEX: Physiological Integrity
The nurse attempts to avoid a pressure injury for a bedridden patient by turning the
patient frequently. What is the most favorable position for the nurse to move this
patient into?
a.
Back-lying
b.
Full lateral
c.
30-degree lateral
d.
Full prone
ANS: C
It is preferable to use the 30-degree lateral incline position.
DIF: Cognitive Level: Application
TOP: Pressure injuries
REF: p. 205
OBJ: 5
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
11.
One reason the nurse focuses on oral hygiene is to maintain a healthy state of the
oral cavity. What is another reason to promote oral hygiene?
a.
To improve self-esteem
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b.
To stimulate appetite
c.
To restore tooth destruction
d.
To assist with periodontitis
ANS: B
A sense of well-being can stimulate appetite.
DIF: Cognitive Level: Comprehension REF: p. 211
TOP: Oral hygiene
OBJ: 6
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
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12.
How will the nurse correctly replace a patient‘s dentures after cleaning?
a.
Inserting the lower denture first
b.
Asking the patient to insert them
c.
Inserting both dentures together
d.
Inserting the upper denture first
ANS: D
When reinserting dentures, replace the upper dentures first.
DIF: Cognitive Level: Application
TOP: Oral hygiene
REF: p. 213
OBJ: 6
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
13.
Proper hair care is important for the patient‘s self-image. What is the proper water
temperature when shampooing a patient‘s hair?
a.
101°F (38.3°C)
b.
105°F (40.5°C)
c.
110°F (43.3°C)
d.
120°F (48.8°C)
ANS: C
Water at 110°F (38.3°C) should be used to shampoo a patient‘s hair.
DIF: Cognitive Level: Knowledge
REF: p. 193 OBJ: 6 TOP: Hair
care
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
14.
When must the nurse remember to use an electric razor when shaving a patient?
a.
When a bleeding tendency is present
b.
When there is a risk for suicide
c.
When the facial hair is fine
d.
When speed is essential
ANS: A
A patient with a bleeding disorder should use an electric razor.
DIF: Cognitive Level: Application
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REF: p. 214 OBJ: 6 TOP:
Shaving
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
15.
The nurse is bathing a patient with a deep vein thrombosis in the left leg. What
modification will the nurse make when attending to the left leg?
a.
Washing the leg with long, firm strokes and drying with a towel
b.
Omitting washing the leg at all
c.
Gently washing the leg and patting dry with a towel
d.
Applying lotion in long, smooth strokes
ANS: C
The lower extremities of people with circulatory disorders are gently washed and patted
dry, omitting any stroking or massaging.
DIF: Cognitive Level: Application
REF: p. 196 OBJ: 3 TOP:
Bathing
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
16.
The nurse is providing hand and foot care to a patient and notices the patient has
extremely hard nails. Who is the person best prepared to provide nail care for
patients with extremely hard nails?
a.
Health care provider
b.
RN
c.
CNA
d.
Podiatrist
ANS: D
If the patient‘s nails are extremely hard, a podiatrist should provide care.
DIF: Cognitive Level: Comprehension
REF: p. 216 OBJ: 6 TOP: Foot
care
KEY: Nursing Process Step:
N/A
MSC: NCLEX: Physiological Integrity
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17.
How often should the nurse cleanse the meatal-catheter junction of a patient with an
indwelling catheter?
a.
At least once a day
b.
At least twice a day
c.
At bedtime
d.
Each shift
ANS: B
Catheter care should be performed at least two times daily.
DIF: Cognitive Level: Comprehension REF: p. 214
TOP: Catheter care
OBJ: 8
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
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18.
The nurse is preparing to perform perineal care for the female patient. What is the best
method for using a bath blanket to drape the patient?
a.
Square position
b.
Long position
c.
Diamond position
d.
Rectangular position
ANS: C
Drape the patient with a bath blanket in the diamond position.
DIF: Cognitive Level: Application
REF: p. 218
OBJ: 8 TOP:
Perineal care KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
19.
Clear water is used to cleanse the eyes. It is important to use proper technique when
cleansing the eyes to prevent infection. What direction will the water flow when
cleansing a patient‘s eyes?
a.
Upward toward the forehead
b.
Downward toward the chin
c.
From the outer toward the inner canthus
d.
From the inner toward the outer canthus
ANS: D
The eye is cleansed from the inner to outer canthus.
DIF: Cognitive Level: Comprehension
REF: p. 219 OBJ: 6 TOP: Eye
care
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
20.
How frequently should the nurse clean the nares of patients who have a nasogastric tube
or are receiving oxygen by nasal cannula?
a.
At least every 2 hours
b.
At least every 6 hours
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c.
At least every 8 hours
d.
At least every 10 hours
ANS: C
When receiving oxygen by a nasal cannula or when a nasogastric tube is in place, the
nurse should cleanse the nares every 8 hours.
DIF: Cognitive Level: Application
REF: p. 221 OBJ: 6 TOP:
Nasal care
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
21.
The nurse must follow the principles of medical asepsis while making a patient‘s
bed, including procedures for handling linens. How should the nurse handle soiled
linens?
a.
Place on the floor
b.
Fan in the air
c.
Hold away from the uniform
d.
Place at the end of the bed
ANS: C
Soiled linen should not come into contact with a uniform.
DIF:
Cognitive Level: Application REF: p. 224 | p. 225
OBJ: 10
TOP: Bed making
KEY: Nursing
Process Step: Implementation MSC: NCLEX: Safe,
Effective Care Environment
22.
How should the nurse cleanse the meatal opening when performing male perineal care?
a.
From the meatus outward
b.
With an alcohol swab
c.
In a circular motion
d.
With a cotton-tipped applicator
ANS: A
The nurse should cleanse the meatal opening from the meatus outward.
DIF:
Cognitive Level: Application REF: p. 214 | p. 219
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OBJ: 8
TOP: Perineal care KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity
23.
The nurse lowers the bed to place the patient on the bedpan. The angle of the head of the
bed should be raised to:
a.
20 degrees.
b.
45 degrees.
c.
90 degrees.
d.
30 degrees.
ANS: D
Elimination is facilitated with the head of the bed elevated 30 degrees.
DIF: Cognitive Level: Application
p. 225
REF:
OBJ: 12 TOP: Elimination KEY:
Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
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24.
What does the nurse recognize is important to consider when using the nursing process to
plan hygiene care of the patient?
a.
Nurse‘s orders
b.
Health care provider‘s orders
c.
Patient‘s preferences
d.
Outcome goals
ANS: C
Individual patients will have individual desires and choices.
DIF: Cognitive Level: Application
REF: p. 228 OBJ: 2 TOP:
Hygiene
KEY: Nursing Process Step:
Planning
MSC: NCLEX: Physiological Integrity
25.
The nurse is providing personal hygiene for a Hindu patient from India. What
intervention should the nurse implement?
a.
Not serve meat
b.
Shampoo the patient‘s hair weekly
c.
Give a daily bath
d.
Cut nails monthly
ANS: C
A daily bath is part of the religious duty of Indian Hindus.
DIF: Cognitive Level: Application
REF: p. 188 OBJ: 2 TOP:
Hygiene
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
26.
The nurse is assisting a patient to perform personal hygiene. What is the most
important focus of the nurse when assisting this patient?
a.
Nursing care
b.
Independence
c.
Repetition
d.
Performance
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ANS: B
The nurse should encourage the patient‘s independence as much as possible.
DIF: Cognitive Level: Comprehension
REF: p. 187 OBJ: 2 TOP:
Hygiene
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
27.
The nurse discovers a reddened area over a patient‘s hip. What should be the nurse‘s first
intervention?
a.
Cover the area with an occlusive dressing.
b.
Apply mild ointment with a cotton-tipped applicator.
c.
Press the area gently to assess for blanching.
d.
Rub gently to increase circulation.
ANS: C
If the area is a stage 1 decubitus injury, the area will not blanch.
DIF: Cognitive Level: Application
TOP: Pressure injuries
REF: p. 203
OBJ: 5
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
28.
The nurse is educating a patient regarding a tub bath. What is the maximum length of
time the nurse should instruct the patient to remain in the water?
a.
5 to 10 minutes
b.
10 to 20 minutes
c.
20 to 30 minutes
d.
30 to 40 minutes
ANS: B
A patient should not stay in the water for more than 20 minutes.
DIF: Cognitive Level: Comprehension
REF: p. 216 OBJ: 3 TOP:
Hygiene
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
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29.
Where should a nurse performing a backrub begin?
a.
Shoulder
b.
Base of the neck
c.
Sacral area
d.
Lumbar area
ANS: C
The nurse should begin a massage in the sacral area.
DIF: Cognitive Level: Comprehension
REF: p. 200 OBJ: 7 TOP:
Hygiene
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
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30.
The nurse is caring for a patient experiencing presbycusis. What intervention
should the nursing personnel be instructed to implement?
a.
Speak quickly to the patient.
b.
Speak in loud tones to the patient.
c.
Speak slowly and clearly to the patient.
d.
Tell the patient they must purchase a hearing aid.
ANS: C
Age-related hearing loss, presbycusis, is a common finding in older adults. It is
important to speak slowly and clearly to the patient with presbycusis. Not all patients
with this type of hearing loss require a hearing aid.
DIF: Cognitive Level: Application
REF: p. 220
OBJ: 6 TOP:
Hearing loss KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
31.
A health care provider orders a patient to be placed in the Trendelenburg‘s position. How
will the nurse position the bed?
a.
On the floor
b.
Parallel with the floor
c.
Tilted with the head of the bed down
d.
Tilted with the foot of the bed down
ANS: C
The entire bed is tilted downward with the head of the bed down when placing a patient in
the Trendelenburg‘s position.
DIF: Cognitive Level: Application
REF: p. 191 OBJ: 1 TOP:
Positioning
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
32.
The health care provider orders a patient to be placed in the reverse Trendelenburg‘s
position. How should the nurse place the bed?
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a.
On the floor
b.
Parallel with the floor
c.
Tilted with the head of the bed down
d.
Tilted with the foot of the bed down
ANS: D
The entire bed is tilted downward with the foot of the bed down when placing a patient in
the reverse Trendelenburg‘s position.
DIF: Cognitive Level: Application
REF: p. 191 OBJ: 1 TOP:
Positioning
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
33.
Which guideline should be followed when giving a backrub?
a.
Observing the skin for abnormalities
b.
Massaging for at least 10 minutes
c.
Following massage with a brisk alcohol rub
d.
Conversing with patient continually throughout the backrub
e.
Using alcohol-based lotion for disinfection
ANS: A
The backrub should last for about 3 to 5 minutes, giving the nurse an opportunity to
observe for skin abnormalities. Conversation should be kept to a minimum to
enhance relaxation. Alcohol either as a rub or used as disinfectant is drying to the
skin.
DIF: Cognitive Level: Application
REF: p. 201 OBJ: 7 TOP:
Backrub
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1.
The nurse is preparing to make an occupied bed. What procedure will the nurse
follow to correctly complete this task? (Select all that apply.)
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a.
Remove spread and blanket separately.
b.
Place soiled sheet at end of bed.
c.
Place bath blanket over patient on top sheet.
d.
Slide mattress to bottom of bed.
e.
Position patient to far side of bed.
ANS: A, C, E
When making an occupied bed the nurse will remove the spread and blanket
separately. The bath blanket is placed over the patient on the top sheet and the patient
is positioned to the far side of the bed. Soiled linen is placed in the laundry bin, not at
the end of the bed. The mattress is slid to the top of the bed.
DIF: Cognitive Level: Application
REF: p. 222
OBJ: 11
TOP: Making occupied bed KEY: Nursing Process
Step: Implementation MSC: NCLEX: Safe, Effective
Care Environment
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COMPLETION
1.
The nurse avoids dragging the patient across the bed linen to decrease the potential risk of
skin injury by
.
ANS:
friction
Dragging the patient across bed linen rather than lifting can cause skin damage from
friction.
DIF:
Cognitive Level: Comprehension REF:
p. 202
OBJ: 5 | 9 TOP: Friction
KEY:
Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment
2.
Because of its effect on epithelization, the LPN/LVN should confirm the order to
use
or alcohol on a
stage 3 pressure injury.
ANS:
peroxide
Peroxide and alcohol have a negative effect on epithelization of a pressure injury.
DIF: Cognitive Level: Knowledge
TOP: Pressure injuries
REF: p. 205
OBJ: 5
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Safe, Effective Care
Environment
3.
To prevent skin breakdown in a wheelchair-bound patient, the nurse teaches the patient to
shift the patient‘s weight every
minutes.
ANS:
15
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People who are wheelchair-bound should shift their weight by pushing on the arms of
their chair every 15 minutes to prevent skin breakdown.
DIF: Cognitive Level: Knowledge
TOP: Skin breakdown
REF: p. 205
OBJ: 5
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
4.
As a safety precaution against breakage of dentures, the nurse should place in the
emesis basin before cleaning the dentures.
ANS:
water
Water in the basin will break the fall of the dentures if they are dropped.
DIF: Cognitive Level: Knowledge
TOP: Oral hygiene
REF: p. 213
OBJ: 6
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Safe, Effective Care
Environment
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Chapter 10: Safety
Cooper: Foundations and Adult Health Nursing, 9th Edition
MULTIPLE
CHOICE
1.
The nurse manager is providing an in-service regarding a ―safe hospital
environment.‖ What will this education mainly focus on preventing?
a.
Falls
b.
Exposure to contaminants
c.
Injury
d.
Electric hazard
ANS: C
A safe environment implies freedom from injury.
DIF: Cognitive Level: Knowledge
REF: p. 235 OBJ: 6 TOP:
Safety
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Safe, Effective Care Environment
2.
What is important for the nurse to determine in order to decrease the risk for injury to a
patient?
a.
If patient can read English
b.
If patient is left-handed
c.
If patient ambulates with assistive device
d.
If patient can dress independently
ANS: B
Patients requiring an assistive device to ambulate are at an increased risk for injury.
DIF: Cognitive Level: Comprehension
REF: p. 237 OBJ: 1 TOP:
Safety
KEY: Nursing Process Step:
Assessment
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MSC: NCLEX: Safe, Effective Care Environment
3.
What skills should health care workers frequently attend in-services about to ensure
that staff has competent skills and risk for falls can be decreased?
a.
Bathing
b.
Feeding
c.
Transferring
d.
Ambulating
ANS: C
The majority of patient falls occur during transfer.
DIF: Cognitive Level: Comprehension
REF: p. 236 OBJ: 3 TOP:
Falls
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Safe, Effective Care Environment
4.
What important safety precaution should the home health nurse teach parents in order to
prevent burns to small children?
a.
Never leave them unattended.
b.
Turn pot handles on stoves away from reach.
c.
Turn hot water on first when filling the bathtub.
d.
Keep side rails up on the crib.
ANS: B
To protect infants and children from burns, turn the pot handles on stoves away from the
child‘s reach.
DIF: Cognitive Level: Application
REF: p. 237 OBJ: 2 TOP:
Safety
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Safe, Effective Care Environment
5.
What must the nurse do before applying a safety reminder device (SRD)?
a.
Get permission from the family.
b.
Assess patient‘s skin condition.
c.
Get a health care provider‘s order.
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d.
Explain the SRD to the patient.
ANS: C
Initially, an order is necessary that specifies the type of SRD and the duration of its
application.
DIF: Cognitive Level: Application
TOP: Safety reminder devices (SRDs)
REF: p. 243
OBJ: 4
KEY:
Nursing Process Step: Planning MSC: NCLEX:
Safe, Effective Care Environment
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6.
What should the nurse do when offering a cup of hot coffee to a frail, older adult patient?
a.
Give the patient a straw.
b.
Dilute the coffee with cold water.
c.
Fill the cup half full.
d.
Offer a bib or an apron.
ANS: C
Filling the cup half full promotes safety and does not change the flavor of the
beverage, nor does it demean the patient as would making him or her wear a bib or
apron.
DIF: Cognitive Level: Application REF: p. 236 | p. 237 | p. 241
OBJ: 2
TOP: Safety KEY: Nursing Process Step:
Implementation MSC: NCLEX: Safe, Effective Care
Environment
7.
What type of fire extinguisher should the nurse use when the oxygen concentrator
machine malfunctions and causes an electric fire?
a.
Type A
b.
Type B
c.
Type C
d.
Type D
ANS: C
Electric fires require type C fire extinguishers.
DIF: Cognitive Level: Application
REF: p. 249 OBJ: 7 TOP:
Fires
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Safe, Effective Care Environment
8.
A disaster situation occurs and involves an explosion in a hospital laundry. What would
this be classified as?
a.
Active
b.
External
c.
Life-threatening
d.
Internal
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ANS: D
Internal disaster often threatens the safety of patients and staff.
DIF: Cognitive Level: Analysis
OBJ: 9
REF: p. 252 | p. 253
TOP: Disaster KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
9.
The emergency department nurse admits a victim of poisoning. Who should the nurse
call to receive the best assistance for dealing with this victim?
a.
American Red Cross
b.
Fire department paramedics
c.
Poison control center
d.
Civil defense office
ANS: C
The nurse can access the local poison control center for assistance in caring for a victim
of poisoning.
DIF: Cognitive Level: Knowledge REF: p. 250 | p. 251
OBJ: 8
TOP: Poisoning
KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity
10.
A nurse instructs an unlicensed assistive personnel about the proper use of a gait belt
and is observing a return demonstration. What action by the unlicensed assistive
personnel should cause the nurse to intervene?
a.
Unlicensed assistive personnel is walking on the patient‘s strong side.
b.
Unlicensed assistive personnel is walking to the side of the patient.
c.
Unlicensed assistive personnel is securing the
gait belt securely around the patient‘s waist.
d.
Unlicensed assistive personnel is grasping the
handles of the gait belt while the patient ambulates.
ANS: A
A gait belt should be securely applied around the patient‘s waist. It has handles attached
for the nurse to grasp while the patient ambulates. The nurse should walk on the patient‘s
weaker side so that assistance may be given if the patient starts to fall.
DIF: Cognitive Level: Application REF: pp. 236-237
OBJ: 4
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TOP: Gait belt
KEY: Nursing Process Step: N/A
MSC:
NCLEX: N/A
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11.
What should a nurse do when encountering a mercury spill?
a.
Vacuum the spill.
b.
Open interior doors.
c.
Close all outside windows.
d.
Open any outside windows.
ANS: D
In the event of a mercury spill, interior doors should be closed and outside windows
should be opened. The spill should not be vacuumed.
DIF: Cognitive Level: Application
REF:
p. 245
OBJ: 9 TOP:
Mercury spill
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
MULTIPLE
RESPONSE
1.
When the nurse ambulates with a patient who has left-sided weakness, what actions
should the nurse take? (Select all that apply.)
a.
Walk on the patient‘s right side.
b.
Keep the patient away from heavy furniture.
c.
Hold the patient‘s arm securely.
d.
Keep the leg nearest the patient behind the patient‘s knee.
e.
Use a gait belt.
ANS: D, E
Ambulating with a person who has an identified weakness requires that the nurse
walk on the same side as the weakness, slightly behind the patient, with the nurse‘s
near leg behind the patient‘s knee. The nurse should use a gait belt and hold the
patient at the waist and the gait belt. Furniture can be used as support.
DIF:
Cognitive Level: Application REF:
pp. 236-237
OBJ: 3 TOP: Ambulating
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Safe, Effective Care Environment
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2.
The nurse assesses a patient in a Posey safety reminder device (SRD) for which
problem that may increase because of the use of SRDs? (Select all that apply.)
a.
Immobility
b.
Lethargy
c.
Risk for impaired circulation
d.
Risk for skin impairment
e.
Incontinence
ANS: A, C, D, E
The use of SRDs increases a patient‘s immobility, risk for skin impairment, risk for
impaired circulation, and incontinence. A SRD would not increase lethargy.
DIF: Cognitive Level: Comprehension REF: p. 240
TOP: Problems associated with SRDs
OBJ: 4
KEY:
Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
3.
A long-term care facility is committing to a restraint-free environment. What will the
health care workers implement to encourage this environment? (Select all that apply.)
a.
Frequent orientation to surroundings.
b.
Explain all procedures and treatments.
c.
Discourage visitors.
d.
Maintain toileting routines.
e.
Minimize exercise and ambulation.
ANS: A, B, D
To encourage a restraint-free environment, health care workers should provide frequent
orientation to surroundings, thoroughly explain all procedures and treatments, and
maintain toileting routines. Visitors should be encouraged so they may sit with the
residents, and frequent exercise and ambulation also should be encouraged.
DIF: Cognitive Level: Application
TOP: Restraint-free environment
REF: p. 257
OBJ: 5
KEY: Nursing
Process Step: Assessment MSC: NCLEX: Safe,
Effective Care Environment
COMPLETION
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is a violent or dangerous act used to intimidate or coerce a person or
1.
government to further a political or social agenda.
ANS:
Terrorism
Terrorism is a violent or dangerous act used to intimidate or coerce a person or
government to further a political or social agenda.
DIF: Cognitive Level: Knowledge
REF: p. 252
OBJ: 9
TOP: Terrorism
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
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2.
When reinforcing the PASS acronym for fire extinguisher use, the nurse reminds the staff
that the final ―S‖ stands for
.
ANS:
sweep
The acronym stands for: P = pull pin, A = aim, S = squeeze, S = sweep.
DIF: Cognitive Level: Knowledge
TOP: Fire extinguisher use
REF: p. 250
OBJ: 7
KEY: Nursing Process
Step: Implementation MSC: NCLEX: Safe, Effective
Care Environment
3.
The nurse conducting a seminar on bioterrorism reviews several types of agents that
may be used as weapons. An agent that does not seriously damage or kill the target
population but only impairs it is classified as
.
ANS:
incapacitating
The agent that only impairs the target rather than killing or seriously damaging it is
classified as an incapacitating agent.
DIF: Cognitive Level: Knowledge
p. 256
REF:
OBJ: 11 TOP:
Bioterrorism KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
4.
The nurse explains that the measurement of radiation exposure is in multiples of Gy.
The number of Gy an individual may absorb before becoming ill with radiation
syndrome is
.
ANS:
0.75
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The amount of radiation absorbed is measured by the Gy. 1 Gy is equal to 100 rad.
Absorption of 0.75 Gy will cause the individual to develop acute radiation syndrome.
DIF: Cognitive Level: Comprehension REF: p. 255
OBJ: 11
TOP: Radiation syndrome KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
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Chapter 11: Admission, Transfer, and Discharge
Cooper: Foundations and Adult Health Nursing, 9th Edition
MULTIPLE
CHOICE
1.
When admitting a patient to the hospital, the nurse observes that the patient is
distracted and tense. What does this behavior suggest as a common reaction to
hospitalization?
a.
Relief about being cared for
b.
Fear of the unknown
c.
Feeling of powerlessness
d.
Concern about cost
ANS: B
Fear of the unknown may be the most common reaction to hospitalization.
DIF:
Cognitive Level: Comprehension REF:
p. 260
OBJ: 3 | 5 TOP: Admission
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Psychosocial Integrity
2.
A nurse is admitting a patient to an acute care facility. During the admission
procedure, what nursing intervention would best help reduce patient anxiety?
a.
Transport the patient by wheelchair.
b.
Inform the health care provider that the patient is admitted.
c.
Greet the patient by name.
d.
Collect financial information during the interview.
ANS: C
Greeting the patient by name is one of the most important aspects of admission.
DIF:
p. 262
Cognitive Level: Application
REF:
OBJ: 1 | 4 | 5 TOP: Admission
KEY: Nursing Process Step:
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Implementation
MSC: NCLEX: Psychosocial Integrity
3.
What essential part of the admission procedure is performed by the RN?
a.
Securing the patient‘s valuables
b.
Confirming the type of insurance coverage
c.
Obtaining a health history
d.
Familiarizing the patient with the room
ANS: C
Admission assessment is performed by the RN.
DIF: Cognitive Level: Knowledge
p. 266
REF:
OBJ: 5 | 6 TOP: Admission
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Safe, Effective Care Environment
4.
When should discharge planning begin?
a.
The day before discharge
b.
On the first day postoperatively
c.
Shortly after admission
d.
When the health care provider orders it
ANS: C
Discharge planning begins shortly after admission.
DIF: Cognitive Level: Knowledge
p. 269
REF:
OBJ: 5 | 8 TOP: Discharge KEY:
Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment
5.
Where can a nurse refer the family of a patient to find a source of financial aid to meet
medical expenses?
a.
A local bank
b.
A clinical nurse specialist
c.
The hospital administration
d.
Social services
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ANS: D
Often a patient will require services of various disciplines within the hospital. Social
services can assist with meeting medical financial obligations.
DIF: Cognitive Level: Comprehension REF: p. 273
TOP: Social services
OBJ: 8
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Safe, Effective Care
Environment
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6.
When a patient demands to be discharged without a health care provider‘s order and
is leaving the unit with his belongings, what should the nurse ask the patient to sign?
a.
A form exercising the patient‘s rights
b.
A discharge against medical advice (AMA) form
c.
An informed consent
d.
An advanced directive
ANS: B
If a health care provider cannot convince the patient to stay, the patient should sign an
against medical advice (AMA) form.
DIF: Cognitive Level: Application REF: p. 273 | p. 274
OBJ: 10
TOP: Discharge
KEY: Nursing
Process Step: Implementation MSC: NCLEX: Safe,
Effective Care Environment
7.
The nurse must be sensitive to an older adult patient experiencing separation anxiety
when admitted to the hospital. When a child experiences separation anxiety, they will
usually cry. What will an older adult often demonstrate when experiencing
separation anxiety?
a.
Withdrawal
b.
Anger
c.
Depression
d.
Regression
ANS: C
The older adult may demonstrate depression as a result of separation anxiety entering the
hospital.
DIF: Cognitive Level: Comprehension
REF: p. 260 OBJ: 3 TOP:
Admission
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Psychosocial Integrity
8.
Upon admission, the nurse notes that a patient without family members present has a
billfold filled with cash. Where can the nurse suggest the money be placed?
a.
In a sealed envelope in the bedside table
b. In the care of hospital
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c.
Locked in the narcotic cupboard
d.
In the hospital safe
ANS: D
Valuables should be locked in the hospital safe.
DIF: Cognitive Level: Application
TOP: Care of valuables
REF: p. 263
OBJ: 6
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Safe, Effective Care
Environment
9.
If a patient has an order for an interagency transfer, where does the nurse explain that the
patient will be moved?
a.
A double room to a private room
b.
One unit of the hospital to another
c.
One room of the unit to another
d.
One facility to another
ANS: D
The interagency transfer moves a patient from one health care agency to another.
DIF: Cognitive Level: Comprehension
REF: p. 268 OBJ: 7 TOP:
Transfer
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Psychosocial Integrity
10.
Before the actual discharge occurs, what must the nurse ensure?
a.
The patient is well enough to go home.
b.
The patient has not been overly medicated.
c.
The patient understands the discharge instructions.
d.
The patient has adequate transportation.
ANS: C
It is essential that the patient be fully aware of the discharge instructions before being
discharged.
DIF: Cognitive Level: Application REF: pp.
268-269
OBJ: 5 | 9 TOP: Discharge
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KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Safe, Effective Care Environment
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11.
A patient who is alert and oriented is threatening to leave the hospital against medical
advice (AMA). What action should the nurse take?
a.
Forcibly detain and restrain the patient.
b.
Administer a sedative hypnotic medication.
c.
Prevent patient from leaving until an AMA form is signed.
d.
Notify the health care provider that the patient is threatening to leave AMA.
ANS: D
When a patient threatens to leave AMA, the health care provider should be notified
immediately. If the health care provider fails to convince the patient to remain in the
facility, the health care provider will ask the patient to sign an AMA form releasing
the facility from legal responsibility for any medical problems the patient may
experience after discharge. If the health care provider is not available, the nurse should
discuss the discharge form with the patient and obtain the patient‘s signature. If the
patient refuses to sign the AMA form, the patient should not be detained. This violates
the patient‘s legal rights. After the patient leaves, the nurse should document the
incident thoroughly in the nurse‘s notes and notify the health care provider. A rational
adult patient who will not sign the AMA form cannot be forcibly detained.
DIF: Cognitive Level: Application
TOP: Against medical advice
REF: p. 275
OBJ: 10
KEY: Nursing
Process Step: Implementation MSC: NCLEX: Safe,
Effective Care Environment
12.
How can the nurse demonstrate cultural sensitivity to a Haitian American patient?
a.
By providing a well-lit room 24 hours a day
b.
By writing out all instructions given to the patient
c.
By allowing the patient to keep leaves in her room
d.
By asking the health care provider to provide all directions to the patient
ANS: C
Many Haitians believe that leaves have a special significance in healing. Leaves may
be found in the clothes and on various parts of the body. Leaves are thought to have
mystical power related to regaining or keeping health.
DIF: Cognitive Level: Application
REF: p. 262
OBJ: 4
TOP: Cultural awareness KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychological Integrity
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13.
A nurse is caring for a Haitian American patient. How might the nurse demonstrate
cultural sensitivity?
a.
Discarding any leaves the patient may have brought with them
b.
Assigning the patient to a room with any Haitian American patient
c.
Instructing the patient to ride in a wheelchair when discharged
d.
Allowing the patient to walk out of the hospital when discharged
ANS: D
Some Haitian Americans associate wheelchairs with being sick. Therefore, on
discharge, the patient who is allowed to walk out of the hospital will be more likely to
feel that care has been effective. A poor patient with a Haitian background and a
wealthy patient with a Haitian background, although from the same country, may find
the same room assignment together in the hospital very distasteful.
DIF: Cognitive Level: Application
REF: p. 262
OBJ: 4
TOP: Cultural awareness KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychological Integrity
MULTIPLE RESPONSE
1.
The nurse adheres to the discharge standards set by The Joint Commission
(TJC), which include that patients will receive instruction regarding which
aspects of care? (Select all that apply.)
a.
Medications
b.
Rehabilitation techniques
c.
Referral to community agencies
d.
Medical equipment to be used
e.
Obtaining health insurance
ANS: A, B, C, D
The Joint Commission (TJC) standards require that a patient have information pertinent
to medication, rehabilitation instructions, referral to community agencies, instruction in
using any medical equipment, family care responsibility, diet, and how to obtain
further treatment if necessary.
DIF: Cognitive Level: Comprehension REF: p. 270
OBJ: 9
TOP: TJC standards for discharge KEY: Nursing
Process Step: Implementation MSC: NCLEX: Safe,
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Effective Care Environment
COMPLETION
1.
The nurse completes thorough documentation before, during, and after a
to ensure
continuity of care.
ANS:
transfer
Clear documentation before, during, and after a transfer ensures that the patient‘s
condition is being monitored and maintains the continuity of care.
DIF:
Cognitive Level: Comprehension REF: p. 269
TOP: Documentation
OBJ: 5 | 7
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Safe, Effective Care
Environment
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2.
Some Orthodox Jewish patients consider sundown Friday to sundown
to be the
Sabbath, which is a time of rest.
ANS:
Saturday
Some Orthodox Jewish patients consider sundown Friday to sundown Saturday to be
the Sabbath, which is a time of rest. These patients may avoid the use of any electronic
equipment, so the nurse should find alternatives to the use of this equipment if
possible.
DIF: Cognitive Level: Knowledge
TOP: Orthodox Jewish culture
REF: p. 262
OBJ: 3
KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Psychosocial Integrity
3.
Because of the stress caused by hospitalization, the nurse assesses a newly admitted older
adult patient for
.
ANS:
disorientation
In a normally alert and oriented older adult, medical conditions that necessitate
hospitalization often result in some level of disorientation.
DIF:
Cognitive Level: Application
REF: p. 261
OBJ: 3 | 5
TOP: Disorientation in older adults KEY: Nursing
Process Step: Assessment MSC: NCLEX:
Psychosocial Integrity
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Chapter 12: Vital Signs
Cooper: Foundations and Adult Health Nursing, 9th Edition
MULTIPLE
CHOICE
1.
What part of the body maintains a balance between heat production and heat loss,
regulating body temperature?
a.
Thymus
b.
Thyroid
c.
Hypothalamus
d.
Adrenal glands
ANS: C
Body temperature is regulated by the hypothalamus.
DIF: Cognitive Level: Knowledge
REF: p. 282
OBJ: 9 | 13
TOP: Vital signs
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
2.
What type of body temperature remains relatively constant?
a.
Surface
b.
Rectal
c.
Oral
d.
Core
ANS: D
The core body temperature remains relatively constant.
DIF: Cognitive Level: Knowledge
REF: p. 282 OBJ: 2 TOP:
Vital signs
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
3.
The nurse uses cooling techniques to keep the body temperature below 105°F
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(40.6°C). What can result from an elevated temperature?
a.
Excessive thirst
b.
Excessive perspiration
c.
Damage to body cells
d.
Increased heart rate
ANS: C
If the temperature exceeds 105°F (40.6°C), normal body cells may be damaged.
DIF: Cognitive Level: Comprehension
REF: p. 283 OBJ: 8 TOP:
Vital signs
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
4.
The emergency department nurse quickly assesses the temperature of an
unconscious patient who has been outside all night in below-freezing temperatures.
What temperature is the nurse aware of that can lead to death?
a.
95.2°F (35.1°C)
b.
93.0°F (33.8°C)
c.
93.2°F (34°C)
d.
90.8°F (32.6°C)
ANS: C
Death can occur if the temperature falls below 93.2° F (34°C).
DIF: Cognitive Level: Comprehension
REF: p. 283 OBJ: 9 TOP:
Vital signs
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
5.
What is the term for a fever that rises and falls but does not return to normal until the
patient is well?
a.
Constant
b.
Intermittent
c.
Remittent
d.
Elevated
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ANS: C
A remittent fever does not return to normal until the patient becomes well.
DIF: Cognitive Level: Knowledge
TOP: Remittent fever
REF: p. 283
OBJ: 9
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
6.
How should the nurse position the ear pinna when using the tympanic thermometer on a
child?
a.
Upward and back
b.
Parallel
c.
Downward and back
d.
Upward and forward
ANS: C
Using the tympanic thermometer for a child, the nurse will tug the ear pinna down and
back.
DIF:
Cognitive Level: Application
TOP: Tympanic thermometer for a child
REF: p. 287
OBJ: 3 | 9
KEY:
Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity
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7.
How should the nurse position the earpieces on a stethoscope to ensure optimum
reception?
a.
Backward
b.
Parallel to the ears
c.
Toward the face
d.
Downward
ANS: C
To ensure the best reception of sound, place earpieces pointing toward the face.
DIF: Cognitive Level: Application
p. 289
REF:
OBJ: 9 | 12 TOP: Vital signs
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
8.
What does the nurse use the diaphragm of the stethoscope to best assess?
a.
Carotid sounds
b.
Lung sounds
c.
Vascular sounds
d.
Low-pitched sounds
ANS: B
Lung sounds are auscultated by using the diaphragm of the stethoscope.
DIF: Cognitive Level: Comprehension REF: p. 300
TOP: Stethoscope use
OBJ: 6 | 9
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
9.
What is the pulse—the expansion and contraction of an artery— produced by?
a.
Contraction of the right atrium
b.
Contraction of the right ventricle
c.
Contraction of the left atrium
d.
Contraction of the left ventricle
ANS: D
Expansion and contraction of an artery is caused by the ejection of blood from the left
ventricle.
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DIF: Cognitive Level: Knowledge
REF: p. 290 OBJ: 4 TOP:
Vital signs
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
10.
When assessing vital signs on a 40-year-old male, the nurse identifies a pulse rate of
120 beats/min. What is this pulse interpreted as by the nurse?
a.
Normal
b.
Bradycardic
c.
Arrhythmic
d.
Tachycardic
ANS: D
If the pulse is faster than 100 beats/min on an adult patient, it is considered to be
tachycardic.
DIF: Cognitive Level: Analysis
REF: p. 290
OBJ: 5 TOP:
Tachycardia
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
11.
The patient‘s pulse is below 60 beats/min. The nurse is aware that the patient is not
receiving digoxin. What does the nurse suspect is causing the bradycardia?
a.
Low exercise tolerance
b.
Unrelieved severe pain
c.
Excessive bed rest
d.
A prone position
ANS: B
Bradycardia can result from unrelieved severe pain.
DIF: Cognitive Level: Analysis
REF: p. 290
OBJ: 5 TOP:
Bradycardia
KEY: Nursing Process Step:
Assessment
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MSC: NCLEX: Physiological Integrity
12.
What site should be selected if a peripheral pulse needs to be assessed quickly?
a.
Radial pulse
b.
Brachial pulse
c.
Carotid pulse
d.
Pedal pulse
ANS: C
The carotid site is the best for finding a pulse quickly.
DIF: Cognitive Level: Application
REF: p. 293 OBJ: 5 TOP:
Carotid
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
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13.
What is the term for the exchange of carbon dioxide and oxygen that takes place at the
alveolar level?
a.
Tachypnea
b.
Internal respiration
c.
External respiration
d.
Bradypnea
ANS: B
Internal respiration is the exchange of gas at the alveolar level.
DIF: Cognitive Level: Knowledge
REF: p. 294
OBJ: 6
TOP: Internal respiration KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
14.
A patient is suspected of having a cardiac arrhythmia. The nurse is concerned with
the findings of an apical rate of 88 and a radial rate of 80. What is the term for the
difference between these two rates?
a.
Pulse pressure
b.
Unequal pulses
c.
Pulse deficit
d.
Tachycardia
ANS: C
The difference between radial and apical pulses is called a pulse deficit.
DIF: Cognitive Level: Knowledge
REF: p. 293
OBJ: 5 TOP:
Pulse deficit
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
15.
The nurse is alarmed when a patient with a severe head injury of the occipital lobe has
a respiratory rate of 10 breaths/min. Where might this finding indicate that there is an
injury?
a.
Cerebellum
b.
Medulla oblongata
c.
Cortex
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d.
Cerebrum
ANS: B
Rate of respiration is controlled by the medulla oblongata.
DIF: Cognitive Level: Analysis
TOP: Respiratory rate
REF: p. 294
OBJ: 6
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
16.
The nurse assesses respirations of a patient demonstrating pursed-lip breathing, flared
nostrils, and retractions. How will the nurse describe these respirations?
a.
Tachypnea
b.
Stertorous
c.
Dyspnea
d.
Cheyne-Stokes
ANS: C
The patient who is using ancillary muscles to breathe is exhibiting dyspnea.
DIF: Cognitive Level: Analysis
REF: p. 295 OBJ: 6 TOP:
Dyspnea
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
17.
A nurse assesses a neonate‘s temperature by using a temporal artery scanner. What
intervention should the nurse implement if the neonate‘s temperature is 96°F
(35.5°C)?
a.
Record the findings.
b.
Notify the health care provider.
c.
Check the axillary temperature.
d.
Check the tympanic temperature.
ANS: A
The neonate‘s temperature normally ranges from 96° to 99.5°F (35.5° to 37.5°C).
Temperature regulation is labile (unstable) during infancy because of immature
physiologic mechanisms. Axillary measurement is considered the least accurate
method and is used less frequently since the advent of the tympanic membrane
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thermometer. Tympanic thermometer readings are suitable for patients of all ages,
except infants.
DIF: Cognitive Level: Application
REF: p. 283 OBJ: 8 TOP:
Vital signs
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
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18.
A nurse assesses a neonate‘s temperature by using a temporal artery scanner. What
intervention should the nurse implement if the neonate‘s temperature is 99.5°F
(37.5°C)?
a.
Record the findings.
b.
Notify the health care provider.
c.
Check the axillary temperature.
d.
Check the tympanic temperature.
ANS: A
The neonate‘s temperature normally ranges from 96° to 99.5°F (35.5° to 37.5°C).
Temperature regulation is labile (unstable) during infancy because of immature
physiologic mechanisms. Axillary measurement is considered the least accurate
method and is used less frequently since the advent of the tympanic membrane
thermometer. Tympanic thermometer readings are suitable for patients of all ages,
except infants.
DIF: Cognitive Level: Application
REF: p. 283 OBJ: 8 TOP:
Vital signs
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
19.
A nurse assesses a patient‘s dorsalis pedis pulse. The pulse is difficult to feel and not
palpable when only slight pressure is applied. How should the nurse document this
finding?
a.
Weak pulse
b.
Normal pulse
c.
Thready pulse
d.
Bounding pulse
ANS: C
A thready pulse is difficult to feel and is not palpable when only slight pressure is
applied. A weak pulse is somewhat stronger than a thready pulse but not palpable
when light pressure is applied. A normal pulse is easily felt but not palpable when
moderate pressure is applied. A bounding pulse feels full and springlike even under
moderate pressure.
DIF: Cognitive Level: Analysis
REF:
p. 291
KEY:
OBJ: 4 | 15 TOP: Pulses
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Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
20.
A nurse assesses a patient‘s dorsalis pedis pulse. The pulse is not palpable when
light pressure is applied. How should the nurse document this finding?
a.
Weak pulse
b.
Normal pulse
c.
Thready pulse
d.
Bounding pulse
ANS: A
A thready pulse is difficult to feel and is not palpable when only slight pressure is
applied. A weak pulse is somewhat stronger than a thready pulse but not palpable
when light pressure is applied. A normal pulse is easily felt but not palpable when
moderate pressure is applied. A bounding pulse feels full and springlike even under
moderate pressure.
DIF: Cognitive Level: Analysis
REF:
p. 291
KEY:
OBJ: 4 | 15 TOP: Pulses
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
21.
A nurse assesses a patient‘s dorsalis pedis pulse. The pulse is easily felt but not
palpable when moderate pressure is applied. How should the nurse document this
finding?
a.
Weak pulse
b.
Normal pulse
c.
Thready pulse
d.
Bounding pulse
ANS: B
A normal pulse is easily felt but not palpable when moderate pressure is applied. A
thready pulse is difficult to feel and is not palpable when only slight pressure is
applied. A weak pulse is somewhat stronger than a thready pulse but not palpable
when light pressure is applied. A bounding pulse feels full and springlike even under
moderate pressure.
DIF: Cognitive Level: Analysis
REF:
p. 291
KEY:
OBJ: 4 | 15 TOP: Pulses
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Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
22.
A nurse assesses a patient‘s dorsalis pedis pulse. The pulse feels full and springlike
even under moderate pressure. How should the nurse document this finding?
a.
Weak pulse
b.
Normal pulse
c.
Thready pulse
d.
Bounding pulse
ANS: D
A bounding pulse feels full and springlike even under moderate pressure. A thready
pulse is difficult to feel and is not palpable when only slight pressure is applied. A
weak pulse is somewhat stronger than a thready pulse but not palpable when light
pressure is applied. A normal pulse is easily felt but not palpable when moderate
pressure is applied.
DIF: Cognitive Level: Analysis
REF:
p. 291
KEY:
OBJ: 4 | 15 TOP: Pulses
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
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MULTIPLE
RESPONSE
1.
When instructing a primary caregiver about keeping a daily log of blood pressure
readings, what instructions should the nurse include? (Select all that apply.)
a.
Take the reading at different times during the day.
b.
Apply the cuff approximately 2 in above the antecubital fossa.
c.
If unable to get a reading the first time, immediately reinflate the cuff.
d.
Assess pulse with the bell of the stethoscope.
e.
Apply the cuff snugly.
ANS: B, E
Readings for a blood pressure log should be taken at the same time every day on the
same arm. The cuff should be applied 2 in above the antecubital fossa and snugly
secured. The pulse should be assessed with the diaphragm of the stethoscope. If unable
to get a reading the first time, the cuff should be deflated completely and reinflated
after several minutes.
DIF:
Cognitive Level: Application
REF: p. 279 | p. 280 OBJ:
7
TOP: Blood pressure
KEY: Nursing Process Step: Assessment
2.
MSC: NCLEX: Physiological Integrity
When assessing factors that may influence the patient‘s pulse rate, what should the
nurse take into consideration? (Select all that apply.)
a.
Age
b.
Sex
c.
Emotion
d.
Temperature
e.
Religion
ANS: A, B, C, D
All the options listed can affect the pulse rate, except religion.
DIF: Cognitive Level: Application
TOP: Influences on pulse rate
REF: p. 290
OBJ: 5
KEY: Nursing
Process Step: Assessment MSC: NCLEX:
Physiological Integrity
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3.
A patient is admitted to a medical surgical unit. What factors will determine how
frequently vital signs will be assessed? (Select all that apply.)
a.
Desire of the patient
b.
Judgment of need by the nurse
c.
Discretion of the family
d.
Orders of the health care provider
e.
Patient‘s condition
ANS: B, D, E
Whether and how frequently vital signs are measured depends on the nurse‘s judgment
of need, orders of the health care provider, and patient‘s condition. Desire of the
patient and family members cannot override these factors, but can be taken into
consideration within reason of these factors.
DIF: Cognitive Level: Comprehension REF:
p. 280
OBJ: 11 TOP:
Frequency of vital signs measurement
KEY: Nursing Process Step:
Implementation MSC:
NCLEX: Physiological
Integrity
4.
The home health nurse is preparing to educate a patient regarding electronic selfblood pressure measurement. What information should the nurse provide regarding
this procedure? (Select all that apply.)
a.
Expect precise values.
b.
Proper measurement techniques are necessary.
c.
Cuff fits over clothing.
d.
Stethoscope is not required.
e.
Recalibration is not necessary.
ANS: B, C, D
Self-blood pressure monitoring requires proper measurement techniques, cuff is made to
fit over clothing, and stethoscopes are not required. Values may be inaccurate and
recalibration is necessary at least once a year.
DIF: Cognitive Level: Application
TOP: Self-blood pressure measurement
REF: p. 305
OBJ: 14
KEY:
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Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity
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5.
The health care provider orders daily weights on a patient residing in a long-term
care setting. What actions should the nurse implement to assess weight
accurately? (Select all that apply.)
a.
Weigh patient at the same time each day.
b.
Schedule weighing immediately after breakfast.
c.
Encourage patient to void before being weighed.
d.
Ensure same amount of clothing is worn by patient.
e.
Calibrate by setting scale at zero after each weight.
ANS: A, C, D
Accurate assessment of weight should occur at the same time each day, preferably at 6
a.m. before breakfast. The patient should be encouraged to void before being weighed
and the same amount of clothing should be worn each day. The scale should be
calibrated to zero before (not after) each weight is taken.
DIF: Cognitive Level: Application
REF: p. 306
OBJ: 10
TOP: Weight measurement KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological
Integrity
COMPLETION
1.
The nurse assesses for the fifth vital sign, which is
.
ANS:
pain
Pain is considered the fifth vital sign.
DIF: Cognitive Level: Knowledge
REF: p. 280
OBJ: 1
TOP: Pain as a vital sign KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
2.
If a patient has an axillary temperature of 96.2°F (35.6°C), the nurse understands that the
true temperature is
°F.
ANS:
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97.2
Axillary temperatures are considered to be 1°F (–17.2°C) below core temperature.
DIF: Cognitive Level: Comprehension REF: p. 288
TOP: Axillary temperature
OBJ: 3
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
3.
The nurse assesses the blood pressure as 192/86, noting that the patient has a pulse
pressure of
.
ANS:
106
The pulse pressure is the difference between the diastolic and systolic readings.
DIF: Cognitive Level: Analysis
TOP: Pulse pressure
REF: p. 297
OBJ: 7
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
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Chapter 13: Physical Assessment
Cooper: Foundations and Adult Health Nursing, 9th Edition
MULTIPLE
CHOICE
1.
The nurse is collecting data during an initial assessment. What can be seen, heard,
measured, or felt and is objective?
a.
Symptom
b.
Observation
c.
Sign
d.
Assessment
ANS: C
A sign can be seen, heard, measured, or felt.
DIF: Cognitive Level: Knowledge
TOP: Assessment
2.
REF: p. 311
OBJ: 1
KEY: Nursing Process Step: Assessment
MSC: NCLEX: N/A
As part of an assessment, the nurse asks the patient for subjective information related
to the present illness. What are the subjective findings perceived by the patient?
a.
Assessments
b.
Symptoms
c.
Signs
d.
Observations
ANS: B
Symptoms are subjective indications of illness that are perceived by the patient.
DIF: Cognitive Level: Knowledge
TOP: Assessment
3.
REF: p. 312
OBJ: 1
KEY: Nursing Process Step: Assessment
MSC: NCLEX: N/A
Any disturbance of a structure or function of the body is a pathologic condition. What is
the term for this condition?
a.
Injury
b.
Condition
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c.
Disease
d.
Pathology
ANS: C
A disease is any disturbance of a structure or function of the body.
DIF: Cognitive Level: Knowledge
REF: p. 312
OBJ: 2
TOP: Disease KEY: Nursing Process Step: Assessment
4.
MSC: NCLEX: N/A
The nurse is assessing a patient for collection of subjective and objective data. What will
this data provide the basis for making?
a.
Care plan
b.
Medical diagnosis
c.
Nursing assessment
d.
Patient problem
ANS: D
Nurses rely on assessment of signs and symptoms to formulate a patient problem.
DIF: Cognitive Level: Comprehension REF: p. 313
TOP: Assessment
5.
OBJ: 11
KEY: Nursing Process Step: Assessment
MSC: NCLEX: N/A
The nurse is discussing the origin of diabetes with a diabetic patient. What will
the nurse discuss as the most appropriate explanation for the cause of this
disease?
a.
Pituitary
b.
Adrenals
c.
Pancreas
d.
Thyroid
ANS: C
Diabetes mellitus results from dysfunction of the pancreas.
DIF: Cognitive Level: Comprehension
REF: p. 312 OBJ: 2 TOP:
Disease
KEY: Nursing Process Step:
Evaluation
MSC: NCLEX: Physiological Integrity
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6.
There are four categories of factors that increase an individual‘s vulnerability to
develop a disease: genetic, physiologic, age, and lifestyle. What is the term for these
factors?
a.
Risk factors
b.
Causative factors
c.
Etiologic factors
d.
Hazardous factors
ANS: A
Risk factors are placed into four categories.
DIF: Cognitive Level: Knowledge
REF: p. 313 OBJ: 3 TOP:
Disease
KEY: Nursing Process Step:
Evaluation
MSC: NCLEX: Physiological Integrity
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7.
When discussing diabetes with a patient, the nurse describes this disease as falling into
which group in terms of duration?
a.
Acute
b.
Organic
c.
Chronic
d.
Functional
ANS: C
Diabetes mellitus is an example of a chronic disease.
DIF: Cognitive Level: Comprehension
REF: p. 313 OBJ: 4 TOP:
Disease
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
8.
What is the term used to describe a disease where there has been a partial or
complete disappearance of clinical and subjective characteristics of the disease?
a.
Acute
b.
Functional
c.
Chronic
d.
Remission
ANS: D
Remission means there has been partial or complete disappearance of the clinical and
subjective characteristics.
DIF: Cognitive Level: Knowledge
REF: p. 313 OBJ: 4 TOP:
Disease
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
9.
What type of disease results in a structural change in an organ that interferes with its
functioning?
a.
Functional disease
b.
Organic disease
c.
Acute disease
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d.
Chronic disease
ANS: B
An organic disease results in a structural change in an organ.
DIF: Cognitive Level: Knowledge
REF: p. 313 OBJ: 2 TOP:
Disease
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
10.
The signs and symptoms of both infection and inflammation include erythema,
edema, and pain. What is considered the major difference between infection and
inflammation?
a.
Inflammation is a result of bacteria.
b.
Inflammation is a protective response.
c.
Inflammation is a disease process.
d.
Inflammation produces tissue damage.
ANS: B
Inflammation is a protective response.
DIF: Cognitive Level: Comprehension
REF: p. 313 OBJ: 5 TOP:
Disease
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
11.
A nursing assessment is a process of collecting data to establish a database. The
information contained in the database is a basis for:
a.
a complete physical examination.
b.
a medical assessment.
c.
an individualized plan of care.
d.
writing nursing orders.
ANS: C
The information contained in the database is the basis for an individualized plan of care.
DIF: Cognitive Level: Comprehension REF: p. 316
OBJ: 13
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TOP: Assessment
12.
KEY: Nursing Process Step: Assessment
MSC: NCLEX: N/A
The nurse is meeting a patient for the first time. What is the first thing the nurse will do to
initiate a nurse-patient relationship?
a.
Appear interested.
b.
Introduce herself/himself.
c.
Provide support.
d.
Communicate trust.
ANS: B
The first step in a nurse-patient relationship is for the nurse to introduce herself/himself.
DIF: Cognitive Level: Application
TOP: Nurse-patient relationship
REF: p. 318
OBJ: 9
KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Psychosocial Integrity
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13.
What should a patient interview being conducted by the nurse convey to the patient?
a.
The nurse has feelings of concern.
b.
The nurse has limited time.
c.
The nurse is very intelligent.
d.
The nurse has answers to problems.
ANS: A
The nurse must convey feelings of concern.
DIF: Cognitive Level: Comprehension
REF: p. 319 OBJ: 9 TOP:
Interview
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
14.
What does the nurse recognize as the initial step in conducting an assessment of a patient?
a.
A body systems review
b.
The nursing health history
c.
Biographic data
d.
The present illness
ANS: B
The nursing health history is the initial step in the assessment process.
DIF: Cognitive Level: Comprehension REF:
p. 318
OBJ: 11 TOP: Assessment KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
15.
When collecting data related to the present illness, the nurse must obtain detailed and
comprehensive data. What does this data help to establish?
a.
A patient problem
b.
A nursing care plan
c.
Appropriate interventions
d.
Nursing orders
ANS: C
The data collected related to the present illness must be detailed and comprehensive to
allow planning of appropriate interventions.
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DIF: Cognitive Level: Comprehension REF:
p. 320
OBJ: 10 TOP: Assessment KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
16.
During the nursing interview, several histories are taken. What is the history that
involves data concerning habits and lifestyle patterns?
a.
Family history
b.
Environmental history
c.
Past health history
d.
Psychosocial history
ANS: C
The nurse identifies habits and lifestyle patterns under the past health history.
DIF: Cognitive Level: Knowledge
REF:
p. 320
KEY:
OBJ: 10 TOP: Interview
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
17.
The nurse uses a systematic method for collecting data on all body systems, including
normal functioning and any noted changes. What is this method?
a.
Nursing interview
b.
Review of systems
c.
Nursing assessment
d.
Health history
ANS: B
A review of systems is a systematic method.
DIF: Cognitive Level: Knowledge
REF:
p. 321
KEY:
OBJ: 11 TOP: Interview
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
18.
The nurse is developing a nursing care plan for a newly admitted patient. What is the
first step the nurse will take in developing this care plan?
a.
Health history
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b.
Review of systems
c.
Family history
d.
Nursing assessment
ANS: D
The nursing assessment is the critical step in forming the nursing care plan.
DIF: Cognitive Level: Application
p. 325
REF:
OBJ: 11 TOP: Assessment KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
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19.
The patient should be assessed as soon as possible after admission. Who performs this
initial assessment?
a.
Health care provider
b.
Charge nurse
c.
LPN/LVN
d.
RN
ANS: D
The initial assessment is done by the registered nurse.
DIF: Cognitive Level: Knowledge
REF: p. 324 OBJ: 8 TOP:
Assessment KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
20.
A patient was admitted with a complaint of abdominal pain. Later, the nurse
observed the patient demonstrating dyspnea. What type of assessment does this
change in condition require?
a.
Individualized
b.
Focused
c.
Specialized
d.
Systematic
ANS: B
When the nurse observes a change in the patient‘s condition, the assessment is focused.
DIF: Cognitive Level: Application
p. 324
REF:
OBJ: 12 TOP: Assessment KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
21.
When performing a nursing physical assessment, the nurse uses a head-to-toe
approach. Where will the nurse begin when using this method?
a.
Skin assessment
b.
Neurologic assessment
c.
Circulatory assessment
d.
Respiratory assessment
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ANS: B
When performing a head-to-toe assessment, the nurse begins with a neurologic assessment.
DIF: Cognitive Level: Application
p. 325
REF:
OBJ: 11 TOP: Assessment KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
22.
An older adult patient is being assessed for skin turgor. The nurse identifies
decreased skin turgor demonstrated by slow return of the skin to the previous position
after being grasped and raised. What can the nurse conclude is responsible for this
assessment?
a.
Dehydration
b.
Edema
c.
Skin breakdown
d.
Malnutrition
ANS: A
Dehydration results in decreased skin turgor.
DIF: Cognitive Level: Analysis
p. 327
REF:
OBJ: 12 TOP: Assessment KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
23.
During a physical assessment, the nurse listens for adventitious lung sounds.
Crackles are classified as fine, medium, or coarse. When are these sounds most
often auscultated?
a.
During expiration
b.
Following expiration
c.
During inspiration
d.
Following inspiration
ANS: C
Crackles are usually heard during inspiration.
DIF:
Cognitive Level: Comprehension
REF: pp. 328-329
TOP: Assessment
OBJ: 12
KEY: Nursing
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Process Step: Assessment
MSC: NCLEX: Physiological Integrity
24.
Auscultating the heart sounds should result in a ―lub-dup‖ sound when using the bell
and the diaphragm of the stethoscope. What causes the ―lub‖ sound?
a.
Opening of the AV valves
b.
Opening of the semilunar valves
c.
Closing of the AV valves
d.
Closing of the semilunar valves
ANS: C
The ―lub-dup‖ sound of the heart is caused by the closing of the AV and semilunar
valves, respectively. (lub-dup or lub-dub?)
DIF: Cognitive Level: Comprehension REF:
p. 330
OBJ: 12 TOP: Assessment KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
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25.
The nurse assesses a patient for capillary refill after the fingernail is compressed for
5 seconds. What should the nurse expect the refill time to be?
a.
1 second
b.
2 seconds
c.
3 seconds
d.
4 seconds
ANS: C
Capillary refill should take fewer than 3 seconds.
DIF: Cognitive Level: Application
p. 332
REF:
OBJ: 12 TOP: Assessment KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
26.
Listening for bowel sounds should be done over all four quadrants of the abdomen
using the diaphragm of the stethoscope. What is the normal rate of bowel sounds per
minute?
a.
2 to 10
b.
3 to 20
c.
4 to 32
d.
5 to 40
ANS: C
The normal rate of bowel sounds per minute is 4 to 32.
DIF: Cognitive Level: Knowledge
p. 332
REF:
OBJ: 12 TOP: Assessment KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
27.
A patient has edema of the lower extremities. The nurse is assessing whether it is
pitting and to what degree. After pressing the skin against a bony prominence for 5
seconds, the nurse identifies 2+ pitting edema. When did the edema disappear?
a.
10 to 15 seconds
b.
20 to 25 seconds
c.
30 to 35 seconds
d.
40 to 45 seconds
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ANS: A
The 2+ pitting edema is identified because the pitting edema disappears in 10 to 15
seconds.
DIF:
Cognitive Level: Application REF: p. 331 | p. 334
OBJ: 12
TOP: Assessment
KEY: Nursing
Process Step: Assessment MSC: NCLEX:
Physiological Integrity
28.
Various techniques are used by the nurse when performing a physical assessment.
One of these techniques is percussion. What is percussion used to determine?
a.
Sounds for auscultation
b.
Data about physical features
c.
Changes in structural integrity
d.
Density of underlying tissue
ANS: D
The sounds indicate the density of the underlying tissue.
DIF: Cognitive Level: Comprehension REF:
p. 334
OBJ: 12 TOP: Assessment KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
29.
The nurse is obtaining a history of a patient‘s present illness. The PQRST system is
used for the interview. What does the R stand for in this system?
a.
Random
b.
Region
c.
Result
d.
Recent
ANS: B
In the PQRST system, the R stands for region.
DIF: Cognitive Level: Knowledge
p. 320
REF:
OBJ: 10 TOP: Assessment KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
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30.
When performing a physical examination of a patient, the nurse uses a technique that
is particularly useful in identifying areas of tenderness or masses of the abdomen.
What is this technique?
a.
Auscultation
b.
Deep palpation
c.
Light palpation
d.
Percussion
ANS: B
Deep palpation is used to detect tenderness or masses of the abdomen.
DIF: Cognitive Level: Comprehension
REF: p. 333 OBJ: 8 TOP:
Assessment KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
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31.
The nurse is performing auscultation of breath sounds on a respiratory patient. The
sounds heard on inspiration and expiration are low-pitched, coarse, gurgling, and
have a snoring sound. What best identifies these sounds?
a.
Crackles
b.
Plural friction rub
c.
Rhonchi
d.
Sonorous wheezes
ANS: D
Sonorous wheezes have a low-pitched, coarse, gurgling, snoring quality and usually
indicate the presence of mucus in the trachea and large airways.
DIF: Cognitive Level: Analysis
p. 329
REF:
OBJ: 12 TOP: Assessment KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
32.
What is the suggested sequence for a systematic approach to begin auscultating the
thorax?
a.
Anterior thorax
b.
Apices
c.
Left lateral thorax
d.
Right lateral thorax
ANS: B
The suggested sequence for a systematic auscultation of the thorax is to begin with the
apices.
DIF: Cognitive Level: Comprehension REF:
p. 328
OBJ: 11 TOP: Assessment KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
33.
A nurse is gathering objective data when admitting a patient. Which assessment
finding reported by the patient is considered objective?
a.
Complains of nausea
b.
States, ―I hurt all over.‖
c.
Complains of feeling anxious
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d.
Appears to be anxious
ANS: D
Objective data can be seen, heard, measured, or felt by the examiner. It is information
that is observable and measurable and can be verified by more than one person.
Anxiety is the only objective assessment finding. All other options are examples of
subjective data.
DIF: Cognitive Level: Application
REF: p. 312 OBJ: 1 TOP:
Assessment KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
34.
A nurse is gathering objective data when admitting a patient. Which assessment finding is
considered objective data?
a.
The patient complains of chest pain.
b.
The patient states, ―I am having trouble breathing.‖
c.
The patient complains of coughing up sputum.
d.
The patient expectorates red-tinged sputum.
ANS: D
Objective data can be seen, heard, measured, or felt by the examiner. It is information
that is observable and measurable and can be verified by more than one person.
Expectoration of red-tinged sputum is the only objective assessment finding. All other
options are examples of subjective data.
DIF: Cognitive Level: Application
REF: p. 312 OBJ: 1 TOP:
Assessment KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
35.
A nurse is gathering subjective data when admitting a patient. Which assessment
finding reported by the patient is considered subjective data?
a.
Complains of chest pain.
b.
Is experiencing dyspnea.
c.
Appears to be anxious.
d.
Expectorates red-tinged sputum.
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ANS: A
Symptoms are subjective indications of illness that are perceived by the patient.
Examples of symptoms are pain, nausea, vertigo, pruritus, diplopia, numbness, and
anxiety. The nurse is unaware of symptoms unless the patient describes the sensation.
Symptoms are referred to as subjective data. Chest pain is the only subjective
assessment finding. All other options are examples of objective data.
DIF: Cognitive Level: Application
REF: p. 312 OBJ: 1 TOP:
Assessment KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
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36.
A nurse is gathering subjective data when admitting a patient. Which assessment
finding reported by the patient is considered subjective data?
a.
Complains of pruritus.
b.
Is experiencing erythema.
c.
Appears to be experiencing pruritus.
d.
Has a generalized rash.
ANS: A
Symptoms are subjective indications of illness that are perceived by the patient.
Examples of symptoms are pain, nausea, vertigo, pruritus, diplopia, numbness, and
anxiety. The nurse is unaware of symptoms unless the patient describes the sensation.
Symptoms are referred to as subjective data. Pruritus is the only subjective assessment
finding. All other options are examples of objective data.
DIF: Cognitive Level: Application
REF: p. 312 OBJ: 1 TOP:
Assessment KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
37.
A nurse is gathering subjective data when admitting a patient. Which assessment
finding reported by the patient is considered subjective data?
a.
Complains of diplopia
b.
Is experiencing nystagmus
c.
Demonstrates facial grimacing
d.
Has a generalized rash
ANS: A
Symptoms are subjective indications of illness that are perceived by the patient.
Examples of symptoms are pain, nausea, vertigo, pruritus, diplopia, numbness, and
anxiety. The nurse is unaware of symptoms unless the patient describes the sensation.
Symptoms are referred to as subjective data. Diplopia is the only subjective
assessment finding. All other options are examples of objective data.
DIF: Cognitive Level: Application
REF: p. 312 OBJ: 1 TOP:
Assessment KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
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38.
What should the nurse begin by assessing when performing a head-to-toe assessment?
a.
Support system
b.
Skin integrity
c.
Pain level
d.
Neurologic status
ANS: D
When performing a head-to-toe assessment, the nurse begins with a neurologic
assessment, then assesses the skin, hair, head, and neck, including the eyes, ears,
nose, and mouth. The chest, back, arms, abdomen, perineal area, legs, and feet are
examined in that order.
DIF: Cognitive Level: Comprehension REF:
p. 325
OBJ: 11 TOP: Assessment KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
39.
During a head-to-toe assessment, the nurse assesses the patient‘s abdomen. Which area
should the nurse assess next?
a.
Chest
b.
Arms
c.
Legs and feet
d.
Perineal area
ANS: D
When performing a head-to-toe assessment, the nurse begins with a neurologic
assessment, then assesses the skin, hair, head, and neck, including the eyes, ears,
nose, and mouth. The chest, back, arms, abdomen, perineal area, legs, and feet are
examined in that order.
DIF: Cognitive Level: Application
p. 325
REF:
OBJ: 11 TOP: Assessment KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
40.
During a head-to-toe assessment, the nurse assesses the patient‘s perineal area. Which
area should the nurse assess next?
a.
Chest
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b.
Arms
c.
Abdomen
d.
Legs and feet
ANS: D
When performing a head-to-toe assessment, the nurse begins with a neurologic
assessment, then assesses the skin, hair, head, and neck, including the eyes, ears,
nose, and mouth. The chest, back, arms, abdomen, perineal area, legs, and feet are
examined in that order.
DIF: Cognitive Level: Application
p. 325
REF:
OBJ: 11 TOP: Assessment KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
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41.
During a neurologic assessment, the nurse notes a patient has a unilateral, dilated,
and nonreactive pupil. This is a sign that the patient is experiencing pressure on
which cranial nerve?
a.
I
b.
II
c.
III
d.
IV
ANS: C
The third cranial nerve runs parallel to the brainstem. The function of the oculomotor
nerve is essential for eye movements. A traumatic brain injury can result in increased
intracranial pressure, edema to the brainstem with pressure on cranial nerve III,
causing the ominous sign of a unilateral, dilated, and nonreactive pupil.
DIF: Cognitive Level: Analysis
p. 325
REF:
OBJ: 12 TOP: Assessment KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
42.
A health care provider needs to insert a vaginal speculum into a patient for a vaginal
examination. In what position should the nurse place the patient?
a.
Sims
b.
Prone
c.
Lithotomy
d.
Dorsal recumbent
ANS: C
The lithotomy position provides maximal exposure of genitalia and facilitates insertion of
a vaginal speculum.
DIF: Cognitive Level: Application
REF: p. 317 OBJ: 6 TOP:
Assessment KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
43.
A health care provider needs to assess extension of a patient‘s hip joint. In what position
should the nurse place the patient?
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a.
Sims
b.
Prone
c.
Lithotomy
d.
Dorsal recumbent
ANS: B
Prone position is used to assess extension of a patient‘s hip joint.
DIF: Cognitive Level: Application
REF: p. 317 OBJ: 6 TOP:
Assessment KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
44.
A health care provider needs to assess a patient for a heart murmur. In what position
should the nurse place the patient?
a.
Sims
b.
Prone
c.
Lithotomy
d.
Lateral recumbent
ANS: D
The lateral recumbent position aids in detecting heart murmurs.
DIF: Cognitive Level: Application
REF: p. 317 OBJ: 6 TOP:
Assessment KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
45.
A health care provider needs to assess a patient‘s rectal area. In what position should the
nurse place the patient?
a.
Sims
b.
Prone
c.
Lithotomy
d.
Knee-chest
ANS: D
Knee-chest position provides maximum exposure of the rectal area.
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DIF: Cognitive Level: Application
REF: p. 317 OBJ: 6 TOP:
Assessment KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
46.
A nurse needs to auscultate a patient‘s lung sounds. In what position should the nurse
place the patient?
a.
Sims
b.
Prone
c.
Sitting
d.
Lithotomy
ANS: C
Sitting upright provides full expansion of the lungs and provides better visualization of
symmetry of upper body parts.
DIF: Cognitive Level: Application
p. 317
REF:
OBJ: 11 TOP: Assessment KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
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47.
During a physical assessment, the nurse notes a patient has a bluish discoloration of
the skin and mucous membranes. How should the nurse document this finding?
a.
Dyspnea
b.
Cyanosis
c.
Diaphoresis
d.
Ecchymosis
ANS: B
Cyanosis is a bluish discoloration of the skin and mucous membranes caused by an
increase of deoxygenated hemoglobin in the blood.
DIF: Cognitive Level: Knowledge
p. 314
REF:
OBJ: 13 TOP: Assessment KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
48.
During a physical assessment, the nurse notes a patient has a lack of appetite resulting
in an inability to eat. What should the nurse document that the patient is
experiencing?
a.
Dyspnea
b.
Asthenia
c.
Anorexia
d.
Ecchymosis
ANS: C
Anorexia is a lack of appetite resulting in the inability to eat. This symptom can occur in
many disease conditions.
DIF: Cognitive Level: Knowledge
p. 314
REF:
OBJ: 13 TOP: Assessment KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
49.
During a physical assessment, the nurse notes a patient has a loss of strength and
energy. What should the nurse document that the patient is experiencing?
a.
Dyspnea
b.
Cyanosis
c.
Asthenia
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d.
Ecchymosis
ANS: C
Asthenia is a condition of debility, loss of strength and energy, and depleted vitality.
DIF: Cognitive Level: Knowledge
p. 314
REF:
OBJ: 13 TOP: Assessment KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
50.
During a physical assessment, the nurse notes that a patient‘s heart rate is 56
beats/min. What should the nurse document that the patient is experiencing?
a.
Dyspnea
b.
Cyanosis
c.
Diaphoresis
d.
Bradycardia
ANS: D
Bradycardia is a circulatory condition in which the myocardium contracts steadily but
at a rate of less than 60 contractions per minute.
DIF: Cognitive Level: Application
p. 314
REF:
OBJ: 13 TOP: Assessment KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
51.
During a physical assessment, the patient complains of difficulty in passing stools.
What should the nurse document that the patient is experiencing?
a.
Dyspnea
b.
Cyanosis
c.
Constipation
d.
Ecchymosis
ANS: C
Constipation is difficulty in passing stools or an incomplete or infrequent passage of
hard stools. There are many causes, both organic and functional.
DIF: Cognitive Level: Knowledge
p. 314
REF:
OBJ: 13 TOP: Assessment KEY:
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Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
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52.
During a physical assessment, the nurse observes a patient experiencing a sudden
audible expulsion of air from the lungs. What should the nurse document that the
patient is experiencing?
a.
Dyspnea
b.
Cyanosis
c.
Coughing
d.
Ecchymosis
ANS: C
Coughing is a sudden audible expulsion of air from the lungs. Coughing is an
essential protective response that serves to clear the lungs, bronchi, or trachea of
irritants and secretions or to prevent aspiration of foreign material into the lungs. It is
a common sign of diseases of the larynx, bronchi, and lungs.
DIF: Cognitive Level: Knowledge
p. 314
REF:
OBJ: 13 TOP: Assessment KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
53.
During a physical assessment, the nurse notes a patient has profuse secretions of
sweat. What should the nurse document that the patient is experiencing?
a.
Dyspnea
b.
Cyanosis
c.
Diaphoresis
d.
Ecchymosis
ANS: C
Diaphoresis is the secretion of sweat, especially the profuse secretion associated
with an elevated body temperature, physical exertion, exposure to heat, and
mental or emotional stress.
DIF: Cognitive Level: Knowledge
p. 314
REF:
OBJ: 13 TOP: Assessment KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
54.
During a physical assessment, the nurse notes a patient passes frequent loose liquid
stools. What should the nurse document that the patient is experiencing?
a. Dyspnea
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b.
Cyanosis
c.
Diaphoresis
d.
Diarrhea
ANS: D
Diarrhea is the frequent passage of loose liquid stools. It generally results from
increased motility in the colon. This is usually a sign of an underlying disorder. The
characteristics of the diarrhea give evidence as to the source. Dark black, tarry stools
can mean there is bleeding in the intestines. Bright red blood in the feces indicates
active bleeding from the lower portion of the intestinal tract.
DIF: Cognitive Level: Knowledge
p. 314
REF:
OBJ: 13 TOP: Assessment KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
55.
During a physical assessment, the nurse notes that a patient has bright red blood in the
feces. What does the nurse recognize as the most likely cause of this bleeding?
a.
Bleeding in the upper intestinal tract
b.
Bleeding in the lower intestinal tract
c.
Bleeding in the entire intestinal tract
d.
Consumption of cranberry juice
ANS: B
Bright red blood in the feces indicates active bleeding from the lower portion of the
intestinal tract.
DIF: Cognitive Level: Application
p. 314
REF:
OBJ: 12 TOP: Assessment KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
56.
A nurse is caring for a patient with congestive heart failure. During the physical
assessment, the nurse notes the patient is experiencing difficulty breathing.
What should the nurse document that the patient is experiencing?
a.
Dyspnea
b.
Cyanosis
c.
Diaphoresis
d.
Ecchymosis
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ANS: A
Dyspnea is shortness of breath or difficulty in breathing that may be caused by
certain heart and lung conditions, strenuous exercise, or anxiety.
DIF: Cognitive Level: Knowledge
p. 314
REF:
OBJ: 13 TOP: Assessment KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
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57.
A patient has discoloration of an area of their mucous membrane caused by
extravasation of blood into the subcutaneous tissue. What should the nurse
document that the patient has?
a.
Dyspnea
b.
Cyanosis
c.
Diaphoresis
d.
Ecchymosis
ANS: D
Ecchymosis is discoloration of an area of the skin or mucous membrane caused by
the extravasation of blood into subcutaneous tissues as a result of trauma to the
underlying blood vessels or by fragility of the vessel walls (also called a bruise).
DIF: Cognitive Level: Application
p. 314
REF:
OBJ: 13 TOP: Assessment KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
58.
When admitting a patient to the hospital, the nurse notes the patient has mild
sunburn. How should the nurse document this finding?
a.
Dyspnea
b.
Cyanosis
c.
Erythema
d.
Ecchymosis
ANS: C
Erythema is redness or inflammation of the skin or mucous membranes that is the result
of dilation and congestion of superficial capillaries; erythema is seen in mild sunburn.
DIF: Cognitive Level: Application
p. 314
REF:
OBJ: 13 TOP: Assessment KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
59.
When assessing a patient with hepatitis, the nurse notes a yellow tinge to the patient‘s
skin. What does the nurse understand as the most likely cause of the jaundice?
a.
Heart
b.
Liver
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c.
Brain
d.
Intestines
ANS: B
Jaundice is a yellow tinge to the skin; it may indicate obstruction in the flow of bile from
the liver.
DIF: Cognitive Level: Comprehension REF:
p. 314
OBJ: 12 TOP: Assessment KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
60.
When assessing a patient, the nurse notes a yellow tinge to the patient‘s skin. How should
the nurse document this finding?
a.
Dyspnea
b.
Cyanosis
c.
Jaundice
d.
Ecchymosis
ANS: C
Jaundice is a yellow tinge to the skin; it may indicate obstruction in the flow of bile from
the liver.
DIF: Cognitive Level: Application
p. 314
REF:
OBJ: 13 TOP: Assessment KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
61.
When assessing a patient, the nurse notes that the patient is unable to lie flat to
breathe. When the nurse assists the patient into a sitting position, the patient is able
to breathe more easily. What should the nurse document that the patient is
experiencing?
a.
Dyspnea
b.
Cyanosis
c.
Jaundice
d.
Orthopnea
ANS: D
Orthopnea is an abnormal condition in which a person must sit or stand to breathe
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deeply or comfortably. It occurs in many disorders of the respiratory and cardiac
systems.
DIF: Cognitive Level: Application
p. 315
REF:
OBJ: 13 TOP: Assessment KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
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62.
When assessing a patient, the nurse notes that the patient has an unnatural paleness
of color to the skin. How should the nurse document this finding?
a.
Skin pallor
b.
Pruritus
c.
Sallow skin
d.
Jaundice
ANS: A
Pallor is an unnatural paleness or absence of color in the skin; it may result from a
decrease in hemoglobin and erythrocytes.
DIF: Cognitive Level: Application
p. 315
REF:
OBJ: 13 TOP: Assessment KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
63.
When assessing a patient, the patient complains of an uncomfortable sensation
leading to an urge to scratch. The nurse notes the patient scratches frequently. How
should the nurse document this finding?
a.
Dyspnea
b.
Cyanosis
c.
Jaundice
d.
Pruritus
ANS: D
Pruritus is a symptom of itching and an uncomfortable sensation leading to an urge to
scratch. Some causes are allergy, infection, jaundice, elevated serum urea, and skin
irritation.
DIF: Cognitive Level: Application
p. 315
REF:
OBJ: 13 TOP: Assessment KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
64.
A health care provider documents that a patient is having purulent drainage from a
wound. What does the nurse understand is most likely the cause?
a.
Ringworm
b.
Viral infection
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c.
Fungal infection
d.
Bacterial infection
ANS: D
Purulent drainage is a creamy, viscous, pale yellow or yellow-green fluid exudate that
is the result of fluid remains of liquefied necrosis of tissues. Bacterial infection is the
most common cause. The character of the pus, including its color, consistency,
quantity, or odor, may be of diagnostic significance.
DIF: Cognitive Level: Comprehension
REF: p. 315 OBJ: 5 TOP:
Assessment KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
65.
A health care provider documents that a patient has a sallow complexion. How does the
nurse interpret this information?
a.
Yellow color to the skin
b.
Blue color to the skin
c.
Red color to the skin
d.
Gray color to the skin
ANS: A
Sallow is an unhealthy, yellow color; usually said of a complexion or skin.
DIF: Cognitive Level: Application
p. 315
REF:
OBJ: 12 TOP: Assessment KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
66.
A health care provider documents that a patient has a scleral icterus. How does the nurse
describe the color of the patient‘s sclera?
a.
Red
b.
Blue
c.
Green
d.
Yellow
ANS: D
Scleral icterus means the color of the sclera is yellow. The jaundice is due to coloring of
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the sclera with bilirubin that infiltrates all tissues of the body.
DIF: Cognitive Level: Application
p. 315
REF:
OBJ: 12 TOP: Assessment KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
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67.
A health care provider documents that a patient has a scleral icterus. What is the cause of
this coloring?
a.
Bilirubin
b.
Hemoglobin
c.
Serum potassium
d.
Serum magnesium
ANS: A
Scleral icterus means the color of the sclera is yellow. The jaundice is due to coloring of
the sclera with bilirubin that infiltrates all tissues of the body.
DIF: Cognitive Level: Comprehension REF:
p. 315
OBJ: 12 TOP: Assessment KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
68.
What is the third assessment technique in a standard physical examination?
a.
Auscultation
b.
Percussion
c.
Inspection
d.
Palpation
ANS: A
The usual sequence of assessment is inspection, palpation, auscultation, and lastly
percussion.
DIF: Cognitive Level: Comprehension REF: p. 317
TOP: Physical examination series
OBJ: 11
KEY: Nursing
Process Step: Assessment MSC: NCLEX:
Physiological Integrity
MULTIPLE RESPONSE
1.
When assessing a female for risk factors associated with coronary artery disease,
what information should the nurse include? (Select all that apply.)
a.
Family history of illness
b.
Diet
c.
Smoking
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d.
Exercise
e.
Number of pregnancies
ANS: A, B, C, D
With the exception of information relative to pregnancies, all options would be
informative about risk for heart disease.
DIF: Cognitive Level: Comprehension
REF: p. 313 OBJ: 3 TOP: Risk
factors
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
2.
Which are infectious diseases? (Select all that apply.)
a.
Measles
b.
Pneumonia
c.
Hay fever
d.
Tuberculosis
e.
Osteoarthritis
f.
Acquired immunodeficiency syndrome
ANS: A, B, D, F
Infectious diseases result from the invasion of microorganisms into the body.
Examples of infectious diseases include acquired immunodeficiency syndrome (AIDS),
tuberculosis, measles, and pneumonia. Hay fever is a manifestation of an allergic
reaction, and osteoarthritis is an example of a degenerative disease.
DIF: Cognitive Level: Knowledge
REF: p. 312
OBJ: 2
TOP: Infectious diseases KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
3.
The nurse is preparing to perform a physical assessment. What essential supplies should
this nurse gather? (Select all that apply.)
a.
Flashlight
b.
Gloves
c.
Red pen
d.
Thermometer
e. Scissors
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ANS: A, B, D, E
Items essential to the nurse‘s assessment are a penlight or flashlight, a stethoscope, a
blood pressure cuff, a thermometer, gloves, gait belt, watch with second hand,
scissors, black pen, and a tongue blade.
DIF: Cognitive Level: Application
REF: p. 324
OBJ: 7
TOP: Physical assessment KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
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COMPLETION
1.
An unpleasant sensation caused by noxious (extremely destructive or harmful)
stimulation of the sensory nerve endings is
.
ANS:
pain
Pain is an unpleasant sensation caused by noxious (extremely destructive or harmful)
stimulation of the sensory nerve endings. It is a cardinal symptom of inflammation and
is valuable in the diagnosis of many disorders and conditions. Pain has varied
manifestations: mild or severe, chronic, acute, burning, dull or sharp, precisely or
poorly localized, or referred.
DIF: Cognitive Level: Knowledge
REF: p. 315 OBJ: 4 TOP: Pain
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
2.
When auscultating the chest, a nurse hears crackles in both lower lobes. To further
assess this finding, the nurse should ask the patient to
.
ANS:
cough
It is a useful assessment to determine that the patient can clear the secretions by
coughing.
DIF: Cognitive Level: Application
REF:
p. 314
KEY:
OBJ: 11 TOP: Crackles
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
3.
The nurse observes that an older adult patient has no hair on the lower legs. The
nurse should assess further for the sufficiency of arterial
.
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ANS:
flow
Reduced arterial flow causes lack of hair on the lower extremities due to inadequate
blood flow.
DIF: Cognitive Level: Application
REF: p. 327
OBJ: 12
TOP: Vascular assessment KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
4.
Signs that are perceived by an examiner and can be seen,
, measured, or felt are
known as objective data.
ANS:
heard
Objective data is a sign that can be seen, heard, measured, or felt by the examiner.
DIF: Cognitive Level: Knowledge
TOP: Objective data
REF: p. 311
OBJ: 2
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
5.
Symptoms that are perceived by the patient are known as
data.
ANS:
subjective
Symptoms are subjective indications of illness that are perceived by the patient.
Symptoms are referred to as subjective data.
DIF: Cognitive Level: Knowledge
TOP: Subjective data
REF: p. 312
OBJ: 2
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
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6.
A condition in which there is a lack of appetite resulting in the inability to eat is known as
.
ANS:
anorexia
Anorexia is a lack of appetite resulting in the inability to eat. It can occur in many disease
conditions.
DIF: Cognitive Level: Knowledge
REF: p. 314 OBJ: 4 TOP:
Anorexia
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
7.
A condition of debility, loss of strength and energy, and depleted vitality is known as
.
ANS:
asthenia
Asthenia is a condition of debility, loss of strength and energy, and depleted vitality.
DIF: Cognitive Level: Knowledge
REF: p. 314 OBJ: 4 TOP:
Asthenia
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
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8.
A circulatory condition in which the myocardium contracts steadily but at a rate of less
than 60 contractions per minute is known as
.
ANS:
bradycardia
Bradycardia is a circulatory condition in which the myocardium contracts steadily but
at a rate of less than 60 contractions per minute.
DIF: Cognitive Level: Knowledge
REF: p. 314
OBJ: 4 TOP:
Bradycardia
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
9.
A condition in which a patient experiences bluish discoloration of the skin and
mucous membranes caused by an increase of deoxygenated hemoglobin in the
blood is known as
.
ANS:
cyanosis
Cyanosis is a bluish discoloration of the skin and mucous membranes caused by an
increase of deoxygenated hemoglobin in the blood.
DIF: Cognitive Level: Knowledge
REF: p. 314 OBJ: 4 TOP:
Cyanosis
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
10.
Discoloration of an area of the skin or mucous membrane that is caused by the
extravasation of blood into the subcutaneous tissues as a result of trauma to the
underlying blood vessels or by fragility of the vessel walls is known as
.
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ANS:
ecchymosis
Ecchymosis is discoloration of an area of the skin or mucous membrane caused by the
extravasation of blood into the subcutaneous tissues as a result of trauma to the
underlying blood vessels or by fragility of the vessel walls.
DIF: Cognitive Level: Knowledge
REF: p. 314
OBJ: 4 TOP:
Ecchymosis
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
11.
Redness or inflammation of the skin or mucous membranes that is the result of
dilation and congestion of superficial capillaries is known as .
ANS:
erythema
Erythema is redness or inflammation of the skin or mucous membranes that is the result
of dilation and congestion of superficial capillaries.
DIF: Cognitive Level: Knowledge
REF: p. 314 OBJ: 4 TOP:
Erythema
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
12.
A yellow tinge to the skin that may indicate obstruction in the flow of bile from the liver
is known as
.
ANS:
jaundice
Jaundice is a yellow tinge to the skin; it may indicate obstruction in the flow of bile from
the liver.
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DIF: Cognitive Level: Knowledge
REF: p. 314 OBJ: 4 TOP:
Jaundice
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
13.
An abnormal condition in which a person must sit or stand to breathe deeply or
comfortably is known as
.
ANS:
orthopnea
Orthopnea is an abnormal condition in which a person must sit or stand to breathe deeply
or comfortably.
DIF: Cognitive Level: Knowledge
REF: p. 315 OBJ: 4 TOP:
Orthopnea
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
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14.
A symptom of itching and an uncomfortable sensation leading to an urge to scratch is
known as
.
ANS:
pruritus
Pruritus is a symptom of itching and an uncomfortable sensation leading to an urge to
scratch.
DIF: Cognitive Level: Knowledge
REF: p. 315 OBJ: 4 TOP:
Pruritus
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
15.
A creamy, viscous, pale yellow or yellow-green fluid exudate that is the result of fluid
remains of liquefied necrosis of
is known as purulent drainage.
ANS:
tissues
Purulent drainage is a creamy, viscous, pale yellow or yellow-green fluid exudate that
is the result of fluid remains of liquefied necrosis of tissues.
DIF: Cognitive Level: Knowledge
TOP: Purulent drainage
REF: p. 315
OBJ: 4
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
16.
An abnormal condition in which the heart contracts regularly but at a rate greater than
100 beats/min is known as
.
ANS:
tachycardia
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Tachycardia is an abnormal condition in which the heart contracts regularly but at a rate
greater than 100 beats/min.
DIF: Cognitive Level: Knowledge
REF: p. 315
OBJ: 4 TOP:
Tachycardia
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
17.
An abnormally rapid rate of breathing that is seen in many disease conditions is known as
.
ANS:
tachypnea
Tachypnea is an abnormally rapid rate of breathing that is seen in many disease
conditions.
DIF: Cognitive Level: Knowledge
REF: p. 315 OBJ: 4 TOP:
Tachypnea
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
18.
A condition in which there is a temporary loss of consciousness associated with an
increased rate of respiration, tachycardia, pallor, perspiration, and coolness of the skin
is known as
.
ANS:
syncope
Syncope is a temporary loss of consciousness (partial or complete) associated with
an increased rate of respiration, tachycardia, pallor, perspiration, and coolness of
skin.
DIF: Cognitive Level: Knowledge
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REF: p. 326 OBJ: 4 TOP:
Syncope
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
19.
Cultural beliefs and personal characteristics determine behavior in individuals and
families. More than half of all health problems are the result of behavior and
lifestyle.
ANS:
health
Cultural beliefs and personal characteristics determine health behavior in
individuals and families. More than half of all health problems are the result of
behavior and lifestyle.
DIF: Cognitive Level: Knowledge
REF: p. 322
OBJ: 14
TOP: Cultural sensitivity KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
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Chapter 14: Oxygenation
Cooper: Foundations and Adult Health Nursing, 9th Edition
MULTIPLE
CHOICE
1.
When an older adult patient with chronic emphysema comes to the emergency
department in respiratory distress, at what rate should the nurse begin oxygen per
nasal cannula?
a.
2 L/min
b.
3 L/min
c.
4 L/min
d.
5 L/min
ANS: A
Administering O2 at more than 2 L/min to a person with chronic pulmonary disease may
cause respiratory failure.
DIF: Cognitive Level: Application
TOP: O2 administration
REF: p. 340
OBJ: 1
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
2.
The nurse instructs a patient receiving home O2 therapy to drink plenty of fluids to
help keep bronchial secretions liquefied. What is the recommended fluid?
a.
Milk
b.
Water
c.
Tea with artificial sweetener
d.
Coffee
ANS: B
Water is the best option. Drinks with caffeine, sugar, or dairy products are not helpful to
liquefy secretions.
DIF: Cognitive Level: Application
REF: p. 345 OBJ: 1 TOP:
Fluids
KEY: Nursing Process Step:
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Implementation
MSC: NCLEX: Physiological Integrity
3.
The wife of a patient with a cuffed tracheostomy asks why the cuff is inflated
intermittently. What is the purpose of the inflated cuff?
a.
Prevent regurgitation after meals.
b.
Hold the trachea open until it is completely healed.
c.
Dilate the tracheal opening for passage of secretions.
d.
Prevent aspiration when eating.
ANS: D
The cuff is inflated to prevent aspiration while eating or when cleaning the tracheostomy
tube.
DIF: Cognitive Level: Analysis
TOP: Cuffed tracheostomy tubes
REF: p. 346
OBJ: 7
KEY: Nursing
Process Step: Implementation MSC: NCLEX: Safe,
Effective Care Environment
4.
Which of the following is an appropriate nursing measure when performing tracheostomy
care?
a.
Wear clean gloves.
b.
Insert the catheter without suction.
c.
Suction for 1 minute before removing the catheter.
d.
Place the used catheter in a plastic shield for later use.
ANS: B
Insertion of the suction catheter without suction reduces the probability of tissue injury.
Sterile gloves should be used for tracheostomy care. Suctioning should be done for a
maximum of 10 seconds at a time. A used catheter should be disposed of appropriately.
DIF: Cognitive Level: Application
TOP: Tracheal suction
REF: p. 347
OBJ: 7
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
5.
An 80-year-old male patient has been admitted to the acute care facility with the
diagnosis of pneumonia. He is receiving oxygen via nasal cannula at 2 L/min. The
nurse assesses respirations at 24/min, PaO2 level 88 mm Hg, and pink skin tone.
What action should the nurse implement?
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a.
Notify the health care provider. (Space added)
b.
Increase oxygen to 4 L/min.
c.
Record PaO2 level.
d.
Administer nebulizer treatment.
ANS: C
The nurse would document PaO2 level. Normal arterial oxygen levels sometimes
decrease with age, but not usually low enough to fall outside the normal range. It may
be possible for an 80-year-old person to have an arterial partial pressure oxygen
(PaO2) level (the amount of oxygen found in the arterial circulation) between 80 and
85 mm Hg (normal range is 80 to 100 mm Hg) without experiencing significant
alterations in health.
DIF: Cognitive Level: Comprehension
REF: p. 344 OBJ: 1 TOP:
PaO2 levels KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
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6.
What is the appropriate value for the venturi mask? (Capitalize Venturi)
Oxygen delivery devices with percent of oxygen delivered
Delivery device
Amount of delivered FiO2
Nasal cannula
1–6 L/min = 24%–44% O2
Simple face mask
5–8 L/min = 35%–55% O2
Venturi mask
Partial rebreather mask
6–12 L/min = 60%–90% O2
Nonrebreather mask
6–15 L/min = 70%–100%
O2
a.
1–6 L/min = 24%–44% O2
b.
5–8 L/min = 35%–55% O2
c.
4–10 L/min = 24%–55% O2
d.
6–12 L/min = 60%–90% O2
e.
6–15 L/min = 70%–100% O2
ANS: C
DIF: Cognitive Level: Knowledge
REF: p. 340 OBJ: 1
TOP:
O2 administration
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1.
A patient has a new health care provider‘s order for oxygen administration at
2 L via nasal cannula. Who can initiate implementation of this order? (Select
all that apply.)
a.
RN
b.
UAP
c.
Respiratory therapist
d.
EMT
e.
Nutritional specialist
ANS: A, C, D
Oxygen therapy may be initiated by a respiratory therapist, a nurse, an emergency
medical technician (EMT), or any other licensed health care provider with an appropriate
order for the oxygen. In some facilities, there is a respiratory care department, staffed by
respiratory therapists who assume the responsibility of administering oxygen and delivering
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treatments that will improve a patient‘s ventilation and oxygenation. Adjustment of the
oxygen flow rate is not delegated to UA nor nutritional specialist.
DIF: Cognitive Level: Comprehension REF: p. 340
TOP: O2 administration
OBJ: 1
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
2.
The nurse is caring for a patient with an endotracheal tube. What interventions will the
nurse implement? (Select all that apply.)
a.
Change or clean all respiratory therapy equipment every 24 hours.
b.
Turn and reposition the patient every 2 hours.
c.
Provide constant airway humidification.
d.
Encourage intake of fruits and vegetables.
e.
Elevate the head of the bed.
ANS: B, C, E
Nursing interventions for the patient with an endotracheal tube include turning and
repositioning every 2 hours for maximal ventilation and lung expansion, constant
airway humidification and elevation of the head of the bed to assist with ventilation.
Equipment should be changed or cleaned at least every 8 hours. Patients with
endotracheal tubes are allowed nothing by mouth (NPO). It is necessary to provide
parenteral or enteral nourishment.
DIF: Cognitive Level: Application
TOP: Endotracheal care
REF: p. 350
OBJ: 7
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
COMPLETION
1.
A
cannula is a device consisting of small tubes inserted into the nares and
is the most common way to administer oxygen.
ANS:
nasal
A nasal cannula is device consisting of small tubes inserted into the nares and is the most
common way to administer oxygen.
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DIF: Cognitive Level: Knowledge
TOP: O2 administration
REF: p. 340
OBJ: 1
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
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2.
When suctioning a tracheostomy suction may be applied for a maximum of
seconds at
a time never longer.
ANS:
10
ten
Suctioning should be done for a maximum of 10 seconds at a time. Prolonged suctioning
depletes oxygen supply.
DIF: Cognitive Level: Application
TOP: Tracheal suction
REF: p. 348
OBJ: 7
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
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Chapter 15: Elimination and Gastric Intubation
Cooper: Foundations and Adult Health Nursing, 9th Edition
MULTIPLE
CHOICE
1.
After a Foley catheter has been removed, the nurse should assess the patient for:
a.
hemorrhage.
b.
constipation.
c.
urinary retention.
d.
bladder spasm.
ANS: C
While an indwelling urinary catheter is in place, the bladder loses tone and can retain
urine after the removal of the catheter.
DIF: Cognitive Level: Application
TOP: Catheter removal
REF: p. 364
OBJ: 1
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
2.
What would be the correct explanation of catheter care?
a.
Cleansing the first 2 in of the catheter with soap and water every shift
b.
Disinfecting the entire catheter with alcohol every shift
c.
Lubricating the catheter with antiseptic lotion every 24 hours
d.
Cleansing the meatal-catheter junction every 24 hours
ANS: A
The first 2 in of the catheter should be cleaned with soap and water every shift or more
often if the patient is incontinent. Alcohol and lotions are contraindicated. Catheter
care should be done every shift.
DIF: Cognitive Level: Application
TOP: Catheter care
REF: p. 368
OBJ: 1
KEY: Nursing Process
Step: Planning MSC: NCLEX: Safe, Effective Care
Environment
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During insertion of a Foley catheter, the patient grimaces as the balloon is inflated. What
3.
is the immediate reaction of the nurse?
a.
Withdraw the catheter.
b.
Ask the patient to bear down.
c.
Continue to inflate the balloon.
d.
Advance the catheter into the bladder.
ANS: D
Grimacing is a sign of pain indicating that the balloon might be in the urethra instead
of the bladder. The catheter should be advanced before inflation.
DIF: Cognitive Level: Application
TOP: Catheterization
REF: p. 360
OBJ: 1
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
4.
When explaining the difference between a colostomy and an ileostomy, the nurse
explains which of the following about an ileostomy?
a.
It is always permanent.
b.
It drains semiliquid stool.
c.
It has a much larger stoma.
d.
It does not need a pouch.
ANS: B
The ileostomy is higher in the GI tract and drains semiliquid stool. The ileostomy is
very similar in appearance to the colostomy, may not be permanent, and needs a
pouch.
DIF: Cognitive Level: Comprehension
REF: p. 383 OBJ: 7 TOP:
Ileostomy
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
5.
Before inserting a nasogastric tube, what measurement should the nurse take?
a.
Tip of the nose to the earlobe to the xiphoid process
b.
Bridge of the nose to the xiphoid process
c.
Nose to the top of the ear to the stomach
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d.
Clavicular notch to the stomach
ANS: A
The measurement is from the tip of the nose to the ear lobe to the xiphoid process.
DIF: Cognitive Level: Application
REF: p. 376
OBJ: 3
TOP: Nasogastric (NG) tube KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological
Integrity
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MULTIPLE RESPONSE
1.
Bladder training is initiated on a patient preparing for discharge to home from an
acute care setting. When should voiding times be scheduled? (Select all that apply.)
a.
At least every hour
b.
At patients request
c.
Before each meal
d.
At bedtime
e.
Upon waking up in morning
ANS: C, D, E
Typical voiding times are upon rising, before each meal, and at bedtime. When initiating
bladder training the nurse should assist the patient to void as scheduled, check the patient
for wetness periodically, and remind or assist the patient to the toilet as scheduled.
DIF: Cognitive Level: Application
TOP: Bladder training
REF: p. 373
OBJ: N/A
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
2.
The nurse administers an enema to a patient as ordered. What should be documented?
(Select all that apply.)
a.
Date
b.
Time
c.
Type and volume of enema
d.
Temperature of solution
e.
Characteristics of results
f.
How patient tolerates procedure
ANS: A, B, C, D, E, F
Following an enema date, time, type and volume of enema, temperature of solution,
characteristics of results and how patient tolerated procedure should all be
documented.
DIF: Cognitive Level: Application
REF: p. 385 OBJ: 6 TOP:
Enemas
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
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COMPLETION
is the inability to control urine or bowel elimination and can be a
1.
psychologically distressing and socially disruptive problem, especially among older
adults.
ANS:
Incontinence
Incontinence is the inability to control urine or bowel elimination. It can be a
psychologically distressing and socially disruptive problem, especially among older
adults.
DIF: Cognitive Level: Knowledge
p. 370
REF:
OBJ: N/A TOP:
Incontinence KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
2.
A
tube is a flexible, hollow tube that is passed into the stomach via the
nasopharynx.
ANS:
nasogastric
A nasogastric tube is a flexible, hollow tube that is passed into the stomach via the
nasopharynx.
DIF: Cognitive Level: Knowledge
REF: p. 373
OBJ: 3
TOP: Nasogastric (NG) tube KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
3.
A
is the diversion of urine away from a diseased or defective bladder through a
surgically created opening or stoma in the skin.
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ANS:
urostomy
A urostomy is the diversion of urine away from a diseased or defective bladder through a
surgically created opening or stoma in the skin.
DIF: Cognitive Level: Knowledge
REF: p. 383 OBJ: 8 TOP:
Urostomy
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
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Chapter 16: Care of Patients Experiencing Urgent
Alterations in Health Cooper: Foundations and Adult
Health Nursing, 9th Edition
MULTIPLE
CHOICE
1.
When administering first aid in emergency situations, the nurse must first survey
victims for severity of injuries. What term correctly describes this process?
a.
The Good Samaritan law
b.
An emergency interview
c.
Triage
d.
Taking vital signs
ANS: C
This process of patient classification is called triage.
DIF:
Cognitive Level: Knowledge REF: p. 393 | p. 394
OBJ: 1
TOP: First aid KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
2.
The Good Samaritan law will protect all people who offer assistance. What is necessary
for this protection?
a.
A license
b.
The person acts prudently
c.
Licensed supervision
d.
The patient improves
ANS: B
The Good Samaritan law will protect any person who follows a prudent course of action.
DIF: Cognitive Level: Comprehension REF:
p. 394
OBJ: 2 TOP: Good
Samaritan law
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
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3.
A nurse is assessing victims in an emergency situation. What will the nurse assess for
first?
a.
Hemorrhage
b.
Fractures
c.
Mobility
d.
Abnormal breathing
ANS: D
A life-threatening situation of the highest priority is arrested or abnormal breathing.
DIF: Cognitive Level: Application
REF: p. 394
OBJ: 1
TOP: ABC of assessment KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
4.
CPR has been initiated at an accident site. When can CPR be terminated?
a.
Victim is clinically dead.
b.
Victim is brain dead.
c.
Paramedics arrive.
d.
Rescuer perceives CPR is futile.
ANS: C
There is a moral obligation to continue CPR once it has been initiated unless the rescuer is
exhausted and cannot continue, trained medical personnel take over CPR, or a licensed
health care provider pronounces the victim dead.
DIF: Cognitive Level: Comprehension
REF: p. 394
OBJ: 4 TOP:
Cardiopulmonary resuscitation (CPR)
KEY: Nursing Process Step:
Implementation MSC:
NCLEX: Physiological
Integrity
5.
The nurse determines clinical death and initiates CPR immediately. How long is
resuscitation considered possible?
a.
If cardiopulmonary arrest has existed for no more 2 minutes
b.
If cardiopulmonary arrest has existed for no more 3 minutes
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c.
If cardiopulmonary arrest has existed for no more 4 minutes
d.
If cardiopulmonary arrest has existed for no more 5 minutes
ANS: C
CPR can reverse clinical death if initiated before 4 minutes.
DIF: Cognitive Level: Comprehension
REF: p. 395
OBJ: 3 TOP:
Cardiopulmonary resuscitation (CPR)
KEY: Nursing Process Step:
Implementation MSC:
NCLEX: Physiological
Integrity
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6.
When assessing the adult victim for pulselessness, the CPR rescuer should palpate
the most reliable and accessible pulse. Which pulse will be palpated?
a.
Radial
b.
Brachial
c.
Carotid
d.
Femoral
ANS: C
When assessing the adult victim for pulselessness, the most reliable and accessible pulse
is the carotid.
DIF: Cognitive Level: Application
REF: p. 396
OBJ: 4 TOP:
Cardiopulmonary resuscitation (CPR)
KEY: Nursing Process Step: Assessment
7.
MSC: NCLEX: Physiological Integrity
When a patient suddenly experiences respiratory difficulty in the cafeteria, the nurse
begins assessment for foreign-body airway obstruction. What is the most
appropriate question to ask the victim?
a.
―What did you swallow?‖
b.
―Are you choking?‖
c.
―Are you OK?‖
d.
―Can I help you?‖
ANS: B
With complete airway obstruction, the victim cannot speak. Ask, ―Are you
choking?‖ With this question the nurse pinpoints the problem and can perform the
Heimlich maneuver with no wasted time.
DIF: Cognitive Level: Application
REF: p. 400
OBJ: 1
TOP: Heimlich maneuver KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
8.
The patient arrived at the emergency department in pain and bleeding profusely with the
following vital signs: BP 80/54, P 102, RR
22.
What does the nurse recognize that these symptoms indicate?
a.
Inadequate perfusion
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b.
Circulatory shock
c.
Massive vasodilation
d.
Heart failure
ANS: B
Shock results from failure of the circulatory system to provide sufficient blood
circulation.
DIF: Cognitive Level: Analysis
REF: p. 402 OBJ: 7 TOP:
Shock
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
9.
CPR has been initiated on an adult patient. How will the nurse confirm the effectiveness
of CPR?
a.
Assessing an EKG pattern with each compression
b.
Assessing a palpable carotid pulse during each compression
c.
Assuring a compression depth of to 2 in
d.
Observing pupils that change from pinpoint to dilated
ANS: B
During effective CPR, a carotid pulse is palpable during each compression.
DIF: Cognitive Level: Application
REF: p. 396
OBJ: 4 TOP:
Cardiopulmonary resuscitation (CPR)
KEY: Nursing Process Step:
Implementation MSC:
NCLEX: Physiological
Integrity
10.
A patient with multiple serious injuries sustained in a motorcycle accident is lying
beside his wrecked motorcycle unconscious and bleeding when the rescuer arrives at
the scene. What will be the rescuer‘s priority action?
a.
Assessing blood loss
b.
Assessing respiratory status
c.
Obtaining vital signs
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d.
Organizing laypeople at the scene
ANS: B
Priority intervention is to assess respiratory status.
DIF: Cognitive Level: Application
REF: p. 417 OBJ: 4 TOP: First
aid
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
11.
The worried mother of an accident victim asks the nurse how much circulating blood
an average adult male is supposed to have. What will the nurse reply?
a.
8 pints
b.
10 pints
c.
12 pints
d.
14 pints
ANS: C
An average adult male has 12 pints of blood.
DIF: Cognitive Level: Knowledge
TOP: Circulating blood volume
REF: p. 403
OBJ: 8
KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity
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12.
The nurse is assessing a patient who is severely bleeding and at risk for hypovolemic
shock. What can the nurse anticipate?
a.
Slow, labored breathing
b.
Hot, flushed skin
c.
Edematous extremities
d.
Weak, thready pulse
ANS: D
The pulse becomes weak and thready with hypovolemic shock.
DIF: Cognitive Level: Application
REF: p. 402
OBJ: 7
TOP: Symptoms of shock KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
13.
A nurse assesses an accident victim who has bright red blood spurting from a
laceration on his right forearm. Where will the nurse apply pressure after applying
direct pressure and elevating the limb?
a.
Right subclavian artery
b.
Right radial artery
c.
Right ulnar artery
d.
Right brachial artery
ANS: D
Arterial bleeding is characterized by the spurting of bright red blood and can be
controlled by direct pressure, elevation, and indirect pressure on the appropriate
pressure point. The brachial artery is the closest pressure point to the injury.
DIF:
Cognitive Level: Application REF: pp. 403-404
TOP: Pressure points
OBJ: 10
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
14.
The nurse is attempting to control bleeding in a patient with a profusely bleeding
scalp wound. What is the most effective initial treatment of this bleeding?
a.
Elevate the head.
b.
Apply direct pressure.
c.
Apply an ice pack.
d.
Apply indirect pressure.
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ANS: B
The most effective general treatment of bleeding is to apply direct pressure.
DIF: Cognitive Level: Application
REF: p. 404
OBJ: 10
TOP: Control of bleeding KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
15.
When other methods have failed to stop the bleeding and the victim‘s life is in danger,
the rescuer at the scene applies a tourniquet to a young woman‘s leg above the knee.
What is another step that is essential for the rescuer to follow?
a.
Never release the tourniquet.
b.
Wrap the tourniquet around the limb twice.
c.
Mark the patient with a ―T.‖
d.
Leave the limb elevated.
ANS: A
A tourniquet must never be released once it is in place. All other options are
enhancements to the procedure of the tourniquet application, but not essential.
DIF:
Cognitive Level: Application REF: p. 404 | p. 405
OBJ: 8
TOP: Tourniquet
KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity
16.
The nurse is teaching a patient with epistaxis about the best way to control bleeding.
What information will the nurse relay to this patient?
a.
Place ice on the nose and pinch the nostrils.
b.
Maintain a flat position.
c.
Pack nostrils with cotton.
d.
Lean backward.
ANS: A
Apply steady pressure to both nostrils while applying ice to the nose is the best way to
attempt to control the bleeding of epistaxis.
DIF: Cognitive Level: Application
REF: p. 405 OBJ: 8 TOP:
Epistaxis
KEY: Nursing Process Step:
Implementation
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MSC: NCLEX: Physiological Integrity
17.
A farm worker who has been kicked in the stomach by a mule passes a foul, black, tarry
stool. What is this called?
a.
Loose stool
b.
Melena
c.
Hematuria
d.
Hemoptysis
ANS: B
When internal bleeding occurs, the patient may demonstrate hemoptysis (bloody
sputum), hematemesis (bloody vomit), melena (foul black tarry stool), or hematuria
(bloody urine).
DIF: Cognitive Level: Knowledge
REF: p. 406 OBJ: 2 TOP:
Melena
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
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18.
A machinist visits the industrial nurse‘s clinic with a deep laceration of the thigh. What
should be the nurse‘s first action?
a.
Splint the thigh and apply tape to approximate the edges.
b.
Apply ice and a pressure dressing to the thigh.
c.
Give a tetanus booster injection.
d.
Wash the laceration with an antiseptic.
ANS: D
Lacerations should be cleaned thoroughly and bandaged to approximate the edges.
DIF: Cognitive Level: Application
REF: p. 419 OBJ: 9 TOP:
Wounds
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
19.
The patient‘s lower chest has been punctured with a knife that is still in place. What
should the nurse‘s first action be?
a.
Remove the knife.
b.
Apply an airtight dressing over the wound.
c.
Place the patient in a modified Trendelenburg‘s position.
d.
Immobilize the knife with dressings and tape.
ANS: D
When the patient‘s lower chest has been punctured with the weapon still in place, the
nurse should immobilize the weapon with dressings and tape.
DIF: Cognitive Level: Application
REF: p. 408 OBJ: 9 TOP:
Wounds
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
20.
A patient arrives in the emergency department with a sucking wound to the left chest.
What is the first action the nurse should take?
a.
Place several layers of gauze dressing over the wound.
b.
Place the patient in a supine position.
c.
Cover the wound with an airtight dressing taped on three sides.
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d.
Turn the patient to the left side.
ANS: C
Sucking chest wounds should be dressed with a flutter dressing so that air can escape
the pleural space, but no more air can be sucked in.
DIF: Cognitive Level: Application
REF: p. 408
OBJ: 9
TOP: Sucking chest wounds KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological
Integrity
21.
The nurse is assisting a victim of an accident who requires bandaging of the right
lower extremity. What should the nurse do when applying the bandage?
a.
Use sterile material.
b.
Leave the toes exposed.
c.
Bandage the extremity tightly.
d.
Bend the knee after bandaging.
ANS: B
The tips of the toes should remain exposed to assess circulation.
DIF: Cognitive Level: Application
REF: p. 408 OBJ: 1 TOP:
Bandaging
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
22.
A patient who had taken a poisonous substance is brought to the emergency
department. What is the first action the nurse should take?
a.
Give syrup of ipecac.
b.
Contact the poison control center.
c.
Give milk to coat the stomach.
d.
Observe for symptoms.
ANS: B
The nurse should immediately call the poison control center.
DIF:
Cognitive Level: Application REF: p. 409 | p. 410
OBJ: 11
TOP: Poison KEY: Nursing Process Step:
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Implementation MSC: NCLEX: Physiological Integrity
23.
A patient has been stung by a bee and is brought to the emergency department. The
nurse observes the sting site and identifies that the stinger is still in the skin. What
action should the nurse take?
a.
Remove it with sterile tweezers.
b.
Soak the area with a cold compress.
c.
Scrape the stinger with the side of a knife.
d.
Squeeze the surrounding tissue to expel the stinger.
ANS: C
The stinger should be removed with the side of a knife by scraping to avoid forcing more
venom into the skin.
DIF: Cognitive Level: Application
REF: p. 411 OBJ: 1 TOP:
Wounds
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
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24.
The patient with heatstroke has been undressed and treated with cold packs and a
fan. The patient‘s temperature is now down to 101.2°F (38.4°C). The patient starts
to shiver. What action should the emergency department nurse take?
a.
Raise the head of the bed.
b.
Offer warm liquids.
c.
Remove cold packs and fan.
d.
Continue with cooling interventions.
ANS: C
The cooling techniques have caused the patient to shiver, which will increase the patient‘s
temperature.
DIF: Cognitive Level: Application
p. 413
REF:
OBJ: 12 TOP: Heatstroke KEY:
Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
25.
The patient is admitted to the emergency department, having suffered frostbite to the
hands, which are grayish-white in color. What action should the nurse implement
when attempting to warm the hands?
a.
Have the patient rub the hands together briskly.
b.
Wipe the hands vigorously with a warm towel.
c.
Run tepid water over the hands to warm slowly.
d.
Wrap the hands in hot, moist towels.
ANS: D
Warming the hands in moist towels will warm the hands slowly. Friction of frozen body
parts should be avoided.
DIF: Cognitive Level: Application
REF:
p. 414
KEY:
OBJ: 12 TOP: Frostbite
Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
26.
A visitor in the hospital slips and falls. The patient‘s arm appears dislocated and the
visitor is unable to move it. What is the first action the nurse should implement?
a.
Apply cold packs.
b.
Check range of motion.
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c.
Splint the arm.
d.
Apply an Ace bandage.
ANS: C
The nurse should splint the arm where it lies and not attempt to move or rearrange the
limb.
DIF: Cognitive Level: Application
REF:
p. 415
KEY:
OBJ: 13 TOP: Fracture
Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
27.
The patient is brought to the emergency department after having fractured an arm 12
hours ago. The arm is very edematous from the fingers to the elbow, and the patient
cannot move it. What should be the initial action of the nurse?
a.
Test range of motion.
b.
Take the vital signs.
c.
Place ice packs on the arm.
d.
Check fingers for capillary refill.
ANS: D
Swelling from the fracture can impede circulation.
DIF:
Cognitive Level: Application REF: pp.
414-415
OBJ: 13 TOP: Injuries
KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
28.
When assessing a patient who has suffered a burn injury, the nurse classifies the burn
as a deep partial-thickness burn. What is this observation most likely based upon?
a.
Painful reddened skin
b.
Charred skin with milky-white areas
c.
Erythema and blisters
d.
Erythema, pain, and swelling
ANS: C
With deep partial-thickness burns, blister formation may be seen with erythema.
DIF: Cognitive Level: Comprehension REF:
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p. 417
OBJ: 12 TOP: Burns
KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
29.
The nurse arrives on the scene of a fire. What is the first thing the nurse will do for a burn
victim?
a.
Apply dressings.
b.
Cover with a blanket.
c.
Cool the burn immediately.
d.
Apply topical ointment.
ANS: C
The burn should be cooled immediately to stop the burning process.
DIF: Cognitive Level: Application
REF:
p. 417
KEY:
OBJ: 12 TOP: Burns
Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
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30.
A patient is admitted to the hospital after receiving a blow to the head. The patient
begins to show signs of shock. How should the patient be positioned?
a.
With the head lower than the body
b.
Flat with the legs elevated
c.
Flat on the back
d.
In a side-lying position
ANS: C
If head injuries are suspected, the victim must be kept flat.
DIF: Cognitive Level: Application
REF: p. 403 OBJ: 1 TOP:
Shock
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
31.
While on break in the hospital cafeteria a nurse witnesses her pregnant coworker
start to choke. The coworker is conscious, but unable to breathe. Where should the
nurse administer thrusts?
a.
Below the navel
b.
The chest
c.
At the xiphoid process
d.
The upper back
ANS: B
If the victim is pregnant or obese, chest thrusts are acceptable instead of abdominal
thrusts. To provide chest thrusts, the nurse should place his or her hands in the same
position that is used for chest compressions during CPR.
DIF: Cognitive Level: Knowledge
REF: p. 401 OBJ: 5 TOP:
Choking
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
32.
A burn patient is brought into the emergency department with the following burns:
half of the front torso, entire left arm, and front of left leg. The nurse should record
that the patient has a
% burn.
a. 27
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b.
25
c.
50
d.
43
ANS: A
Half of the front torso = 9, entire left arm = 9, front of the left leg = 9.
DIF: Cognitive Level: Analysis
TOP: Rule of Nines
REF: p. 417
OBJ: 12
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
COMPLETION
1.
When treating an infant choking on a foreign body, the nurse should use a combination of
back
and chest thrusts.
ANS:
blows
If the nurse is assisting a child who has aspirated a foreign body, the nurse may treat
the child in a manner similar to the adult with performance of abdominal thrusts.
However, there is a potential for injury if the nurse uses this maneuver in the infant.
The nurse should use a combination of back blows and chest thrusts with an infant.
DIF: Cognitive Level: Application
REF: p. 401 OBJ: 6 TOP:
Choking
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
2.
If a spinal injury is suspected, before the rescuer starts CPR, the trachea should be opened
with a jaw
maneuver.
ANS:
thrust
The jaw-thrust maneuver does not hyperextend the neck.
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DIF: Cognitive Level: Application
p. 397
REF:
OBJ: 14 TOP:
Cardiopulmonary resuscitation (CPR)
KEY: Nursing Process Step:
Implementation MSC:
NCLEX: Physiological
Integrity
3.
When two nurses perform two-person CPR, there should be two slow breaths for every
30
.
ANS:
compressions
Two slow breaths are given after every 30 compressions.
DIF: Cognitive Level: Application
TOP: Two-person CPR
REF: p. 398
OBJ: 4
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
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4.
The acronym RICE directs the nurse in the care of a sprain. The ―C‖ in the acronym
stands for
.
ANS:
compression
The acronym stands for Rest, Ice, Compression, and Elevation.
DIF: Cognitive Level: Knowledge REF: pp.
415-416
OBJ: 13 TOP: Sprain
KEY:
Nursing Process Step: Application
MSC: NCLEX: Physiological Integrity
5.
When performing on an infant, the breastbone is depressed approximately one-third of
the chest diameter or in.
ANS:
CPR
The breastbone is depressed one-third the chest diameter or in when doing CPR on an
infant.
DIF: Cognitive Level: Application
REF: p. 399
OBJ: 4 TOP:
Cardiopulmonary resuscitation (CPR)
KEY: Nursing Process Step:
Implementation MSC:
NCLEX: Physiological
Integrity
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Chapter 17: Dosage Calculation and
Medication Administration Cooper:
Foundations and Adult Health Nursing, 9th
Edition
MULTIPLE
CHOICE
1.
What is the correct conversion for the improper fraction ?
a.
7
b.
8
c.
7.79
d.
79.7
ANS: B
Divide the numerator by the denominator. The correct conversion for the improper
fraction is 8.
DIF: Cognitive Level: Comprehension REF: p. 425
TOP: Math KEY: Nursing Process Step: N/A
2.
OBJ: 3
MSC: NCLEX: N/A
Which of the following fractions is the largest?
a.
3/4
b.
1/4
c.
1/2
d.
1/8
ANS: A
The smaller the denominator, the larger the fraction.
DIF: Cognitive Level: Knowledge
REF: p. 424
TOP: Math KEY: Nursing Process Step: N/A
3.
OBJ: 3
MSC: NCLEX: N/A
Which of the following fractions is the smallest?
a.
1/8
b.
1/4
c.
1/2
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d.
3/4
ANS: A
The larger the denominator, the smaller the fraction.
DIF: Cognitive Level: Knowledge
REF: p. 425
TOP: Math KEY: Nursing Process Step: N/A
4.
OBJ: 3
MSC: NCLEX: N/A
What is the product of 1/2  3/4?
a.
3/8
b.
4/5
c.
2/3
d.
1/4
ANS: A
Multiply the numerators. Multiply the denominators.
The first step when multiplying fractions is to multiply the two numerators. The
second step is to multiply the two denominators. Finally, simplify the new fractions.
The fractions can also be simplified before multiplying by factoring out common
factors in the numerator and denominator.
DIF: Cognitive Level: Comprehension REF: p. 425
TOP: Math KEY: Nursing Process Step: N/A
5.
OBJ: 3
MSC: NCLEX: N/A
What is 3/8 divided by 1/4?
a.
1 1/2
b.
1 1/3
c.
1 3/4
d.
1 2/3
ANS: B
Write the problem down correctly, invert the second number, and multiply.
1
3/8 divided by =
4
3/8  4/1 = 12/8 = 3/2 or 1 1/3
DIF: Cognitive Level: Comprehension REF: p. 427
TOP: Math KEY: Nursing Process Step: N/A
OBJ: 3
MSC: NCLEX: N/A
6. What is 2.34 + 0.77?
a.
0.01
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b.
90.4
c.
2.417
d.
3.11
ANS: D
Align the decimal point of each decimal fraction in a column and add.
DIF: Cognitive Level: Comprehension REF: p. 428
TOP: Math KEY: Nursing Process Step: N/A
OBJ: 3
MSC: NCLEX: N/A
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7.
What is 6.147 rounded to the nearest tenth?
a.
6.2
b.
6.15
c.
6.14
d.
6.1
ANS: D
A subsequent number that is 5 or larger can increase the previous number by one
whole number. A subsequent number that is less than 5 will leave the number
unchanged.
DIF: Cognitive Level: Application
REF: p. 424
TOP: Math KEY: Nursing Process Step: N/A
8.
OBJ: 3
MSC: NCLEX: N/A
What is 2.5  2?
a.
1.25
b.
5
c.
50
d.
22.5
ANS: B
When multiplying, decimal points do not have to be aligned. The decimal point in the
answer is determined by the number of decimal points found to the right of the decimal
point in the numbers multiplied.
DIF: Cognitive Level: Application
REF: p. 428
TOP: Math KEY: Nursing Process Step: N/A
9.
OBJ: 3
MSC: NCLEX: N/A
What is 4.5 divided by 3?
a.
0.75
b.
1.5
c.
d.
5
0.66
ANS: B
In the divisor, move the decimal point all the way to the right and move the decimal
point in the dividend the same number of places as moved in the divisor.
DIF: Cognitive Level: Application
REF: p. 428
OBJ: 3
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TOP: Math KEY: Nursing Process Step: N/A
10.
MSC: NCLEX: N/A
What is 0.9% expressed as a decimal?
a.
9
b.
0.9
c.
0.09
d.
0.009
ANS: D
Remove the % and move the decimal point two places to the left.
DIF: Cognitive Level: Application
REF: p. 429
TOP: Math KEY: Nursing Process Step: N/A
11.
OBJ: 3
MSC: NCLEX: N/A
What is expressed as a percent?
a.
50%
b.
20%
c.
10%
d.
5%
ANS: B
Change a fraction to a percent by dividing the numerator by the denominator and
multiplying by 100.
DIF: Cognitive Level: Application
REF: p. 429
TOP: Math KEY: Nursing Process Step: N/A
12.
OBJ: 3
MSC: NCLEX: N/A
Which is the same ratio as 2:100?
a.
1:50
b.
5:300
c.
1:20
d.
4:25
ANS: A
The value of a ratio is not changed if both sides are multiplied or divided by the same
number.
DIF: Cognitive Level: Application
REF: p. 429
TOP: Math KEY: Nursing Process Step: N/A
OBJ: 3
MSC: NCLEX: N/A
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13.
The medication order reads ―Ibuprofen 600 mg PO tid.‖ The bottle is labeled
―Ibuprofen 200 mg/tab.‖ How many tablets should the nurse administer?
a.
1
b.
2
c.
3
d.
6
ANS: C
Desired dose over available dose times the unit. The unit is what the available dose is
contained in.
DIF:
Cognitive Level: Application REF:
pp. 428-429
OBJ: 3 TOP: Math
KEY:
Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment
14.
The health care provider has ordered furosemide 20 mg stat. The ampule is
labeled 40 mg/mL. What dose should the nurse administer?
a.
0.8 mL
b.
0.5 mL
c.
2.0 mL
d.
8.0 mL
ANS: B
Desired dosage over the available dosage times the unit. The unit is what the available
dosage is contained in.
DIF: Cognitive Level: Analysis
REF: pp. 428-429
TOP: Math KEY: Nursing Process Step: Assessment
15.
OBJ: 3
MSC: NCLEX: N/A
0.5 L is equal to how many mL?
a.
0.0005 mL
b.
0.05 mL
c.
50 mL
d.
500 mL
ANS: D
Big to small, move decimal point three places to the right.
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DIF: Cognitive Level: Application
REF: p. 424
TOP: Math KEY: Nursing Process Step: N/A
16.
OBJ: 3
MSC: NCLEX: N/A
The average adult dose of Phenergan is 50 mg. Using the Young rule for a 10-year-old,
what is the correct dosage for the child?
a.
23 mg
b.
25 mg
c.
30 mg
d.
35 mg
ANS: A
[Age of the child over age of the child + 12]  the average adult dose = child‘s dose.
DIF: Cognitive Level: Analysis
REF:
pp. 426-427
KEY:
OBJ: 4 TOP: Math
Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment
17.
A 35-lb child is to receive an IM medication. The average adult dose is 75 mg. Using
the Clark rule, what dosage should the nurse administer?
a.
30.5 mg
b.
25.5 mg
c.
20.5 mg
d.
17.5 mg
ANS: D
[Weight of child in pounds ÷ 150]  average adult dose = child‘s dose.
DIF:
Cognitive Level: Application REF:
pp. 426-427
OBJ: 4 TOP: Math
KEY:
Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment
18.
Tylenol gr V is ordered. The available tablet is 0.3 g. What dosage should the nurse
administer?
a.
1 tablet
b.
1.5 tablets
c.
tablet
d.
2 tablets
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ANS: A
Gram to grain, multiply by 15. (0.3  15 = 4.5 grains).
DIF:
Cognitive Level: Application REF:
pp. 426-427
OBJ: 2 TOP: Math
KEY:
Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment
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19.
Lanoxin 0.125 mg is to be given. The nurse converts the dose to how many grams?
a.
1.250 g
b.
1250 g
c.
0.000125 g
d.
0.00125 g
ANS: C
Small, arrow to big, move the decimal point three places in the direction the arrow points;
move decimal three places to the left.
DIF: Cognitive Level: Application
REF: p. 424 OBJ: 1 TOP:
Math
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Safe, Effective Care Environment
20.
Atropine 0.4 mg is to be given. Ampule is labeled gr 1/150/mL. What dose should the
nurse administer?
a.
1.5 mL
b.
0.25 mL
c.
0.5 mL
d.
1 mL
ANS: D
To convert mg to gr, divide by 60.
DIF: Cognitive Level: Application
REF: p. 425 OBJ: 2 TOP:
Math
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Safe, Effective Care Environment
21.
A 150-lb man is to receive a medication based on milligrams/kilograms. He is to
receive 1 mg/kg. What dosage should the nurse administer?
a.
50 mg
b.
68 mg
c.
75 mg
d.
80 mg
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ANS: B
2.2 lb equals 1 kg.
DIF: Cognitive Level: Application
REF: p. 423 OBJ: 1 TOP:
Math
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Safe, Effective Care Environment
22.
0.5 g of medication is ordered. The label reads 125 mg/mL. What is the correct dose to be
administered?
a.
1 mL
b.
2 mL
c.
3 mL
d.
4 mL
ANS: D
Desired dose over available dose  the unit. Unit is what the available dose is contained
in.
DIF: Cognitive Level: Application
REF: p. 423 OBJ: 3 TOP:
Math
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Safe, Effective Care Environment
23.
What is the main organ that inactivates and metabolizes drugs?
a.
Spleen
b.
Liver
c.
Lungs
d.
Pancreas
ANS: B
The liver is the main organ that inactivates and metabolizes drugs.
DIF: Cognitive Level: Comprehension REF: p. 432
TOP: Pharmacology
OBJ: 8
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
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24.
When giving a subcutaneous injection to a very thin patient, how does the nurse alter the
injection technique?
a.
Using a 23-gauge needle
b.
Spreading the skin before injection
c.
Pinching up the skin and inserting the needle at a 45-degree angle
d.
Injecting the medicine quickly to reduce pain
ANS: C
The subcutaneous technique changes when injecting a thin patient. The selection of
needles is the same (-in needle of 27 or 28 gauge), the site selection is the same, but the
technique changes to pinch up the skin and inject at a 45-degree angle.
DIF: Cognitive Level: Application
TOP: Subcutaneous injections
REF: p. 473
OBJ: 11
KEY: Nursing
Process Step: Implementation MSC: NCLEX: Safe,
Effective Care Environment
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25.
The nurse cautions a patient taking an anticoagulant that he should avoid taking
aspirin because one drug may increase the action of the other drug. What is the
correct term for this effect?
a.
Compatibility
b.
Antagonism
c.
Synergism
d.
Cooperation
ANS: C
When one drug increases the action of another drug, it is called synergism.
DIF: Cognitive Level: Comprehension REF: p. 433
TOP: Pharmacology
OBJ: 7
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
26.
When a patient comes into the emergency department with a narcotic overdose, the
nurse anticipates that the patient will be treated with Narcan. What drug classification
is Narcan?
a.
Enhancer
b.
Substitute
c.
Control
d.
Antagonist
ANS: D
An antagonist is a drug that will block the action of another drug, such as Narcan with
Demerol.
DIF: Cognitive Level: Comprehension REF: p. 433
TOP: Pharmacology
OBJ: 7
KEY: Nursing Process
Step: Planning MSC: NCLEX: Physiological
Integrity
27.
The nurse administered a sedative to an older adult who was having difficulty
sleeping. Later, the patient was walking the halls and becoming agitated. What is this
drug response known as?
a.
Expected
b.
Untoward
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c.
Idiosyncratic
d.
Hypersensitive
ANS: C
An unexpected response to a medication is termed idiosyncratic.
DIF: Cognitive Level: Application
TOP: Pharmacology
REF: p. 433
OBJ: 8
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
28.
In some health care facilities, the LPN/LVN is allowed to take telephone orders from a
health care provider. What is one precaution the nurse must take when receiving a
verbal order?
a.
Write quickly.
b.
Repeat the order to the health care provider.
c.
Have another nurse listen on an extension.
d.
Sign and initial the health care provider‘s name on the order.
ANS: B
The nurse should always repeat the order to the health care provider. The nurse should
write slowly to avoid making a mistake. It is not necessary to have another nurse listen
to the verbal order. The nurse should not sign the health care provider‘s name to the
order.
DIF: Cognitive Level: Application
TOP: Pharmacology
REF: p. 437
OBJ: 13
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Safe, Effective Care
Environment
29.
The nurse who was going off shift had prepared the medications for the nurse who
was going to relieve her to save the oncoming nurse time. What would be the correct
action of the oncoming nurse?
a.
Give the medications when ordered.
b.
Recheck the medications.
c.
Never give medications another person has prepared.
d.
Identify each medication as it is given.
ANS: C
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The nurse should never give a medication that has been prepared by another person.
DIF: Cognitive Level: Application
TOP: Pharmacology
REF: p. 439
OBJ: 9
KEY: Nursing Process
Step: Evaluation MSC: NCLEX: Safe, Effective
Care Environment
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30.
What important principle should be taken to prevent medication errors?
a.
Placing an unlabeled syringe on the medication cart
b.
Following the six rights of medication administration
c.
Leaving a medication with the patient only when family is there
d.
Always charting medications before the end of the shift
ANS: B
Following the six rights ensures excellent drug administration practice. Unlabeled
syringes should never be left on a medication cart. Medications should never be left in
a patient‘s room. Medications should be charted immediately after they are
administered.
DIF: Cognitive Level: Application
REF:
p. 438
OBJ: 10 TOP:
Pharmacology
KEY: Nursing
Process Step: N/A MSC: NCLEX: Safe,
Effective Care Environment
31.
When the patient complains about his IV lines and asks if he can have the
medication by mouth, what is the most appropriate response by the nurse?
a.
―Pills are difficult for many patients to swallow.‖
b.
―Medication by mouth is absorbed more slowly than by any other route.‖
c.
―It takes more time for the nurse to prepare and administer oral medications.‖
d.
―It leads to more errors to give pills, because the pills all look alike.‖
ANS: B
Medications that enter the GI tract are absorbed more slowly than by any other route.
It is not known whether or not this particular patient has difficulty swallowing. The
decision to give IV medications does not depend on the time of administration. It is
not true that all pills look alike.
DIF: Cognitive Level: Application
TOP: Pharmacology
REF: p. 442
OBJ: 11
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
32.
What landmarks are used for the administration of an intramuscular injection into the
gluteal site?
a.
The tip of the coccyx and the greater trochanter
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b.
Between the center of the gluteus and the iliac spine
c.
Between the posterior iliac crest and the greater trochanter
d.
On an imaginary line between the center of the gluteus and the greater trochanter
ANS: C
The gluteal site is marked by the greater trochanter and the posterior iliac crest.
DIF: Cognitive Level: Application
TOP: Pharmacology
REF: p. 469
OBJ: 16
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Safe, Effective Care
Environment
33.
What screening test is accomplished by performing an intradermal injection?
a.
Diabetes
b.
Tuberculosis
c.
Hepatitis
d.
Meningitis
ANS: B
Intradermal injection absorption is slow, which makes it the best route for tuberculosis
screening.
DIF: Cognitive Level: Comprehension REF: p. 472
TOP: Pharmacology
OBJ: 11
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
MULTIPLE RESPONSE
1.
What should the nurse do with an injection of 2 mL of Demerol that the patient has
refused? (Select all that apply.)
a.
Independently waste the drug in a secure place.
b.
Record in the narcotic log that the drug was wasted.
c.
Chart in the patient‘s record the reason the medication was refused.
d.
Get any staff member to sign the narcotic log as witness to the drug being wasted.
e.
Confirm the count is correct on the narcotic log.
ANS: B, C, E
When a controlled substance is wasted, the actual wasting must be witnessed by a
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licensed person, the narcotic log must be signed by both the nurse wasting the drug
and the witness, and the narcotic count is confirmed by both people.
DIF: Cognitive Level: Analysis
TOP: Wasting a controlled drug
REF: p. 480
OBJ: 9
KEY: Nursing
Process Step: Implementation MSC: NCLEX: Safe,
Effective Care Environment
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COMPLETION
1.
To help relax the anal sphincter during the insertion of a suppository, the nurse should ask
the patient to
.
ANS:
exhale
Exhaling will help relax the anal sphincter.
DIF: Cognitive Level: Application
REF: p. 447
OBJ: 8
TOP: Rectal suppository KEY: Nursing Process
Step: Intervention MSC: NCLEX: Safe, Effective
Care Environment
2.
When giving a tubal medication, the nurse should flush the tubing with 30 to 50
of
water.
ANS:
mL
The water will enhance the absorption of the drug and also clear the tubing.
DIF: Cognitive Level: Application
TOP: Tubal administration
REF: p. 446
OBJ: 8
KEY: Nursing Process
Step: Implementation MSC: NCLEX: Safe, Effective
Care Environment
3.
The following information is included in a
health care provider‘s order: Jane Doe
September 23
Amoxicillin 250 mg PO every 6 hours for 10 days
Dr. John Smith
The essential component missing is the
.
ANS:
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time
The health care provider‘s order should include the patient‘s name, date, time,
medication, dose, route, frequency, and health care provider‘s signature.
DIF: Cognitive Level: Analysis
p. 480
REF:
OBJ: 13 TOP:
Health care provider‘s order
KEY:
Nursing Process Step: N/A MSC: NCLEX: N/A
4.
The order is for 100 mL to run over 8 hours as a ―piggyback.‖ The drop factor of the
secondary unit is 15. The nurse should set the drop control to deliver 3 gtts/ .
ANS:
min
100 mL divided by 8 = 12.5 mL/h
DIF: Cognitive Level: Application
TOP: Pharmacology
REF: p. 425
OBJ: 3
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Safe, Effective Care
Environment
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Chapter 18: Fluids and Electrolytes
Cooper: Foundations and Adult Health Nursing, 9th Edition
MULTIPLE
CHOICE
1.
What percentage of an adult‘s body weight consists of water?
a.
10% to 20%
b.
30% to 40%
c.
50% to 60%
d.
70% to 80%
ANS: C
The percentage of water declines to 50% to 60% in adults.
DIF: Cognitive Level: Knowledge
REF: p. 483 OBJ: 1 TOP:
Fluids
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
2.
When administering intravenous (IV) fluids, the nurse ensures that the IV fluids are
infusing as ordered to prevent dehydration in an adult. When could dehydration
become lethal?
a.
If the patient loses 5% of body fluid
b.
If the patient loses 10% of body fluid
c.
If the patient loses 15% of body fluid
d.
If the patient loses 20% of body fluid
ANS: D
A loss of 20% of body fluid in an adult is fatal.
DIF: Cognitive Level: Knowledge
REF: p. 483 OBJ: 1 TOP:
Fluids
KEY: Nursing Process Step:
Implementation
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MSC: NCLEX: Physiological Integrity
3.
The nurse uses a diagram to show that fluids in the interstitial and intravascular
compartments are combined. What do they combine to form?
a.
Intercellular compartment
b.
Circulating compartment
c.
Vertical compartment
d.
Extracellular compartment
ANS: D
The fluids in the interstitial and intravascular compartments are combined to form the
extracellular compartment.
DIF: Cognitive Level: Knowledge
REF: p. 483
OBJ: 1
TOP: Fluid compartments KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
4.
The nurse encourages a patient who has been vomiting to drink fluids because the
body fluid lost daily must match the amount of fluid taken in to maintain
homeostasis. What is the recommended daily amount of fluid for an adult?
a.
1000 mL
b.
1500 mL
c.
2050 mL
d.
2500 mL
ANS: D
Daily fluid intake and output is about 2200 to 2700 mL/day, and urinary output is about
1000 to 2000 mL/day.
DIF: Cognitive Level: Knowledge
REF: p. 489 OBJ: 1 TOP:
Fluids
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
5.
The nurse must keep an accurate intake and output record to assess kidney
efficiency. In order for the kidneys to remove waste, what is the least amount of
hourly urine output the kidneys must produce to remove waste?
a.
10 mL
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b.
20 mL
c.
30 mL
d.
40 mL
ANS: C
The kidneys must excrete a minimum of 30 mL/h to eliminate waste products.
DIF: Cognitive Level: Knowledge
REF: p. 485 OBJ: 6 TOP:
Fluids
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
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6.
The nurse weighs a patient at the same time of day with the same scale and same
clothing. What is this a simple and accurate method of determining?
a.
An accurate weight
b.
Water balance
c.
Adequate nutrition
d.
Urinary output
ANS: B
A simple and accurate method of determining water balance is to weigh the patient under
the same conditions each day.
DIF: Cognitive Level: Comprehension
REF: p. 485 OBJ: 8 TOP:
Fluids
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
7.
When a patient takes substances into the body, they first enter the extracellular
compartment. What must the substances enter to carry out their function?
a.
Horizontal compartment
b.
Intracellular compartment
c.
Compartmental
d.
Vertical compartment
ANS: B
To carry out their function, substances must enter the cell.
DIF: Cognitive Level: Comprehension
REF: pp. 483-484
TOP: Fluids KEY: Nursing Process Step: N/A
8.
OBJ: 2
MSC: NCLEX: N/A
What is the method by which inhaled oxygen is moved into the intravascular
compartment called?
a.
Active transport
b.
Oxygenation
c.
Passive transport
d.
Mass movement
ANS: C
Passive transport occurs when the patient inhales oxygen into the lungs, with the oxygen
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passing by diffusion into the intravascular compartment.
DIF: Cognitive Level: Comprehension
TOP: Transport process
REF: pp. 485-486
OBJ: 4
KEY: Nursing Process
Step: Intervention MSC: NCLEX: Physiological
Integrity
9.
The nurse explains to a patient that the drug Lasix reduces edema by drawing water
from the interstitial space into the intravascular space. What is this process called?
(Consider using furosemide instead of Lasix like NCLEX)
a.
Diffusion
b.
Filtration
c.
Osmosis
d.
Homeostasis
ANS: C
Osmosis is the movement of water from an area of lower concentration to an area of
higher concentration.
DIF: Cognitive Level: Knowledge
TOP: Transport process
REF: p. 486
OBJ: 2
KEY: Nursing Process
Step: Intervention MSC: NCLEX: Physiological
Integrity
10.
What does actively transporting electrolytes from an area of higher concentration to an
area of lower concentration require?
a.
Hydrostatic pressure
b.
Osmotic pressure
c.
Blood pressure
d.
Pulse pressure
ANS: A
Electrolytes are moved by hydrostatic pressure, which is a form of active transport.
DIF: Cognitive Level: Comprehension REF: p. 487
TOP: Transport process
OBJ: 4
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
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11.
Electrolytes are not measured by weight; their chemical activity is expressed in
milliequivalents. What does 1 mEq of potassium have the same combining power
as?
a.
1 mEq of nitrogen
b.
1 mEq of oxygen
c.
1 mEq of hydrogen
d.
1 mEq of magnesium
ANS: C
Electrolytes are measured in milliequivalents: 1 mEq of any electrolyte is equal to 1 mEq
of hydrogen.
DIF: Cognitive Level: Knowledge
REF: p. 487 OBJ: 5 TOP:
Electrolytes KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
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12.
Sodium is the most abundant electrolyte in the body. The location of electrolytes is
important for maintaining homeostasis. Sodium is the major electrolyte in which fluid
compartment?
a.
Intracellular
b.
Intravascular
c.
Extracellular
d.
Interstitial
ANS: C
Sodium is the major extracellular electrolyte.
DIF: Cognitive Level: Knowledge
REF: p. 487
OBJ: 5
TOP: Electrolytes
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
13.
The lactating mother is counseled by the nurse to eat adequate amounts of meat and
legumes. What level will this help to increase?
a.
Potassium
b.
Chloride
c.
Magnesium
d.
Phosphorus
ANS: D
Phosphorus should be increased during pregnancy and lactation.
DIF: Cognitive Level: Knowledge
REF: p. 493 OBJ: 5 TOP:
Electrolytes KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
14.
A nurse assesses an edematous cardiac patient. The nurse is aware that this
condition is a result of retained fluid. What is the patient considered to be?
a.
Hyponatremic
b.
Hypokalemic
c.
Hypernatremic
d.
Hypercalcemic
ANS: C
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Hypernatremia is a greater-than-normal concentration of sodium, which leads to retained
fluids and edema.
DIF: Cognitive Level: Comprehension
REF: p. 488 OBJ: 5 TOP:
Electrolytes KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
15.
What is the nurse closely assessing for in a patient with hypokalemia?
a.
Systemic edema
b.
Cardiac complications
c.
Muscle cramping
d.
Impaired kidney function
ANS: B
Hypokalemia can affect cardiac function.
DIF: Cognitive Level: Application
REF: p. 489 OBJ: 5 TOP:
Electrolytes KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
16.
The nurse modifies the care plan for the immobilized patient after assessing a calcium
level of 6.2 mEq/L. What nursing assessment should the nurse include when
modifying this care plan?
a.
Osteoporosis
b.
Tooth loss
c.
Renal calculi
d.
Contractures
ANS: C
Hypercalcemia occurs when calcium levels exceed 5.8 mEq/L. It may occur when
calcium stored in the bone enters the circulation, for example, in patients who are
immobilized. Renal calculi may develop because of high levels of calcium.
DIF:
Cognitive Level: Application REF:
pp. 492-493
OBJ: 5 TOP: Electrolytes
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KEY: Nursing Process Step:
Planning
MSC: NCLEX: Physiological Integrity
17.
Homeostasis of the hydrogen ion concentration in body fluids depends on the
ratio of carbonic acid to bicarbonate in the extracellular fluid. What is this
ratio?
a.
1:5
b.
1:10
c.
1:15
d.
1:20
ANS: D
The ratio needed for homeostasis is 1 part carbonic acid to 20 parts bicarbonate.
DIF: Cognitive Level: Knowledge
REF: p. 494
OBJ: 3
TOP: Electrolytes
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
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18.
When reading the laboratory report of a patient with excessive diarrhea, the nurse
notes that the pH is 7.10, and the PaCO2 and the PaO2 are normal. What should the
nurse recognize as this patient‘s state from this information alone?
a.
Respiratory acidosis
b.
Metabolic acidosis
c.
Respiratory alkalosis
d.
Metabolic alkalosis
ANS: B
The profile of a patient in metabolic acidosis is that the blood pH will be below 7.35
and the oxygen readings are within normal limits.
DIF: Cognitive Level: Comprehension
REF: p. 498 OBJ: 7 TOP:
Electrolytes KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
19.
What should the nurse expect when assessing a patient with respiratory alkalosis?
a.
Slow respirations
b.
Muscle weakness
c.
Strong, even heart rate
d.
Flushed face
ANS: B
Tetany and muscle weakness, tachypnea, and cardiac arrhythmias are symptomatic of
respiratory alkalosis.
DIF: Cognitive Level: Application
REF: p. 497 OBJ: 7 TOP:
Electrolytes KEY: Nursing Process Step:
Analysis
MSC: NCLEX: Physiological Integrity
20.
Three body systems work at different speeds to keep the pH in the narrow range of
normal. What is the order of effectiveness for these three systems?
a.
Blood buffers, kidneys, and lungs
b.
Kidneys, lungs, and blood buffers
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c.
Blood buffers, lungs, and kidneys
d.
Lungs, kidneys, and blood buffers
ANS: C
The three systems are blood buffers, lungs, and kidneys. The blood buffers‘ speed is a
fraction of a second, the lungs take minutes, and the kidneys take hours to days.
DIF: Cognitive Level: Comprehension REF: p. 495
TOP: Acid-base balance
OBJ: 6
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
21.
A patient admitted in a state of extreme anxiety has vital signs of T 98.6°F (37°C), P
81, BP 130/86, R 32. What will result if this hyperventilation continues?
a.
Metabolic acidosis
b.
Metabolic alkalosis
c.
Respiratory acidosis
d.
Respiratory alkalosis
ANS: D
Respiratory alkalosis is caused by hyperventilation as the lungs blow off large amounts of
CO2.
DIF: Cognitive Level: Application
TOP: Acid-base balance
REF: p. 497
OBJ: 7
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
22.
A patient began vomiting and continued to do so for several hours. What is the result of
this loss of stomach contents?
a.
Metabolic acidosis
b.
Metabolic alkalosis
c.
Respiratory acidosis
d.
Respiratory alkalosis
ANS: B
The most common cause of metabolic alkalosis is vomiting gastric contents.
DIF: Cognitive Level: Application
REF: p. 498
OBJ: 7
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TOP: Acid-base balance
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
23.
What should the nurse focus on when creating a nursing care plan for a patient with
metabolic acidosis?
a.
Frequent periods of ambulation
b.
Increasing fluid intake
c.
Decreasing fluid intake
d.
Deep-breathing exercises
ANS: D
Deep breathing will cause the patient to blow off CO2 and assist in increasing the pH and
reduce the acidity.
DIF:
Cognitive Level: Application
REF: p. 495 | p. 496 OBJ:
8
TOP: Acid-base balance
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
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24.
The nurse is educating a patient regarding the need to avoid foods high in potassium.
What food choices led the nurse to conclude that teaching was not effective?
a.
Apples and green beans
b.
Kiwis and onions
c.
Apricots and asparagus
d.
Grapes and lima beans
ANS: C
Apricots and asparagus are potassium-rich.
DIF: Cognitive Level: Application
TOP: Nursing process
REF: p. 489
OBJ: 8
KEY: Nursing Process
Step: Planning MSC: NCLEX: Physiological
Integrity
MULTIPLE RESPONSE
1.
What are the three types of passive transport? (Select all that apply.)
a.
Diffusion
b.
Titration
c.
Osmosis
d.
Distillation
e.
Filtration
ANS: A, C, E
The three types of passive transport are diffusion, osmosis, and filtration.
DIF: Cognitive Level: Knowledge
TOP: Passive transport
REF: p. 485
OBJ: 4
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
2.
What are the three buffer systems of the body? (Select all that apply.)
a.
Bicarbonate/carbonic acid system
b.
Respiratory system
c.
Renal system
d.
GI system
e.
Integumentary system
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ANS: A, B, C
The bicarbonate/carbonic acid system, the respiratory system, and the renal system are
the buffer systems of the body.
DIF: Cognitive Level: Knowledge
TOP: Buffer systems
REF: p. 495
OBJ: 6
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
COMPLETION
1.
The nurse expects an adult with normal
function to void a minimum of 120 mL of
urine in 4 hours.
ANS:
kidney
The norm is to excrete at least 30 mL/h. In 4 hours, the urine output is expected to be 120
mL.
DIF: Cognitive Level: Comprehension REF: p. 496
TOP: Kidney output
OBJ: 8
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
2.
A child has been having an asthma attack for the last 8 hours. Because of the
child‘s inability to exhale effectively, the nurse assesses for respiratory
.
ANS:
acidosis
Retained CO2 will lead to respiratory acidosis.
DIF:
Cognitive Level: Application REF: pp. 496-497
OBJ: 7
TOP: Respiratory acidosis KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
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3.
The nurse explains that a normal adult will lose approximately 350 mL of water through
respiration in the course of a(n)
.
ANS:
day
Adults lose about 350 mL of water daily through respiration.
DIF: Cognitive Level: Knowledge
TOP: Insensible loss
REF: p. 484
OBJ: 8
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
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Chapter 19: Nutritional Concepts and Related
Therapies Cooper: Foundations and Adult
Health Nursing, 9th Edition
MULTIPLE
CHOICE
The nurse makes nutrition a focus in the care plan. Where does nutrition play the most
1.
important role?
a.
Weight control
b.
Sustained appetite
c.
Building strong bones
d.
Health maintenance
ANS: D
Nutrition is the total of all processes involved in taking in and using food
substances for proper growth, functioning, and maintenance of health.
DIF: Cognitive Level: Comprehension
REF: p. 523 OBJ: 1 TOP:
Nutrition
KEY: Nursing Process Step:
Planning
MSC: NCLEX: Health Promotion and Maintenance
2.
The nurse is explaining the activity recommendations from the USDA‘s new
MyPlate plan. What is the minimum amount of moderate weekly exercise needed
to balance nutritional intake?
a.
15 minutes
b.
1 hour and 15 minutes
c.
2 hours and 30 minutes
d.
60 minutes
ANS: C
MyPlate recommends a minimum of 2 hours and 30 minutes of moderate aerobic
physical activity a week to balance nutritional intake and 1 hour and 15 minutes of
vigorous physical activity a week.
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DIF: Cognitive Level: Knowledge
REF: p. 549 OBJ: 2 TOP:
MyPlate
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
What are some elements found in food that are necessary for good health but the body
3.
cannot make?
a.
Important nutrients
b.
Lifesaving nutrients
c.
Essential nutrients
d.
Necessary nutrients
ANS: C
Elements found in food that our bodies cannot make are essential nutrients.
DIF: Cognitive Level: Knowledge
REF: p. 526 OBJ: 3 TOP:
Nutrition
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
4.
To demonstrate the energy-producing potential of different foods, the nurse explains
that 3 g of lean meat produces 12 kcal/g. How many kcal/g does 3 g of fish oil
produce?
a.
6 kcal/g
b.
15 kcal/g
c.
21 kcal/g
d.
27 kcal/g
ANS: D
Fat provides 9 kcal/g.
DIF: Cognitive Level: Analysis
REF: p. 526 OBJ: 3 TOP:
Nutrition
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
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5.
What has replaced the USDA‘s Recommended Dietary Allowance (RDA)?
a.
Nutrition Recommended Allowance (NRA)
b.
National Bionutritional Allowance (NBA)
c.
Dietary Reference Intake (DRI)
d.
Dietary Guidelines for Americans (DGA)
ANS: C
The Dietary Reference Intake (DRI) has replaced the Recommended Dietary Allowance
(RDA).
DIF: Cognitive Level: Knowledge
REF: p. 524 OBJ: 2 TOP:
Nutrition
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
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6.
How many kcal/g does 1 g of alcohol provide?
a.
4 kcal/g
b.
5 kcal/g
c.
6 kcal/g
d.
7 kcal/g
ANS: D
Alcohol provides 7 kcal/g of energy.
DIF:
Cognitive Level: Knowledge
REF: NIT
Alcohol
OBJ: 3 TOP:
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
7.
The nurse is educating a group of high school students regarding nutrition. How
should the nurse respond when the students ask what occurs when protein, mineral,
iron, and fat combine?
a.
Body processes are regulated.
b.
Energy is provided.
c.
Tissue is built and repaired.
d.
Body function is restored.
ANS: C
Many nutrients are necessary to build and repair tissue, including protein, minerals, iron,
and fat.
DIF: Cognitive Level: Comprehension
REF: p. 526 OBJ: 4 TOP:
Nutrition
KEY: Nursing Process Step:
Evaluation
MSC: NCLEX: Health Promotion and Maintenance
8.
When reviewing a patient‘s dietary intake, the nurse recommends that sugar
consumption be reduced to the recommended daily level. What is this level?
a.
No more than 24% of total daily kilocalories
b.
No more than 16% of total daily kilocalories
c.
No more than 8% of total daily kilocalories
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d.
No more than 4% of total daily kilocalories
ANS: C
DRIs relating to carbohydrates indicate that 45% to 65% of an adult‘s total calorie
intake should be in the form of carbohydrates and that added sugars should be limited
to no more than 8% (approximately 40 g) of the total number of calories consumed
daily.
DIF: Cognitive Level: Knowledge
REF: p. 527 OBJ: 3 TOP:
Nutrition
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
9.
What carbohydrate is not usually consumed and is stored in the liver and in some
muscles?
a.
Sugar
b.
Glucose
c.
Lipids
d.
Glycogen
ANS: D
Glycogen is not generally consumed in the diet but is the body‘s storage form of
carbohydrate. It is found mainly in the liver, with some storage in the muscles.
DIF: Cognitive Level: Knowledge
REF: p. 528 OBJ: 4 TOP:
Glycogen
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
10.
What is the term for stored fat that insulates the body and serves as a cushion to protect
organs?
a.
Subcutaneous tissue
b.
Adipose tissue
c.
Cohesive tissue
d.
Lipid tissue
ANS: B
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Fat is stored in the body as adipose tissue.
DIF: Cognitive Level: Knowledge
TOP: Adipose tissue
REF: p. 529
OBJ: 4
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
11.
The nurse is providing information about high cholesterol levels. What is the rationale for
avoiding saturated fats?
a.
They block absorption of nutrients.
b.
They interfere with metabolism.
c.
They increase blood cholesterol.
d.
They must be hydrogenated.
ANS: C
Saturated fats tend to increase blood cholesterol.
DIF: Cognitive Level: Comprehension REF: p. 529
TOP: Saturated fats
OBJ: 6
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
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12.
When discussing the digestion and metabolism of fat, the nurse tells the patient who
has a history of cholecystitis and who is on a low-fat diet that fat must be emulsified
to be digested. What is the substance necessary for emulsification?
a.
Sugar
b.
Cholesterol
c.
Bile
d.
Protein
ANS: C
Bile is necessary to emulsify fat.
DIF: Cognitive Level: Knowledge
TOP: Function of bile
REF: p. 530
OBJ: 6
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
13.
The body uses 22 common amino acids, but 9 of them must be obtained from
protein in the diet. What are these proteins considered?
a.
Essential
b.
Basic
c.
Fundamental
d.
Primary
ANS: A
Essential amino acids must be consumed in the diet, because the body cannot make them.
DIF: Cognitive Level: Knowledge
REF:
p. 531
OBJ: 4 TOP:
Essential amino acids
KEY: Nursing
Process Step: N/A MSC: NCLEX: Health
Promotion and Maintenance
14.
The nurse is educating a patient on a vegan diet. What supplement will the
nurse encourage this patient to take to avoid a deficiency?
a.
B6
b.
B12
c.
K
d.
D
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ANS: B
B12 is almost exclusively found in animal products, but it can be supplemented with
fortified cereals or vitamins.
DIF:
Cognitive Level: Application REF: p. 531 | p. 535
OBJ: 7
TOP: B12 deficit
KEY: Nursing
Process Step: Assessment MSC: NCLEX: Health
Promotion and Maintenance
15.
A fit, young woman was at zero nitrogen balance. The nurse discovers that this
patient is now pregnant with her first child. For what is this patient at risk?
a.
Embolism
b.
Anabolism
c.
Catabolism
d.
Metabolism
ANS: B
When more nitrogen is consumed than is excreted, anabolism occurs. This is also called a
positive nitrogen balance.
DIF: Cognitive Level: Application
TOP: Nitrogen balance
REF: p. 531
OBJ: 8
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Health Promotion
and Maintenance
16.
The nurse explains that a patient with a heart problem should follow a decreased
sodium diet. What will a decreased sodium diet prevent or help reduce?
a.
Stroke
b.
Fluid excretion
c.
Heart attacks
d.
Obesity
ANS: C
Sodium attracts water and causes fluid retention. Hypervolemia increases the heart‘s
workload, which can lead to a heart attack.
DIF: Cognitive Level: Comprehension REF: p. 556
TOP: Fluid retention
OBJ: 2
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
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Maintenance
17.
The patient complains to the nurse that he feels terrible since he has been taking
several different kinds of vitamin preparations. What should the nurse assess for
indications of vitamin toxicity?
a.
Edema
b.
Hypertension
c.
Fatigue
d.
Diarrhea
ANS: C
Toxicity usually occurs from the use of large supplemental doses of vitamins and
minerals and presents as fatigue, nausea, vomiting, and headache.
DIF: Cognitive Level: Application
TOP: Vitamin toxicity
REF: p. 532
OBJ: 7
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Health Promotion
and Maintenance
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18.
The nurse cautions a patient with a pancreatic disorder that the disorder will interfere
with the digestion of fats and may lead to a clotting disorder. What is the cause of
these potential problems?
a.
Inability to use vitamin B
b.
Inability to use vitamin C
c.
Inability to use vitamin D
d.
Inability to use vitamin K
ANS: D
Vitamins A, D, E, and K are fat-soluble. Difficulty with fat metabolism will result in
the inability to use fat-soluble vitamins. Vitamin K plays a role in blood clotting. It is
important in maintaining four of the eleven clotting factors found in the blood.
DIF: Cognitive Level: Comprehension REF: p. 532
OBJ: 7
TOP: Fat-soluble vitamins KEY: Nursing Process
Step: Assessment MSC: NCLEX: Health Promotion
and Maintenance
19.
The home health nurse is caring for a patient that has undergone removal of a part of
the stomach. What condition associated with partial stomach removal should the
nurse look for when assessing the patient?
a.
A stomach ulcer
b.
Digestive problems
c.
Pernicious anemia
d.
Malabsorption
ANS: C
Pernicious anemia results when the intrinsic factor is missing due to surgery on the
stomach.
DIF: Cognitive Level: Application
REF: p. 535
OBJ: 17
TOP: Pernicious Anemia KEY: Nursing Process
Step: Assessment MSC: NCLEX: Health Promotion
and Maintenance
20.
A patient taking a diuretic is assessed by the nurse as having an erratic pulse and
muscle weakness. What electrolyte should the nurse suspect is deficient?
a.
Sodium
b. Potassium
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c.
Chloride
d.
Iron
ANS: B
Diuretics can deplete potassium through urine excretion and lead to muscle weakness and
cardiac arrhythmias.
DIF: Cognitive Level: Application
REF: p. 538
OBJ: 9
TOP: Potassium depletion KEY: Nursing Process
Step: Assessment MSC: NCLEX: Health Promotion
and Maintenance
21.
A patient who has hypertension is complaining about the lack of taste with the lowsodium diet that has been prescribed. What should the nurse emphasize that sodium
may do?
a.
Contribute to hypertension.
b.
Interfere with blood clotting.
c.
Produce stomach ulcers.
d.
Decrease calcium in the bones.
ANS: A
Sodium may contribute to hypertension.
DIF: Cognitive Level: Comprehension REF: p. 538
OBJ: 1
TOP: Sodium-induced hypertension KEY: Nursing
Process Step: Implementation MSC: NCLEX: Health
Promotion and Maintenance
22.
The young woman who is breastfeeding will need an increase of calories and
protein. What foods should the nurse suggest as sources of protein?
a.
Green, leafy vegetables
b.
Citrus fruits
c.
Asparagus
d.
Nuts
ANS: D
Nuts are a safe source of protein for lactating women.
DIF: Cognitive Level: Comprehension REF: p. 538
OBJ: 4
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TOP: Protein source
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
23.
At approximately 4 to 6 months of age, solid food is introduced to a baby.
What foods with high iron content should be recommended by the nurse?
a.
Pureed fruit
b.
Fortified cereals
c.
Fruit juice
d.
Rice
ANS: B
At approximately 4 to 6 months, iron-rich foods, such as fortified cereal and pureed meat,
are introduced to a baby.
DIF: Cognitive Level: Comprehension REF: p. 536
TOP: Iron-rich foods
OBJ: 8
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
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24.
A school nurse is teaching a group of adolescents about adequate nutrition. What
increased intake should the nurse encourage?
a.
Potassium and sodium
b.
Chloride and magnesium
c.
Iron and calcium
d.
Vitamins and minerals
ANS: C
Dietary inadequacies in adolescence include iron and calcium.
DIF:
Cognitive Level: Application
REF: p. 537 | p. 539 OBJ:
8
TOP: Adolescent nutrition
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
25.
A nurse caring for a patient who is prescribed a full-liquid diet recognizes that this
diet lacks some nutrients. What nutrients are lacking?
a.
Fat-soluble vitamins
b.
Potassium
c.
Iron and fiber
d.
Water-soluble vitamins
ANS: C
A full-liquid diet is deficient in iron and fiber.
DIF: Cognitive Level: Comprehension REF: p. 547
TOP: Full-liquid diets
OBJ: 10
KEY: Nursing Process
Step: Planning MSC: NCLEX: Health Promotion
and Maintenance
26.
The nurse has assessed a patient‘s body mass index (BMI) to be 19.6. This
assessment of weight versus height indicates that this patient‘s weight category is in
which category?
a.
Low health risk
b.
Overweight
c.
Obese
d.
Morbidly obese
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ANS: A
A BMI between 18.5 and 24.9 is associated with the lowest health risk. Those with
BMIs between 25 and 29.9 are considered overweight, and those with BMIs of 30 or
greater are considered obese. A BMI of less than 18.5 is considered underweight and is
also associated with health risks.
DIF: Cognitive Level: Analysis
TOP: Body mass index (BMI)
REF: p. 549
OBJ: 12
KEY: Nursing
Process Step: Assessment MSC: NCLEX: Health
Promotion and Maintenance
27.
The nurse is counseling a patient about the difference between type 1 and type 2
diabetes. What should the nurse stress that patients with type 2 diabetes are required to
receive on a daily basis?
a.
Regular carbohydrate-controlled meals
b.
Oral hyperglycemic agents
c.
Insulin injections
d.
Stringent low-calorie diets
ANS: A
People with type 2 diabetes must take daily regulated meals with controlled
carbohydrate content. Type 1 diabetics must have insulin injections.
DIF: Cognitive Level: Comprehension REF: p. 552
TOP: Nutrition in type 2 diabetes
OBJ: 1
KEY: Nursing
Process Step: Implementation MSC: NCLEX: Health
Promotion and Maintenance
28.
Careful attention to carbohydrate consumption can improve metabolic control of
diabetes. The nurse teaches a meal planning approach that focuses on the total
amount of carbohydrates eaten at a meal. What is this meal planning approach
called?
a.
Carbohydrate splitting
b.
Reduced caloric intake
c.
Carbohydrate counting
d.
Carbohydrate balancing
ANS: C
Carbohydrate counting is a meal planning approach that focuses on the total amount of
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carbohydrates eaten.
DIF: Cognitive Level: Knowledge
REF: p. 552
OBJ: 13
TOP: Carbohydrate counting KEY: Nursing Process
Step: Implementation MSC: NCLEX: Health Promotion
and Maintenance
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29.
The patient who had a gastrostomy complains to the nurse about frequent episodes
of dumping syndrome. What can the nurse recommend to this patient to decrease
this problem?
a.
Eat small, frequent meals.
b.
Include more fiber in meals.
c.
Increase seasoning on food.
d.
Limit intake to semiliquids.
ANS: A
The symptoms of dumping syndrome can be reduced by consuming small frequent meals
of mildly seasoned food; extra fiber is not essential.
DIF:
Cognitive Level: Application REF: pp. 552-553
OBJ: 2
TOP: Dumping syndrome KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
30.
The nurse reminds the male patient with lactose intolerance that he can avoid the
unpleasant symptoms of nausea, bloating, flatulence, and diarrhea, if he will
avoid certain foods. What product should the patient be instructed to avoid?
a.
Soy beans
b.
Rice
c.
Milk
d.
High fiber
ANS: C
Lactose intolerance occurs as a result of a lack of lactase that makes it impossible to break
down milk sugar.
DIF: Cognitive Level: Application
REF: p. 553
OBJ: 2
TOP: Lactose intolerance KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
31.
A patient diagnosed with renal failure is unable to excrete protein waste products and
develops a condition that requires a
protein-restricted diet. The nurse instructs the patient that azotemia can be diminished by
substituting other food groups for protein. What is an example of a food that this patient
can substitute for protein?
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a.
Potatoes
b.
Beans
c.
Cheese
d.
Soy products
ANS: A
The foods that a patient with renal disease can substitute for energy are in the
carbohydrate group. Potatoes are the only carbohydrate listed.
DIF: Cognitive Level: Comprehension REF:
p. 556
OBJ: 11 TOP: Azotemia
KEY:
Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
32.
What is a nursing intervention to decrease the thirst of a patient who is on a fluid
restriction?
a.
Rinsing the mouth with warm water
b.
Sipping carbonated drinks
c.
Sucking on occasional ice chips
d.
Limiting tooth brushing to once per day
ANS: C
Sucking on occasional ice chips is a way to decrease thirst without adding a large
amount of fluid. Rinsing the mouth with cool water and frequent tooth brushing are
helpful also. Carbonated drinks contain sodium and will enhance fluid retention.
DIF: Cognitive Level: Application
TOP: Fluid restrictions
REF: p. 557
OBJ: 16
KEY: Nursing Process
Step: Planning MSC: NCLEX: Health Promotion
and Maintenance
33.
The nurse recognizes that when a patient is unable to consume adequate nutrition by
mouth, an alternative route such as a feeding ostomy may be used. What is the proper
term for feeding a patient by this method?
a.
Total parenteral nutrition (TPN)
b.
Nasogastric
c.
Enteral
d.
Parenteral
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ANS: C
The administration of nutritionally balanced liquid foods through a feeding ostomy is
called enteral nutrition.
DIF: Cognitive Level: Knowledge
TOP: Enteral feedings
REF: p. 557
OBJ: 2
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
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34.
The nurse teaches a patient who has a nonfunctioning or dysfunctional GI tract that
total parenteral nutrition (TPN) will be infused. Where will the infusion occur?
a.
Through the carotid artery
b.
Through the superior vena cava
c.
Through the femoral vein
d.
Through the inferior vena cave
ANS: B
TPN solution is usually infused through the superior vena cava.
DIF: Cognitive Level: Comprehension REF: p. 565
TOP: Total parenteral nutrition
OBJ: 2
KEY: Nursing
Process Step: Implementation MSC: NCLEX: Health
Promotion and Maintenance
MULTIPLE RESPONSE
1.
Which are the energy-providing food groups? (Select all that apply.)
a.
Carbohydrates
b.
Fats
c.
Proteins
d.
Vitamins
e.
Minerals
ANS: A, B, C
The food groups that provide energy are carbohydrates, fats, and proteins.
DIF: Cognitive Level: Application
TOP: Energy-producing food groups
REF: p. 526
OBJ: 3
KEY:
Nursing Process Step: Evaluation MSC: NCLEX:
Health Promotion and Maintenance
COMPLETION
1.
To simplify food values, the measurement of energy obtained by food is defined as the .
ANS:
kilocalorie
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The kilocalorie is the energy value by which foods are measured for their energyproducing potential.
DIF: Cognitive Level: Knowledge
REF: p. 526 OBJ: 3 TOP:
Kilocalorie
KEY: Nursing Process Step:
Intervention
MSC: NCLEX: Health Promotion and Maintenance
2.
The body mass index (BMI) of a man 6 ft tall weighing 250 lb is
.
ANS:
33.9
The BMI is calculated by dividing the pounds expressed as
kilograms by the height in meters squared. 6 ft = 72 in ÷ 39.37 =
1.83 m
250 lb ÷ 2.2 = 113.6 kg
113.6 ÷ (1.83  1.83) = 33.9
DIF: Cognitive Level: Analysis
REF: p. 548 | p. 549 OBJ:
12
TOP: Calculating body
mass index (BMI)
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and
Maintenance
3. Insoluble
softens stools, speeds transit of foods through the digestive
tract, and reduces pressure in the colon.
ANS:
fiber
Insoluble fiber softens stools, speeds transit of foods through the digestive tract, and
reduces pressure in the colon. Thus it may help relieve constipation and reduce the risk of
certain gastrointestinal (GI) disorders, such as diverticulosis or hemorrhoids.
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DIF: Cognitive Level: Knowledge
REF: p. 528 OBJ: 5 TOP:
Fiber
KEY: Nursing Process Step:
N/A
MSC: NCLEX: Health Promotion and Maintenance
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Chapter 20: Complementary and Alternative
Therapies Cooper: Foundations and Adult
Health Nursing, 9th Edition
MULTIPLE
CHOICE
1.
The nurse is caring for a patient recovering from a hip replacement and is
providing education regarding exercises in physical therapy. What type of therapy
should the nurse call these exercises?
a.
Alternative therapies
b.
Complementary therapies
c.
Comfort therapies
d.
Body therapies
ANS: B
Complementary therapies are used in addition to conventional therapies.
DIF: Cognitive Level: Knowledge
TOP: Complementary therapies
REF: p. 570
OBJ: 1
KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity
2.
An older adult patient tells the home health nurse, ―My health care provider
hasn‘t helped my arthritis at all. I am using the chiropractor now.‖ What change
has the patient made?
a.
Western medicine to complementary therapy
b.
Complementary therapy to alternative therapy
c.
Alternative therapy to allopathic medicine
d.
Allopathic medicine to alternative therapy
ANS: D
Alternative therapies may become the primary treatment modality; for instance, the patient
switching from traditional (allopathic) medicine to chiropractic (alternative).
DIF: Cognitive Level: Comprehension
REF: p. 587 OBJ: 1 TOP:
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Therapies
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
3.
What is the responsibility of the National Center for Complementary and Alternative
Medicine (NCCAM)?
a.
To certify alternative medical health care providers
b.
To evaluate effectiveness of alternative medical treatments
c.
To set standards for the practice of alternative medicine
d.
To train alternative medical health care providers
ANS: B
The National Center for Complementary and Alternative Medicine was established to
facilitate the evaluation of alternative medical treatment.
DIF: Cognitive Level: Comprehension REF: p. 571
TOP: National Center for CAM
OBJ: 1
KEY: Nursing
Process Step: Implementation MSC: NCLEX: Safe,
Effective Care Environment
4.
What is the importance of the nurse asking about the patient‘s use of alternative therapies
when obtaining a health history?
a.
Alternative therapies can be covered by insurance.
b.
Alternative therapies have unfortunate interactions with traditional therapies.
c.
Alternative therapies can be substituted for allopathic medicine.
d.
Alternative therapies have curative and healing power.
ANS: B
Some alternative therapies may have serious side effects. As a rule, complementary
and alternative (CAM) therapies are not curative or healing as is allopathic medicine.
Some complementary therapies are covered by insurance, but alternative remedies are
not.
DIF: Cognitive Level: Comprehension
REF: p. 571
OBJ: 3 TOP:
Complementary and alternative (CAM)
therapies
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
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5.
The nurse is obtaining health history information on a new patient at a health
care provider‘s office and he or she records a barbiturate medication on the
current list. What herb should the nurse ask if the patient is taking?
a.
St. John‘s wort
b.
Aloe vera
c.
Valerian
d.
Ginkgo
ANS: C
Valerian enhances the effect of barbiturates.
DIF:
p. 574
Cognitive Level: Application
REF:
OBJ: 3 | 5 TOP: Valerian KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
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6.
What should the nurse instruct a patient who takes tincture of rosemary to do several
times a day?
a.
Assess pulse frequently.
b.
Avoid constipation.
c.
Watch for hypoglycemia.
d.
Wear sunscreen.
ANS: D
Rosemary can cause photosensitivity.
DIF:
Cognitive Level: Application
p. 576
REF:
OBJ: 2 | 5 TOP: Rosemary KEY:
Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
7.
What is true regarding manufacturers of herbal remedy products?
a.
They do extensive field testing on the products.
b.
They must show dosage equivalents.
c.
They must adhere to standards of strength.
d.
They do not have to demonstrate their safety.
ANS: D
Herbal remedy manufacturers are not required by law to demonstrate the safety of their
products.
DIF:
Cognitive Level: Comprehension
REF: p. 572 | p. 575 OBJ:
4
TOP: Herbal remedies
KEY: Nursing Process Step:
Implementation MSC:
NCLEX: Safe, Effective Care
Environment
8.
Herbs have not been approved for use as drugs. How are herbs allowed to be sold?
a.
For pain relief
b.
To improve body strength
c.
To prolong life
d.
As diet supplements
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ANS: D
Herbs are sold as food supplements.
DIF: Cognitive Level: Comprehension REF:
p. 572
OBJ: 4 TOP:
Herbal remedies
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
9.
What is the goal of herbal therapy?
a.
Treat symptoms.
b.
Restore balance.
c.
Treat disease.
d.
Improve nutrition.
ANS: B
The goal of herbal therapy is to restore balance.
DIF: Cognitive Level: Comprehension REF:
p. 572
OBJ: 4 TOP:
Herbal therapy
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
10.
Confusion and misinformation relative to herbal medicine can make patients
reluctant to disclose their herbal use to health care providers. What should be the
nurse‘s approach?
a.
Instructive
b.
Nonjudgmental
c.
Inquisitive
d.
Determined
ANS: B
A nonjudgmental open attitude will encourage the patient to share information
about the use of CAM (complementary and alternative medicine).
DIF: Cognitive Level: Application
TOP: Health interview
REF: p. 575
OBJ: 2
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
11.
What will placing an herb in alcohol or vinegar make?
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a.
A suspension
b.
An emulsion
c.
An infusion
d.
A tincture
ANS: D
Tinctures are made by placing the herb in alcohol or vinegar.
DIF: Cognitive Level: Knowledge
TOP: Making herbal remedies
REF: p. 575
OBJ: 5
KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity
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12.
During a follow-up visit with a patient recently started on Coumadin, the home
health nurse is concerned after seeing an herbal remedy that enhances the effect of
anticoagulants by the patient‘s bedside. What is this herbal remedy?
a.
Cayenne
b.
Aloe vera
c.
Asian ginseng
d.
Kava
ANS: C
Asian ginseng may enhance the effect of Coumadin.
DIF: Cognitive Level: Comprehension
REF: p. 572 OBJ: 5 TOP:
Ginseng
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Safe, Effective Care Environment
13.
Acupuncture is a complementary therapy that uses fine needles placed in
acupoints. What is the believed purpose of these acupoints?
a.
―Close the gate‖ for pain transmission.
b.
Align the internal organs.
c.
Open meridians to release qi.
d.
Stimulate the ―centering‖ of qi.
ANS: C
Acupuncture therapy uses needles placed in acupoints to open meridians to release qi (life
force).
DIF: Cognitive Level: Comprehension REF: p. 577
OBJ: 7
TOP: Acupuncture KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
14.
The nurse is educating a patient with phlebitis of the left leg. What alternative therapy
should this patient avoid until the condition is resolved?
a.
Acupuncture
b.
Therapeutic massage
c.
Yoga
d.
Acupressure
ANS: B
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Therapeutic massage is contraindicated in conditions such as thrombosis, phlebitis, and
infective skin diseases.
DIF: Cognitive Level: Application
TOP: Therapeutic massage
REF: p. 579
OBJ: 9
KEY: Nursing Process
Step: Implementation MSC: NCLEX: Safe, Effective
Care Environment
15.
What type of alternative therapy is the nurse practicing when using essential oils to
provide inhalation treatments?
a.
Magnet therapy
b.
Respiratory therapy
c.
Herbal therapy
d.
Aromatherapy
ANS: D
Aromatherapy uses pure essential oils to provide health benefits.
DIF: Cognitive Level: Comprehension REF: p. 580
TOP: Aromatherapy
OBJ: 10
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
16.
The nurse is educating a patient regarding reflexology. Information includes that
reflexology is a therapy based on the theory that the entire body can be reached by
applying pressure to specific areas. Where is pressure mainly applied?
a.
Hands
b.
Head
c.
Back
d.
Feet
ANS: D
In reflexology it is thought that the entire body can be reached by applying pressure to
specific areas on the feet.
DIF:
Cognitive Level: Comprehension
pp. 580-581
REF:
OBJ: 2 | 11 TOP: Reflexology
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychological Integrity
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17.
What type of therapy is contraindicated in patients with pacemakers?
a.
Relaxation therapy
b.
Magnetic therapy
c.
Yoga therapy
d.
Imagery therapy
ANS: B
Magnet therapy interferes with pacemaker function.
DIF: Cognitive Level: Knowledge
REF:
p. 581
OBJ: 12 TOP:
Magnetic therapy
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
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18.
Which term describes using the conscious mind to create situations that evoke physical
changes in the body?
a.
Imagination
b.
Self-hypnosis
c.
Imagery
d.
Visualization
ANS: C
Imagery uses the conscious mind to create images that evoke physical changes in the
body.
DIF: Cognitive Level: Knowledge
REF: p. 581 OBJ: 1 TOP:
Imagery
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
19.
The nurse describes a therapy that can produce a state of decreased cognitive,
physiologic, and/or behavioral arousal. To what alternative therapy is the nurse
referring?
a.
Subconscious
b.
Imagery
c.
Sleep
d.
Relaxation
ANS: D
Relaxation is the state of general decreased cognitive, physiologic, and/or behavior
arousal.
DIF:
Cognitive Level: Knowledge REF: pp.
581-582
OBJ: 1 | 2 TOP: Relaxation
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Psychosocial Integrity
20.
What is a therapeutic treatment that joins the mind and body and increases muscle tone
and flexibility?
a.
Acupressure
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b.
Spiritual enrichment
c.
Yoga therapy
d.
Therapeutic massage
ANS: C
Yoga therapy is the joining of the mind, body, and spirit to enrich the quality of one‘s life.
Yoga also increases muscle tone and flexibility.
DIF: Cognitive Level: Knowledge
REF:
p. 583
KEY:
OBJ: 14 TOP: Yoga
Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
21.
What training system may help prevent osteoporosis?
a.
Acupressure
b.
Yoga
c.
Therapeutic massage
d.
Tai chi
ANS: D
Tai chi, although a martial arts skill, increases balance and timing and may prevent
osteoporosis.
DIF: Cognitive Level: Knowledge
REF:
p. 584
KEY:
OBJ: 15 TOP: Tai chi
Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
22.
A patient wants to use aromatherapy to treat pneumonia, but the hospital policy
will not allow burning of eucalyptus-scented candles. What should the nurse
suggest the patient use instead?
a.
Another essential oil
b.
Prescribed medications
c.
A topical eucalyptus product
d.
Massage therapy
ANS: C
Eucalyptus oils can be used for inhalation or may be applied topically.
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DIF: Cognitive Level: Application
TOP: Aromatherapy
REF: p. 576
OBJ: 10
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
23.
A patient admitted with lower back pain is not sure that the prescribed treatment is
helping and asks what alternative therapies might help. What should the nurse
suggest?
a.
Herbal therapy
b.
Chiropractic therapy
c.
Acupressure
d.
Reflexology
ANS: B
Chiropractic therapy is currently viewed as an acceptable treatment for certain disorders,
including back pain.
DIF: Cognitive Level: Application
REF: p. 577
OBJ: 6 TOP:
Chiropractic
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
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MULTIPLE RESPONSE
1.
Herbal remedies vary from pharmaceutical remedies in what ways? (Select all that
apply.)
a.
Herbal remedies use the whole plant.
b.
Herbal remedies have no quality control.
c.
Herbal remedies have no standard dose.
d.
Herbal remedies are sold as food supplements.
e.
Herbal remedies are always safe and effective.
ANS: A, B, C, D
Herbal remedies are not always safe and effective.
DIF: Cognitive Level: Comprehension REF: p. 575
TOP: Herbal remedies
OBJ: 1
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
2.
Founded in 1992, the National Center for Complementary and Alternative
Medicine (NCCAM) has the responsibility for what actions? (Select all that apply.)
a.
Evaluating alternative treatments
b.
Distributing information to the public
c.
Coordinating and conducting research
d.
Removing defective products from the market
e.
Regulating third-party reimbursement
ANS: A, B, C
The National Center for Complementary and Alternative Medicine has the
responsibility to evaluate treatments, distribute information, and conduct research. It
has no power to remove defective products from the market or deal with insurance
payments.
DIF: Cognitive Level: Knowledge
p. 572
REF:
OBJ: 1 TOP:
National Center for CAM KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
3.
The nurse recommends that a patient have animal-assisted therapy (AAT) sessions
because this therapy has been found to have what effects? (Select all that apply.)
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a.
Improvement in mood
b.
Decrease in blood pressure
c.
Decrease in blood sugar
d.
Reduction of allergies
e.
Increase in socialization skills
ANS: A, B, E
Animal-assisted therapy (AAT) has been found to improve mood, decrease blood
pressure, and increase socialization skills. AAT has not been found to decrease blood
sugar or reduce allergies.
DIF: Cognitive Level: Comprehension REF: p. 583
TOP: Animal-assisted therapy (AAT)
OBJ: 13
KEY:
Nursing Process Step: Implementation MSC: NCLEX:
Psychosocial Integrity
4.
Why do people often choose complementary and alternative medicine (CAM)? (Select all
that apply.)
a.
CAM is less invasive.
b.
CAM is more holistic.
c.
CAM is focused on treatment of disease.
d.
CAM is dedicated to health maintenance.
e.
CAM is within the control of the patient.
ANS: A, B, D, E
CAM is less invasive, more holistic, dedicated to health maintenance, and within
control of the patient. CAM is focused on prevention, not treatment.
DIF: Cognitive Level: Comprehension
REF: p. 571 OBJ: 1 TOP:
CAM
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
COMPLETION
1.
The nurse reassures a patient that
of all adults in the United States take some form of
CAM therapy each year.
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ANS:
one-third
It is estimated that one-third of all adults in the United States take some form of herbal or
natural product supplement alone or in combination with conventional medicines but
rarely report this practice to their health care providers.
DIF: Cognitive Level: Knowledge
REF: p. 571
OBJ: 3
TOP: Herbal supplements KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
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2.
People with fractures, rheumatoid arthritis, and osteoporosis are not candidates for
therapy.
ANS:
chiropractic
Contraindications for chiropractic therapy include acute myelopathy, fractures,
dislocations, rheumatoid arthritis, and osteoporosis.
DIF: Cognitive Level: Comprehension REF: p. 577
TOP: Chiropractic
OBJ: 6
KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
is a noninvasive method an individual can employ to learn control of
3.
the body to manage certain conditions. Monitoring equipment is used to measure vital
signs and muscle tension. The messages are sent back to the individual.
ANS:
Biofeedback
Biofeedback is a noninvasive method an individual can employ to learn control of the
body to manage certain conditions. It may be considered when other therapies have not
been successful or in conjunction with other treatments. Health concerns such as
anxiety, stress, irritable bowel syndrome, and asthma may be managed using
biofeedback.
DIF: Cognitive Level: Knowledge
REF: p. 585
OBJ: 16
TOP: Biofeedback KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
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Chapter 21: Pain Management, Comfort, Rest,
and Sleep Cooper: Foundations and Adult
Health Nursing, 9th Edition
MULTIPLE
CHOICE
1.
A patient reports to the nurse that he is experiencing a moderate amount of back
pain rated 6 out of 10 on the pain scale. What should the nurse recognize about this
assessment?
a.
Pain is objective for the nurse.
b.
Pain is easy to recognize.
c.
Pain is subjective for the patient.
d.
Pain is easily relieved if found early.
ANS: C
Pain is subjective. Pain is exactly what the patient says it is.
DIF:
Cognitive Level: Comprehension REF:
p. 592
OBJ: 3 | 5 TOP: Pain
KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
2.
A patient has pain in the left arm secondary to coronary insufficiency. This is an example
of what type of pain?
a.
Acute pain
b.
Chronic pain
c.
Referred pain
d.
Subacute pain
ANS: C
An example of referred pain is coronary insufficiency manifested by pain in the left
arm, which is a distant location from the real source of discomfort.
DIF:
p. 593
Cognitive Level: Comprehension REF:
OBJ: 1 | 2 TOP: Pain
KEY:
Nursing Process Step: Assessment
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MSC: NCLEX: Physiological Integrity
3.
The nurse reassures a patient that most acute pain is intense and of short duration. How
long does can acute pain usually last?
a.
1 week
b.
Less than 6 months
c.
At least 9 months
d.
More than 1 year
ANS: B
Acute pain lasts less than 6 months.
DIF: Cognitive Level: Comprehension
REF: p. 593 OBJ: 1 TOP: Pain
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
4.
What is the defining term for continuous or intermittent pain that does not serve as a
warning of tissue damage?
a.
Acute
b.
Unrelieved
c.
Chronic
d.
Subacute
ANS: C
Chronic pain can be continuous or intermittent and may not be indicative of tissue
damage.
DIF: Cognitive Level: Knowledge
REF:
p. 593
KEY:
OBJ: 1 | 2 TOP: Pain
Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
5.
The nurse is planning interventions for a patient experiencing pain. When the nurse
assess the patient, which of the following can act in a synergistic relationship?
a.
Inflammatory process
b.
Circulatory disorder
c.
Food allergy
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d.
Fatigue
ANS: D
Fatigue, sleep disturbance, and depression act in a synergistic relationship.
DIF:
p. 593
Cognitive Level: Comprehension REF:
OBJ: 2 | 7 TOP: Pain
KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
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6.
The nurse is giving a backrub to a patient to relieve pain. What pain theory is the nurse
using?
a.
Synergism
b.
Gate control
c.
Distraction
d.
Guided imagery
ANS: B
The pressure of a backrub will close the gate, according to the gate control theory of pain.
DIF: Cognitive Level: Comprehension
REF: p. 595 OBJ: 4 TOP: Pain
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
7.
A young athlete asks the nurse why he felt little pain when he broke his leg during a
game. Which of the following can have an effect on this patient‘s perception of
pain?
a.
Hormones
b.
Enzymes
c.
Adrenaline
d.
Endorphins
ANS: D
Endorphins found in the pituitary gland and other areas of the central nervous system
create the same effect as morphine, producing an analgesic effect.
DIF:
p. 593
Cognitive Level: Comprehension REF:
OBJ: 1 | 2 TOP: Pain
KEY:
Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
8.
When assessing pain which of the following is included in pain assessment?
a.
The initial assessment
b.
Discharge planning
c.
Assessing vital signs
d.
Care planning
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ANS: C
Making pain a vital sign would ensure that pain is monitored on a regular basis.
DIF: Cognitive Level: Comprehension
REF: p. 594 OBJ: 6 TOP: Pain
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
9.
Why should a nurse promptly administer a prescribed analgesic after a pain assessment?
a.
The health care provider has ordered it.
b.
It is an efficient use of time.
c.
Unrelieved pain can cause setbacks.
d.
It meets the goals of the nursing care plan.
ANS: C
Appropriate pain management can bring about quicker recoveries, shorter hospital stays,
fewer readmissions, and can improve the quality of life.
DIF: Cognitive Level: Comprehension REF:
p. 595
OBJ: 10 TOP: Pain
KEY:
Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
10.
The nurse obtains information from a patient about the site, severity, and duration of the
pain. What type of data is this considered?
a.
Patient data
b.
Objective data
c.
Focused data
d.
Subjective data
ANS: D
Information from the patient concerning site, severity, and duration of the pain is
subjective data that only the patient knows.
DIF: Cognitive Level: Comprehension
REF: p. 596 OBJ: 5 TOP: Pain
KEY: Nursing Process Step:
Assessment
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MSC: NCLEX: Physiological Integrity
11.
The nurse is assessing pain reported by a Latino male patient. What is important
for the nurse to take into consideration when observing objective data?
a.
Latino men are suspicious of female caregivers.
b.
Latino men have a cultural bias against use of narcotics.
c.
Latino men believe pain is necessary for cure.
d.
Latino men feel it is unmanly to admit to pain.
ANS: D
Many Latino men feel that to admit to being in pain is unmanly.
DIF: Cognitive Level: Application
TOP: Latino culture
REF: p. 603
OBJ: 10
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
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12.
Which documentation sample is the most helpful to share assessment findings and pain
relief interventions?
a.
1600: Patient reports chest pain. Medicated with morphine sulfate.
b.
1600: Patient reports sharp chest pain. Morphine sulfate given IM.
c.
1600: Patient reports sharp pain in left chest radiating
to neck. Morphine sulfate 5 mg administered IM in
right deltoid.
d.
1600: Patient requested medication for pain in left
chest. Morphine sulfate 10 mg PO given.
ANS: C
The nurse should record subjective information relative to the pain, as well as the
intervention and administration route.
DIF: Cognitive Level: Application
REF: p. 603
TOP: Pain medication documentation
OBJ: 10
KEY:
Nursing Process Step: Implementation MSC: NCLEX:
Safe, Effective Care Environment
13.
The nurse teaches noninvasive pain relief techniques, such as guided imagery,
biofeedback, and relaxation. What is the primary advantage of these techniques?
a.
Can be done any time.
b.
Does not require a nurse.
c.
Gives the patient some control.
d.
Is most effective.
ANS: C
The greatest advantage of noninvasive pain relief techniques is that they give the patient
some control.
DIF: Cognitive Level: Comprehension REF: p. 595
TOP: Noninvasive pain control
OBJ: 11
KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Psychosocial Integrity
14.
The nurse explains that transcutaneous electric nerve stimulation (TENS) provides a
continuous mild electric current to the skin. How does the TENS unit act to reduce
pain?
a. Distracts the patient.
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b.
Blocks endorphin production.
c.
Warms the skin.
d.
Blocks pain impulses.
ANS: D
TENS works by blocking pain impulses.
DIF: Cognitive Level: Comprehension REF:
p. 595
OBJ: 11 TOP: TENS
KEY:
Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
15.
An American Indian patient requests that an egg yolk be placed in a saucer and put
under his bed to absorb the pain. What should the nurse do?
a.
Explain that medication will relieve the pain better.
b.
Place the egg in a saucer under the bed.
c.
Ask the health care provider for permission.
d.
Warn that housekeeping staff will remove the egg.
ANS: B
The nurse should use methods of pain control that the patient believes will work.
DIF: Cognitive Level: Application
REF: p. 606
OBJ: 10
TOP: Cultural considerations KEY: Nursing Process
Step: Implementation MSC: NCLEX: Psychosocial
Integrity
16.
The home health nurse is caring for a patient with an implanted pacemaker.
What type of pain management would be contraindicated?
a.
Peripheral analgesics
b.
A TENS unit
c.
Opioid analgesics
d.
Adjuvant analgesics
ANS: B
A TENS unit may interfere with the function of the pacemaker.
DIF: Cognitive Level: Application
p. 595
REF:
OBJ: 10 TOP: Pain
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control
KEY: Nursing Process Step: Analysis
MSC: NCLEX: Physiological Integrity
17.
The nurse is trying to reassure a patient who is concerned about receiving addictive
drugs. What percentage of patients become addicted to analgesics?
a.
Less than 0.1%
b.
Less than 1%
c.
Less than 5%
d.
Less than 6%
ANS: B
Research findings suggest that less than 1% of patients receiving analgesics become
addicted.
DIF: Cognitive Level: Knowledge
REF:
p. 596
KEY:
OBJ: 10 TOP: Addiction
Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
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18.
The nurse is caring for a patient using patient-controlled analgesia (PCA). What is a
major advantage to this method?
a.
Less expensive
b.
More effective
c.
Less addictive
d.
Quicker
ANS: D
The use of the PCA gives quicker relief as there is no delay in waiting for the nurse to
respond to the request for analgesia.
DIF: Cognitive Level: Comprehension REF: p. 600
OBJ: 10
TOP: Patient-controlled analgesia (PCA) KEY:
Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity
19.
A patient tearfully declares the use of relaxation techniques does not work for
her. What is the best action for the nurse to implement?
a.
Give up on the idea.
b.
Encourage the patient to try again.
c.
Assure the patient that not everyone is successful.
d.
Give the patient a sedative.
ANS: B
Some alternative approaches to pain control require practice. Encouragement to try again
is appropriate.
DIF: Cognitive Level: Application
TOP: Alternate methods of pain control
REF: p. 606
OBJ: 11
KEY:
Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity
20.
A patient is receiving an opioid narcotic. What common side effect should the nurse be
aware of when assessing this patient?
a.
Addiction
b.
Vomiting
c.
Constipation
d.
Diarrhea
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ANS: C
Constipation is the most common opioid narcotic side effect for which patients do not
develop a tolerance.
DIF: Cognitive Level: Comprehension REF:
p. 598
OBJ: 10 TOP:
Constipation KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
21.
A male patient reports to the home health nurse that he does not feel rested although he
has slept 8 hours. For what should the nurse assess?
a.
Having vivid dreams
b.
Eating a heavy meal before going to bed
c.
Consuming an excessive amount of alcohol
d.
Taking an anxiolytic medication
ANS: D
Anxiolytic (antianxiety) medications interfere with REM sleep, which is when people
achieve full rest.
DIF:
Cognitive Level: Application REF: pp.
608-609
OBJ: 14 | 15 TOP: Sleep KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
22.
Although denying pain, a patient is irritable, responds slowly, and exhibits periods of
tachycardia. What should the nurse assess for in this patient?
a.
Electrolyte imbalance
b.
Allergic response
c.
Sleep deprivation
d.
Constipation
ANS: C
With sleep deprivation, patients may experience a variety of physiologic and psychological
symptoms.
DIF: Cognitive Level: Application
TOP: Sleep deprivation
REF: p. 609
OBJ: 16
KEY: Nursing Process
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Step: Assessment MSC: NCLEX: Physiological
Integrity
23.
When preparing a patient for sleep, dimming the lights and decreasing the noise levels
are examples of nursing interventions. What are these interventions designed to do?
a.
Mimic usual sleep patterns.
b.
Decrease environmental stimuli.
c.
Prepare the patient for sleep.
d.
Provide for more rest.
ANS: B
Environmental stimuli should be decreased when preparing the patient for sleep.
DIF: Cognitive Level: Comprehension REF:
p. 610
OBJ: 13 TOP: Sleep
KEY:
Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
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24.
What is the best approach for a nurse to use when planning pain relief measures?
a.
Use a variety of pain relief methods.
b.
Use only nonopioid analgesics.
c.
Use at least three alternating methods.
d.
Use only one method at a time.
ANS: A
A variety of methods applied simultaneously have an additive effect on pain control.
DIF: Cognitive Level: Comprehension REF:
p. 606
control
OBJ: 10 TOP: Pain
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
25.
The nurse is trying to establish an effective relationship with a patient in pain. What
is the best statement for the nurse to make when beginning the assessment?
a.
―I‘ll check to see if you can have anything.‖
b.
―Let me give you a backrub and see if it helps.‖
c.
―I believe you are in pain.‖
d.
―When was your last medication for pain?‖
ANS: C
A nursing intervention to establish an effective relationship is to believe the patient.
Although the other options are not wrong, they do not help establish an effective
relationship.
DIF: Cognitive Level: Application REF: p. 593 | p. 602
OBJ: 10
TOP: Pain
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
26.
What action should the nurse take when evaluating the effectiveness of new or revised
therapies for pain relief?
a.
Observe the patient performing activities of daily living.
b.
Observe the patient‘s facial expressions.
c.
Frequently assess subjective data.
d.
Perform evaluation of outcome goals.
ANS: D
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Continuous evaluation allows the nurse to determine if new or revised therapies are
required.
DIF: Cognitive Level: Application
REF:
p. 611
KEY:
OBJ: 10 TOP: Pain
Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity
27.
The home health nurse is instructing the family of an older adult patient with arthritis
about sleep promotion. What intervention can best promote sleep for the older adult
patient?
a.
Giving nonsteroidal anti-inflammatory drugs (NSAIDs) in the mornings
b.
Administering diuretics in the mornings
c.
Encouraging daytime sleeping
d.
Avoiding the stimulation of backrubs or warm drinks before bedtime
ANS: B
Older adults sleep lightly. Give NSAIDs before bedtime for comfort. Diuretics should
be given in the mornings to reduce having to wake up to go to the bathroom during the
night. Daytime sleeping may negatively affect nighttime sleep. Nonpharmacologic
interventions are helpful to induce sleep.
DIF: Cognitive Level: Comprehension REF: p. 598
TOP: Sleep promotion
OBJ: 13
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
28.
The nurse is using a pain scale of 0 to 10 to assess pain in a postoperative patient.
What is considered the maximum pain level at which a patient can usually function
effectively?
a.
2
b.
3
c.
4
d.
5
ANS: C
Most patients do not function effectively if the pain level exceeds 4 on a scale of 10.
DIF: Cognitive Level: Knowledge
REF: p. 605 OBJ: 8 TOP: Pain
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KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
29.
A patient is receiving epidural analgesics. What should the nurse monitor closely in this
patient?
a.
Temperature elevation from 98° to 99.2°F (36.6° to 37.3°C)
b.
Increase in pulse rate from 88 to 99
c.
Decrease in respirations from 16 to 14
d.
Decrease in blood pressure from 120/80 to 110/68
ANS: C
Administering epidural analgesics requires close monitoring for respiratory depression.
None of the other options is indicative of opiate toxicity.
DIF: Cognitive Level: Application
TOP: Opiate toxicity
REF: p. 601
OBJ: 10
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
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30.
When should a nurse administer prescribed analgesic medication when treating a
postoperative patient?
a.
Before activity
b.
Only when requested by the health care provider
c.
Only when requested by the family
d.
Only when requested by the patient
ANS: A
To control pain early, an analgesic should be given 30 to 40 minutes before a patient
must walk or perform an activity. PRN medications should be given around the clock
to effectively control moderately severe to severe pain. Waiting for the patient or
family to request analgesics results in delays in administration and inadequate pain
control.
DIF: Cognitive Level: Application
p. 606
control
REF:
OBJ: 10 TOP: Pain
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
31.
What action should the nurse implement when assisting a postoperative patient with pain
control and comfort?
a.
Pull the patient up in bed.
b.
Lift the patient up in bed.
c.
Tighten constricting bandages.
d.
Restrict fluid and dietary intake.
ANS: B
Pain control and comfort measures include loosening constricting bandages, lifting,
not pulling the patient up in bed, and preventing constipation by encouraging
appropriate fluid and dietary intake.
DIF: Cognitive Level: Application
p. 605
control
REF:
OBJ: 10 TOP: Pain
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
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32.
A nurse is caring for a patient who requires long-term management for severe pain.
What should be the drug of choice for this patient?
a.
Aspirin
b.
Morphine
c.
Oxycodone
d.
Acetaminophen
ANS: B
Morphine and hydromorphone are the opioids of choice for long-term management of
severe pain.
DIF: Cognitive Level: Analysis
REF: p. 599 OBJ: 9 TOP: Pain
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
33.
The pain relief intervention that stimulates large cutaneous nerve fibers to ―close the
gate‖ is the
a.
PRI
b.
TENS
c.
CTG
d.
UTI
unit.
ANS: B
TENS (transcutaneous electric nerve stimulator) stimulates cutaneous nerve fibers with
electric impulses, which follow the same spinal pathway as do pain impulses. The
cutaneous nerves ―close the gate‖ to the pain impulses.
DIF: Cognitive Level: Knowledge
REF:
p. 595
KEY:
OBJ: 4 | 11 TOP: TENS
Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1.
The nurse should administer an analgesic to an unconscious patient after observing which
signs? (Select all that apply.)
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a.
Increased heart rate from 82 to 94
b.
Decreased systolic blood pressure
c.
Increased muscle tension
d.
Perspiration on upper lip
e.
Facial grimacing
ANS: A, C, D, E
Pain indicators in the unconscious patient might include increased heart rate, blood
pressure, and muscle tension; diaphoresis; and grimacing.
DIF:
Cognitive Level: Application REF:
p. 591 | p. 605 OBJ: 10
TOP: Assessing
pain in the unconscious patient
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
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2.
A patient tells the nurse he is reluctant to report his pain because he does not want to
be a bother. What problems is the nurse aware that unrelieved pain can cause? (Select
all that apply.)
a.
Decreased oxygen demand
b.
Depression
c.
Respiratory dysfunction
d.
Decreased GI motility
e.
Irritability
ANS: B, C, D, E
Pain, which is unrelieved, can cause many physical and psychological symptoms,
including depression, respiratory dysfunction, decreased GI motility, and irritability. Pain
causes increased oxygen demand.
DIF: Cognitive Level: Comprehension REF: p. 595
TOP: Unrelieved pain
OBJ: 10
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
COMPLETION
1.
The nurse clarifies that the term peripheral analgesics describes the group of drugs also
referred to as
.
ANS:
NSAIDs
Peripheral analgesics are also the group of drugs referred to as NSAIDs.
DIF: Cognitive Level: Knowledge
p. 599
REF:
OBJ: 10 TOP:
Nonsteroidal anti-inflammatory drugs
(NSAIDs)
KEY: Nursing Process Step:
Implementation MSC:
NCLEX: Physiological
Integrity
2. The nurse is aware that
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the state at which a person is mentally relaxed, free from worry,
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and is physically calm is
.
ANS:
rest
When a person is mentally relaxed, free from worry, and is physically calm, he or she is
at rest.
DIF: Cognitive Level: Knowledge
REF:
p. 606
KEY:
OBJ: 12 TOP: Rest
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
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Chapter 22: Surgical Wound Care
Cooper: Foundations and Adult Health Nursing, 9th Edition
MULTIPLE
CHOICE
1.
The nurse is instructing a patient who has a drain in a surgical wound. How will the nurse
indicate that the wound will heal?
a.
Primary intention
b.
Secondary intention
c.
Tertiary intention
d.
Deliberate intention
ANS: C
When wounds are kept open by a drain, they heal by tertiary intention.
DIF: Cognitive Level: Comprehension REF: p. 616
TOP: Tertiary intention
OBJ: 4
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
2.
What technique will the nurse implement to assist the postoperative patient to cough?
a.
Support the patient‘s back.
b.
Offer an antitussive.
c.
Splint the abdomen with a pillow.
d.
Lean patient against the bedside table.
ANS: C
To assist a postoperative patient to cough, splinting the abdomen with pillow, hands,
or a towel roll is helpful to relieve stress on the suture line.
DIF: Cognitive Level: Application
REF: p. 617 OBJ: 8 TOP:
Suture lines KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
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3.
The day following surgery, the nurse notes bloody drainage on the dressing. How
will the nurse describe this drainage when documenting?
a.
Serosanguineous
b.
Sanguineous
c.
Serous
d.
Purulent
ANS: B
The term sanguineous means bloody. It is indicative of active bleeding.
DIF: Cognitive Level: Application
REF: p. 619 OBJ: 1 TOP:
Drainage
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
4.
What is the advantage of an occlusive dressing?
a.
Allows air to the incision.
b.
Keeps the incision moist.
c.
Delays epithelialization.
d.
Does not have to be changed.
ANS: B
Occlusive dressings keep the incision moist and increase epithelialization.
DIF: Cognitive Level: Comprehension REF: p. 620
OBJ: 7
TOP: Occlusive dressings KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
5.
When removing the dressing on a patient, the nurse discovers that the gauze dressing
has adhered to the wound. What intervention should the nurse implement?
a.
Call the RN.
b.
Gently remove the gauze with sterile forceps.
c.
Cover with occlusive dressing.
d.
Moisten the dressing with sterile water.
ANS: D
When a dressing has adhered to the wound, the nurse may moisten the dressing with
sterile water or sterile normal saline to loosen it.
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DIF: Cognitive Level: Application
TOP: Dry dressings
REF: p. 621
OBJ: 7
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
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6.
The nurse is providing instruction to a patient regarding home wound irrigation.
How far should the patient hold the handheld showerhead from the wound when
irrigating the wound?
a.
2.5 in
b.
6 in
c.
12 in
d.
18 in
ANS: C
When wound irrigation is done at home with a handheld showerhead, the showerhead
should be held approximately 12 in from the wound.
DIF: Cognitive Level: Comprehension REF: p. 628
TOP: Wound irrigation
OBJ: 11
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
7.
The nurse is irrigating a leg wound of a patient on the trauma unit. Where should the
nurse direct the flow of the irrigant?
a.
From the area of least contamination to the area of most contamination
b.
Forcefully into the wound
c.
Gently over the skin into the wound
d.
From a distance of about 12 in
ANS: A
The irrigant should flow from the least contaminated area to the most contaminated
area to prevent microorganisms from entering the wound.
DIF: Cognitive Level: Application
TOP: Wound irrigation
REF: p. 625
OBJ: 11
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
8.
The nurse observes a loop of bowel protruding from the surgical incision.
What is the first intervention the nurse should implement?
a.
Call the RN.
b.
Cover the bowel with a sterile saline dressing.
c.
Turn the patient to the side of the evisceration.
d.
Raise the patient up to a high Fowler‘s position.
ANS: B
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Although the RN must be notified, covering the loop of the bowel takes priority. The
patient may be raised to a semi-Fowler‘s position to relieve strain on the suture line.
DIF: Cognitive Level: Application
REF: p. 632
OBJ: 8 TOP:
Evisceration
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
9.
The nurse is removing every other staple from a surgical wound, which has been
closed with 15 staples. The wound begins to separate after removal of 3 of the 15.
What nursing action should be implemented?
a.
Remove 7 more alternate staples and securely tape with Steri-Strips.
b.
Cover with moist dressing and apply a binder.
c.
Continue to remove staples as ordered because this is an expected outcome.
d.
Leave the 12 staples in place and record the separation.
ANS: D
If the wound separates during the removal of staples, cease the removal, cover with a dry
dressing, and record the separation.
DIF:
Cognitive Level: Application
REF: p. 629 | p. 630 OBJ:
9
TOP: Staple removal
KEY: Nursing Process Step:
Implementation MSC:
NCLEX: Physiological
Integrity
10.
The health care provider has not ordered a dressing change for a draining wound on a
patient in an acute care setting. How should the nurse assess the amount of drainage?
a.
Weigh the patient to estimate the weight of the saturated dressing.
b.
Reinforce the dressing.
c.
Circle and date the outline of the exudate on the dressing.
d.
Count each dressing as 1 mL of drainage.
ANS: C
Without an order to change the dressing, the drainage should be circled and dated.
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Should the dressing become saturated, the dressing can be reinforced but the exudate
should still be circled.
DIF: Cognitive Level: Application
TOP: Draining wounds
REF: p. 633
OBJ: 7
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
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11.
The Centers for Disease Control and Prevention (CDC) classifies wounds according
to the amount of contamination. What is the classification for an uninfected surgical
wound with less than a 5% chance of becoming infected postoperatively?
a.
Dirty wound
b.
Clean-contaminated wound
c.
Contaminated wound
d.
Clean wound
ANS: D
A clean wound is an uninfected surgical wound with less than a 5% chance of becoming
infected postoperatively.
DIF: Cognitive Level: Comprehension REF: p. 615
TOP: Wounds
OBJ: 5
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
12.
Hemostasis begins as soon as the injury occurs and a clot begins to form. What is
the substance in the clot that holds the wound together?
a.
Fibrin
b.
Thrombin
c.
Protime
d.
Calcium
ANS: A
Fibrin in the clot begins to hold the wound together.
DIF: Cognitive Level: Knowledge
REF: p. 616 OBJ: 1 TOP:
Wounds
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
13.
What phase of wound healing is a wound in when blood and fluid flow into the
vascular space and produce edema, erythema, heat, and pain?
a.
Healing
b.
Inflammatory
c.
Reconstruction
d.
Maturation
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ANS: B
During the inflammatory phase, blood and fluid leak out of the blood vessels into the
vascular space.
DIF: Cognitive Level: Comprehension
REF: p. 633 OBJ: 1 TOP:
Wounds
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
14.
What marked advantage does primary intention have over other phases of wound
healing?
a.
Healing is rapid.
b.
Healing rarely becomes infected.
c.
Minimal scarring results.
d.
Healing is painless.
ANS: C
Wounds that heal by primary intention have minimal scarring.
DIF: Cognitive Level: Comprehension
REF: p. 616 OBJ: 4 TOP:
Wounds
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
15.
The nurse is caring for a patient during the first 24 hours following surgery. How
often will the nurse assess for bleeding under the dressing?
a.
Every 30 minutes
b.
Every 60 minutes
c.
Every 2 to 4 hours
d.
Every 5 to 8 hours
ANS: C
The nurse inspects the dressing every 2 to 4 hours for the first 24 hours.
DIF: Cognitive Level: Application
REF: p. 619 OBJ: 6 TOP:
Wounds
KEY: Nursing Process Step:
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Assessment
MSC: NCLEX: Physiological Integrity
16.
The nurse is preparing to perform a dressing change on a patient following a
total hip replacement. When should the nurse administer an analgesic drug in an
attempt to promote patient comfort during the dressing change?
a.
After the dressing change
b.
At least 15 minutes before the dressing change
c.
At least 30 minutes before the dressing change
d.
At least 1 hour before the dressing change
ANS: C
It may help to give an analgesic at least 30 minutes before exposing the wound.
DIF: Cognitive Level: Application
REF: p. 621 OBJ: 7 TOP:
Wounds
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
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17.
The nurse informs a patient that a wet-to-dry dressing is applied wet and allowed to
dry. This drying process causes it to adhere to the wound. What is the result of this
intervention when the dressing is removed?
a.
Destruction of tissue
b.
Bleeding
c.
Mechanical débridement
d.
Prevention of infection
ANS: C
The primary purpose of a wet-to-dry dressing is to débride a wound mechanically.
DIF: Cognitive Level: Comprehension
REF: p. 623 OBJ: 7 TOP:
Wounds
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
18.
The nurse assessing a postoperative patient discovers that the pulse is rapid, blood
pressure has decreased, urinary output has decreased, and the dressing is dry.
What can the nurse determine is indicated by these findings?
a.
Pain shock
b.
Dehydration
c.
Internal hemorrhage
d.
Acute infection
ANS: C
If a patient has a rapid pulse, decreased blood pressure, decreased urinary output, and the
dressing is dry, then the diagnosis is most likely an internal hemorrhage.
DIF: Cognitive Level: Analysis
TOP: Postoperative
REF: pp. 628-629
OBJ: 3
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
19.
What is the usual length of time before suture removal?
a.
2 to 3 days
b.
4 to 5 days
c.
5 to 6 days
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d.
7 to 10 days
ANS: D
Sutures are generally removed within 7 to 10 days.
DIF: Cognitive Level: Knowledge
REF: p. 629 OBJ: 9 TOP:
Wounds
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
20.
The nurse carefully measures drainage during the first 24 hours after surgery on a
patient with a Jackson-Pratt drain. What is the maximum amount of drainage
considered normal?
a.
50 mL
b.
100 mL
c.
200 mL
d.
300 mL
ANS: D
Drainage greater than 300 mL in 24 hours is considered abnormal.
DIF: Cognitive Level: Comprehension
REF: p. 633 OBJ: 3 TOP:
Drainage
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
21.
What is the classification for the Jackson-Pratt drainage removal system?
a.
Sterile drainage system
b.
Closed drainage system
c.
Open drainage system
d.
Self-measuring drainage system
ANS: B
The Jackson-Pratt removal system is a type of closed drainage system.
DIF: Cognitive Level: Knowledge
REF:
p. 633
KEY:
OBJ: 10 TOP: Drainage
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Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
22.
The nurse is caring for a patient with a surgical wound. How can the nurse promote
healing?
a.
Offer fluids every 4 hours.
b.
Encourage the consumption of large meals.
c.
Encourage up to 1000 mL of daily fluid intake.
d.
Encourage the consumption of small frequent meals.
ANS: D
To promote wound healing, dietary services can provide small frequent feedings.
Fluids, when tolerated, should be offered hourly. Unless contraindicated, the nurse
should encourage an intake of 2000 to 2400 mL in 24 hours.
DIF: Cognitive Level: Application
TOP: Wound healing
REF: p. 616
OBJ: 2
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
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23.
The nurse is instructing a patient about the effects of smoking. What accurate information
does the nurse provide?
a.
Smoking increases the amount of tissue oxygenation.
b.
Smoking increases the amount of functional hemoglobin in blood.
c.
Smoking may decrease platelet aggregation and cause hypercoagulability.
d.
Smoking interferes with normal cellular
mechanisms that promote release of oxygen.
ANS: D
Smoking reduces the amount of functional hemoglobin in blood, thus decreasing tissue
oxygenation. Smoking may increase platelet aggregation and hypercoagulability. Smoking
interferes with normal cellular mechanisms that promote release of oxygen to tissues.
DIF: Cognitive Level: Comprehension
REF: p. 618 OBJ: 6 TOP:
Smoking
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
24.
The nurse is preparing a presentation regarding the effects of diabetes mellitus. What
will the nurse include regarding the effects of diabetes mellitus?
a.
Improves overall tissue perfusion.
b.
Promotes release of oxygen to tissues.
c.
Causes hemoglobin to have a greater affinity for oxygen.
d.
Causes hemoglobin to have a decreased affinity for oxygen.
ANS: C
Diabetes mellitus is a chronic disease that causes small blood vessel disease that
impairs tissue perfusion. It also causes hemoglobin to have greater affinity for oxygen,
so it fails to release oxygen to tissues.
DIF: Cognitive Level: Comprehension REF: p. 618
TOP: Diabetes mellitus
OBJ: 6
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
25.
The nurse assessing a patient‘s wound notes a clear watery drainage. How will the nurse
most accurately document this finding?
a.
Serous drainage
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b.
Purulent drainage
c.
Sanguineous drainage
d.
Serosanguineous drainage
ANS: A
Serous drainage has the appearance of clear, watery plasma. Purulent drainage has the
appearance of thick, yellow, green, tan, or brown drainage. Sanguineous drainage is
bright red and indicates active bleeding. Serosanguineous drainage is pale, red, and
watery, and is a mixture of serous and sanguineous drainage.
DIF: Cognitive Level: Comprehension
REF: p. 619 OBJ: 5 TOP:
Drainage
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
26.
The nurse assessing a patient‘s wound notes thick, yellow drainage. How will the nurse
most accurately document this finding?
a.
Serous drainage
b.
Purulent drainage
c.
Sanguineous drainage
d.
Serosanguineous drainage
ANS: B
Purulent drainage has the appearance of thick, yellow, green, tan, or brown drainage.
Serous drainage has the appearance of clear, watery plasma. Sanguineous drainage is
bright red and indicates active bleeding. Serosanguineous drainage is pale, red, and
watery, and is a mixture of serous and sanguineous drainage.
DIF: Cognitive Level: Comprehension
REF: p. 616 OBJ: 5 TOP:
Drainage
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
27.
The nurse assessing a patient‘s wound notes pale red watery drainage. How will the nurse
most accurately document this finding?
a.
Serous drainage
b.
Purulent drainage
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c.
Sanguineous drainage
d.
Serosanguineous drainage
ANS: D
Serosanguineous drainage is pale, red, and watery, and is a mixture of serous and
sanguineous drainage. Serous drainage has the appearance of clear, watery plasma.
Purulent drainage has the appearance of thick, yellow, green, tan, or brown drainage.
Sanguineous drainage is bright red and indicates active bleeding.
DIF: Cognitive Level: Comprehension
REF: p. 619 OBJ: 5 TOP:
Drainage
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
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28.
The nurse assessing a patient‘s wound notes bright red drainage. How will the nurse most
accurately document this finding?
a.
Serous drainage
b.
Purulent drainage
c.
Sanguineous drainage
d.
Serosanguineous drainage
ANS: C
Sanguineous drainage is bright red and indicates active bleeding. Serous drainage
has the appearance of clear, watery plasma. Purulent drainage has the appearance of
thick, yellow, green, tan, or brown drainage. Serosanguineous drainage is pale, red,
and watery and is a mixture of serous and sanguineous drainage.
DIF: Cognitive Level: Comprehension
REF: p. 619 OBJ: 5 TOP:
Drainage
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
29.
The nurse is assisting a patient to a sitting position when the patient suddenly
complains of feeling that his surgical incision has separated. What does the nurse
recognize that this indicates?
a.
Cellulitis
b.
Dehiscence
c.
Evisceration
d.
Extravasation
ANS: B
Dehiscence is separation of a surgical incision or rupture of a wound closure.
DIF: Cognitive Level: Comprehension
REF: p. 629 OBJ: 8 TOP:
Dehiscence
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
30.
The nurse is preparing to redress a wound and will secure the dressing using a
gauze bandage as ordered by the health care provider. What is an advantage of
gauze bandages?
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a.
Provision of warmth.
b.
Applies strong pressure.
c.
Antibacterial effects.
d.
Prevents skin maceration.
ANS: D
Gauze bandages are lightweight and inexpensive, mold easily around contours of the
body, and permit air circulation that helps prevent skin maceration (the softening and
breaking down of skin from prolonged exposure to moisture). Flannel bandages provide
warmth. Elastic bandages are effective for pressure application. Gauze bandages do not
have antibacterial effects.
DIF: Cognitive Level: Comprehension REF: p. 638
OBJ: 13
TOP: Bandages and binders KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
31.
A patient with a diagnosis of insulin-dependent diabetes mellitus is being treated for
a stage 2 foot injury. The patient refuses to follow an ADA diet as ordered by a
health care provider and is morbidly obese. The nurse assesses the injury to be
healing, free from signs and symptoms of infection, with a positive pedal pulse and
warm to touch. What patient problem will be identified as a priority?
a.
Infection
b.
Altered nutrition: more than body requirements
c.
Impaired skin integrity
d.
Altered peripheral tissue perfusion
ANS: B
The nurse‘s assessment identifies no signs of infection, that the wound is healing with
positive pedal pulse and skin warm to touch ruling out infection, impaired skin integrity,
and altered peripheral tissue perfusion as priorities at this time. The priority patient
problem for this patient is altered nutrition: more than body requirements related to diet
noncompliance.
DIF:
Cognitive Level: Analysis
REF: p. 616 | p. 642 OBJ:
14
TOP: Patient problem
KEY: Nursing Process Step: Diagnosis
MSC: NCLEX: Physiological Integrity
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MULTIPLE RESPONSE
1.
The nurses employed at a wound therapy clinic are preparing an educational inservice about the vacuum-assisted closure (VAC) device for hospital nurses. What
accurate information will be included in this in-service? (Select all that apply.)
a.
Positive pressure is applied by this device.
b.
Healing is facilitated by decrease in drainage.
c.
Promotes formulation of granulation tissue.
d.
Reduces local and peripheral edema.
e.
Drops bacterial level in wound.
ANS: C, D, E
Vacuum-assisted closure (VAC) devices apply negative pressure and increase
drainage. Healing is facilitated by promotion of granulation tissue, decreased local and
peripheral edema, and in 3 to 4 days following application a drop in bacterial level in
the wound should be observed.
DIF: Cognitive Level: Comprehension REF: p. 633
TOP: Vacuum-assisted device
OBJ: 12
KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity
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2.
Which are the phases of wound healing? (Select all that apply.)
a.
Reconstruction
b.
Hemostasis
c.
Inflammation
d.
Granulation
e.
Maturation
ANS: A, B, C, E
The steps in wound healing are hemostasis, inflammation, reconstruction, and maturation.
DIF: Cognitive Level: Knowledge
TOP: Wound healing
REF: p. 616
OBJ: 1
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
3.
Which solutions can be used on a wet-to-dry dressing? (Select all that apply.)
a.
Normal saline
b.
Lactated Ringer
c.
Acetic acid
d.
Dakin
e.
Lysol
ANS: A, B, C, D
Normal saline, sterile water, lactated Ringer, acetic acid, or Dakin solution are all
acceptable for use on wet-to-dry dressings.
DIF: Cognitive Level: Comprehension REF: p. 623
TOP: Wet-to-dry dressings
OBJ: 7
KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological
Integrity
4.
What are the advantages of a transparent dressing? (Select all that apply.)
a.
Adheres to undamaged skin.
b.
Contains the exudate.
c.
Reduces wound contamination.
d.
Serves as a barrier to external bacteria.
e.
Slows epithelial growth.
ANS: A, B, C, D
Transparent dressings have the advantages of adhering to undamaged skin, containing the
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exudate, reducing wound contamination, serving as a barrier to external bacteria, and
speeding epithelial growth.
DIF: Cognitive Level: Comprehension REF: p. 625
OBJ: 7
TOP: Transparent dressings KEY: Nursing
Process Step: Planning MSC: NCLEX:
Physiological Integrity
COMPLETION
1.
The nurse assures a patient that the purple, raised, immature scar of a surgical wound is
normal and caused by
formation.
ANS:
collagen
Collagen forms as an immature scar over a new surgical wound.
DIF: Cognitive Level: Knowledge
TOP: Immature scarring
REF: p. 616
OBJ: 1
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
2.
The nurse encourages a patient recovering from a hysterectomy to drink at least
mL of
fluid a day.
ANS:
2000
A recovering surgical patient should drink between 2000 and 2400 mL of fluid daily.
DIF: Cognitive Level: Comprehension
REF: p. 617 OBJ: 2 TOP:
Fluid intake KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
3.
When preparing to remove a dressing, the nurse should don
gloves.
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ANS:
clean
To remove a dressing, clean gloves are appropriate.
DIF: Cognitive Level: Comprehension REF: p. 620
OBJ: 7
TOP: Removal of a dressing KEY: Nursing Process
Step: Implementation MSC: NCLEX: Safe, Effective
Care Environment
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Chapter 23: Specimen Collection and
Diagnostic Testing Cooper: Foundations and
Adult Health Nursing, 9th Edition
MULTIPLE
CHOICE
1.
New health care provider orders are transcribed for a patient to receive a
colonoscopy. What must be completed before the colonoscopy to indicate the patient
has been given full knowledge about what will be done along with its risks and
complications?
a.
Patients‘ rights
b.
Advance directive
c.
Informed consent
d.
Patient protection
ANS: C
Informed consent states that the patient must fully understand and be aware of the risks
and complications of what is to be done.
DIF: Cognitive Level: Comprehension REF: p. 648
OBJ: 1
TOP: Proper preparation KEY: Nursing Process
Step: Planning MSC: NCLEX: Safe, Effective Care
Environment
2.
The nurse is preparing a patient for a diagnostic examination. What can the nurse
implement to assist with reducing anxiety?
a.
Explain the costs of the examination.
b.
Demonstrate use of equipment.
c.
Answer questions for clarification.
d.
Fill out required paperwork.
ANS: C
The nurse must be prepared to answer questions that the patient may have to reduce
anxiety and give valid information.
DIF: Cognitive Level: Application
REF: p. 648
OBJ: 2
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TOP: Proper preparation KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
3.
A patient is required to provide a sample of body excretions per health care provider
order. What action can the nurse take when providing proper instructions to lessen
the patient‘s embarrassment?
a.
Instruct patient to provide the specimen behind a screen.
b.
Instruct patient to obtain his or her own specimen.
c.
Instruct patient to return later when he or she is more comfortable.
d.
Instruct patient to use a CNA for assistance to obtain the specimen.
ANS: B
With proper instruction, many patients may obtain their own specimen.
DIF: Cognitive Level: Application
REF: p. 666
OBJ: 3
TOP: Specimen collection KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
4.
What health care professional has the responsibility for notifying the health care
provider when laboratory and diagnostic studies deviate from the norm?
a.
Laboratory technician
b.
Cooperating health care provider
c.
Nurse
d.
Supervisor
ANS: C
It is the nurse‘s responsibility to notify the health care provider when laboratory and
diagnostic studies deviate from the norm.
DIF: Cognitive Level: Knowledge
TOP: Diagnostic studies
REF: p. 666
OBJ: 4
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Safe, Effective
Care Environment
5.
What is the term for the cleanest part of a voided urine specimen that is collected after
voiding is initiated and before it is finished?
a.
Sterile specimen
b.
―Caught‖ specimen
c.
Midstream specimen
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d.
Patient-collected specimen
ANS: C
A midstream urine specimen is collected after voiding is initiated and before it is
completed.
DIF: Cognitive Level: Knowledge
p. 667
REF:
OBJ: 5 | 6 TOP: Specimen KEY:
Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment
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6.
The patient is to be catheterized for residual urine. The nurse must perform this
catheterization within how many minutes following voiding?
a.
40 minutes
b.
30 minutes
c.
20 minutes
d.
10 minutes
ANS: D
Catheterization is performed within 10 minutes of the patient voiding to check for
residual urine.
DIF: Cognitive Level: Knowledge
REF: p. 667 OBJ: 8 TOP:
Specimen
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Safe, Effective Care Environment
7.
The process for collecting a blood specimen for measuring blood glucose levels
begins by asking the patient to hold the selected arm at his or her side for 30
seconds. From what anatomic location is the specimen obtained?
a.
Tip of the finger
b.
Cubital fossa
c.
Side of the finger
d.
Center of the thumb
ANS: C
The specimen should be collected from the side of the selected finger to avoid painful
fingertip sticks.
DIF: Cognitive Level: Knowledge
REF: p. 671 OBJ: 9 TOP:
Specimen
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
8.
What type of stool specimen must be sent to the laboratory immediately?
a.
Occult blood
b.
Ova and parasites
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c.
Infection
d.
Fats
ANS: B
A stool specimen for the presence of ova or parasites must be taken to the laboratory
immediately.
DIF: Cognitive Level: Knowledge
REF:
p. 670
KEY:
OBJ: 10 TOP: Specimen
Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment
9.
What is the probable source of bright red blood in the stool?
a.
Stomach
b.
Small intestine
c.
Lower gastrointestinal tract
d.
Higher intestinal tract
ANS: C
When blood in the stool is bright red, the site of bleeding is most likely from the lower
gastrointestinal tract.
DIF:
Cognitive Level: Comprehension
OBJ: 4 | 10 TOP: Specimen
REF: p. 670 | p. 673
KEY: Nursing
Process Step: Assessment MSC: NCLEX:
Physiological Integrity
10.
A sputum specimen is ordered on a patient diagnosed with pneumonia. When is the
best time for the nurse to the attempt to collect this specimen?
a.
At bedtime
b.
After lunch
c.
In the early morning
d.
After breakfast
ANS: C
Early morning before a meal is the best time to collect a sputum specimen.
DIF: Cognitive Level: Knowledge
REF:
p. 673
KEY:
OBJ: 11 TOP: Specimen
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Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment
11.
A patient is unable to obtain a sputum specimen by coughing and expectorating.
What is the best way for the nurse to collect this specimen?
a.
Ask the patient to spit.
b.
Direct the patient to turn, cough, and breathe deeply.
c.
Perform tracheal suctioning.
d.
Perform a bronchoscopy.
ANS: C
Some patients cannot expectorate and must have the trachea suctioned to obtain a
specimen.
DIF: Cognitive Level: Application
REF:
p. 673
KEY:
OBJ: 11 TOP: Specimen
Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment
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12.
The nurse is collecting a specimen for a wound culture. What should be avoided when
collecting this specimen?
a.
A dressing
b.
Deep in the wound
c.
The outer edge of the wound
d.
Old drainage
ANS: D
The nurse should not collect a wound culture from old drainage.
DIF: Cognitive Level: Application
REF: p. 673 OBJ: 5 TOP:
Specimen
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Safe, Effective Care Environment
13.
Anaerobic organisms tend to grow within body cavities. What will the nurse use to collect
an anaerobic specimen?
a.
Sterile cotton applicator
b.
Sterile culture tube
c.
Sterile syringe tip
d.
Sterile glass rod
ANS: C
To collect an anaerobic specimen deep in a body cavity, the nurse uses a sterile syringe
tip.
DIF: Cognitive Level: Application
REF: p. 673 OBJ: 5 TOP:
Specimen
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Safe, Effective Care Environment
14.
The nurse is obtaining a throat culture. What area will the nurse swab with a cotton-tipped
applicator?
a.
Larynx
b.
Oral mucosa
c.
Pharynx
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d.
Trachea
ANS: C
The nurse should swab the tonsillar area (pharynx) with a sterile cotton-tipped applicator
to obtain a specimen for a throat culture.
DIF:
Cognitive Level: Application REF:
pp. 678-679
OBJ: 4 TOP: Specimen
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Safe, Effective Care Environment
15.
The nurse explains that electrocardiograms are graphic representations of electric
impulses generated by the heart. What type of abnormalities can an
electrocardiogram identify?
a.
Those that produce a cardiac cycle
b.
Those that interfere with electric conduction
c.
Those that result from an interrupted blood flow
d.
Those that interfere with heart contraction
ANS: B
Electrocardiograms identify abnormalities that interfere with electric conduction.
DIF: Cognitive Level: Comprehension REF: p. 683
TOP: Electrocardiogram
OBJ: 13
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Safe, Effective Care
Environment
16.
What is the rationale for the nurse to assess a patient‘s knowledge of an ordered
procedure?
a.
To determine difficulties the patient may encounter
b.
To determine the nurse‘s role in the procedure
c.
To determine health teaching required
d.
To determine anxiety the patient has
ANS: C
The nurse will need to assess the patient‘s knowledge of the procedure to determine the
level of health care teaching needed.
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DIF: Cognitive Level: Comprehension REF: p. 683
TOP: Teaching needs
OBJ: 2
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
17.
What should the nurse assess the patient for before administration of contrast media?
a.
Has been NPO.
b.
Is allergic to iodine.
c.
Has emptied the bladder.
d.
Has taken medication.
ANS: B
The patient should always be assessed for allergies to iodine before administration of
contrast media.
DIF: Cognitive Level: Application
TOP: Diagnostic examination
REF: p. 650
OBJ: 2
KEY: Nursing
Process Step: Assessment MSC: NCLEX: Safe,
Effective Care Environment
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18.
The nurse is administering Telepaque for a cholecystogram. How frequently will the
nurse administer 1 tablet of Telepaque before this procedure?
a.
Every 5 minutes
b.
Every 10 minutes
c.
Every 15 minutes
d.
Every 20 minutes
ANS: C
Telepaque should be taken one at a time, waiting 15 minutes after each tablet.
DIF: Cognitive Level: Application
TOP: Diagnostic examination
REF: p. 658
OBJ: 2
KEY: Nursing
Process Step: Implementation MSC: NCLEX: Safe,
Effective Care Environment
19.
Following a liver biopsy, the nurse should observe for hemorrhage and ensure that the
patient is kept on bed rest for 24 hours. How should the nurse keep the patient for the
first 1 to 2 hours?
a.
On his or her left side
b.
On his or her back
c.
On his or her right side
d.
In high Fowler‘s position
ANS: C
The nurse should keep the patient on his or her right side for 1 to 2 hours.
DIF:
Cognitive Level: Application
TOP: Diagnostic examination
REF: p. 660
OBJ: 1 | 2
KEY: Nursing
Process Step: Implementation MSC: NCLEX: Safe,
Effective Care Environment
20.
The patient has undergone a lumbar puncture. What position will the nurse
place the patient in for up to 12 hours to avoid discomfort from postpuncture
spinal headache?
a.
Supine
b.
Lateral
c.
Sims
d.
Prone
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ANS: A
The nurse should place the patient in the supine position and keep in reclining position for
12 hours.
DIF:
Cognitive Level: Application
TOP: Diagnostic examination
REF: p. 660
OBJ: 1 | 2
KEY: Nursing
Process Step: Implementation MSC: NCLEX: Safe,
Effective Care Environment
21.
The procedure for collecting a sterile urine specimen via a catheter port includes
clamping the Foley catheter tubing below the catheter port. How long will the
clamp remain in place?
a.
5 minutes
b.
10 minutes
c.
20 minutes
d.
30 minutes
ANS: D
Clamp just below the catheter port for 30 minutes.
DIF: Cognitive Level: Comprehension
REF: p. 669 OBJ: 1 TOP:
Specimen
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Safe, Effective Care Environment
22.
The nurse is caring for a patient following a bronchoscopy and maintains NPO status
for 2 hours. What additional assessment will indicate to the nurse that this patient‘s
risk for aspiration has decreased?
a.
Patient is fully awake.
b.
Patient asks for a drink.
c.
Gag reflex has returned.
d.
Preoperative medication has worn off.
ANS: C
The nurse should not allow the patient to eat or drink after a bronchoscopy until the gag
reflex has returned.
DIF: Cognitive Level: Application
REF: p. 654
OBJ: 1
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TOP: Diagnostic examination
KEY: Nursing
Process Step: Implementation MSC: NCLEX: Safe,
Effective Care Environment
23.
The nurse has an order to perform occult blood testing on a patient‘s emesis. What
color will the sample turn to indicate that the test is positive for occult blood?
a.
Red
b.
Blue
c.
Green
d.
Yellow
ANS: B
If the sample turns blue, the test is positive for occult blood; if it turns green, it is negative
for occult blood.
DIF: Cognitive Level: Comprehension REF: p. 673
OBJ: 1
TOP: Occult blood testing KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
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24.
What should the nurse do when preparing the patient for an abdominal scan?
a.
Assess laboratory results only for liver function.
b.
Assess patient for allergies to dye or shellfish.
c.
Instruct patient to limit fluid intake immediately following procedure.
d.
Instruct patient to be NPO for 1 hour before scan if contrast medium is used.
ANS: B
The patient should be assessed for allergies to dye or shellfish. When a patient has an
abdominal scan, laboratory results should be assessed for kidney function. The patient
should be instructed to be NPO for 4 hours before the examination if contrast medium
is to be used. The patient should be encouraged to consume fluids after the
examination.
DIF:
Cognitive Level: Application
TOP: Diagnostic examination
REF: p. 651
OBJ: 1 | 2
KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity
25.
What should the nurse do when preparing the patient for an arteriography?
a.
Verify if the patient has been taking anticoagulants.
b.
Keep the patient NPO for 24 hours before the procedure.
c.
Instruct the patient to have a full bladder for the procedure.
d.
Inform the patient that a coldness may be felt when dye is injected.
ANS: A
When a patient has an arteriography, the nurse should assess if the patient has been
taking anticoagulants. The patient is kept NPO for 2 to 8 hours before the procedure.
The nurse informs the patient that a warm flush may be felt when dye is injected. The
patient is instructed to void before the arteriography.
DIF:
Cognitive Level: Application
TOP: Diagnostic examination
REF: p. 651
OBJ: 1 | 2
KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity
26.
The nurse is preparing a patient for a barium enema. What color will the nurse
inform the patient his stools will be following this procedure?
a.
Blue
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b.
White
c.
Green
d.
Brown
ANS: B
Immediately following a barium enema, a patient‘s stools are white until all of the barium
is expelled.
DIF:
Cognitive Level: Comprehension REF: p. 652
TOP: Diagnostic examination
OBJ: 2 | 3
KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity
27.
What should the nurse do when preparing the patient for an amniocentesis?
a.
Restrict food intake.
b.
Restrict fluid intake.
c.
Monitor fetal heart tones.
d.
Inform patient results will be available immediately.
ANS: C
When a patient has an amniocentesis, fetal heart tones should be monitored. There are
no fluid or food restrictions, and the patient should be told to contact her health care
provider to obtain results, which are usually available after 2 weeks.
DIF: Cognitive Level: Application
TOP: Diagnostic examination
REF: p. 651
OBJ: 2
KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity
28.
What should the nurse do when preparing the patient for a bone scan?
a.
Sedate the patient.
b.
Restrict food intake.
c.
Restrict fluid intake.
d.
Encourage water intake.
ANS: D
Before a bone scan, the patient is encouraged to drink several glasses of water. No
fasting or sedation is required before a bone scan.
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DIF: Cognitive Level: Application
TOP: Diagnostic examination
REF: p. 653
OBJ: 2
KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity
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29.
What should the nurse do when preparing the patient for a brain scan?
a.
Allow the patient to wear a wig during the scan.
b.
Allow the patient to wear a partial denture plate during the scan.
c.
Inform the patient that a clicking noise will be heard during the scan.
d.
Keep the patient NPO for 12 hours before scan if contrast dye is used.
ANS: C
Before a brain scan, the patient is kept NPO for 4 hours if contrast dye is to be used,
the patient is instructed not to wear a wig, hairpins, clips, or partial denture plates, and
the nurse informs the patient that a clicking noise is made as the scanner moves.
DIF: Cognitive Level: Application
TOP: Diagnostic examination
REF: p. 653
OBJ: 2
KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity
30.
What should the nurse do when preparing the patient for a bronchoscopy?
a.
Instruct the patient to hold his or her breath during the procedure.
b.
Instruct the patient to remain NPO 24 hours before the procedure.
c.
Obtain informed consent after premedicating the patient.
d.
Reassure the patient that he or she will be able to breathe during the procedure.
ANS: D
The nurse should reassure a patient before a bronchoscopy that they will be able to
breathe during the procedure. The patient is instructed to remain NPO after midnight
(4 to 8 hours) before the procedure. Informed consent must be obtained before the
patient is premedicated.
DIF: Cognitive Level: Application
TOP: Diagnostic examination
REF: p. 654
OBJ: 2
KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity
31.
What should the nurse encourage the patient to consume when preparing for an
electroencephalogram (EEG)?
a.
Tea
b.
Food
c.
Cola
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d.
Coffee
ANS: B
Food intake should be encouraged, but coffee, tea, and colas should be eliminated before
an EEG.
DIF: Cognitive Level: Application
TOP: Diagnostic examination
REF: p. 656
OBJ: 2
KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity
32.
What intervention should the nurse implement when preparing the patient for a glucose
tolerance test (GTT)?
a.
Restrict water intake before the test.
b.
Encourage exercise before the test.
c.
Keep patient NPO 8 hours before the test.
d.
Instruct patient to have a full bladder for the test.
ANS: C
A patient having a glucose tolerance test should be kept NPO for 8 hours before the
test except for water consumption so that they can provide urine samples. The patient
should empty their bladder before the examination.
DIF: Cognitive Level: Application
TOP: Diagnostic examination
REF: p. 658
OBJ: 2
KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity
33.
What should the nurse do when preparing the patient for an exercise tolerance test
(treadmill)?
a.
Withhold all foods and fluids before the test.
b.
Withhold all heart medications before the test.
c.
Allow the patient to drink water before the test.
d.
Allow the patient to consume food before the test.
ANS: C
A patient having an exercise tolerance test is kept NPO, except for water, for 4 hours until
after the test. The nurse should never withhold the patient‘s heart medications before this
test.
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DIF: Cognitive Level: Application
TOP: Diagnostic examination
REF: p. 657
OBJ: 2
KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity
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34.
A patient has just had a liver biopsy. What should the nurse do immediately following
this procedure?
a.
Assist the patient up to a chair.
b.
Keep the patient on his or her left side.
c.
Assist the patient with ambulation.
d.
Tell the patient to avoid coughing.
ANS: D
The nurse should tell the patient to avoid coughing or straining, which may cause
increased intraabdominal pressure. Immediately following a liver biopsy, the patient
is kept on bed rest for 24 hours. The patient should lie on his or her right side for
about 1 to 2 hours.
DIF: Cognitive Level: Application
TOP: Diagnostic examination
REF: p. 660
OBJ: 1
KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity
MULTIPLE RESPONSE
1.
The nurse is preparing to collect a urine specimen. What will this nurse include
when labeling this specimen? (Select all that apply.)
a.
Date and time of collection
b.
Identification of last name only
c.
Room number
d.
Medical record number
e.
Insurance information
ANS: A, C, D
When labeling a specimen date and time of collection, room number and medical
record number should be included. Patient should be identified by full name. Insurance
information is not necessarily included.
DIF: Cognitive Level: Application
REF: p. 673
OBJ: 7
TOP: Labeling specimens KEY: Nursing Process Step:
Implementation MSC: NCLEX: Safe, Effective Care
Environment
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COMPLETION
1.
After a bone scan, the nurse assesses a hematoma at the injection site of the dye.
The nurse should apply
soaks
or compresses.
ANS:
warm
Heat will speed absorption of collected blood.
DIF: Cognitive Level: Application
TOP: Hematoma at injection site
REF: p. 653
OBJ: 1
KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity
2.
When initiating a 24-hour urine collection, the nurse asks the patient to void. The nurse
then
the specimen.
ANS:
discards
The first voided specimen of a 24-hour collection is discarded.
DIF: Cognitive Level: Application
REF: p. 670 | p. 692 OBJ:
4|8
TOP: 24-hour urine
specimen
KEY: Nursing Process Step:
Implementation MSC:
NCLEX: Safe, Effective Care
Environment
3.
Following an intravenous pyelogram, the nurse should watch the patient closely for a
delayed reaction to the dye, usually occurring within
to
hours following the
procedure.
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ANS:
2, 6
26
two,
six
two
six
Delayed reactions to iodine may not be obvious until 2 to 6 hours postprocedure.
DIF: Cognitive Level: Application
TOP: Iodine allergy
REF: p. 690
OBJ: 1
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Safe, Effective
Care Environment
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4.
When collecting a stool specimen for a guaiac (occult blood in stool), the nurse
should take a specimen from
different
parts of the stool.
ANS:
tw
o
2
The selection of different parts of the stool gives a broader testing range of the specimen.
DIF: Cognitive Level: Application
REF: p. 690
OBJ: 10
TOP: Occult blood specimen KEY: Nursing Process
Step: Implementation MSC: NCLEX: Safe, Effective
Care Environment
5.
When performing a venipuncture, the tourniquet should be left on no more than
to
minutes.
ANS:
1, 2
12
one,
two
one
two
Occluding the vein for longer than 1 or 2 minutes may cause damage to the vein or cause
it to rupture.
DIF: Cognitive Level: Application
TOP: Venipuncture
REF: p. 682
OBJ: 12
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Safe, Effective Care
Environment
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Chapter 24: Lifespan Development
Cooper: Foundations and Adult Health Nursing, 9th Edition
MULTIPLE
CHOICE
The nurse tells a mother that the blueprint for all inherited traits, such as height, is found
1.
in which of the following?
a.
Sperm
b.
Ovary
c.
Chromosomes
d.
Nucleus of the cell
ANS: C
The blueprint for all inherited traits is found in the chromosomes.
DIF: Cognitive Level: Knowledge
REF: p. 697 OBJ: 4 TOP:
Growth
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
2.
The nurse discovers during the intake assessment of a 5-year-old child that the child
lives with his biological parents and siblings. How would the nurse categorize this
family type?
a.
Extended family
b.
Blended family
c.
Social family
d.
Nuclear family
ANS: D
The nuclear family is considered the traditional family pattern.
DIF: Cognitive Level: Knowledge
REF: p. 698 OBJ: 4 TOP:
Family
KEY: Nursing Process Step:
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Assessment
MSC: NCLEX: Health Promotion and Maintenance
3.
A newborn baby weighs 7 lb at birth. What does the nurse anticipate the baby‘s weight
will be at 1 year of age?
a.
14 lb
b.
17 lb
c.
21 lb
d.
25 lb
ANS: C
By 1 year, birth weight is expected to triple. Thus, the weight at 1 year would be 7 lb
times three, which would equal 21 lb.
DIF: Cognitive Level: Application
REF: p. 704 OBJ: 4 TOP:
Growth
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
4.
The mother of a 5-month-old child is concerned because the child cannot sit by
himself. The nurse explains that sitting alone is not expected until the baby reaches
what age?
a.
6 months
b.
7 months
c.
8 months
d.
9 months
ANS: B
By the end of the seventh month, most babies can sit up without support.
DIF: Cognitive Level: Application
TOP: Development
REF: p. 705
OBJ: 4
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
5.
A young mother asks the nurse how long she should wait before introducing solid
food to her infant. The nurse explains that breast milk will provide all the nutrition her
infant needs for how many months?
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a.
2 to 3 months
b.
4 to 6 months
c.
7 to 9 months
d.
10 to 12 months
ANS: B
Breast milk or formula is the only nutrition needed for the first 4 to 6 months of an
infant‘s life.
DIF: Cognitive Level: Application
REF: p. 707 OBJ: 4 TOP:
Nutrition
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
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6.
When a mother asks the nurse about introducing solid foods into the child‘s diet, which of
the following would be the best answer?
a.
―Introduce meat first.‖
b.
―Introduce one solid food at a time several days apart.‖
c.
―Introduce solid foods by mixing two or three foods together.‖
d.
―Introduce solid foods by adding strained food to the infant‘s bottle.‖
ANS: B
The best advice is to introduce one solid at a time, allowing several days between.
Cereals should be introduced first, followed by fruits and vegetables. Meats should be
introduced last. Avoid mixing foods to allow the infant to develop an interest in
different tastes. Strained foods should not be added to a bottle.
DIF: Cognitive Level: Application
REF: p. 707 OBJ: 4 TOP:
Nutrition
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
7.
A baby‘s muscular development progresses in what type of pattern?
a.
Regressive
b.
Erratic
c.
Cephalocaudal
d.
Unpredictable
ANS: C
Muscular development proceeds from head to foot (cephalocaudal).
DIF: Cognitive Level: Comprehension
REF: p. 697 OBJ: 4 TOP:
Growth
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
8.
At what age does a child typically possess the physiologic, neuromuscular, and
psychological maturity necessary to master toilet training?
a.
6 to 10 months
b.
10 to 14 months
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c.
14 to 18 months
d.
18 to 24 months
ANS: D
Children reach psychological and physiologic maturity for toilet training by 18 to 24
months.
DIF: Cognitive Level: Application
TOP: Toilet training
REF: p. 709
OBJ: 5
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
9.
How can a family best assist a toddler who is attempting to feed himself?
a.
Encourage the child to use a fork.
b.
Feed the child themselves using a fork.
c.
Encourage large portions for easier handling.
d.
Offer the child finger foods.
ANS: D
Toddlers need to develop autonomy and do things for themselves in a trial-and-error
method. Finger foods allow the child a feeling of independence.
DIF: Cognitive Level: Application
TOP: Development
REF: p. 710
OBJ: 5
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
10.
A 5-year-old who has an imaginary friend with whom he converses frequently is
displaying characteristics consistent with which of Piaget‘s stages of cognitive
development?
a.
Operational stage
b.
Preoperational stage
c.
Formal operations stage
d.
Concrete operations stage
ANS: B
Piaget‘s preoperational stage describes the preschooler as imaginative and egocentric,
believing in magical thinking.
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DIF: Cognitive Level: Application
TOP: Development
REF: p. 713
OBJ: 3
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Health Promotion
and Maintenance
11.
A 14-year-old male patient has undergone a leg amputation. What should be the primary
focus of the patient‘s care plan?
a.
Nutritional status
b.
Academic progress
c.
Body image
d.
Socialization needs
ANS: C
Body image is a major developmental task of the adolescent. Nutritional status,
academic progress, and socialization should be addressed, but they would not be
the primary focus.
DIF: Cognitive Level: Analysis
p. 718
REF:
OBJ: 10 TOP: Adolescent KEY:
Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance
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12.
According to Piaget, what is the cognitive developmental level of the adolescent?
a.
Concrete operational stage
b.
Sensorimotor stage
c.
Preoperational stage
d.
Formal operational stage
ANS: D
The formal operational stage is the cognitive developmental level of adolescence.
DIF: Cognitive Level: Knowledge
REF:
p. 718
OBJ: 3 TOP:
Cognitive development
KEY: Nursing
Process Step: N/A MSC: NCLEX: Health
Promotion and Maintenance
13.
The nurse performing a routine physical assessment on a 25-year-old understands that
the patient is most likely experiencing which of the following?
a.
A gradual decline in physical capabilities
b.
Optimal level of functioning
c.
Slight diminishing of visual acuity
d.
Minimal hearing loss
ANS: B
During early adult years, the body is at an optimal level of functioning. The gradual
decline in physical capabilities, diminishing of visual acuity, and hearing loss will not
occur until later in adulthood.
DIF: Cognitive Level: Application
TOP: Early adulthood
REF: p. 721
OBJ: 6
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Health Promotion
and Maintenance
14.
Erikson identifies intimacy as a developmental task of adulthood. What will occur if
intimacy is not established?
a.
Inferiority
b.
Isolation
c.
Mistrust
d.
Guilt
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ANS: B
Intimacy versus isolation is a developmental task of adulthood.
DIF: Cognitive Level: Knowledge
REF: p. 721 OBJ: 8 TOP:
Erikson
KEY: Nursing Process Step:
N/A
MSC: NCLEX: Health Promotion and Maintenance
15.
What is the leading cause of death in young adults?
a.
Diabetes
b.
Accidents
c.
Hypertension
d.
Testicular cancer
ANS: B
The leading cause of death in young adults is accidents.
DIF: Cognitive Level: Knowledge
REF:
p. 722
KEY:
OBJ: 11 TOP: Accidents
Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
16.
A 53-year-old woman complains of night sweats and mood swings. The nurse
recognizes that these symptoms most likely relate to which condition?
a.
Menopause
b.
Weight problems
c.
Dietary problems
d.
Thyroid problems
ANS: A
Signs and symptoms of menopause may include sweats and mood swings.
DIF: Cognitive Level: Application
REF: p. 723 OBJ: 6 TOP:
Menopause
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
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17.
A 58-year-old male is concerned about some hearing loss he is experiencing. The
nurse recognizes that this might be due to a sensory change of this age group
known as which of the following?
a.
Presbycusis
b.
Otitis externa
c.
Presbyopia
d.
Otitis media
ANS: A
Presbycusis is a normal age-related loss of hearing. Otitis externa and otitis media
are infections of the ear. Presbyopia is a condition in which it becomes difficult to
focus on objects nearby.
DIF: Cognitive Level: Application
REF: p. 722 OBJ: 6 TOP:
Middle age
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
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18.
What is the correct term for prejudice against older adults?
a.
Socialism
b.
Sexism
c.
Racism
d.
Ageism
ANS: D
Ageism is a form of discrimination and prejudice against the older adult.
DIF: Cognitive Level: Knowledge
REF:
p. 725
OBJ: 13 TOP: Late
adulthood
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
19.
What theory claims that there is a hereditary basis for aging?
a.
Activity theory
b.
Physiologic theory
c.
Disengagement theory
d.
Biological programming theory
ANS: D
Biological programming theory suggests a hereditary basis for aging.
DIF: Cognitive Level: Application
REF: p. 726
TOP: Aging KEY: Nursing Process Step: N/A
20.
OBJ: 14
MSC: NCLEX: N/A
The nurse reminds an older adult patient that the task for the older adult is to
achieve ego integrity. Failure to achieve this task results in which of the following?
a.
Failure
b.
Despair
c.
Reminiscing
d.
Accomplishment
ANS: B
The challenge of late adulthood is integrity versus despair.
DIF: Cognitive Level: Knowledge
REF: p. 727 OBJ: 8 TOP:
Older adult
KEY: Nursing Process Step:
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Implementation
MSC: NCLEX: Health Promotion and Maintenance
21.
When assessing the home for fall risks and increased safety for an 85-year-old,
what should be a suggestion of the home health nurse?
a.
Bright lights be kept on at all times.
b.
Sponge baths be taken rather than showers.
c.
Excess furniture be removed.
d.
Loose, comfortable shoes be worn.
ANS: C
Clearing the home of excess furniture and scatter rugs, the use of night-lights, and
wearing supportive shoes reduce the risk of falls in older adults. It is not necessary to
keep bright lights on at all times. It is not necessary to avoid showers.
DIF: Cognitive Level: Application
REF: p. 730 OBJ: 7 TOP:
Older adult
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
22.
The home health nurse assesses an older adult‘s respiratory function carefully
because age-related changes in the respiratory system could result in which of the
following?
a.
Vital capacity
b.
Susceptibility to respiratory infections
c.
Expiratory capacity due to increased chest size
d.
Oxygen and carbon dioxide exchange
ANS: B
Older adults are more susceptible to respiratory infections.
DIF: Cognitive Level: Application
REF: p. 728 OBJ: 6 TOP:
Older adult
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Health Promotion and Maintenance
23.
What is the family pattern in which the relationships are unequal and the parents
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attempt to control the children with strict, rigid rules and expectations?
a.
Autocratic family pattern
b.
Patriarchal family pattern
c.
Matriarchal family pattern
d.
Democratic family pattern
ANS: A
In the autocratic family pattern the relationships are unequal. The parents attempt to
control the children with strict, rigid rules and expectations. This family pattern is least
open to outside influence.
DIF: Cognitive Level: Knowledge
REF:
p. 700
OBJ: 1 TOP:
Family patterns
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
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24.
Which family pattern is least open to outside influence?
a.
Autocratic family pattern
b.
Patriarchal family pattern
c.
Matriarchal family pattern
d.
Democratic family pattern
ANS: A
In the autocratic family pattern the relationships are unequal. The parents attempt to
control the children with strict, rigid rules and expectations. This family pattern is least
open to outside influence.
DIF: Cognitive Level: Knowledge
REF:
p. 700
OBJ: 1 TOP:
Family patterns
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
25.
What is the family pattern in which the male usually assumes the dominant role
and functions in the work role, controls the finances, and makes most of the
decisions?
a.
Autocratic family pattern
b.
Patriarchal family pattern
c.
Matriarchal family pattern
d.
Democratic family pattern
ANS: B
In the patriarchal family pattern, the male usually assumes the dominant role. The male
member functions in the work role, is responsible for control of finances, and makes most
decisions.
DIF: Cognitive Level: Knowledge
REF:
p. 700
OBJ: 1 TOP:
Family patterns
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
26.
What is the family pattern in which the female assumes primary dominance in the
areas of childcare and homemaking, as well as financial decision making?
a.
Autocratic family pattern
b.
Patriarchal family pattern
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c.
Matriarchal family pattern
d.
Democratic family pattern
ANS: C
In the matriarchal family pattern, the female assumes primary dominance in
areas of childcare and homemaking, as well as financial decision making.
DIF: Cognitive Level: Knowledge
REF:
p. 700
OBJ: 1 TOP:
Family patterns
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
27.
What is the family pattern in which the adult members function as equals?
a.
Autocratic family pattern
b.
Patriarchal family pattern
c.
Matriarchal family pattern
d.
Democratic family pattern
ANS: D
In the democratic family pattern, the adult members function as equals. Children are
treated with respect and recognized as individuals. This style encourages joint
decision making, and it recognizes and supports the uniqueness of each individual
member. This family pattern favors negotiation, compromise, and growth.
DIF: Cognitive Level: Knowledge
REF:
p. 700
OBJ: 1 TOP:
Family patterns
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
28.
What is the stage of family development that begins when the couple acknowledges that
they are considering marriage?
a.
Expectant stage
b.
Parenthood stage
c.
Establishment stage
d.
Engagement/commitment stage
ANS: D
The engagement/commitment stage begins when the couple acknowledges to
themselves and others that they are considering marriage. At this time, opposition or
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support will be evident from friends and parents. Wedding plans must be arranged.
Housing, work, and furnishings are some of the items discussed and explored.
DIF: Cognitive Level: Knowledge
REF:
p. 700
OBJ: 1 TOP:
Family development
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
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29.
What is the stage of family development that extends from the wedding until the birth of
the first child?
a.
Expectant stage
b.
Parenthood stage
c.
Establishment stage
d.
Engagement/commitment stage
ANS: C
The establishment stage extends from the wedding until the birth of the first child.
During this phase, one of the important tasks is the adjustment from the single
independent to the married, interdependent state. The challenges facing the newly
married couple include learning to live with another person, decision making, conflict
resolution, and communication.
DIF: Cognitive Level: Knowledge REF: pp.
700-701
OBJ: 1 TOP: Family development
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
30.
What is the stage of family development that begins when conception begins and
continues through the pregnancy?
a.
Expectant stage
b.
Parenthood stage
c.
Establishment stage
d.
Engagement/commitment stage
ANS: A
The expectant stage begins when conception occurs and continues through the pregnancy.
DIF: Cognitive Level: Knowledge
REF:
p. 701
OBJ: 1 TOP:
Family development
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
31.
What is the stage of family development that begins at the birth or adoption of the first
child?
a.
Expectant stage
b.
Parenthood stage
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c.
Establishment stage
d.
Engagement/commitment stage
ANS: B
The parenthood stage begins at the birth or adoption of the first child.
DIF: Cognitive Level: Knowledge REF: pp.
701-702
OBJ: 1 TOP: Family development
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
32.
What stage of family development involves the grown children departing from home?
a.
Expectant stage
b.
Senescence stage
c.
Establishment stage
d.
Disengagement stage
ANS: D
The disengagement stage of parenthood is the period of family life when the grown
children depart from the home.
DIF: Cognitive Level: Knowledge
REF:
p. 702
OBJ: 1 TOP:
Family development
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
33.
What is known as the last stage in the life cycle?
a.
Expectant stage
b.
Senescence stage
c.
Establishment stage
d.
Disengagement stage
ANS: B
The senescence stage is the last stage of the life cycle, which requires the individual to
cope with a large range of changes. For the older adult the family unit continues to be
a major source of satisfaction and pleasure. Most older adults prefer to live
independently.
DIF: Cognitive Level: Knowledge
REF:
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p. 702
OBJ: 1 TOP:
Family development
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
34.
The nurse recognizes that during the first 5 months of life, an infant is expected to
gain approximately how many pounds per month?
a.
0.5
b.
1
c.
1.5
d.
2
ANS: C
The infant is expected to gain about 1.5 lb per month until 5 months.
DIF: Cognitive Level: Application
REF:
p. 704
OBJ: 4 TOP:
Growth and development
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
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35.
A nurse is caring for a neonate who weighs 7 lb 3 oz at birth. What should the infant‘s
weight be at 1 year?
a.
10 lb 3 oz
b.
14 lb 6 oz
c.
21 lb 9 oz
d.
28 lb 12 oz
ANS: C
By the time the baby is 1 year of age, the birth weight should have tripled.
DIF: Cognitive Level: Analysis
REF:
p. 704
OBJ: 4 TOP:
Growth and development
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
36.
A nurse is caring for a neonate who is 22 in in height. What will the child‘s expected
height be at 1 year?
a.
29 in
b.
33 in
c.
44 in
d.
56 in
ANS: B
Height increases by about 1 in per month for the first 6 months. By 12 months of age,
the infant‘s birth length has increased about 50%.
DIF: Cognitive Level: Analysis
REF:
p. 704
OBJ: 4 TOP:
Growth and development
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
37.
What is the average apical heart rate for a 2-month-old infant?
a.
80 beats/min
b.
100 beats/min
c.
120 beats/min
d.
150 beats/min
ANS: C
At 2 months of age, the average apical rate is about 120 beats/min.
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DIF: Cognitive Level: Knowledge
REF:
p. 704
OBJ: 4 TOP:
Growth and development
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
38.
What is the average resting respiratory rate for a 12-month-old child?
a.
15 breaths/min
b.
20 breaths/min
c.
30 breaths/min
d.
50 breaths/min
ANS: C
Average resting respiratory rate for the 12-month-old is about 30 breaths/min.
DIF: Cognitive Level: Knowledge
REF:
p. 704
OBJ: 4 TOP:
Growth and development
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
39.
A nurse assessing a 2-month-old infant would expect the infant to do which of the
following?
a.
Crawl on the floor.
b.
Creep on the floor.
c.
Sit up steadily without support.
d.
Hold its head up while in the prone position.
ANS: D
At 2 months the infant is able to hold the head up while in the prone position. Infants may
crawl at 7 months and creep at about 9 months. By the end of the seventh month, infants
can sit up steadily without support.
DIF: Cognitive Level: Knowledge
TOP: Growth and development
REF: p. 705
OBJ: 4
KEY: Nursing
Process Step: Assessment MSC: NCLEX: N/A
40.
A nurse assessing a 4-month-old infant would expect the infant to do which of the
following?
a.
Crawl up the stairs.
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b.
Creep on the floor at least 30 ft.
c.
Walk upright with a waddling gait.
d.
Hold head at a 90-degree angle while prone.
ANS: D
At 4 months the infant is able to hold the head up steadily to a 90-degree angle while in
the prone position. Infants may crawl at 7 months and creep at about 9 months. Standing
with support and walking occur at about 8 to 15 months.
DIF: Cognitive Level: Knowledge
TOP: Growth and development
REF: p. 705
OBJ: 4
KEY: Nursing
Process Step: Assessment MSC: NCLEX: N/A
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41.
A nurse teaching the mother about infant oral hygiene instructs the mother to offer the
infant sips of:
a.
cola.
b.
milk.
c.
juice.
d.
water.
ANS: D
Oral hygiene for the young infant consists of offering sips of clear water and wiping
and massaging the infant‘s gums. Cola, milk, and juice should not be introduced at this
young age.
DIF: Cognitive Level: Application
REF: p. 705 OBJ: 4 TOP:
Dentition
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: N/A
42.
A mother asks the nurse when she should introduce solid foods into her infant‘s diet.
What would be the most correct response?
a.
Introduce fruits and vegetables first.
b.
Mix foods to allow the infant variety.
c.
Introduce only one new food at a time.
d.
Introduce new foods at 24-hour intervals.
ANS: C
Only one new food should be introduced at a time, followed by several days between
new foods. Cereals should be introduced first, followed by fruits and vegetables, and
last meats. Food should not be mixed to allow the infant to develop interest in different
foods and tastes.
DIF: Cognitive Level: Application
REF: p. 707 OBJ: 4 TOP: Diet
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: N/A
43.
What is the leading cause of injury and death among infants and young children?
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a.
Accidents
b.
Child abuse
c.
Drug abuse
d.
Adolescent parents
ANS: A
Accidents are the leading cause of injury and death of infants and young children.
DIF: Cognitive Level: Knowledge
p. 708
REF:
OBJ: 11 TOP: Prevention KEY:
Nursing Process Step: Implementation
MSC: NCLEX: N/A
44.
A nurse assessing a toddler should consider which finding abnormal?
a.
Lumbar lordosis
b.
Cyanotic nail beds
c.
A protruding abdomen
d.
A convex lumbar curve
ANS: B
Normal assessment findings in a toddler include lumbar lordosis (convex lumbar
curve) and a protruding abdomen. Cyanotic nail beds are an abnormal finding.
DIF: Cognitive Level: Application
REF:
p. 708
OBJ: 4 TOP:
Abnormal findings
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
45.
Which theory of aging suggests that the body becomes less able to tolerate the ―self‖?
a.
Free radical theory
b.
Autoimmunity theory
c.
Wear-and-tear theory
d.
Biological programming theory
ANS: B
The autoimmunity theory holds that with aging, the body becomes less able to
recognize or tolerate the ―self.‖ As a result the immune system produces antibodies
that act against the self.
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DIF: Cognitive Level: Knowledge
REF:
p. 726
OBJ: 14 TOP:
Theories of aging
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
46.
Which theory of aging suggests that there should be a natural withdrawal between the
individual and society?
a.
Free radical theory
b.
Autoimmunity theory
c.
Wear-and-tear theory
d.
Disengagement theory
ANS: D
According to supporters of the disengagement theory of aging, there should be a
natural withdrawal, or disengagement, between the individual and society.
DIF: Cognitive Level: Knowledge
REF:
p. 726
OBJ: 14 TOP:
Theories of aging
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
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47.
Which theory of aging suggests that the older person who is more socially active is more
likely to adjust well to aging?
a.
Activity theory
b.
Autoimmunity theory
c.
Wear-and-tear theory
d.
Disengagement theory
ANS: A
According to the activity theory, the older person who is more active socially is more
likely to adjust well to aging.
DIF: Cognitive Level: Knowledge
REF:
p. 726
OBJ: 14 TOP:
Theories of aging
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
48.
Which theory of aging suggests that previously developed coping abilities and the
ability to maintain previous roles and activities are critical to adjustment to old age?
a.
Continuity theory
b.
Autoimmunity theory
c.
Wear-and-tear theory
d.
Disengagement theory
ANS: A
Supporters of the continuity theory suggest that the critical factors in adjustment
to old age are previously developed coping abilities and the ability to maintain
previous roles and activities.
DIF: Cognitive Level: Knowledge REF: pp.
726-727
OBJ: 14 TOP: Theories of aging
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
49.
Which of the following measures would be included in a teaching plan to instruct new
parents on reducing the incidence of sudden infant death syndrome?
a.
Bottle-feed an infant at night.
b.
Place infants on their stomach to sleep.
c.
Keep an infant‘s room well ventilated.
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d.
Place soft bedding and pillows in an infant‘s crib.
ANS: C
Steps to reduce the incidence of sudden infant death syndrome include placing infants
on their back to sleep, avoiding exposure to cigarette smoke, avoiding using soft
bedding or pillows, keeping rooms well ventilated, breastfeeding if possible, and
maintaining regular medical checkups for infants.
DIF: Cognitive Level: Application
REF: p. 707 OBJ: 4 TOP:
Safety
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: N/A
50.
A nurse instructing a group of parents about safety rules for infants and young
children should include which of the following measures in the teaching plan?
a.
Remove plants from the child‘s reach.
b.
Provide the infant with a pillow at night.
c.
Use a plastic covering on the infant‘s mattress.
d.
Keep the crib sides up and set the mattress at the highest setting.
ANS: A
Safety rules for infants and young children include keeping the crib sides up and the
mattress set at the lowest setting, never using plastic bags or coverings on mattresses or
near the infant‘s playthings, avoiding the use of pillows with small infants, and removing
plants from the child‘s reach.
DIF: Cognitive Level: Application
REF: p. 709 OBJ: 4 TOP:
Safety
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: N/A
51.
A child who uses senses and motor abilities to understand the world is displaying
characteristics consistent with which stage of Piaget‘s cognitive development?
a.
Sensorimotor stage of cognitive development
b.
Preoperational stage of cognitive development
c.
Formal operational stage of cognitive development
d.
Concrete operational stage of cognitive development
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ANS: A
The Piaget‘s sensorimotor stage of cognitive development uses senses and motor
abilities to understand the world; this period begins with reflexes and coordinates
sensorimotor skills.
DIF: Cognitive Level: Application
REF: p. 704
TOP: Piaget KEY: Nursing Process Step: Assessment
OBJ: 3
MSC: NCLEX: N/A
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52.
A child who has just begun to demonstrate object permanence is in which of the Piaget‘s
stages of cognitive development?
a.
Sensorimotor
b.
Preoperational thought
c.
Formal operational thought
d.
Concrete operational thought
ANS: A
The Piaget‘s sensorimotor stage of cognitive development uses senses and motor
abilities to understand the world; this period begins with reflexes and coordinates
sensorimotor skills. While in this stage, a child learns that an object still exists when
it is out of sight (object permanence).
DIF: Cognitive Level: Application
REF: p. 704
TOP: Piaget KEY: Nursing Process Step: Assessment
53.
OBJ: 3
MSC: NCLEX: N/A
A child who has just begun to demonstrate egocentric thinking is in which of the Piaget‘s
stages of cognitive development?
a.
Sensorimotor
b.
Preoperational thought
c.
Formal operational thought
d.
Concrete operational thought
ANS: B
The Piaget‘s preoperational stage of cognitive development includes the development of
egocentric thinking (understanding the world from only one perspective, that of the
self).
DIF: Cognitive Level: Application
REF: p. 704
TOP: Piaget KEY: Nursing Process Step: Assessment
54.
OBJ: 3
MSC: NCLEX: N/A
A child has just begun to demonstrate the ability to understand and apply logical
operations to help interpret specific experiences or perceptions. Which of the
following stages of Piaget‘s cognitive development is this describing?
a.
Sensorimotor
b.
Preoperational thought
c.
Formal operational thought
d.
Concrete operational thought
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ANS: D
The Piaget‘s concrete operational stage of cognitive development includes the ability
to understand and apply logical operations or principles to help interpret specific
experiences or perceptions.
DIF: Cognitive Level: Application
REF: p. 704
TOP: Piaget KEY: Nursing Process Step: Assessment
55.
OBJ: 3
MSC: NCLEX: N/A
A child who is able to use a systematic, scientific problem-solving approach is in
which of the Piaget‘s stages of cognitive development?
a.
Sensorimotor
b.
Preoperational thought
c.
Formal operational thought
d.
Concrete operational thought
ANS: C
The Piaget‘s formal operational stage of cognitive development includes the ability to use
a systematic, scientific problem-solving approach.
DIF: Cognitive Level: Application
REF: p. 704
TOP: Piaget KEY: Nursing Process Step: Assessment
56.
OBJ: 3
MSC: NCLEX: N/A
According to Erikson, an infant who was abandoned by his or her primary
caregiver is at risk for developing which of the following?
a.
Guilt
b.
Mistrust
c.
Isolation
d.
Confusion
ANS: B
During infancy a child‘s developmental task is basic trust versus mistrust.
DIF: Cognitive Level: Application
REF: p. 706
OBJ: 8
TOP: Erikson
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
MULTIPLE RESPONSE
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1.
Separation anxiety includes which stages? (Select all that apply.)
a.
Detachment
b.
Protest
c.
Anger
d.
Despair
e.
Withdrawal
ANS: A, B, D
The phases of separation anxiety are protest, despair, and detachment.
DIF: Cognitive Level: Knowledge
REF: p. 707
OBJ: 9
TOP: Separation anxiety KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
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2.
The nurse informs a group of college students that young adults will face which
challenges in this particular time of life? (Select all that apply.)
a.
Starting a family
b.
Selecting housing
c.
Job security
d.
Relations with extended family
e.
Establishing intimacy
ANS: A, B, C, D, E
All options are developmental tasks of the young adult of today.
DIF: Cognitive Level: Application
p. 721
Young adult
REF:
OBJ: 11 TOP:
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
COMPLETION
1.
The process that refers to gradual change and differentiation is
.
ANS:
development
Development is the process of gradual change and differentiation.
DIF: Cognitive Level: Knowledge
REF:
p. 697
OBJ: 4 TOP:
Development
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
2.
Any substance such as a drug, alcohol, or virus that interferes with fetal development is
called a(n)
.
ANS:
teratogen
A teratogen is any substance that interferes with fetal development, such as a drug,
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alcohol, or a virus.
DIF: Cognitive Level: Knowledge REF: pp. 697-698
TOP: Teratogen
OBJ: 4
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
3.
Growth and development that proceeds from the head toward the feet is known as .
ANS:
cephalocaudal
Cephalocaudal is defined as growth and development that proceeds from the head toward
the feet.
DIF: Cognitive Level: Knowledge
REF:
p. 697
OBJ: 4 TOP:
Development
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
4.
Growth and development that moves from the center toward the outside is known as
.
ANS:
proximodistal
Proximodistal refers to growth and development that moves from the center toward the
outside.
DIF: Cognitive Level: Knowledge
REF:
p. 697
OBJ: 4 TOP:
Development
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
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Chapter 25: Loss, Grief, Dying, and Death
Cooper: Foundations and Adult Health Nursing, 9th Edition
MULTIPLE
CHOICE
1.
What is the final stage of human growth and development?
a.
Integrity
b.
Death
c.
Despair
d.
Resolution
ANS: B
Death is the final stage of growth and development.
DIF: Cognitive Level: Knowledge
REF: p. 734
TOP: Death KEY: Nursing Process Step: N/A
2.
OBJ: 3
MSC: NCLEX: N/A
A young nurse caring for a dying patient hastens through the care and leaves the
room as quickly as possible. What common reaction to the care of the dying is the
nurse exhibiting?
a.
Efficiency
b.
Anger
c.
Withdrawal
d.
Anxiety
ANS: C
Withdrawal is a common reaction to the care of the dying.
DIF: Cognitive Level: Comprehension
REF: p. 736 OBJ: 5 TOP:
Withdrawal KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Psychosocial Integrity
3.
Changes in health care reimbursement measures have resulted in which of the
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following changes regarding care of the terminally ill?
a.
Patients spend more time in hospitals.
b.
Nurses provide more care in hospitals.
c.
More patients die at home.
d.
Patients spend more time in rehab facilities.
ANS: C
Due to changes in reimbursement measures, more patients are dying at home.
DIF: Cognitive Level: Application
REF: p. 755 OBJ: 2 TOP:
Death
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Psychosocial Integrity
4.
How does a perceived loss differ from an actual loss?
a.
A perceived loss is more quickly resolved.
b.
A perceived loss is situational.
c.
A perceived loss is easily overlooked.
d.
A perceived loss has a superficial response.
ANS: C
Perceived losses are easily overlooked.
DIF: Cognitive Level: Comprehension
REF: p. 736 OBJ: 1 TOP:
Loss
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Psychosocial Integrity
5.
Upon being told of her father‘s death, the daughter cries out, ―No! Oh, God, no!‖ What
stage of grief is the daughter in?
a.
Anger
b.
Bargaining
c.
Denial
d.
Prayer
ANS: C
The daughter is exhibiting signs of denial, which is commonly one of the first stages of
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grief.
DIF: Cognitive Level: Comprehension
REF: p. 737 OBJ: 4 TOP:
Grief
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Psychosocial Integrity
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6.
What should the nurse do before approaching a grieving family member?
a.
Offer sympathy
b.
Assess level of resolution
c.
Give assurance that the pain will pass
d.
Encourage the family member to return to normal activities
ANS: B
The nurse should assess each aspect of grieving to fully understand where family
members are in their grief in order to offer the most effective assistance.
DIF: Cognitive Level: Application
REF: p. 757 OBJ: 6 TOP:
Grief
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Psychosocial Integrity
7.
A dying patient uses the call light frequently to ask the nurse to do simple tasks. The
nurse recognizes this as a fear of:
a.
increased pain.
b.
failure.
c.
abandonment.
d.
isolation.
ANS: C
A major fear of the dying patient is fear of abandonment.
DIF: Cognitive Level: Application
REF:
p. 753
KEY:
OBJ: 10 TOP: Death
Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity
8.
What is the first thing the nurse should do before involving the family in the care of a
dying patient?
a.
Ask the patient if he or she wants family care.
b.
Ask family members if they want to assist with care.
c.
Check the hospital policy on the family giving care.
d.
Set a caring example.
ANS: B
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Ascertaining whether the family wants to assist in the patient‘s daily care will clarify
what the family members are comfortable doing.
DIF: Cognitive Level: Application
REF:
p. 747
KEY:
OBJ: 13 TOP: Death
Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
9.
Which of the following would lead the home health nurse to make a patient
problem of unresolved grief for a patient who was widowed 5 months ago?
a.
Seeing that the patient keeps a picture of the husband by her bed.
b.
The patient said tearfully, ―I can‘t believe he is gone.‖
c.
Assessing that the patient eats out frequently rather than cooking at home.
d.
The patient says that she attends church three times a week.
ANS: B
Unresolved grief results when a grieving person does not move past some stage of the
grief process. The widow is still in denial. It would be expected for the widow to keep
pictures of her husband in the home. Eating out frequently and attending church would
not lead to a diagnosis of unresolved grief, but instead would be encouraged.
DIF: Cognitive Level: Analysis
TOP: Unresolved grief
REF: p. 739
OBJ: 4
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
10.
When the nurse is developing a care plan for a terminally ill patient, what might be a
realistic goal?
a.
The patient will remain pain-free.
b.
The patient will function optimally.
c.
The patient will spend time out of bed.
d.
The patient will demonstrate improved nutritional status.
ANS: B
The goal of the care plan for a terminally ill patient is to assist the patient to function
optimally. The other options are not realistic.
DIF: Cognitive Level: Application
REF:
p. 735
KEY:
OBJ: 10 TOP: Care plan
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Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance
11.
Following the death of a day-old infant, the nurse brings the baby to the parents. What
is the rationale for the parents‘ visit with the deceased baby?
a.
Bond with the family.
b.
Reinforce the individuality of the baby.
c.
Generate preparation for another child.
d.
Make the death a reality.
ANS: D
When possible, the parents should see, touch, and hold the infant to cope better with the
reality of the death.
DIF: Cognitive Level: Application
REF: p. 747 OBJ: 6 TOP:
Death
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Psychosocial Integrity
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12.
The nurse spends a great deal of time in the room of a dying 12-year-old because the
nurse knows that most children are aware of their condition and want the nurse to do
which of the following?
a.
Keep them clean.
b.
Help them eat.
c.
Care about them.
d.
Keep them comfortable.
ANS: C
Children, like adults, fear abandonment as death approaches and gain comfort from the
presence of the nurse.
DIF: Cognitive Level: Analysis
TOP: Childhood death
REF: p. 740
OBJ: 6
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
13.
After a health care provider in the emergency department has pronounced a 2-yearold dead following a swimming pool accident, the mother tearfully says to the father,
―I am so sorry. I am so sorry.‖ What is the mother expressing?
a.
Fear
b.
Guilt
c.
Hostility
d.
Grief
ANS: B
Parents often harbor extreme guilt in an ―out of sequence death.‖
DIF: Cognitive Level: Analysis
REF: p. 749
OBJ: 4
TOP: Out of sequence death KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
14.
What is the termination of tube feedings to a dying patient considered?
a.
Active euthanasia
b.
Holistic care
c.
Passive euthanasia
d.
Terminal care
ANS: C
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Permitting the death of a patient by withholding treatments is referred to as passive
euthanasia.
DIF: Cognitive Level: Comprehension REF: p. 749
OBJ: 7
TOP: Passive euthanasia KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
15.
How is a durable power of attorney helpful to an incapacitated patient?
a.
It directs treatment in accordance with the patient‘s wishes.
b.
It directs an agent to make health care decisions.
c.
It gives power to an agent to make decisions
regarding health, property, and other assets.
d.
It can only be executed by an attorney.
ANS: B
The durable power of attorney gives an agent the power to make health care decisions.
It can be executed by anyone and does not extend beyond health care issues. A living
will directs treatment according to the patient‘s wishes.
DIF: Cognitive Level: Application
TOP: Durable power of attorney
REF: p. 750
OBJ: 7
KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Psychosocial Integrity
16.
When a nurse informs a patient‘s spouse that the patient has died, the spouse
states, ―You must be mistaken.‖ Which of Kübler-Ross‘s stages of dying is the
spouse demonstrating?
a.
Anger
b.
Denial
c.
Depression
d.
Bargaining
ANS: B
When experiencing denial, the individual acts as though nothing has happened and may
refuse to believe or understand that loss has occurred.
DIF: Cognitive Level: Comprehension REF: p. 739
TOP: Stages of dying
OBJ: 3
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
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Integrity
17.
A patient whose spouse died 1 year earlier complains of feeling overwhelmingly
lonely and has withdrawn from interpersonal interactions. The patient is
demonstrating what stage of dying according to Kübler-Ross‘s stages of dying
theory?
a.
Anger
b.
Denial
c.
Depression
d.
Bargaining
ANS: C
When experiencing depression, the individual feels overwhelmingly lonely and withdraws
from interpersonal interaction.
DIF: Cognitive Level: Comprehension REF: p. 739
TOP: Stages of dying
OBJ: 3
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
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18.
A nurse is caring for the dying mother of a 7-year-old child. What is important for the
nurse to understand regarding the child?
a.
The child associates death with aggression.
b.
The child believes his or her own death cannot be avoided.
c.
The child lacks understanding of the concept of death.
d.
The child understands death as the inevitable end of life.
ANS: A
A child from 5 to 9 years old understands that death is final, believes one‘s own death
can be avoided, associates death with aggression or violence, and believes wishes or
unrelated actions can be responsible for death. A child between the ages of 9 to 12
years understands that death is the inevitable end of life.
DIF: Cognitive Level: Application
TOP: Understanding of death
REF: p. 740
OBJ: 4
KEY: Nursing
Process Step: Assessment MSC: NCLEX:
Psychosocial Integrity
19.
The nurse explains to a grieving husband that the process of the resolution of the hurt
and the reestablishment of his life is called the
a.
grief
b.
renewal
c.
denial
d.
acceptance
process.
ANS: A
The grief process includes the resolution of the hurt and the reestablishment of life
activities following bereavement.
DIF: Cognitive Level: Comprehension REF: p. 736
TOP: Grief process
OBJ: 13
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
MULTIPLE
RESPONSE
1.
The home health nurse assesses that the goal of grief resolution has been
accomplished when the nurse observes that a widow has performed which activities?
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(Select all that apply.)
a.
Adjusted to an environment without the spouse.
b.
Put financial affairs in order.
c.
Made plans for a lengthy trip.
d.
Sought new relationships.
e.
Acquired a job.
ANS: A, D
Environmental adjustment and seeking new relationships are clear evidence of grief
resolution. A trip, arranging financial affairs, or finding employment may be a form of
denial or activities that may be dictated by the situation and is not necessarily
resolution of grief.
DIF:
Cognitive Level: Analysis
REF: p. 737 | p. 739 OBJ:
13
TOP: Grief resolution
KEY: Nursing Process Step: Evaluation
2.
MSC: NCLEX: Psychosocial Integrity
Which of the five aspects of human functioning must a nurse address when dealing with a
grieving person? (Select all that apply.)
a.
Physical
b.
Emotional
c.
Intellectual
d.
Financial
e.
Spiritual
ANS: A, B, C, E
The five areas of human function are physical, emotional, intellectual, sociocultural, and
spiritual.
DIF:
Cognitive Level: Comprehension
pp. 739-740
REF:
OBJ: 5 TOP: Aspects of human
function
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
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Chapter 26: Health Promotion and Pregnancy
Cooper: Foundations and Adult Health Nursing, 9th Edition
MULTIPLE
CHOICE
1.
Where does implantation of the fertilized ovum usually occur?
a.
Lower uterine wall
b.
Side of the uterus
c.
Fundus of the uterus
d.
Body of the uterus
ANS: C
Implantation usually occurs in the fundus of the uterus.
DIF: Cognitive Level: Knowledge
REF: p. 762
OBJ: 1 TOP:
Implantation KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
2.
A patient has been diagnosed with a tubal pregnancy. What is the typical outcome of a
tubal pregnancy?
a.
The patient will carry the pregnancy to term and have a cesarean delivery.
b.
The patient will have to remain in bed for the remainder of the pregnancy.
c.
The patient will spontaneously abort this ectopic pregnancy.
d.
The patient will require surgery to remove the zygote.
ANS: D
Any pregnancy where implantation occurs outside the uterine cavity is called ectopic.
Tubal pregnancies usually must be resolved by surgical removal of the zygote.
DIF: Cognitive Level: Analysis
REF: p. 762 OBJ: 1 TOP:
Pregnancy
KEY: Nursing Process Step:
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Assessment
MSC: NCLEX: Physiological Integrity
3.
How long does the embryonic stage of pregnancy typically last?
a.
3 weeks
b.
4 weeks
c.
6 weeks
d.
8 weeks
ANS: D
The embryonic stage encompasses the first 8 weeks.
DIF: Cognitive Level: Knowledge
REF: p. 763 OBJ: 1 TOP:
Pregnancy
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
4.
Why is the nurse concerned about a patient in her first trimester of pregnancy being
exposed to German measles?
a.
The disease is capable of causing a spontaneous abortion.
b.
The disease is capable of causing birth defects.
c.
The disease is capable of causing high fever and convulsions.
d.
The disease is capable of interfering with placental implantation.
ANS: B
Rubella is a known teratogen, which can cause birth defects.
DIF: Cognitive Level: Application
REF: p. 763 OBJ: 1 TOP:
Teratogen
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Health Promotion and Maintenance
5.
Which hormone is secreted by the placenta?
a.
Follicle-stimulating hormone (FSH)
b.
Alpha-fetoprotein (AFP)
c.
Human chorionic gonadotropin (HCG)
d. Luteinizing hormone
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ANS: C
The placenta functions as an endocrine gland, secreting estrogen, progesterone, and HCG.
DIF: Cognitive Level: Comprehension REF: p. 763
TOP: Placenta function
OBJ: 2
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
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6.
What protects the fetus from most bacterial infections?
a.
The yolk sac
b.
The placental barrier
c.
The cotyledons
d.
The chorionic villa
ANS: B
The placental barrier protects the embryo/fetus from most bacteria, but not from
viruses or drugs. The cotyledons are sections that make up the placenta. The chorionic
villa are tiny vascular projections on the chorionic surface that help form the
placenta.
DIF: Cognitive Level: Comprehension REF: p. 763
TOP: Placental barrier
OBJ: 2
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
7.
What period of the maternity cycle does the intrapartal period cover?
a.
Beginning of pregnancy to midterm
b.
Conception to third trimester
c.
Onset of labor to delivery of the baby
d.
Onset of labor to delivery of the placenta
ANS: D
The intrapartal period of the maternity cycle covers the onset of labor to delivery of the
placenta. The antepartal period begins at conception and continues until the onset of
labor. The postpartal period begins after the delivery of the placenta and continues for
approximately 6 weeks, until the reproductive organs return to their prepregnancy state.
DIF: Cognitive Level: Knowledge
TOP: Intrapartal period
REF: p. 777
OBJ: 3
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
8.
A woman who has just discovered she is pregnant states that the first day of her last
menstrual period was July 10. What will be her expected date of birth (EDB)?
a.
April 10
b.
April 17
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c.
May 10
d.
October 17
ANS: B
To determine the EDB (estimated date of birth), the woman should count from the first
day of her last menstrual period. Count back 3 months and forward 7 days.
DIF: Cognitive Level: Application
REF: p. 780
OBJ: 4
TOP: Estimated date of birth (EDB) KEY: Nursing
Process Step: Assessment MSC: NCLEX: Health
Promotion and Maintenance
9.
Which is a positive sign of pregnancy?
a.
Positive pregnancy test
b.
Positive Chadwick sign
c.
Ultrasonic tracing of the fetus
d.
Positive Goodell sign
ANS: C
A positive sign of pregnancy is an ultrasonic tracing of the fetus. A positive pregnancy
test, positive Chadwick sign, and positive Goodell sign are all probable signs of
pregnancy.
DIF: Cognitive Level: Comprehension REF: p. 780
TOP: Positive signs of pregnancy
OBJ: 4
KEY: Nursing
Process Step: Assessment MSC: NCLEX:
Physiological Integrity
10.
What is the cause of frequent urination in early pregnancy?
a.
Increased fluid intake
b.
The fetus‘s kidneys functioning
c.
Retention of fluid
d.
Increased circulating volume
ANS: D
Early in pregnancy, the increase in circulating volume and the enlarging uterus
placing pressure on the bladder cause urinary frequency.
DIF: Cognitive Level: Application
REF: p. 786
OBJ: 7
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TOP: Frequency of urination KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological
Integrity
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11.
A woman asks the nurse about the safety of sexual intercourse during her
pregnancy. Which response by the nurse is the most correct?
a.
―Sexual activity should be avoided after the first trimester.‖
b.
―Sexual activity should be ceased in the case of vaginal bleeding.‖
c.
―Sexual activity should be avoided in the second trimester.‖
d.
―Sexual activity should be limited to activity that does not include intercourse.‖
ANS: B
Sexual intercourse can be enjoyed throughout pregnancy unless it is
contraindicated by other conditions. In the case of vaginal bleeding, sexual activity
should cease until the cause of the bleeding is determined by the health care
provider.
DIF: Cognitive Level: Analysis
TOP: Sexual activity during pregnancy
REF: p. 788
OBJ: 5
KEY:
Nursing Process Step: Implementation MSC: NCLEX:
Psychosocial Integrity
12.
A woman tells the nurse that this is her third pregnancy. She has had twin girls at
full term and one miscarriage. How does the nurse record the information?
a.
G2, T2, L3
b.
G4, T3, A1, L1
c.
G3, T3, A2, L1
d.
G3, T1, A1, L2
ANS: D
Standard obstetrical terminology is: G = gravida, T = term birth, P = preterm birth, A =
abortion, L = living children.
DIF: Cognitive Level: Comprehension REF: p. 780
TOP: Terminology
OBJ: 3
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Health Promotion
and Maintenance
13.
During which gestational week can a primigravida expect to first feel fetal movement?
a.
8
b.
10
c.
16
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d.
20
ANS: C
At about 16 to 18 weeks, the sensation of the first movement is felt.
DIF: Cognitive Level: Knowledge
REF: p. 778 OBJ: 4 TOP:
Quickening
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
14.
At what week of fetal development can the nurse expect to first hear fetal heart tones with
an amplified stethoscope?
a.
10
b.
12
c.
14
d.
16
ANS: D
During week 16, the fetal heart can be heard with an amplified stethoscope.
DIF: Cognitive Level: Knowledge
REF: p. 767 OBJ: 4 TOP:
Fetal age
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
15.
The nurse assures an anxious primigravida that during fetal development from
week 34 and beyond, maternal antibodies are transferred to the baby. How long
will these antibodies provide the baby with immunity?
a.
1 month
b.
3 months
c.
4 months
d.
6 months
ANS: D
The maternal antibodies that are transferred to the baby provide immunity for 6 months.
DIF: Cognitive Level: Application
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REF: p. 770 OBJ: 2 TOP:
Pregnancy
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
16.
Early in the first trimester, a woman complains of morning sickness. What does the nurse
suggest to aid with the discomfort?
a.
Eating something with a high-fat content
b.
Eating dry crackers before getting up
c.
Eating three well-balanced meals
d.
Getting rest and taking antiemetics
ANS: B
A remedy for morning sickness is to eat a few dry crackers before getting up.
DIF: Cognitive Level: Application
TOP: Morning sickness
REF: p. 765
OBJ: 7
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
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17.
What does the increase in circulating blood volume during pregnancy cause in the
mother?
a.
Shortness of breath
b.
Frontal headaches
c.
Decreased white blood cell count
d.
Decreased hemoglobin
ANS: D
Maternal circulating volume increases 30% to 40%, causing a virtual decrease in
hemoglobin.
DIF: Cognitive Level: Analysis
TOP: Decreased Hgb
REF: p. 785
OBJ: 2
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
18.
A woman entering the 22nd week of pregnancy complains that she has become
unsightly because of chloasma. What should the nurse recommend to reduce the
appearance of the chloasma?
a.
Use heavy makeup.
b.
Take extra doses of vitamin A.
c.
Avoid exposure to the sun.
d.
Reduce caffeine intake.
ANS: C
At week 22, skin pigment changes called chloasma are found. Avoiding exposure to the
sun will reduce the pigmentation.
DIF: Cognitive Level: Analysis
REF: p. 783 OBJ: 7 TOP:
Chloasma
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Psychosocial Integrity
19.
During the final weeks of pregnancy, urinary frequency may return due to the
enlarged uterus, compressing the bladder against the pelvic bones. What does the
nurse suggest to aid in relieving the urinary frequency?
a.
Decrease fluid intake.
b.
Use the knee-chest position.
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c.
Sleep on her side.
d.
Avoid fluid intake in evening.
ANS: C
The patient should decrease pressure on the bladder at night by sleeping on her side.
Fluids should not be decreased unless directed by a health care provider.
DIF: Cognitive Level: Application
REF: p. 765 OBJ: 7 TOP:
Frequency
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
20.
A pregnant teenager presents with the following complaints. Which complaint could be
an indicator of a serious complication?
a.
Painful hemorrhoids
b.
Linea nigra
c.
Visual disturbances
d.
Low back pain
ANS: C
Visual disturbances may be an indicator of increased blood pressure and retained
fluids. These are indicators of eclampsia. Hemorrhoids, linea nigra, and back
pain are common discomforts of pregnancy.
DIF: Cognitive Level: Analysis
TOP: Danger signs
REF: p. 782
OBJ: 5
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
21.
During the last trimester of pregnancy, the nurse recommends that the woman wear
low-heeled shoes. What is the nurse trying to prevent with this recommendation?
a.
Lower back pain
b.
Leg cramps
c.
Leg swelling
d.
Joint pain
ANS: A
A remedy for backache is to wear low-heeled shoes.
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DIF: Cognitive Level: Application
TOP: Low back pain
REF: p. 786
OBJ: 7
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
22.
The newly diagnosed primigravida who is 6 weeks pregnant states, ―I don‘t feel like I
have a real baby inside me.‖ To reassure the mother, the nurse provides reassurance
that which of the following is functioning in the 6-week-old embryo?
a.
Brain
b.
Lungs
c.
Hands
d.
Heart
ANS: D
At 6 weeks, the fetus has a pumping heart.
DIF: Cognitive Level: Comprehension REF: p. 763
TOP: Fetal development
OBJ: 1
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
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23.
Smoking by the mother can have what effect in the fetus?
a.
Hearing deficits
b.
Neuromuscular deformities
c.
Cerebral palsy
d.
Low birth weight
ANS: D
Smoking has been proven to cause slow intrauterine growth and low birth weight.
DIF: Cognitive Level: Application
REF: p. 781 OBJ: 5 TOP:
Smoking
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
24.
When can the sex of the fetus be confirmed?
a.
Conception
b.
2 weeks
c.
6 weeks
d.
9 weeks
ANS: D
At 9 weeks the genitalia are well defined.
DIF: Cognitive Level: Knowledge
TOP: Fetal sex determination
REF: p. 765
OBJ: 1
KEY: Nursing
Process Step: Implementation MSC: NCLEX: Health
Promotion and Maintenance
25.
The health care provider decides to send the mother for a test to determine the fetal
lung maturity. What is the name of this fetal well-being test?
a.
Biophysical profile
b.
Alpha-fetoprotein
c.
Amniocentesis
d.
Ultrasound
ANS: C
Amniocentesis helps determine the maturity of the fetal lungs.
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DIF: Cognitive Level: Knowledge
REF:
p. 775
OBJ: 3 TOP:
Amniocentesis
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
26.
When the young primigravida asks about how to adjust her diet for her pregnancy,
what should the nurse suggest the mother add to her diet?
a.
Leafy green vegetables and fruit
b.
Beef and poultry
c.
Foods high in sodium and potassium
d.
Bread and grains
ANS: A
A pregnant woman should eat foods containing roughage, such as raw fruits, vegetables,
and cereals with bran.
DIF: Cognitive Level: Comprehension
REF: p. 786 OBJ: 6 TOP: Diet
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
27.
Which of the following discomforts of a pregnant woman should be reported to the health
care provider at the first occurrence?
a.
Leg cramps
b.
Pelvic discomfort
c.
Vaginal bleeding
d.
Urinary frequency
ANS: C
Vaginal bleeding at any time during pregnancy should be reported to the health care
provider. Leg cramps, pelvic discomfort, and urinary frequency are common discomforts
of pregnancy and not a cause for immediate concern.
DIF: Cognitive Level: Application
TOP: Danger indicators
REF: p. 788
OBJ: 5
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
28.
What do the arteries in the umbilical cord carry?
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a.
Nutrients to the fetus from the placenta
b.
Oxygenated blood to perfuse the placenta
c.
Antibodies from the fetus to the mother
d.
Deoxygenated blood back to the placenta
ANS: D
The arteries of the umbilical cord are unique in that they carry deoxygenated blood back
to the placenta.
DIF: Cognitive Level: Comprehension REF: p. 771
TOP: Umbilical arteries
OBJ: 2
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
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29.
What should a nurse instruct the patient to do before assessing fundal height?
a.
Press her lower back against the examination table.
b.
Empty her bladder.
c.
Take a deep breath and hold it.
d.
Bear down.
ANS: B
The bladder should be emptied before the measurement of the fundal height.
DIF: Cognitive Level: Application
TOP: Fundal height
REF: p. 771
OBJ: 3
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Health Promotion
and Maintenance
MULTIPLE RESPONSE
1.
The nurse concludes that the prenatal patient has no need for further instruction
when she correctly states that amniocentesis can determine which of the baby‘s
characteristics? (Select all that apply.)
a.
Sex
b.
Maturity
c.
Approximate weight
d.
Health
e.
Genetic defects
ANS: A, B, D, E
The amniocentesis can reveal the sex, maturity, health, and some genetic defects.
DIF: Cognitive Level: Analysis
TOP: Amniocentesis
REF: p. 771
OBJ: 3
KEY: Nursing Process
Step: Evaluation MSC: NCLEX: Health Promotion
and Maintenance
2.
Which of the following demonstrate culturally competent care of the pregnant patient?
(Select all that apply.)
a.
Discuss beliefs with the patient and incorporate them in the plan of care.
b.
Prohibit visits from anyone other than immediate family members.
c.
Require the patient‘s participation in every aspect of the health care system.
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d.
Maintain the patient‘s modesty at all times.
e.
Strive to maintain a harmonious environment for the patient.
ANS: A, D, E
The nurse should discuss the patient‘s cultural beliefs and incorporate as many as
possible into the plan of care. Modesty is important in almost all cultures, and the
nurse should take measures to ensure the patient‘s modesty. Absence of a stressful
environment is important for a positive outcome for both mother and baby, and the
nurse should strive to alleviate stress and maintain a harmonious environment. Many
cultures will foster relationships, and visits from extended family members may be
important. The patient may not participate in all aspects of the health care system due
to cultural issues.
DIF:
Cognitive Level: Application REF: pp. 790-791
OBJ: 8
TOP: Cultural considerations KEY: Nursing Process
Step: Intervention MSC: NCLEX: Health Promotion
and Maintenance
COMPLETION
1.
The nurse instructor reminds the nursing student that the ―Shiny Schultz‖ is a
name given to the
side of
the placenta.
ANS:
fetal
The fetal side of the placenta is called the Shiny Schultz and the maternal side is called
the Dirty Duncan.
DIF: Cognitive Level: Knowledge
TOP: Placental sides
REF: p. 763
OBJ: 1
KEY: Nursing Process
Step: Intervention MSC: NCLEX: Health Promotion
and Maintenance
2.
The chorion and the amnion are the two components of the
membrane.
ANS:
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fetal
The fetal membrane is composed of the chorion and the amnion.
DIF: Cognitive Level: Knowledge
REF:
p. 763
OBJ: 1 TOP: Fetal
membrane
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
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3.
During the 30th week of gestation, the nurse would anticipate that the fundal height
would be
cm above the
symphysis.
ANS:
30
thirty
The fundal height is equal to the weeks of gestation.
DIF: Cognitive Level: Application
TOP: Fundal height
REF: p. 771
OBJ: 3
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Health Promotion
and Maintenance
4.
The nurse assesses a reactive result to a nonstress test when the fetal heart rate increases
beats/min.
ANS:
15
fifteen
The reactive criterion is that the fetal heart rate will increase 15 beats/min when
stimulated in the nonstress test.
DIF: Cognitive Level: Application
TOP: Nonstress test
REF: p. 775
OBJ: 3
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Health Promotion
and Maintenance
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Chapter 27: Labor and Delivery
Cooper: Foundations and Adult Health Nursing, 9th Edition
MULTIPLE
CHOICE
1.
A woman who is 38 weeks‘ pregnant tells the nurse that the baby has dropped and she
is having urinary frequency again. What do these symptoms describe?
a.
Lightening
b.
Braxton-Hicks contractions
c.
Initiation of labor
d.
Engagement
ANS: A
The symptoms of lightening are a return of urinary frequency, and the patient is able to
breathe more normally.
DIF: Cognitive Level: Comprehension
REF: p. 798 OBJ: 3 TOP:
Lightening
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Health Promotion and Maintenance
2.
How do Braxton-Hicks contractions differ from labor contractions?
a.
Last several minutes.
b.
Are always regular.
c.
Do not dilate the cervix.
d.
Are only mild.
ANS: C
Braxton-Hicks contractions do not dilate the cervix. Braxton-Hicks contractions remain
irregular, can range from mild to moderate in severity, and increase in duration as the
pregnancy progresses.
DIF: Cognitive Level: Comprehension REF:
p. 799
OBJ: 4 TOP:
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Braxton-Hicks contractions KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
3.
The nurse is trying to differentiate true labor from false labor. Which of the following is
correct regarding true labor?
a.
Discomfort of the contraction is in the fundus.
b.
Contractions do not follow a pattern.
c.
Contractions get stronger with ambulation.
d.
Contractions may stop with ambulation.
ANS: C
Contractions get stronger with ambulation in true labor. True labor is also marked by the
onset of regular, rhythmic contractions.
DIF: Cognitive Level: Comprehension
REF: p. 799 OBJ: 4 TOP:
True labor
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
4.
Why is the size and shape of the true pelvis more important than that of the false pelvis?
a.
The fetal head must be able to pass through the true pelvis.
b.
The true pelvis are the mother‘s measurements.
c.
The size of the false pelvis can change.
d.
The size of the true pelvis needs to be larger.
ANS: A
The size and shape of the true pelvis is more important than the false pelvis because the
fetal head must be able to pass through for vaginal delivery to occur.
DIF: Cognitive Level: Comprehension
REF: p. 800 OBJ: 5 TOP:
True pelvis
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
5.
What method is used to visualize soft tissue and to determine adequacy of the pelvis with
no detrimental effects to the fetus?
a.
Pelvimetry
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b.
Palpation
c.
Ultrasonography
d.
X-ray
ANS: C
In more than 20 years of use, ultrasonography has had no detrimental effects on the
fetus. Pelvimetry and x-ray uses radiation to visualize bony prominences. Pelvimetry
is not used in the pregnant patient due to detrimental effects to the fetus. Palpation
does not allow for visualization of soft tissue.
DIF: Cognitive Level: Comprehension
REF: p. 801 OBJ: 5 TOP:
Ultrasound
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
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6.
What area of the uterus provides the force during a contraction?
a.
Lower portion
b.
Middle portion
c.
Upper portion
d.
Cervical portion
ANS: C
The upper portion of the uterus provides the force during contractions.
DIF: Cognitive Level: Knowledge
REF: p. 801
OBJ: 7 TOP:
Passageway
KEY: Nursing Process Step:
Planning
MSC: NCLEX: Health Promotion and Maintenance
7.
What is the largest diameter of the fetal skull?
a.
Temporal
b.
Biparietal
c.
Lateral
d.
Frontal-occipital
ANS: B
The largest transverse diameter of the fetal skull is the biparietal measurement. If this
is too large, the skull may not be able to enter the mother‘s pelvis.
DIF: Cognitive Level: Knowledge
REF: p. 802
OBJ: 6 TOP:
Passageway
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
8.
A nurse is teaching a group of primigravidas that during delivery, pressure on the
fetal skull may produce changes in the shape of the skull. What is the reshaping of
the skull called?
a.
Pressure response
b.
Overlapping
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c.
Molding
d.
Spacing
ANS: C
The reshaping of the skull bones in response to pressure is called molding.
DIF: Cognitive Level: Knowledge
REF: p. 801 OBJ: 5 TOP:
Molding
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
9.
What is the ideal attitude for the fetal body during labor?
a.
Extension
b.
Lateral
c.
Flexion
d.
Transverse
ANS: C
The ideal attitude for the fetal body is flexion.
DIF: Cognitive Level: Knowledge
REF: p. 802 OBJ: 5 TOP:
Attitude
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
10.
Using Leopold maneuvers to assess fetal position, the nurse finds a soft rounded
prominence at the level of the fundus, a hard round prominence just above the
symphysis pubis, and nodulations on the left side of the uterus. How should the nurse
document the fetal position?
a.
Right occiput anterior (ROA), vertex
b.
Left occiput anterior (LOA), vertex
c.
Right occiput transverse (ROT), breech
d.
Left occiput anterior (LOA), breech
ANS: A
Fetal position can be determined by the Leopold maneuver, which defines the
relationship of the presenting part to the maternal pelvis quadrant. A soft rounded
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prominence at the level of the fundus, a hard round prominence just above the
symphysis pubis, and nodulations on the left side of the uterus indicate a right
occiput anterior (ROA), vertex positioning.
DIF: Cognitive Level: Analysis
TOP: Fetal position
REF: p. 803
OBJ: 5
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Health Promotion
and Maintenance
11.
During the second stage of labor, how often should the nurse should monitor the fetal
heart rate?
a.
Every 5 minutes
b.
Every 15 minutes
c.
Every 30 minutes
d.
Every hour
ANS: A
Fetal heart rate should be assessed every 5 minutes during the second stage of labor.
DIF: Cognitive Level: Application
REF: p. 816
OBJ: 10
TOP: Fetal heart rate (FHR) KEY: Nursing Process
Step: Implementation MSC: NCLEX: Health Promotion
and Maintenance
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12.
Which type of monitor will assesses the intensity of contractions?
a.
External monitor
b.
Fetal monitor
c.
Maternal monitor
d.
Internal monitor
ANS: D
Internal monitoring is used to monitor the intensity of contractions, the frequency and
duration of contractions, and the resting tone of uterine contractions. An external
monitor is used to monitor the fetal heart rate and uterine activity.
DIF: Cognitive Level: Application
TOP: Fetal monitoring
REF: p. 816
OBJ: 13
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
13.
When observing the fetal heart monitor, the nurse recognizes the fetal heart rate (FHR)
decreases to 120 beats/min at the beginning of a contraction and returns to a baseline
of 155 beats/min at the end of the contraction. What should this indicate to the nurse?
a.
Early deceleration due to head compression
b.
That the fetus is in acute distress
c.
Variable decelerations due to cord compression
d.
That these are late decelerations
ANS: A
This indicates early decelerations because of head compression.
DIF: Cognitive Level: Analysis
TOP: Fetal monitoring
REF: p. 815
OBJ: 10
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Health Promotion
and Maintenance
14.
The first-time mother has been told by the nurse that the first stage of labor is the
longest. What would be an appropriate nursing intervention for comfort during this
time?
a.
Cool fluids to drink
b.
A backrub in the sacral area
c.
Assisting to lie in a supine position
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d.
Decreasing illumination in the room
ANS: B
Backache in the sacral area is a common complaint during the first stage of labor. The
keyword is ―comfort‖ in the question. Providing a backrub is providing comfort to the
laboring patient.
DIF: Cognitive Level: Analysis
REF: p. 809
OBJ: 12
TOP: First stage of labor KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
15.
A woman is admitted in active labor, and the nurse assesses the fetal heart rate
(FHR) at 124 beats/min. What action should the nurse take based on the
assessment?
a.
Position patient on her left side.
b.
Start oxygen per nasal cannula.
c.
Reassure the mother the rate is normal.
d.
Notify the health care provider at once.
ANS: C
The normal FHR is 120 to 160 beats/min. No interventions are required.
DIF: Cognitive Level: Application
REF: p. 812
OBJ: 10
TOP: Fetal heart rate (FHR) KEY: Nursing Process
Step: Implementation MSC: NCLEX: Health Promotion
and Maintenance
16.
The patient‘s membranes have just ruptured. What is the first priority of the nurse?
a.
Turn the patient on the left side.
b.
Perform a Nitrazine test.
c.
Check the fetal heart rate (FHR).
d.
Perform a vaginal examination.
ANS: C
The FHR should be assessed immediately after rupture of the membranes to determine
the well-being of the baby.
DIF: Cognitive Level: Application
REF: p. 816
OBJ: 10
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TOP: Ruptured membranes KEY: Nursing Process
Step: Implementation MSC: NCLEX: Health Promotion
and Maintenance
17.
A patient arrives at the hospital having contractions. How should the nurse determine that
the patient is in true labor?
a.
There is no dilation.
b.
The contractions are in the fundus.
c.
The cervix has softened and effaced.
d.
The contractions are irregular.
ANS: C
One sign of true labor is when the cervix has softened and effaced. True labor
contractions are regular and rhythmic.
DIF: Cognitive Level: Analysis
REF: p. 799 OBJ: 4 TOP:
Effacement
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Health Promotion and Maintenance
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18.
The nurse is alarmed as she assesses a protruding umbilical cord from the vagina. What
immediate action should the nurse take?
a.
Monitor intensity of contractions.
b.
Place the patient in the knee-chest position.
c.
Notify the charge nurse.
d.
Ask the patient to perform a Valsalva‘s maneuver.
ANS: B
The knee-chest position reduces the pressure on the prolapsed cord. The charge nurse
will need to be notified, and the contractions will need to be monitored. However, the
priority is reducing the pressure on the prolapsed cord.
DIF: Cognitive Level: Analysis
TOP: Cord prolapse
REF: p. 804
OBJ: 12
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
19.
A nurse is assessing the printout from the fetal monitor. What is the legal responsibility of
the nurse?
a.
Correctly identifying abnormal FHR patterns and prescribing medication
b.
Correctly identifying abnormal FHR patterns and
notifying the health care provider
c.
The nurse is not legally responsible for fetal monitoring
d.
Providing technical assessment to the monitor technicians
ANS: B
Nurses are responsible for the timely notification of the primary caregiver in the
event of an abnormal fetal heart rate (FHR) pattern. The nurse cannot write a
medication order.
DIF: Cognitive Level: Application
TOP: Fetal monitoring
REF: p. 817
OBJ: 10
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Health Promotion
and Maintenance
20.
A mother is in early labor and asks the nurse how long the labor will last. The nurse
explains that the first stage of labor lasts from the beginning of regular contractions
until when?
a. The cervix is completely
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b.
The baby is in position.
c.
The cervix is fully dilated.
d.
The woman begins pushing.
ANS: C
The first stage of labor begins with regular contractions and ends with complete dilation
of the cervix.
DIF: Cognitive Level: Comprehension REF: p. 809
OBJ: 9
TOP: Labor and delivery KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
21.
The nurse is admitting a patient to the labor and delivery unit. While performing the
initial assessment, which assessment is the priority?
a.
The number of previous pregnancies
b.
When the baby is due
c.
When the patient last ate
d.
The timing of contractions
ANS: D
Assessment begins with timing the contractions on admission to form a database.
DIF: Cognitive Level: Analysis
TOP: Admission of labor patient
REF: p. 824
OBJ: 10
KEY: Nursing
Process Step: Assessment MSC: NCLEX: Health
Promotion and Maintenance
22.
During labor, the patient screams at her husband to get out of her sight. What would be
the most appropriate action for the nurse?
a.
Ask the husband to leave the room.
b.
Assure the husband that such behavior is normal.
c.
Remind the patient that the husband wants to help.
d.
Change the patient‘s position.
ANS: B
During labor the patient frequently becomes angry and outspoken. It is a normal
occurrence, but the husband needs to be reassured that such behavior is normal.
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DIF: Cognitive Level: Application
TOP: Care during labor
REF: p. 823
OBJ: 12
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
23.
A primigravida patient is admitted to the labor and delivery unit. During initial
assessment, the baby is found to be engaged. Which statement is true?
a.
The narrowest diameter of the presenting part has reached the pelvic outlet.
b.
The descending part is being initiated through the midpelvis.
c.
The widest diameter of the presenting part crosses the pelvic inlet.
d.
The narrowest diameter of the presenting part is at the ischial spines.
ANS: C
Engagement occurs when the biparietal diameter, which is the widest part of the fetal
head, crosses the pelvic inlet.
DIF: Cognitive Level: Application | Cognitive Level: Analysis REF: p. 807
OBJ: 8
TOP: Engagement
KEY: Nursing
Process Step: Assessment MSC: NCLEX: Health
Promotion and Maintenance
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24.
The health care provider has decided to induce labor with prostaglandin gel and an
amniotomy. When should the nurse expect that labor will start?
a.
1 hour
b.
4 hours
c.
8 hours
d.
12 hours
ANS: A
Medically approved methods of inducing labor include prostaglandin gel application that
usually induces labor in 1 hour or less.
DIF: Cognitive Level: Comprehension REF:
p. 828
OBJ: 13 TOP: Induction
KEY:
Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
25.
A mother has entered the second stage of labor. When does the second stage of labor end?
a.
When the mother begins to push
b.
When the baby‘s head crowns
c.
With delivery of the baby
d.
With delivery of the placenta
ANS: C
The second stage of labor begins with complete dilation and ends with the birth of the
baby.
DIF: Cognitive Level: Knowledge
REF: p. 811
OBJ: 9
TOP: Second stage of labor KEY: Nursing Process
Step: Implementation MSC: NCLEX: Health Promotion
and Maintenance
26.
Why is oxytocin administered in the third stage of labor?
a.
To stimulate lactation
b.
To relieve postpartum pain
c.
To stimulate uterine contractions
d.
To sedate the mother so she can rest
ANS: C
Oxytocin makes the uterus contract and reduces postpartum hemorrhage.
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DIF: Cognitive Level: Application
REF: p. 812
OBJ: 13
TOP: Third stage of labor KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
27.
After the delivery of a newborn, what is the priority action of the nurse?
a.
Place the newborn on the right side.
b.
Cover the cord stump.
c.
Dry the infant immediately.
d.
Suction nose and mouth.
ANS: D
To prevent aspiration of amniotic fluid, the baby should be suctioned, then quickly dried
to prevent hypothermia.
DIF:
Cognitive Level: Application
REF: p. 800 | p. 821 OBJ:
12
TOP: Newborn care
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
28.
An infant presents 5 minutes after delivery with a heart rate of 105, is crying, has
some flexion in the arms, sneezes, and has a pink body and blue limbs. What Apgar
score should be assigned to this infant?
a.
5
b.
7
c.
8
d.
10
ANS: C
The Apgar scoring is: fetal heart rate (FHR) over 100 = 2; crying = 2; flexed arms = 1;
sneeze = 2; pink body, blue limbs = 1.
DIF: Cognitive Level: Application | Cognitive
Level: Analysis REF: p. 820 OBJ: 10
TOP: Apgar scoring
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and
Maintenance
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29.
For the first hour following delivery, how often should the nurse assess the mother?
a.
Every 5 minutes
b.
Every 10 minutes
c.
Every 15 minutes
d.
Every 30 minutes
ANS: C
During the first hour, assessments are done every 15 minutes.
DIF: Cognitive Level: Comprehension REF: p. 812
TOP: Postdelivery assessment
OBJ: 10
KEY: Nursing
Process Step: Assessment MSC: NCLEX: Health
Promotion and Maintenance
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30.
When the nurse performs the Nitrazine test on vaginal secretions of a patient who
thinks her membranes have ruptured, the paper turns yellow. What does this finding
indicate?
a.
Acidic discharge, membranes intact
b.
Acidic discharge, membranes have ruptured
c.
Neutral, not enough discharge to measure
d.
Alkaline, membranes have ruptured
ANS: A
When the Nitrazine paper turns yellow it is indicative of acidic discharge, meaning
the membranes are intact. Amniotic fluid is alkaline and turns the paper blue.
DIF: Cognitive Level: Analysis
TOP: Nitrazine test
REF: p. 799
OBJ: 4
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Health Promotion
and Maintenance
MULTIPLE
RESPONSE
1.
Which assessment findings suggest probable fetal distress? (Select all that apply.)
a.
Fetal heart rate (FHR) of 120
b.
Meconium-stained amniotic fluid
c.
Decreased FHR during contractions
d.
Strong contractions 10 seconds apart
e.
Slow return of FHR to baseline
ANS: B, E
Meconium-stained amniotic fluid and the slow return of the FHR to the baseline are
indicative of fetal distress. All other options are normal.
DIF: Cognitive Level: Analysis
TOP: Fetal distress
REF: p. 817
OBJ: 10
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Health Promotion
and Maintenance
2.
A pregnant woman is discussing her desire to have her baby in a birthing center.
Which factors could exclude the patient from delivering in a birthing center?
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(Select all that apply.)
a.
The patient is a primigravida.
b.
The patient will be having a planned cesarean delivery.
c.
The mother has preeclampsia.
d.
The baby is a boy.
e.
The mother has no support system.
ANS: B, C
Birthing centers are ideal only for women who are considered low risk. Cesarean
deliveries would not be done in a birthing center. The mother with preeclampsia would
be considered high risk and would probably be excluded from delivering in the
birthing center. The number of previous pregnancies, sex of the baby, and mother‘s
support system would not be factors considered when determining risk for delivering
in a birthing center.
DIF: Cognitive Level: Application
TOP: Birth settings
REF: p. 798
OBJ: 2
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
COMPLETIO
N
1.
The nurse explains to the patient whose membranes ruptured an hour ago that delivery
is usually accomplished in
to 24
hours postrupture.
ANS:
18
After the rupture of membranes, labor is usually accomplished in 18 to 24 hours.
DIF: Cognitive Level: Application
REF: p. 799
OBJ: 9
TOP: Ruptured membranes KEY: Nursing Process
Step: Implementation MSC: NCLEX: Health Promotion
and Maintenance
2.
A primigravida has a pelvis of the android type, which usually means the delivery will be
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a
.
ANS:
cesarean
The narrow outlet of the android-type pelvis usually requires a cesarean delivery.
DIF: Cognitive Level: Application
TOP: Android pelvis
REF: p. 800
OBJ: 6
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
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3.
A nurse shows the patient an x-ray of the fetal spine in parallel alignment with the
mother‘s to demonstrate a
lie.
ANS:
longitudinal
A longitudinal lie is when the fetal spine and the maternal spine are parallel to each other.
DIF: Cognitive Level: Application
REF: p. 804 OBJ: 7 TOP:
Fetal lie
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
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Chapter 28: Care of the Mother and Newborn
Cooper: Foundations and Adult Health Nursing, 9th Edition
MULTIPLE
CHOICE
1.
When assessing a mother 12 hours following the delivery of a baby, where should the
nurse expect to palpate the fundus?
a.
2 cm below the umbilicus
b.
At the umbilicus
c.
1 cm below the umbilicus
d.
Halfway between the umbilicus and the symphysis pubis
ANS: B
Within 12 hours, the fundus rises to the level of the umbilicus. The fundus should be
firm. Immediately following delivery, the fundus will be felt halfway between the
umbilicus and the symphysis.
DIF: Cognitive Level: Application
REF: p. 849 OBJ: 1 TOP:
Postpartum
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
2.
What is the name of the vaginal discharge that occurs immediately following delivery?
a.
Lochia serosa
b.
Lochia rubra
c.
Lochia palatine
d.
Lochia alba
ANS: B
The vaginal discharge that occurs immediately following discharge is known as lochia
rubra and is made up mostly of blood. As the placenta heals, the draining turns pink to
dark brown in color and is known as lochia serosa. After about 7 days, the discharge
turns slight yellow to white and is called lochia alba.
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DIF: Cognitive Level: Comprehension
REF: p. 835 OBJ: 1 TOP:
Lochia
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
3.
What is the first secretion produced by the breast?
a.
Prolactin
b.
Colostrum
c.
False milk
d.
Whey
ANS: B
The first secretion to be produced by the breast is colostrum.
DIF: Cognitive Level: Knowledge
REF: p. 837 OBJ: 2 TOP:
Lactation
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
4.
What should be included in a teaching plan regarding breast engorgement?
a.
It typically occurs on the first postpartum day.
b.
It is usually first observed in the axillary region.
c.
It occurs only in women who are not breastfeeding.
d.
It occurs near the nipple on the third postpartum day.
ANS: B
Filling of the breast with milk (engorgement) usually begins in the axillary region on
the third postpartum day when the milk comes in. It occurs regardless of whether the
mother is breastfeeding or bottle-feeding.
DIF: Cognitive Level: Application
TOP: Engorgement
REF: p. 843
OBJ: 2
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
5.
When is breast engorgement most likely to occur?
a.
When the infant‘s mouth surrounds the areola when feeding
b.
When the breast tissue becomes congested
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c.
When the breast is emptied completely at each feeding
d.
When the infant‘s mouth grasps the nipple firmly
ANS: B
Engorgement is the result of venous and lymphatic stasis (congestion). Emptying the
breast at each feeding, the infant grasping the nipple firmly, and the infant‘s mouth
surrounding the areola when feeding are all measures that will aid in decreasing
engorgement.
DIF: Cognitive Level: Application
TOP: Engorgement
REF: p. 852
OBJ: 2
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
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6.
Which statement would be a correct description of colostrum?
a.
Slightly yellow and low in protein
b.
Slightly yellow and provides antibodies
c.
Creamy and high in fat and protein
d.
Colorless and high in fat and carbohydrates
ANS: B
Colostrum is slightly yellow in color and is rich in antibodies.
DIF: Cognitive Level: Comprehension REF:
p. 867
OBJ: 13 TOP: Colostrum KEY:
Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
7.
The new mother has decided not to breastfeed the baby. How should the nurse
correctly instruct the mother to suppress her milk supply?
a.
Pump the breasts to remove milk
b.
Apply warm, moist compresses
c.
Restrict oral fluids
d.
Apply a firm bra and ice packs
ANS: D
If a patient is not breastfeeding, compress the breasts with a firm bra and wrapped ice
packs to suppress the milk supply. Pumping the breasts and applying warm, moist
compresses are instructions for the breast-feeding mother to deal with the painful
symptoms of engorgement.
DIF: Cognitive Level: Application
TOP: Engorgement
REF: p. 852
OBJ: 3
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
8.
During the immediate postpartum period, the mother has a temperature of 100.2°F
(37.8°C), pulse 52, respirations 18, BP 138/84. What should the nurse do?
a.
Report the temperature as abnormal.
b.
Continue to monitor every 15 minutes.
c.
Report the pulse as abnormal.
d.
Nothing as the vital signs are normal.
ANS: D
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The vital signs are normal for a new postpartum patient.
DIF: Cognitive Level: Application
REF: p. 847 OBJ: 1 TOP:
Postpartum
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
9.
Within the first hour following a vaginal delivery, the nurse assesses the mother and
finds the fundus is firm and there is a trickle of bright red blood. What should be the
nurse‘s reaction to the assessment?
a.
This is a normal occurrence.
b.
This is abnormal and should be reported.
c.
The patient should be administered a blood thinner.
d.
The patient should be restricted to bed rest.
ANS: A
A bright red drainage is normal immediately after delivery. The patient should be
monitored at regular intervals. Bed rest is not indicated. A blood thinner would not be
given.
DIF: Cognitive Level: Application
REF: p. 835 OBJ: 1 TOP:
Postpartum
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
10.
What is the appropriate way to assess the fundus of the postpartum patient?
a.
Using the side of one hand moving down from the umbilicus
b.
Using one hand over the lower segment of the uterus
c.
Using one hand pushing upward from the lower uterus
d.
Using one hand on the lower uterine segment while
the other hand locates the fundus of the uterus
ANS: D
The proper way to assess the fundus of a mother who has just given birth is by placing
one hand on the lower uterine segment while the other hand locates the fundus of the
uterus.
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DIF: Cognitive Level: Application
REF: p. 849
OBJ: 1
TOP: Fundal assessment KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
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11.
The postpartum mother with a third degree laceration tells the nurse she is afraid to
have a bowel movement because of her painful episiotomy. What should the nurse
do?
a.
Offer a suppository or enema.
b.
Encourage ambulation.
c.
Offer stool softeners as prescribed.
d.
Offer pain medication before defecating.
ANS: C
Stool softeners are available to ease the pain of defecation caused by hemorrhoids and
birth trauma. Suppositories or enemas are contraindicated in mothers with third or
fourth degree lacerations. Pain medications can often cause constipation. Ambulation
may aid in defecation, but will not soften the stool.
DIF: Cognitive Level: Application
TOP: Postpartum elimination
REF: p. 847
OBJ: 3
KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity
12.
A new mother had spinal anesthesia during a cesarean delivery. She now has a desire
to void and can wiggle her toes. What should be the nurse‘s response when the mother
asks to go the bathroom?
a.
Assess her blood pressure.
b.
Obtain a wheelchair.
c.
Palpate her bladder.
d.
Put slippers on her feet.
ANS: D
The nurse should check that the mother is wearing slippers to ensure better footing. If
the mother has a desire to void and can move her toes, there is no need for her to
remain bedridden.
DIF: Cognitive Level: Application
REF: p. 848
OBJ: 3
TOP: Postspinal anesthesia KEY: Nursing Process
Step: Implementation MSC: NCLEX: Safe, Effective
Care Environment
13.
A mother delivered her baby at midnight and it is now 9 a.m. She wants to sleep and
asks the nurse to take care of the baby. What is this considered?
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a.
Fatigue from labor
b.
Normal ―taking in‖ response
c.
Abnormal ―taking in‖ response
d.
Risk for altered maternal-infant bonding
ANS: B
Her primary focus will be on her own needs such as sleep (―taking in‖ stage).
DIF: Cognitive Level: Analysis
REF: p. 852
OBJ: 5
TOP: ―Taking in‖ response KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
14.
Which of the following would be considered a normal assessment finding in a 1-day
postpartum patient?
a.
Pinkish to brown lochia
b.
Voiding frequently 50 to 75 mL of urine
c.
Complaining of ―after pains‖
d.
Fundus 1 cm above the umbilicus
ANS: C
The common discomfort of after pains is a normal assessment finding at 1-day
postpartum. The normal discharge 1-day postpartum would be lochia rubra, which is
made up of mostly blood. The fundus would be palpated at the level of the umbilicus.
Frequent voiding would be considered abnormal.
DIF: Cognitive Level: Analysis
REF: p. 855 OBJ: 2 TOP:
Postpartum
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
15.
A new Native American mother tells the nurse that when she goes home, her motherin-law will be caring for the baby while she rests. The nurse has concerns. What
should the nurse do?
a.
Explain the importance of ambulating to recover.
b.
Explain the importance of maternal-infant bonding.
c.
Explore ways to blend this with safe health teaching.
d.
Encourage this cultural behavior.
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ANS: C
Follow principles that facilitate nursing practice within transcultural situations.
DIF: Cognitive Level: Analysis
REF: p. 858
OBJ: 5
TOP: Ethnic considerations KEY: Nursing
Process Step: Planning MSC: NCLEX:
Psychosocial Integrity
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16.
Before initially feeding an infant, what reflex should the nurse assess?
a.
Moro reflex
b.
Rooting reflex
c.
Babinski reflex
d.
Swallow reflex
ANS: D
The nurse should verify that the infant is able to swallow normally before feeding.
DIF: Cognitive Level: Application
REF: p. 867 OBJ: 9 TOP:
Postpartum
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Safe, Effective Care Environment
17.
Following delivery of the newborn, which nursing intervention should be carried out
immediately?
a.
Weigh the infant.
b.
Warm the infant.
c.
Bathe the infant.
d.
Inoculate the infant.
ANS: B
Maintenance of body temperature is the primary concern when caring for the newborn.
The infant will also be weighed, bathed, and inoculated, but those measures are not the
primary concern.
DIF: Cognitive Level: Application
TOP: Newborn care
REF: p. 868
OBJ: 8
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
18.
Where would acrocyanosis be assessed on a newborn?
a.
Circumoral area
b.
Brow
c.
Feet
d.
Mucous membrane
ANS: C
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Acrocyanosis is the slightly blue appearance of the hands and feet that is caused by
poor circulation. It can last for 7 to 10 days in the newborn.
DIF: Cognitive Level: Comprehension REF: p. 860
TOP: Newborn assessment
OBJ: 7
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
19.
The nurse identifies that the newborn is jaundiced within the first 24 hours of birth,
with jaundice occurring over bony prominences of the face and the mucous membrane.
What type of jaundice does this represent?
a.
Physiologic
b.
Normal
c.
Pathologic
d.
Transitory
ANS: C
Jaundice that appears within the first 48 hours of life is termed pathologic jaundice
and is abnormal. Pathologic jaundice indicates excessive red blood cell destruction
and it should be reported. Jaundice that appears after the first 48 hours of life is
known as physiologic jaundice and is considered normal.
DIF: Cognitive Level: Application
TOP: Newborn assessment
REF: p. 861
OBJ: 9
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
20.
What is the term for the cream cheese–like substance that protects the infant‘s skin from
amniotic fluid?
a.
Lanugo
b.
Meconium
c.
Desquamation
d.
Vernix caseosa
ANS: D
At birth, the skin is covered with a yellowish-white cream cheese–like substance called
vernix caseosa.
DIF: Cognitive Level: Knowledge
REF: p. 861
OBJ: 8
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TOP: Newborn assessment
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
21.
Which tests are performed to detect inborn errors of metabolism in the newborn?
a.
Blood glucose
b.
Phenylketonuria (PKU)
c.
Blood urea nitrogen (BUN)
d.
Prothrombin time (PT)
ANS: B
State law requires certain diagnostic tests be performed on the newborn,
including PKU, which detects an inborn error of metabolism.
DIF: Cognitive Level: Knowledge
TOP: Newborn care
REF: p. 867
OBJ: 7
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
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22.
Which newborn assessment finding can suggest a chromosomal disorder?
a.
Epstein pearls
b.
Gynecomastia
c.
Babinski reflex
d.
Simian crease
ANS: D
A simian crease may indicate a chromosomal disorder.
DIF: Cognitive Level: Comprehension REF: p. 863
TOP: Newborn assessment
OBJ: 9
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Health Promotion
and Maintenance
23.
Why is vitamin K given by injection to the newborn?
a.
Most mothers have a vitamin K deficiency that develops during pregnancy.
b.
Bacteria that synthesize vitamin K are not present in newborns.
c.
Vitamin K prevents the synthesis of prothrombin.
d.
The newborn does not store vitamin K.
ANS: B
Newborns are not able to synthesize vitamin K in the colon until they have adequate
intestinal flora, therefore, the vitamin K injection is given as a prevention measure
against hemorrhage.
DIF: Cognitive Level: Application
TOP: Care of newborn
REF: p. 867
OBJ: 8
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
24.
What should be included when discussing the care of a circumcised infant after discharge
from the hospital?
a.
Gently remove the yellow exudate from the foreskin.
b.
Apply sterile petroleum gauze after each diaper change.
c.
Wipe the circumcision with alcohol each day.
d.
Avoid the use of cloth diapers until the foreskin has healed.
ANS: B
Wash the penis at diaper change and apply sterile petroleum gauze. The yellow
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exudate should not be removed as it is part of the normal healing process. The
circumcised area should be cleansed gently, not with alcohol. Cloth diapers are
sometimes recommended to promote healing.
DIF: Cognitive Level: Application
TOP: Circumcision
REF: p. 869
OBJ: 11
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
25.
The nurse is caring for a newborn who was circumcised earlier in the day. What should
be included in the plan of care?
a.
Administration of a topical anesthetic to the site
b.
Application of ice to stop bleeding
c.
Retraction of any remaining foreskin
d.
Observation for bleeding for the first 12 hours
ANS: D
The nurse should assess for bleeding for the first 12 hours following the circumcision.
Gentle pressure should be applied to control bleeding. The administration of topical
anesthetic and the retraction of the remaining foreskin are not included in the plan of care.
DIF: Cognitive Level: Application
TOP: Circumcision
REF: p. 869
OBJ: 11
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
26.
Which finding should the nurse suspect as abnormal in the newborn during the initial
assessment?
a.
Eyes crossed at times
b.
Persistent high-pitched cry
c.
Arms and legs flexed
d.
Slight bluish tinge of the extremities
ANS: B
A high-pitched cry may indicate neurologic problems. Occasional crossing of the eyes,
flexing of the arms and legs, and a bluish tinge of the extremities are all considered
normal assessment findings in the newborn.
DIF: Cognitive Level: Analysis
TOP: Newborn assessment
REF: p. 871
OBJ: 9
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Health Promotion
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and Maintenance
27.
What is a characteristic of a normal breast-fed infant‘s stool?
a.
Green and loose
b.
Dark green and sticky
c.
Pale yellow and frequent
d.
Light brown and pasty
ANS: C
Breast-fed infants tend to pass stools frequently and they are pale yellow to golden in
color and pasty in consistency.
DIF: Cognitive Level: Comprehension REF: p. 869
TOP: Breast-fed stool
OBJ: 8
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
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28.
The new mother calls the nurse to her room to show how her baby is ―jerking
around‖ when she changes his position. The nurse understands that the baby is
exhibiting which normal reflex?
a.
Traction reflex
b.
Babinski reflex
c.
Tonic neck reflex
d.
Moro reflex
ANS: D
The Moro reflex (startle reflex) causes the baby to abduct the extremities and fan the
fingers with the thumb and index fingers making a ―C‖ shape followed by flexion and
adduction of the extremities.
DIF:
Cognitive Level: Application REF: p. 863 | p. 864
OBJ: 10
TOP: Reflexes KEY: Nursing Process
Step: Implementation MSC: NCLEX: Health Promotion
and Maintenance
29.
The nurse is giving a bath demonstration for a group of new mothers. What should be
included in the demonstration?
a.
Apply baby powder generously to keep baby dry.
b.
Cleanse perineum from front to back.
c.
Use scented soap to make baby smell good.
d.
Partially submerge head in water when shampooing.
ANS: B
The perineum should be cleansed by wiping from the anterior to the posterior.
Excessive use of powders and scented soaps can irritate the skin. The head should not
be submerged in water.
DIF: Cognitive Level: Application
TOP: Newborn bath
REF: p. 870
OBJ: 4
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
MULTIPLE RESPONSE
1.
Which of the following measures could help prevent infant abduction? (Select all that
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apply.)
a.
Only transport infants by carrying them.
b.
Require staff members to wear appropriate identification badges.
c.
Respond immediately when an alarm sounds.
d.
Never leave infants unattended at any time.
e.
Take all the infants to their mothers at the same time.
ANS: B, C, D
Staff members should always wear appropriate ID badges and should respond
immediately when an alarm sounds. Infants should never be left unattended. Infants
should always be transported in their cribs, never by carrying them. The nurse should
transport only one infant at a time.
DIF: Cognitive Level: Application
TOP: Infant abduction
REF: p. 859
OBJ: 6
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
2.
The nurse is observing a new mother interact with her infant. Which observation
would indicate that bonding is occurring? (Select all that apply.)
a.
The mother is making eye contact with the infant.
b.
The mother is sending the infant to the nursery for feedings.
c.
The mother is cuddling with the infant and napping.
d.
The mother is requesting that the mother-in-law change all diapers.
e.
The mother states that her favorite thing to do with her baby is to breastfeed.
ANS: A, C, E
Eye contact, cuddling, and enjoying infant feeding are all signs of positive parentinfant attachment (bonding). Sending the infant to the nursery for feedings and
having someone else change all diapers could indicate difficulty with bonding.
DIF: Cognitive Level: Application
REF:
p. 841
KEY:
OBJ: 12 TOP: Bonding
Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
3.
A new mother asks for advice on how to quiet her fussy newborn. Which responses
would be appropriate to suggest to the mother?
(Select all that apply.)
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a.
Prewarm the crib sheets with a hot water bottle
b.
Swaddle the newborn tightly in a receiving blanket
c.
Place the baby in a larger crib or infant bed
d.
Offer a pacifier or allow the infant to suckle at the breast
e.
Take the infant for a ride in the car
ANS: A, B, D, E
Oftentimes, infants are comforted by warm sheets. Infants tend to like to be swaddled
snugly. Many infants find comfort sucking a pacifier; breast-fed infants can suckle at
the breast. Car rides are often soothing for infants. A large sleeping space is not
soothing for infants. The opposite is true. A small sleeping space, such as a bassinette,
tends to comfort a fussy baby.
DIF: Cognitive Level: Application
TOP: Infant quieting techniques
REF: p. 871
OBJ: 14
KEY: Nursing
Process Step: Implementation MSC: NCLEX: Health
Promotion and Maintenance
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COMPLETION
1.
After delivery of a 9-lb baby, the nurse assesses a perineal laceration extending
through the muscles of the perineum. The nurse records this as a
-degree
laceration.
ANS:
second
A second-degree laceration extends through the superficial tissues into the muscles of the
perineum.
DIF: Cognitive Level: Analysis
TOP: Second-degree lacerations
REF: p. 837
OBJ: 3
KEY: Nursing
Process Step: Assessment MSC: NCLEX:
Physiological Integrity
2.
The nurse describes the return of the postpartum patient‘s uterus to a pregravid state as .
ANS:
involution
Involution is the decrease in size of the uterus to a prepregnant state.
DIF: Cognitive Level: Knowledge
REF: p. 835 OBJ: 2 TOP:
Involution
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
3.
The new mother tells the home health nurse that she is concerned about her 5-dayold infant‘s hard, dried umbilical stump. What time frame should the nurse give the
mother for the umbilical stump to fall off? 10 to 14
.
ANS:
days
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The umbilical stump will turn brownish black and fall off within 10 to 14 days after birth.
DIF: Cognitive Level: Knowledge
TOP: Mummification
REF: p. 863
OBJ: 4
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
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Chapter 29: Care of the High-Risk Mother, Newborn, and
Family with Special Needs Cooper: Foundations and Adult
Health Nursing, 9th Edition
MULTIPLE
CHOICE
1.
A patient is admitted to the hospital with hyperemesis gravidarum. The patient is
malnourished and severely dehydrated. The care plan should be altered to include
which interventions?
a.
Hyperalimentation
b.
IV fluids and electrolyte replacement
c.
Hormone replacement therapy
d.
Vitamin supplements
ANS: B
Medical treatment is aimed at meeting fluid and electrolyte replacement.
DIF: Cognitive Level: Application
TOP: Hyperemesis gravidarum
REF: p. 910
OBJ: 1
KEY: Nursing
Process Step: Planning MSC: NCLEX:
Physiological Integrity
2.
A patient with hyperemesis gravidarum asks the nurse what would have happened if
she had not come to the hospital. What result is the best response by the nurse?
a.
A large for gestational age infant
b.
Anorexia nervosa
c.
Preterm delivery
d.
Maternal or fetal death
ANS: D
If untreated, hyperemesis gravidarum can result in maternal or fetal death.
DIF: Cognitive Level: Application
TOP: Hyperemesis gravidarum
REF: p. 879
OBJ: 1
KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity
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3.
How should twins who share a placenta and come from one fertilized ovum be identified?
a.
Dizygotic
b.
Trizygotic
c.
Genetically different
d.
Monozygotic
ANS: D
Monozygotic twins, also known as identical twins, originate from one fertilized
ovum and share a placenta. Monozygotic twins carry the same genetic code.
Dizygotic twins are the result of two separate ova being fertilized at the same time.
DIF: Cognitive Level: Comprehension REF: p. 879
TOP: Multifetal pregnancy
OBJ: 1
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Health Promotion
and Maintenance
4.
What complication of delivery should the nurse expect with the birth of multiple fetuses?
a.
An ectopic tendency
b.
Difficulty with breast-feeding
c.
A vaginal delivery
d.
Loss of uterine tone
ANS: D
Delivery of multiple fetuses is often complicated by loss of uterine tone. Oftentimes
multiple fetuses are delivered by cesarean. An ectopic tendency would present before
delivery. While it can be difficult to breastfeed multiple infants, this does not relate to
the delivery.
DIF: Cognitive Level: Application
REF: p. 879
OBJ: 1
TOP: High-risk pregnancy KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
5.
A patient is admitted to the hospital with signs of an ectopic pregnancy. What should the
plan of care include for the patient?
a.
Long-term bed rest
b.
Episodes of extreme hypertension
c.
Surgery to remove the embryo/fetus
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d.
Treatment for dehydration
ANS: C
An ectopic implantation occurs somewhere outside the uterus and either resolves
itself in a spontaneous abortion or requires surgical intervention.
DIF: Cognitive Level: Application
REF: p. 880
OBJ: 1
TOP: Ectopic pregnancy KEY: Nursing Process
Step: Planning MSC: NCLEX: Physiological
Integrity
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6.
What percent of first-trimester pregnancies spontaneously abort?
a.
5% to 10%
b.
10% to15%
c.
20% to 25%
d.
40% to 50%
ANS: B
It is estimated that 10% to 15% of first-trimester pregnancies end in spontaneous
abortion.
DIF: Cognitive Level: Knowledge
REF: p. 882 OBJ: 1 TOP:
Abortions
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Psychosocial Integrity
7.
What symptom, no matter what stage of pregnancy, should be reported immediately?
a.
Backache
b.
Urinary frequency
c.
Vaginal bleeding
d.
Uterine tightening
ANS: C
Women should be instructed to contact their health care provider if any bleeding occurs
during pregnancy.
DIF: Cognitive Level: Comprehension REF: p. 883
TOP: Vaginal bleeding
OBJ: 2
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
8.
A patient in her second trimester of pregnancy arrives at the hospital complaining of
bright red, painless vaginal bleeding. What condition should the nurse immediately
suspect?
a.
Abruptio placentae
b.
Hemorrhage
c.
Placenta previa
d.
Placentitis
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ANS: C
Placenta previa is a serious condition that consists of bright red painless vaginal
bleeding occurring after 20 weeks of pregnancy. The major symptoms of abruptio
placentae are severe abdominal pain and uterine rigidity.
DIF: Cognitive Level: Application
TOP: Placenta previa
REF: p. 885
OBJ: 2
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
9.
A pregnant woman comes to the hospital 3 weeks before her estimated date of birth
(EDB) complaining of severe pain and a rigid abdomen. What should the nurse
immediately suspect as the cause of the pain?
a.
Placenta previa
b.
Appendicitis
c.
Ectopic pregnancy
d.
Abruptio placentae
ANS: D
The major symptoms of abruptio placentae are severe pain and a rigid abdomen.
Placenta previa consists of painless bleeding. Appendicitis is not usually
accompanied by a rigid abdomen. Symptoms of an ectopic pregnancy would usually
occur in the first trimester.
DIF: Cognitive Level: Application
REF: p. 887
OBJ: 2
TOP: Abruptio placentae KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
10.
A patient presents with symptoms of abruptio placentae. To facilitate uterine-placental
perfusion, in what position would the nurse place the patient?
a.
Prone position
b.
Trendelenburg‘s position
c.
Supine position
d.
Modified side-lying position
ANS: D
A modified side-lying position facilitates uterine-placental perfusion.
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DIF: Cognitive Level: Application
REF: p. 888
OBJ: 2
TOP: Abruptio placentae KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
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11.
A pregnant woman visits a clinic visit during her 21st week of pregnancy. The
nurse identifies edema, hypertension, and proteinuria. What condition does the
nurse suspect?
a.
Allergy
b.
Protein deficiency
c.
Circulatory problem
d.
Gestational hypertension
ANS: D
Gestational hypertension (GH), formerly referred to as pregnancy-induced hypertension
(PIH), is a disease encountered during pregnancy or early in the puerperium, characterized
by increasing hypertension, proteinuria, and generalized edema. These signs generally
appear after the 20th week of pregnancy.
DIF: Cognitive Level: Analysis
REF: p. 890
OBJ: 4 TOP:
Pregnancy-induced hypertension (PIH)
KEY: Nursing Process Step: Assessment
12.
MSC: NCLEX: Physiological Integrity
What condition is a possible cause of gestational hypertension?
a.
Too much salt
b.
A toxin
c.
Renal disease
d.
Diabetes
ANS: C
Gestational hypertension may be caused by other existing conditions, such as renal
disease.
DIF: Cognitive Level: Knowledge
REF: p. 890
OBJ: 4 TOP:
Pregnancy-induced hypertension (PIH)
KEY: Nursing Process Step: Assessment
13.
MSC: NCLEX: Physiological Integrity
What should the nurse hope to identify by keeping a record of a patient‘s blood pressure
during prenatal visits?
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a.
Ketoacidosis
b.
Placenta previa
c.
Gestational diabetes
d.
Gestational hypertension
ANS: D
Blood pressure should be assessed routinely during pregnancy, because symptoms of
gestational hypertension include hypertension.
DIF: Cognitive Level: Comprehension
REF: p. 890
OBJ: 4 TOP:
Pregnancy-induced hypertension (PIH)
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and
Maintenance
14.
The nurse is assessing a ―kick count‖ for a patient with gestational hypertension. What
result should be a cause for concern?
a.
Less than three kicks per hour
b.
Less than five kicks per hour
c.
Less than seven kicks per hour
d.
Less than nine kicks per hour
ANS: A
A kick count of fewer than three per hour is considered serious and a cause for concern.
DIF: Cognitive Level: Application
REF: p. 892
OBJ: 3 TOP:
Pregnancy-induced hypertension (PIH)
KEY: Nursing Process Step: Assessment
15.
MSC: NCLEX: Physiological Integrity
When discussing toxoplasmosis infection during pregnancy, what should the nurse caution
the patient to avoid?
a.
Contacting with an infected person
b.
Emptying cat litter boxes bare-handed
c.
Having unprotected sex
d.
Eating excessive amounts of shellfish
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ANS: B
A pregnant woman should wear gloves whenever having contact with cat feces as this
is a possible source of toxoplasmosis infection.
DIF: Cognitive Level: Application
REF: p. 897 OBJ: 6 TOP:
Infection
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
16.
What is a major complication of gestational diabetes that affects the infant?
a.
Lack of nutrition
b.
Dehydration
c.
Hypoglycemia
d.
Hyperglycemia
ANS: C
A result of gestational diabetes is neonatal hypoglycemia.
DIF: Cognitive Level: Comprehension
REF: p. 897 OBJ: 1 TOP:
Diabetes
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
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17.
A pregnant patient who has type 2 diabetes (NIDDM) may require insulin. Why is the
insulin necessary?
a.
The growing baby will require more glucose.
b.
Oral hypoglycemic agents may be teratogenic.
c.
Increased hormone levels raise blood glucose.
d.
Oral hypoglycemics do not reach the fetus.
ANS: B
Oral hypoglycemics are discontinued because of teratogenic effects.
DIF: Cognitive Level: Comprehension
REF: p. 898 OBJ: 5 TOP:
Diabetes
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
18.
Why is the fetus dependent on the mother for glucose control?
a.
The insulin requirements are higher.
b.
Insulin is destroyed by the placenta.
c.
Insulin does not cross the placenta.
d.
Insulin is absorbed by the fetus.
ANS: C
Insulin will not cross the placenta, but high glucose levels do. Therefore, it is imperative
that the mother control glucose levels.
DIF: Cognitive Level: Analysis
REF: p. 901 OBJ: 5 TOP:
Diabetes
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
19.
A patient with a history of rheumatic heart disease is being admitted to the labor and
delivery unit. To prevent further stress on the heart, what should the nurse anticipate
to be ordered?
a.
Oxygen administration
b.
Administering large amount of IV fluids
c.
Positioning the patient on her back
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d.
Encouraging activity between contractions
ANS: A
Oxygen is administered to increase blood oxygen saturation and decrease the stress on
the heart. IV fluid administration is kept to a minimum to prevent fluid overload. The
patient would be positioned in a semi-Fowler‘s position to improve circulation. The
patient should be encouraged to rest between contractions to conserve energy.
DIF: Cognitive Level: Application
REF: p. 901
OBJ: 12
TOP: Cardiovascular defects KEY: Nursing
Process Step: Planning MSC: NCLEX: Health
Promotion and Maintenance
20.
A 14-year-old pregnant adolescent arrives at the hospital in early labor. The nurse
should recognize that the adolescent is at a greater risk for which problem?
a.
Calcium deficit
b.
Cephalopelvic disproportion
c.
Bleeding tendency
d.
Low hemoglobin levels
ANS: B
There are several physiologic concerns for pregnant adolescents, including cephalopelvic
disproportion.
DIF: Cognitive Level: Analysis
REF: p. 903
OBJ: 7
TOP: Adolescent pregnancy KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
21.
When should the gestational age of the infant be determined?
a.
Within 5 to 10 minutes of delivery
b.
Within 1 to 2 hours of delivery
c.
Within 2 to 8 hours of delivery
d.
Within 12 to 24 hours of delivery
ANS: C
The gestational age tests are done within 2 to 8 hours of delivery.
DIF: Cognitive Level: Comprehension REF: p. 908
OBJ: 9
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TOP: Gestational age
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Health Promotion
and Maintenance
22.
The newborn infant has oxygenation problems and a lack of subcutaneous fat. What
should the nurse determine as the gestational age of this infant?
a.
20 to 37 completed weeks of pregnancy
b.
38 to 41 completed weeks of pregnancy
c.
14 to 36 completed weeks of pregnancy
d.
42 or more completed weeks of pregnancy
ANS: A
The lungs of preterm infants have not fully developed; therefore, they have problems
with oxygenation. Preterm infants also lack subcutaneous fat. The gestational age of
the preterm is classified as 20 to 37 complete weeks of pregnancy.
DIF: Cognitive Level: Analysis
REF: p. 909 OBJ: 9 TOP:
Preterm
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Health Promotion and Maintenance
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23.
Compared to older infants of comparable weight, how much higher is the morbidity and
mortality rate for preterm infants?
a.
One to two times
b.
Two to three times
c.
Three to four times
d.
Four to five times
ANS: C
The morbidity and mortality rate for preterm infants is higher by three to four times that
of an older infant of similar weight.
DIF:
Cognitive Level: Comprehension
REF: pp. 907-908
TOP: Preterm
OBJ: 9
KEY: Nursing
Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
24.
A neonate is born with weak muscle tone, froglike extremities, and ears that fold
easily. From these observations, what gestational age should the nurse give this
infant?
a.
Full term
b.
Small for gestational age
c.
Preterm
d.
Postterm
ANS: C
Preterm infant posture is froglike, the muscle tone is weak, and the ears are easily folded.
DIF: Cognitive Level: Analysis
REF: p. 910 OBJ: 9 TOP:
Preterm
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
25.
A primigravida is Rh negative and her husband is Rh positive. She is concerned
about the health of the fetus. The nurse explains that there is little danger to the fetus
if it is Rh positive; however, the mother would become sensitized during delivery. If
this were the case, the mother would produce what in subsequent pregnancies?
a. Rh-negative blood cells
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b.
Rh-positive blood cells
c.
Rh-negative antibodies
d.
Rh-positive antibodies
ANS: D
If the mother is exposed to the Rh antigen, Rh-positive antibodies will be produced
after delivery of an Rh-positive baby. If the baby is Rh negative, no antibodies will be
produced.
DIF: Cognitive Level: Analysis
TOP: Hemolytic disease
REF: p. 912
OBJ: 10
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
26.
The nurse assures a patient who has become sensitized to the Rh antigen that she
can be protected for future pregnancies by receiving what injection?
a.
Iron
b.
Vitamin B12
c.
RhoGAM
d.
Type O blood
ANS: C
RhoGAM prevents the development of naturally occurring maternal antibodies.
DIF: Cognitive Level: Comprehension REF: p. 912
TOP: Hemolytic disease
OBJ: 10
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
27.
The nurse is assessing the newborn and discovers a yellowing of the skin. What is true for
jaundice that appears at birth?
a.
Within normal limits
b.
Pathologic
c.
A result of iron deficiency
d.
Indicating possible hepatitis
ANS: B
Jaundice observed at birth is considered an indicator of a pathologic condition,
erythroblastosis fetalis. It is considered abnormal.
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DIF:
Cognitive Level: Comprehension
TOP: Hemolytic disease
REF: pp. 911-912
OBJ: 10
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
28.
What test is used to identify the maternal level of Rh antibodies in the mother‘s blood?
a.
Indirect Coombs‘ test
b.
Hemolytic test
c.
Rh antibody test
d.
Direct Coombs‘ test
ANS: A
The indirect Coombs‘ test measures the maternal level of antibodies.
DIF: Cognitive Level: Knowledge
TOP: Hemolytic disease
REF: p. 912
OBJ: 3
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
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29.
A nursery nurse is implementing phototherapy for a jaundiced infant. What is the purpose
of the phototherapy?
a.
It is initiated when the bilirubin level reaches 5 mg/dL.
b.
It converts bilirubin to a water-soluble form to be excreted in the urine.
c.
It changes bilirubin to a bile salt to be excreted through the bowel.
d.
It requires eye patches to remain in place 24 hours a day.
ANS: B
Phototherapy converts the bilirubin into a water-soluble form to be excreted by the
kidneys. It is initiated when the bilirubin level reaches 12 to 15 mg/dL. The eye patches
are worn during therapy, but removed for feeding, bathing, and socialization.
DIF: Cognitive Level: Analysis
TOP: Hemolytic disease
REF: p. 912
OBJ: 10
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
30.
Why do alcohol and illegal drugs endanger the fetus?
a.
Both are absorbed into the bloodstream.
b.
Both affect the mother.
c.
Both cross the placental barrier.
d.
Both increase the heart rate of the fetus.
ANS: C
Alcohol and illicit drugs cross the placental barrier and affect the fetus.
DIF:
Cognitive Level: Application
REF: p. 876 | p. 913 OBJ:
8
TOP: Fetal risk from drugs
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
31.
Cognitive impairment, facial abnormalities, and growth retardation are characteristics of
which abnormality in a fetus?
a.
Fetal dependency
b.
Fetal immaturity
c.
Malnutrition dependency
d.
Fetal alcohol syndrome
ANS: D
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Use of alcohol may result in multiple anomalies called fetal alcohol syndrome. The
fetus may also be born with alcohol dependency and immaturity, but the
characteristics noted are specific for fetal alcohol syndrome.
DIF: Cognitive Level: Application
REF: p. 876 OBJ: 8 TOP:
Fetal risk
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
32.
What should be specifically monitored in a patient who is hospitalized with gestational
hypertension?
a.
Blood sugar
b.
Temperature
c.
Level of consciousness
d.
Deep tendon reflexes
ANS: D
If the patient is hospitalized for gestational hypertension, deep tendon reflexes are
monitored. The blood sugar, temperature, and LOC will also be monitored, but they
are not the priority in the hypertensive patient.
DIF: Cognitive Level: Application
REF: p. 891 OBJ: 4 TOP:
Eclampsia
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
33.
What is the antidote for magnesium sulfate toxicity?
a.
Vitamin K
b.
Calcium gluconate
c.
Potassium sulfate
d.
Calcium carbonate
ANS: B
The antidote for magnesium sulfate toxicity is calcium gluconate.
DIF: Cognitive Level: Knowledge
TOP: Maternal risk
REF: p. 892
OBJ: 11
KEY: Nursing Process
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Step: Planning MSC: NCLEX: Safe, Effective Care
Environment
34.
What is a prominent feature of postpartum depression?
a.
Failure to thrive
b.
Rejection of the infant
c.
Inability to care for the baby
d.
Problems with the baby‘s father
ANS: B
A prominent feature of PPD is rejection of the infant.
DIF: Cognitive Level: Comprehension REF: p. 916
OBJ: 1
TOP: Postpartum depression (PPD) KEY: Nursing
Process Step: Assessment MSC: NCLEX:
Psychosocial Integrity
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35.
What is the usual treatment for severe postpartum depression?
a.
Improved nutrition
b.
Vitamin therapy
c.
Pharmacologic interventions
d.
Support group therapy
ANS: C
Support therapy is not enough for major PPD. Pharmacologic interventions are needed in
most instances.
DIF: Cognitive Level: Comprehension REF: p. 878
OBJ: 1
TOP: Postpartum depression (PPD) KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Psychosocial Integrity
MULTIPLE RESPONSE
1.
A pregnant patient with tuberculosis asks the nurse how the disease will affect her
pregnancy and her newborn. What statements by the nurse are most appropriate?
(Select all that apply.)
a.
―You have nothing to worry about. You will be disease free before you deliver.‖
b.
―The tuberculosis can be transmitted to the fetus in rare occurrences.‖
c.
―Your newborn will be tested for tuberculosis after delivery.‖
d.
―There is no approved treatment for the infant if
she tests positive for the disease.‖
e.
―You will not be able to hold your newborn until you
have been cleared according to the health department
guidelines.‖
ANS: B, C, E
TB can be transmitted to a fetus in the womb. Newborns of infected mothers are skin
tested for TB after birth and treated if the skin test is positive. Mothers who have TB
are not allowed to have exposure to their newborn until they have been cleared
according to the health department standards.
DIF: Cognitive Level: Application
TOP: Pulmonary tuberculosis
REF: p. 894
OBJ: 13
KEY: Nursing
Process Step: Implementation MSC: NCLEX: Health
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Promotion and Maintenance
COMPLETION
1.
Following an abruptio placentae, the patient suddenly becomes dyspneic, complains
of chest pain, and begins to ooze blood from her IV insertion site. The nurse assesses
these as indicators of disseminated
coagulation.
ANS:
intravascular
DIC is characterized by dyspnea, chest pain, and uncontrolled bleeding.
DIF: Cognitive Level: Application
REF: p. 887
OBJ: 2 TOP:
Disseminated intravascular coagulation (DIC)
KEY: Nursing Process Step: Assessment
2.
MSC: NCLEX: Physiological Integrity
The nurse reports to the charge nurse that the 3-hour postpartum patient is bleeding
excessively as she has saturated one peripad in less than minutes.
ANS:
15
fifteen
The saturation of one peripad within 15 minutes is considered to be excessive bleeding.
DIF: Cognitive Level: Comprehension REF: p. 889
TOP: Postpartum hemorrhage
OBJ: 3
KEY: Nursing
Process Step: Assessment MSC: NCLEX:
Physiological Integrity
3.
The nurse explains that severe
needs to be controlled because it can develop into
another syndrome called HELLP (Hypertension, Elevated Liver enzymes, and Low
Platelets).
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ANS:
preeclampsia
Progressive preeclampsia can develop into HELLP syndrome.
DIF:
Cognitive Level: Comprehension
REF: p. 890
OBJ:
4 TOP: Hypertension, Elevated Liver enzymes,
and Low Platelets (HELLP) KEY: Nursing
Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
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4.
The patient who has taken the ovulation stimulant clomiphene (Clomid), and who
has been determined to be pregnant, calls the clinic nurse to report that she is
bleeding and has passed a small grapelike object. From this information the nurse
suspects a hydatidiform
.
ANS:
mole
Hydatidiform moles occur frequently in people who have taken Clomid. The physical
changes are similar to a real pregnancy until bleeding occurs and some grapelike clusters
are passed.
DIF: Cognitive Level: Application
REF: p. 880
OBJ: 3
TOP: Hydatidiform mole KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
5.
A woman who is 14 weeks‘ pregnant calls the clinic nurse to report that after a brief
bleeding episode a week ago, her uterus seems to have gotten smaller, but her periods
have not begun. The nurse assesses the indicators for a
abortion.
ANS:
missed
A missed abortion is initiated by a bleeding episode in which the fetus is not expelled.
The uterus begins to shrink, but periods do not resume.
DIF: Cognitive Level: Application
TOP: Missed abortion
REF: p. 880
OBJ: 3
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
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Chapter 30: Health Promotion for the Infant,
Child, and Adolescent Cooper: Foundations and
Adult Health Nursing, 9th Edition
MULTIPLE
CHOICE
1.
The nurse stresses that regular physical activity has been identified as a leading
health indicator. Regular physical activity has which positive effect on children?
a.
Improves social skills.
b.
Reduces fluid retention.
c.
Increases bone and muscle strength.
d.
Increases attention span.
ANS: C
In children, regular physical activity increases bone and muscle strength.
DIF: Cognitive Level: Application
TOP: Physical activity
REF: p. 919
OBJ: 2
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
2.
What is the single most preventable cause of death and disease in the United States
today?
a.
Drug use
b.
Alcohol addiction
c.
Cigarette smoking
d.
Malnutrition
ANS: C
Cigarette smoking continues to be the single most preventable cause of death.
DIF: Cognitive Level: Knowledge
REF: p. 921
OBJ: 1 TOP:
Tobacco use KEY: Nursing Process Step:
Assessment
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MSC: NCLEX: Health Promotion and Maintenance
3.
Smoking contributes to an increased risk of heart and lung disease in children by which
methods?
a.
Air pollution
b.
Allergens in the environment
c.
Environmental smoke
d.
Lack of oxygen in the air
ANS: C
Environmental smoke may result in an increased risk of heart and lung disease,
particularly asthma and bronchitis in children.
DIF: Cognitive Level: Comprehension
REF: p. 922
OBJ: 1 TOP:
Tobacco use KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Health Promotion and Maintenance
4.
Which factor is mostly associated with problems such as domestic violence, sexually
transmitted infections (STIs), school failure, and motor vehicle accidents (MVAs)?
a.
Lack of supervision
b.
Psychological problems
c.
Substance abuse
d.
Physiological problems
ANS: C
Substance abuse is associated with many social problems such as domestic violence,
STIs, school failure, and MVAs.
DIF: Cognitive Level: Knowledge
REF:
p. 923
OBJ: 1 TOP:
Substance abuse
KEY: Nursing
Process Step: N/A MSC: NCLEX: Health
Promotion and Maintenance
5.
Approximately half of all new HIV cases are among people under what age?
a.
50 years
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b.
40 years
c.
30 years
d.
25 years
ANS: D
Approximately half of all new HIV cases are among people younger than 25.
DIF: Cognitive Level: Knowledge
TOP: Sexual behavior
REF: p. 924
OBJ: 1
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
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6.
Which children must be secured in the back seat in a rear-facing safety seat?
a.
Children weighing up to 20 lb
b.
Children weighing between 20 and 30 lb
c.
Children weighing between 30 and 40 lb
d.
Children weighing more than 40 lb
ANS: A
The law states that a child from birth to 20 lb must be situated in a rear-facing
safety seat that is secured in the back seat when riding in an automobile.
DIF: Cognitive Level: Application
REF: p. 925 OBJ: 7 TOP:
Injury
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
7.
The pediatric nurse reminds the parents of a 2-year-old that by this age the
child should be protected against how many vaccine-preventable childhood
diseases?
a.
4
b.
6
c.
8
d.
10
ANS: D
Children who follow the immunization schedule are protected against 10 vaccinepreventable childhood diseases by age 2.
DIF: Cognitive Level: Application
TOP: Immunizations
REF: p. 926
OBJ: 3
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
8.
A major dental problem among very young children is bottle mouth caries. What is a
preventive measure the nurse should suggest?
a.
Juice at bedtime
b.
Milk at bedtime
c.
A sugar-coated pacifier
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d.
Water at bedtime
ANS: D
Specific interventions can prevent bottle mouth caries, such as offering water in the
bedtime bottle.
DIF: Cognitive Level: Application
TOP: Dental health
REF: p. 926
OBJ: 4
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
9.
What practice should be used by a pediatric nurse to remind parents of their
responsibility in reducing the number of accidents involving children?
a.
Child awareness
b.
Good manners
c.
Anticipatory guidance
d.
Strict discipline
ANS: C
Anticipatory guidance has been the most widely used approach to educating parents in
accident prevention.
DIF: Cognitive Level: Application
TOP: Injury prevention
REF: p. 927
OBJ: 9
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
10.
To prevent accidental poisoning of a child, where should medications be placed in the
home?
a.
In a dresser drawer
b.
In the medicine cabinet
c.
In a locked cupboard
d.
On a high shelf
ANS: C
Medications should be kept in a locked cupboard.
DIF: Cognitive Level: Application
REF: p. 928 OBJ: 5 TOP:
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Poisoning
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
11.
What is the leading cause of fatal injury in children younger than 1 year old?
a.
Burns
b.
Poisons
c.
Asphyxiation
d.
Motor vehicle accidents
ANS: C
In children younger than 1 year, the leading cause of fatal injury is asphyxiation by
aspiration of foreign material into the respiratory tract.
DIF: Cognitive Level: Comprehension REF: p. 928
TOP: Asphyxiation
OBJ: 6
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
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12.
What is the third leading cause of accidental death in children 1 to 4 years of age?
a.
Falls
b.
Asphyxiation
c.
Poisons
d.
Burns
ANS: D
Burns are the third leading cause of accidental death in children 1 to 4 years of age.
DIF: Cognitive Level: Knowledge
REF: p. 930 OBJ: 9 TOP:
Burns
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Health Promotion and Maintenance
13.
The school nurse recognizes that lack of physical activity and increased consumption
of fast food by children are causative factors contributing to which of the following
problems?
a.
Nutritional disorders
b.
Weight gain
c.
Type I diabetes
d.
Dental caries
ANS: B
Many factors have contributed to the excess weight carried by children, including lack
of physical activity and increased consumption of fast food.
DIF: Cognitive Level: Analysis
REF: p. 920 OBJ: 1 TOP:
Obesity
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Health Promotion and Maintenance
14.
The nurse sets up a sample physical activities schedule to fit the FDA‘s Dietary
Guidelines for Americans that recommends that children get at least how many
minutes of physical activity per day?
a.
15
b.
30
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c.
45
d.
60
ANS: D
The Dietary Guidelines for Americans recommend that children get at least 60 minutes of
physical activity per day.
DIF: Cognitive Level: Comprehension REF: p. 921
TOP: Physical activity
OBJ: 2
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
15.
What age group is experiencing the largest increase in drug use?
a.
7- to 9-year-olds
b.
10- to 12-year-olds
c.
12- to 13-year-olds
d.
15- to 17-year-olds
ANS: C
Research shows an increase in children aged 12 to 13 years who are experimenting with
drugs.
DIF: Cognitive Level: Knowledge
TOP: Substance abuse
REF: p. 923
OBJ: 1
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
16.
Because the water in the infant‘s residential area is not fluoridated, when
should the nurse suggest that the infant receive supplemental fluoride?
a.
2 months old
b.
4 months old
c.
5 months old
d.
6 months old
ANS: D
Fluoride supplementation should be initiated at 6 months of age if the water in the
infant‘s residential area is not fluoridated.
DIF: Cognitive Level: Application
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REF: p. 927 OBJ: 4 TOP:
Dental care
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
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MULTIPLE RESPONSE
1.
What are reasons that a pediatric nurse should stress that health promotion activities must
be ongoing? (Select all that apply.)
a.
To identify health risks
b.
To encourage healthy behavior
c.
To strengthen family bonds
d.
To improve nutrition
e.
To prevent accidents
ANS: A, B, D, E
Health promotion activities must be ongoing to identify health risks, to encourage
healthy behavior, to improve nutrition, and to prevent accidents. There is no link
between health promotion activities and strengthening family bonds.
DIF: Cognitive Level: Comprehension REF: p. 918
TOP: Health promotion
OBJ: 1
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
2.
The school nurse collaborates with the physical education instructor to increase the
amount of physical activity during the school day. What are major benefits of
physical activity? (Select all that apply.)
a.
Reduced death rates as adults
b.
Reduced risk of cardiovascular disease
c.
Reduced risk of hypertension
d.
Reduced risk of diabetes
e.
Reduced self-esteem
ANS: A, B, C, D
Physical activity reduces death rates as adults, reduces the risk of cardiovascular disease,
and reduces the risk of diabetes and hypertension. Physical activity increases self-esteem.
DIF: Cognitive Level: Comprehension REF: p. 919
OBJ: 2
TOP: Benefits of physical exercise KEY: Nursing
Process Step: Implementation MSC: NCLEX: Health
Promotion and Maintenance
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3.
Which are physical risks associated with excess weight? (Select all that apply.)
a.
Poor eyesight
b.
Heart disease
c.
Arthritis
d.
Stroke
e.
Appendicitis
ANS: B, C, D
Heart disease, arthritis, and stroke are physical risks that are associated with excess
weight. Poor eyesight and appendicitis are not associated with weight gain.
DIF: Cognitive Level: Comprehension REF:
p. 920
OBJ: 10 TOP: Obesity
KEY:
Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
4.
Which of the following interventions should be included when teaching a healthy
behaviors class for parents of adolescents?
(Select all that apply.)
a.
Always monitor the child‘s telephone conversations.
b.
Insist on seatbelt use at all times.
c.
Encourage tanning bed use versus exposure to the sun.
d.
Maintain recommended immunization schedule.
e.
Encourage good dental care.
ANS: B, D, E
Adolescents should always wear seatbelts. Immunizations should be obtained according
to the recommended schedule. Good dental care is important. Parents should give the
child privacy in their telephone conversations. Tanning bed exposure is as detrimental
to skin as exposure to the sun and both should be avoided.
DIF: Cognitive Level: Application
TOP: Healthy behaviors
REF: p. 929
OBJ: 10
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
COMPLETION
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1.
A nurse emphasizes a study that focused on the amount of time children spend using
various media, such as TV, video games, and computers, and stated that by cutting
this time by
%, it would have a significant impact on
increasing physical activity.
ANS:
50
If sedentary time were cut in half, this would have a significant effect on the increase in
physical activity.
DIF: Cognitive Level: Comprehension REF: p. 923
OBJ: 2
TOP: Sedentary lifestyle KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
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2.
The nurse recognizes that preventive programs in schools must be stepped up in order to
prevent violence, especially
.
ANS:
shootings
Premeditated intentional shootings are occurring more frequently among adolescents.
DIF: Cognitive Level: Application
REF:
p. 925
KEY:
OBJ: 10 TOP: Shootings
Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
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Chapter 31: Basic Pediatric Nursing Care
Cooper: Foundations and Adult Health Nursing, 9th Edition
MULTIPLE
CHOICE
1.
What was one of the major strides in pediatric care made by Dr. Abraham Jacobi?
a.
Pediatric wards in hospitals
b.
Free inoculations against smallpox
c.
Milk stations in the city of New York
d.
Serving nutritious foods in orphanages
ANS: C
Dr. Abraham Jacobi, referred to as the father of pediatrics, initiated the establishment
of milk stations in New York demonstrating how to sanitize milk for children.
DIF: Cognitive Level: Knowledge
REF:
p. 934
OBJ: 2 TOP:
Abraham Jacobi
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
2.
What was founded by Lillian Wald?
a.
National Commission on Children
b.
Henry Street Settlement
c.
White House Conference
d.
US Children‘s Bureau
ANS: B
Lillian Wald, regarded as the founder of public health, founded Henry Street
Settlement, which provided nursing services and social assistance.
DIF: Cognitive Level: Knowledge
REF: p. 934
OBJ: 2
TOP: Lillian Wald KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
3.
When the pediatric nurse is attempting to establish a trusting relationship with a child,
what is the most important and lasting thing to do?
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a.
Convey respect.
b.
Talk with the child.
c.
Be honest.
d.
Talk with family.
ANS: C
To establish a trusting relationship, the most important thing is to be honest.
DIF: Cognitive Level: Application
TOP: Pediatric nurse
REF: p. 935
OBJ: 4
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
4.
What is the special category that encompasses children who have congenital
abnormalities, malignancies, gastrointestinal (GI) diseases, or central nervous
system (CNS) anomalies?
a.
Very dependent children
b.
Children requiring special education
c.
Children with special needs
d.
Children requiring long-term care
ANS: C
The definition of children with special needs includes congenital abnormalities,
malignancies, GI diseases, and CNS anomalies.
DIF: Cognitive Level: Comprehension
REF: p. 936 OBJ: 6 TOP:
Children
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
5.
The mother of a child with diabetes asks the nurse in charge of the familycentered pediatric unit if she might see her child‘s laboratory reports. What
response by the nurse is the most appropriate?
a.
―Although the actual reports are not shared, I can tell
you the blood sugar is 200 mg.‖
b.
―I‘ll write them down for you and bring them to your room.‖
c.
―Come to the conference room where we can have
privacy while you look at them.‖
d.
―I‘ll notify the health care provider that you wish to see the reports.‖
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ANS: C
With a family-centered care approach, hospitals welcome parents, and parents have
access to information 24 hours a day.
DIF: Cognitive Level: Analysis
REF: p. 936
OBJ: 5
TOP: Family-centered care KEY: Nursing Process
Step: Implementation MSC: NCLEX: Health Promotion
and Maintenance
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6.
What should be the focus of a practice where the pediatric nurse uses a developmental
approach?
a.
Stimulation of the child to reach expected norms
b.
Age-centered care plans
c.
Strengths and abilities of the child
d.
Characteristics for the particular age
ANS: C
A developmental approach emphasizes the child‘s strengths and abilities and considers
individuality. It builds on what the child can do instead of focusing on what the child
cannot do.
DIF: Cognitive Level: Application
TOP: Developmental approach
REF: p. 938
OBJ: 6
KEY: Nursing
Process Step: Implementation MSC: NCLEX: Health
Promotion and Maintenance
7.
When using anticipatory guidance to prepare a 5-year-old for an IM injection,
what statement by the nurse would be most appropriate?
a.
―Ethan, I‘m going to give you a shot.‖
b.
―Ethan, the health care provider wants you to have
some medicine, and it will hurt.‖
c.
―Ethan, some medicine can only be given with a needle.‖
d.
―Ethan, I am going to give you some medicine that
will sting, but only for a little while.‖
ANS: D
Anticipatory guidance is the psychological preparation of a patient for a stressful
event by explaining what will happen and the probable outcome.
DIF: Cognitive Level: Analysis
REF: p. 938
OBJ: 14
TOP: Anticipatory guidance KEY: Nursing Process
Step: Implementation MSC: NCLEX: Psychosocial
Integrity
8.
When measuring the head circumference of an infant, where should the nurse place the
tape measure?
a.
Across the eyebrows and around the occipital lobe
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b.
Over the zygomatic arches and around the parietal areas
c.
Around forehead and around the crown of the head
d.
Above the eyebrows and pinnas, and around the occipital lobe
ANS: D
Head circumference is measured in children up to 36 months above the eyebrows and
pinnas, and around the occipital lobe.
DIF: Cognitive Level: Application
REF: p. 940
OBJ: 14
TOP: Head circumference KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
9.
What activity by an infant would cause a false elevation of the tympanic temperature?
a.
Having a bowel movement
b.
Crying vigorously
c.
Having just eaten
d.
Having been in a cold room
ANS: B
Crying increases the temperature; eating and bowel movements do not. A cold room
would lower the temperature.
DIF: Cognitive Level: Application
REF: p. 941 OBJ: 7 TOP:
Vital signs
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
10.
What is the correct order for assessing vital signs in an infant to ensure the accuracy of
measurements?
a.
Respiration, temperature, pulse
b.
Pulse, respiration, temperature
c.
Temperature, pulse, respiration
d.
Respiration, pulse, temperature
ANS: D
The respiration is taken first on an infant before the child is disturbed, pulses are assessed
next, and last the temperature is obtained.
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DIF: Cognitive Level: Application
REF: p. 941 OBJ: 7 TOP:
Vital signs
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
11.
Why does obtaining the respirations of an infant require a modified approach from that of
an adult?
a.
Infants breathe through their noses.
b.
Infants have very rapid respirations.
c.
Infants‘ respirations are thoracic in nature.
d.
Infants‘ respiratory movements are abdominal.
ANS: D
In children under 6 or 7 years of age, respiratory movements are abdominal or
diaphragmatic. Abdominal movements must be observed when counting
respirations.
DIF: Cognitive Level: Application
REF: p. 942 OBJ: 7 TOP:
Vital signs
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
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12.
An 8-year-old child asks how a blood pressure is taken. What would be the most
appropriate response?
a.
―This small machine will measure your systolic and diastolic pressure.‖
b.
―The armband will hug your arm and tell me
how well your blood is going through your arm.‖
c.
―The armband will cut off your circulation for a while
and then we can hear when it comes back.‖
d.
―When you are ill we need to know if your blood is still moving in your body.‖
ANS: B
Because children are upset by unfamiliar procedures, it is best to explain each step in
simple terms. It is best not to mention anything that may increase anxiety.
DIF:
Cognitive Level: Application REF:
pp. 942-943
OBJ: 9 TOP: Vital signs
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Psychosocial Integrity
13.
What is the correct way to assess for the presence of jaundice in an African-American
child?
a.
Examine the sclera.
b.
Press the edge of the pinna.
c.
Apply pressure to the gum.
d.
Compare the color on the soles of the feet.
ANS: C
The gums in individuals with dark complexions can be used to assess jaundice by
pressing the gums about the teeth.
DIF: Cognitive Level: Application
REF: p. 944 OBJ: 7 TOP:
Jaundice
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
14.
When discussing growth and development with the parents of a child, the nurse
explains that nutrition is the single most important influence on:
a. cognitive development.
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b.
secondary sexual characteristics.
c.
the production of blood cells.
d.
the growth of bones and muscle.
ANS: D
Nutrition is probably the single most important influence on growth.
DIF: Cognitive Level: Application
REF: p. 947 OBJ: 8 TOP:
Nutrition
KEY: Nursing Process Step:
Planning
MSC: NCLEX: Health Promotion and Maintenance
15.
The mother of a 3-year-old expresses concern about her daughter‘s slowed growth
rate. What would be the most informative response by the nurse?
a.
―Three-year-olds have typically finished a growth
spurt, and you may notice a decreased rate in your
daughter‘s growth.‖
b.
―Children‘s growth is hereditary. She may be of small stature like you.‖
c.
―The growth of a 3-year-old is associated with their nutrition. How is she eating?‖
d.
―Your daughter is healthy and happy. Don‘t worry about her growth right now.‖
ANS: A
Three-year-olds slow down in their growth in a natural cycle.
DIF:
Cognitive Level: Application REF:
pp. 937-938
OBJ: 7 TOP: Growth KEY:
Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
16.
What should be included in the teaching plan for the parents of a 3-year-old child who has
been prescribed an opioid analgesic?
a.
The opioid is likely to cause significant respiratory depression.
b.
The medicine is prescribed with the knowledge that addiction may occur.
c.
The opioid is very effective as a pain control method.
d.
The opioid is only to be given in cases of severe pain.
ANS: C
It is an effective type of analgesia. When administered to children, opioid analgesics
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do not have any greater respiratory depression than when given to an adult, and the
risk of addiction is virtually nonexistent in children.
DIF: Cognitive Level: Application
TOP: Opioid analgesia
REF: p. 956
OBJ: 12
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
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17.
The parents ask about preparation of their toddler for hospital admission. When
does the nurse suggest that the parents tell their toddler of the admission?
a.
A week prior
b.
2 weeks prior
c.
The day of admission
d.
Only 2 or 3 days before
ANS: D
The nurse should suggest the toddler be told only days before. School-age children can be
given more time to prepare. Adolescents should be told as far in advance as possible.
DIF: Cognitive Level: Application
TOP: Hospitalization
REF: p. 953
OBJ: 11
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
18.
When the newly admitted 2-year-old who was potty-trained before admission begins
to wet the bed, the mother is frightened. What statement by the nurse will be most
helpful to the mother?
a.
―Don‘t be concerned. Accidents happen.‖
b.
―Let‘s put a diaper on your child until this gets better.‖
c.
―The stress of hospitalization makes children regress a little.‖
d.
―Your child will relearn ‗potty-training‘ if you are patient.‖
ANS: C
It is not unusual for children to regress when hospitalized. Explaining that
regression is normal during hospitalization will help allay the mother‘s anxiety.
DIF: Cognitive Level: Application
TOP: Hospitalization regression
REF: p. 955
OBJ: 13
KEY: Nursing
Process Step: Implementation MSC: NCLEX: Health
Promotion and Maintenance
19.
When attempting to provide information to the parents of a child undergoing
surgery, the nurse notes that the parents appear confused and do not seem to
remember what they are being told. What is the most probable cause of the parents‘
forgetfulness?
a.
Noisy environment
b.
Serious nature of surgery
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c.
Increased level of parents‘ anxiety
d.
Developmental age of the child
ANS: C
Anxiety of the parents may result in confusion and forgetfulness. It is not known if
the environment is noisy, if the surgery is serious in nature, or what is the
developmental age of the child.
DIF: Cognitive Level: Application
TOP: Hospitalization
REF: p. 958
OBJ: 13
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
20.
What is the best time to bathe an infant?
a.
At bedtime
b.
Early in the morning
c.
After a feeding
d.
Before a feeding
ANS: D
Bathing is usually done before a feeding to reduce the possibility of vomiting,
regurgitation, or stimulation.
DIF: Cognitive Level: Comprehension REF:
p. 959
OBJ: 11 TOP: Feeding
KEY:
Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
21.
How should an infant be positioned after a feeding?
a.
On the stomach
b.
On the right side
c.
On the left side
d.
On the back
ANS: B
After feeding, the infant is positioned on the right side to direct the food into the stomach.
DIF: Cognitive Level: Comprehension REF:
p. 960
OBJ: 11 TOP: Feeding
KEY:
Nursing Process Step: Implementation
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MSC: NCLEX: Physiological Integrity
22.
When a safety reminder device (SRD) is used to protect a child, what is a responsibility
of the nurse?
a.
Apply it loosely.
b.
Remove it every 2 hours.
c.
Place it over clothing.
d.
Apply only one type.
ANS: B
Any SRD should be removed every 2 hours.
DIF: Cognitive Level: Comprehension REF:
p. 961
OBJ: 11 TOP: Safety
KEY:
Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment
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23.
What should be done before initiating a gavage feeding?
a.
Hold the feeding tube under water to check for bubbling.
b.
Check for gastric distention.
c.
Aspirate stomach contents.
d.
Ensure the sterility of feeding equipment.
ANS: C
Aspirating stomach contents and aspirating a small amount of air while listening for
stomach gurgling are the best ways to ensure correct tube placement. Holding the
feeding tube under water to check for bubbling is not an effective method to check
tube placement. Gastric distention would be important following the feeding. A
gavage feeding is not a sterile procedure.
DIF: Cognitive Level: Application
TOP: Tube feedings
REF: p. 960
OBJ: 14
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Safe, Effective Care
Environment
24.
What is the purpose of a mist tent?
a.
To provide a constant oxygen supply
b.
To liquefy respiratory secretions
c.
To aid in lowering temperature
d.
To improve the infant‘s hydration
ANS: B
The purpose of the mist tent is to liquefy respiratory secretions. A constant oxygen
supply can be given by methods other than a mist tent. A mist tent does not lower
temperature or improve hydration.
DIF: Cognitive Level: Comprehension REF:
p. 962
OBJ: 14 TOP: Mist tent
KEY:
Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
25.
What is the maximum amount of time that a nurse should suction an artificial airway?
a.
1 second
b.
5 seconds
c.
30 seconds
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d.
1 minute
ANS: B
The nurse should limit suctioning to no more than 5 seconds.
DIF: Cognitive Level: Comprehension REF: p. 963
TOP: Tracheal suction
OBJ: 14
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
26.
What is a disadvantage of using a mist tent with a toddler?
a.
The nurse must remove the restless child.
b.
The wet bedding and clothing must be changed frequently.
c.
The mist tent must be opened at least once every hour.
d.
All objects must be kept outside of the tent.
ANS: B
Frequent linen and clothing changes will be necessary because of the heavy humidity
in the tent. The nurse can open the tent to soothe the restless child instead of removing
the child. The tent does not have to be opened every hour. Toys can be placed inside
the tent.
DIF: Cognitive Level: Application
REF:
p. 962
KEY:
OBJ: 14 TOP: Mist tent
Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
27.
What is one way to enhance the nutrition of the hospitalized toddler?
a.
Reward with sweets for eating meals.
b.
Discourage participation in noneating activities.
c.
Offer nutritious fluids frequently.
d.
Leave nutritious finger foods out for the child to eat.
ANS: C
Using nutritious liquids may satisfy the nutritional needs when a toddler is ―too
busy‖ to eat. Toddlers should not be left to eat unsupervised because of the danger of
aspiration. Junk food should not be used as rewards. Activities are important and
should not be discouraged.
DIF: Cognitive Level: Application
REF:
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p. 960
OBJ: 11 TOP: Nutrition
KEY:
Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
28.
Why must the pediatric nurse be cautious about medicating infants and young children?
a.
They are less susceptible to medication effects than adults.
b.
They are more susceptible to medication effects than adults.
c.
They are equally susceptible to medication effects as adults.
d.
They are more susceptible to drug interactions than adults.
ANS: B
Newborns and young children are more susceptible to the toxic effects of certain
medications than adults.
DIF: Cognitive Level: Application
p. 966
Medications
REF:
OBJ: 15 TOP:
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
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29.
What is the preferred IM injection site for a 2-year-old?
a.
Deltoid muscle
b.
Upper thigh
c.
Vastus lateralis
d.
Gluteus
ANS: C
The preferred site for an IM injection for a 2-year-old is the vastus lateralis.
DIF: Cognitive Level: Knowledge
TOP: IM medication
REF: p. 967
OBJ: 15
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Safe, Effective Care
Environment
30.
Where is the typical IV insertion site in an infant younger than 9 months of age?
a.
Radial vein
b.
Scalp vein
c.
Femoral vein
d.
Brachial vein
ANS: B
A superficial scalp vein is the injection site for administering IV medication to infants
younger than 9 months of age.
DIF: Cognitive Level: Knowledge
TOP: IV medication
REF: p. 969
OBJ: 15
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Safe, Effective Care
Environment
31.
Following a lumbar puncture of a 2-year-old, what should the nurse do?
a.
Keep the child flat for several hours.
b.
Allow the child to play quietly at will.
c.
Hold the child in a flexed position for 5 minutes.
d.
Stand the child upright immediately.
ANS: B
Children younger than 3 years of age are usually not affected by postlumbar headache.
These children are allowed to play at will following a lumbar puncture.
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DIF: Cognitive Level: Comprehension REF: p. 966
TOP: Lumbar puncture
OBJ: 14
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
32.
What should the nurse do to minimize an unpleasant-tasting drug?
a.
Pour the drug over ice.
b.
Squirt the drug in the mouth with a syringe.
c.
Administer the drug through a straw.
d.
Enlist the parent‘s assistance.
ANS: C
Administering the drug through a straw will diminish an unpleasant taste. Having the
child hold the nose is helpful, as bad taste is associated with the smell of the drug.
Pouring the drug over ice may result in the child not getting the entire amount of the
drug. Squirting the drug into the mouth with a syringe will still allow the child to taste
the medication. The parent‘s assistance should be enlisted, but will not minimize the
taste of the drug.
DIF: Cognitive Level: Application
p. 967
REF:
OBJ: 15 TOP:
Medications
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
33.
A disfiguring facial wound would have the most significant developmental impact on
which child?
a.
4-year-old
b.
6-year-old
c.
10-year-old
d.
14-year-old
ANS: D
The adolescent fears a change in body image associated with surgery.
DIF:
Cognitive Level: Application REF: p. 938 | p. 957
OBJ: 6
TOP: Surgery KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
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34.
When the nurse is inserting a feeding tube in an 8-month-old, what safety reminder
device (SRD) should the nurse most likely use?
a.
Mummy
b.
Clove hitch
c.
Jacket device
d.
Elbow device
ANS: A
The mummy restraint controls the arms and the body of the infant.
DIF: Cognitive Level: Application
TOP: Safety reminder devices (SRDs)
REF: p. 961
OBJ: 14
KEY:
Nursing Process Step: Planning MSC: NCLEX:
Safe, Effective Care Environment
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35.
The nurse clarifies that child abuse and neglect are complicated and preventable problems
falling under which broader term?
a.
Child abandonment
b.
Child mismanagement
c.
Child maltreatment
d.
Child torment
ANS: C
Child maltreatment is a broad term used to describe neglect and abuse of children.
DIF: Cognitive Level: Knowledge
p. 950
REF:
OBJ: 10 TOP: Child abuse KEY:
Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
36.
What observation in an emergency department should lead a nurse to suspect child abuse
in a child with a fractured arm?
a.
Lack of parental concern for the severity of the injury
b.
The child not answering questions concerning the injury
c.
Parents not asking about the child‘s condition
d.
Inconsistency between the injury and the parents‘ explanation of it
ANS: D
Special attention must be paid to injuries that are inconsistent with the parents‘
explanation.
DIF: Cognitive Level: Application
p. 951
REF:
OBJ: 10 TOP: Child abuse KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance
37.
When communicating with parents suspected of child abuse, what should the nurse be
sure to do?
a.
Tell them the law requires reporting of the incident.
b.
Be sympathetic to their needs.
c.
Interact with them in a nonjudgmental manner.
d.
Suggest psychiatric counseling.
ANS: C
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The nurse should maintain a nonjudgmental attitude toward the parents. The nurse
does not have to tell the parents that she is reporting them. The nurse does not have to
be sympathetic, she only has to be professional at all times. It is not the place of the
nurse to suggest counseling.
DIF: Cognitive Level: Application
p. 952
REF:
OBJ: 10 TOP: Child abuse KEY:
Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
38.
After observing parental behavior that leads the nurse to suspect child abuse, when should
the nurse report the abuse?
a.
If the parent confesses to child abuse
b.
If the child admits to being abused
c.
Whenever maltreatment of a child is suspected
d.
When the type of abuse can be determined
ANS: C
Mandatory reporting of child abuse is required when the health care provider has reason
to suspect the child has been abused.
DIF: Cognitive Level: Application
p. 952
REF:
OBJ: 10 TOP: Child abuse KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance
MULTIPLE RESPONSE
1.
The nurse welcomes the presence of the family in a pediatric unit because it reduces
the stressors of hospitalization. Which are common stressors for the hospitalized
child? (Select all that apply.)
a.
Separation
b.
Lack of love
c.
Fear of pain
d.
Unfamiliar food
e.
Loss of control
ANS: A, C, E
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Parents lend stability and comfort for the child and restore his or her sense of control.
DIF: Cognitive Level: Application
REF: p. 954
OBJ: 5
TOP: Parents on the pediatric unit KEY: Nursing
Process Step: Implementation MSC: NCLEX: Health
Promotion and Maintenance
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2.
The nurse clarifies that the family-centered care approach terminates which policies?
(Select all that apply.)
a.
Rigid visiting hours
b.
Freedom to choose which medications to take
c.
Exclusion of family during procedures
d.
Discouraging family to stay overnight
e.
Restricting parents from reading the chart
ANS: A, C, D, E
Family-centered care terminates all the restrictive policies of traditional hospitals.
Medication orders should still be followed.
DIF: Cognitive Level: Application
REF: p. 937
OBJ: 5
TOP: Family-centered care KEY: Nursing Process
Step: Implementation MSC: NCLEX: Health Promotion
and Maintenance
COMPLETION
1.
The pediatric nurse, along with the primary caregiver(s), has a special duty to
the
child and the family.
ANS:
teach
The pediatric nurse is in a position to assess, instruct, and support children and their
families about developmental progress, nutrition, and possible undiagnosed anomalies.
DIF: Cognitive Level: Comprehension
REF: p. 935 OBJ: 4 TOP:
Teaching
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
2.
The nurse is aware that visual acuity evaluation in a child is best assessed after the age of
years.
ANS:
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6
six
A child‘s refraction does not reach 20/20 until about the age of 6.
DIF: Cognitive Level: Comprehension REF: p. 944
TOP: Visual acuity
OBJ: 7
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Health Promotion
and Maintenance
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Chapter 32: Care of the Child with a Physical and Mental
or Cognitive Disorder Cooper: Foundations and Adult
Health Nursing, 9th Edition
MULTIPLE
CHOICE
1.
The nurse uses a diagram to show that the tetralogy of Fallot involves a
combination of four congenital defects. What are the defects?
a.
Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy
b.
Pulmonary stenosis, ventricular septal defect,
overriding aorta, right ventricular hypertrophy
c.
Aortic stenosis, atrial septal defect, overriding aorta, right ventricular hypertrophy
d.
Pulmonary stenosis, ventricular septal defect, aortic
hypertrophy, left ventricular hypertrophy
ANS: B
Tetralogy of Fallot involves a combination of four congenital defects: pulmonary
stenosis, ventricular septal defect, overriding aorta, and right ventricular
hypertrophy.
DIF: Cognitive Level: Knowledge
REF: p. 982
OBJ: 1 TOP:
Heart defect
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
2.
What is the most common clinical manifestation of coarctation of the aorta?
a.
Clubbing of the digits
b.
Upper extremity hypertension
c.
Pedal edema and portal congestion
d.
Loud systolic ejection murmur
ANS: B
Coarctation of the aorta results in hypertension in the upper extremities. The pressure
in the arms is typically 20 mm Hg higher than in the legs.
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DIF: Cognitive Level: Knowledge
REF: p. 983
OBJ: 1 TOP:
Heart defect
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
3.
Parents of a 6-month-old child, who has just been diagnosed with iron deficiency
anemia, ask why it was not diagnosed earlier. What would be the best response by
the nurse?
a.
―Are you sure your child has iron deficiency anemia?‖
b.
―This happens when the maternal stores of iron are depleted at about 6 months.‖
c.
―This anemia is caused by blood loss.‖
d.
―The child may not have had it for a long time.‖
ANS: B
Iron deficiency anemia becomes apparent at about 6 months of age in a full-term infant,
when maternal stores of iron are depleted.
DIF: Cognitive Level: Application
REF: p. 984 OBJ: 2 TOP:
Anemia
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
4.
What should the therapeutic management of iron deficiency anemia include?
a.
Multivitamins
b.
Calcium
c.
Ferrous sulfate
d.
Iodine
ANS: C
Therapeutic management of iron deficiency anemia is iron (ferrous sulfate)
supplementation, nutritional counseling, and treatment of any underlying condition.
DIF: Cognitive Level: Knowledge
REF: p. 984 OBJ: 2 TOP:
Anemia
KEY: Nursing Process Step:
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Implementation
MSC: NCLEX: Physiological Integrity
5.
The parents of a child who has been diagnosed with sickle cell anemia ask why their
child experiences pain. What is the most likely cause of the pain?
a.
Inflammation of the vessels
b.
Obstructed blood flow
c.
Overhydration
d.
Stress-related headaches
ANS: B
The signs and symptoms of sickle cell anemia include the sickle-shaped cells
clumping and obstructing blood flow, which causes severe tissue hypoxia and
necrosis leading to pain.
DIF:
Cognitive Level: Application REF: pp. 984-985
TOP: Blood disorders
OBJ: 2
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
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6.
The parents of a child recently diagnosed with sickle cell anemia ask what can be
done to avoid a sickle cell crisis. What should be included in the medical management
of sickle cell crisis?
a.
Information for the parents including home care
b.
Provisions for adequate hydration and pain management
c.
Pain management and administration of iron supplements
d.
Adequate oxygenation and factor VIII
ANS: B
Medical management of sickle cell crisis includes palliative analgesics, hydration, and
oxygen.
DIF:
Cognitive Level: Application REF: pp. 985-986
TOP: Blood disorders
OBJ: 2
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
7.
Which laboratory results should the nurse anticipate to be abnormal in a child with
hemophilia?
a.
Prothrombin time
b.
Bleeding time
c.
Platelet count
d.
Partial thromboplastin time
ANS: D
Expected laboratory findings for a child with hemophilia include a prolonged partial
thromboplastin time. The prothrombin time, bleeding time, and platelet count are
typically normal.
DIF: Cognitive Level: Comprehension REF: p. 986
TOP: Blood disorders
OBJ: 3
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
8.
The parents of a child with acute lymphoblastic leukemia ask about the best
approach for maintaining remission of the disease. What would be the most
effective therapy?
a.
Surgery to remove enlarged lymph nodes
b.
Long-term chemotherapy
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c.
Nutritional supplements to enhance blood cell production
d.
Blood transfusions to replace ineffective red cells
ANS: B
The treatment of choice is methotrexate, a chemotherapeutic agent, to produce remission.
DIF: Cognitive Level: Application
TOP: Blood disorders
REF: p. 989
OBJ: 4
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
9.
What most influences the severity of respiratory distress syndrome (RDS)?
a.
Poor cough and gag reflex
b.
The gestational age at birth
c.
Administering high concentrations of oxygen
d.
The sex of the infant
ANS: B
RDS is caused by a deficiency of surfactant and it occurs almost exclusively in preterm,
low–birth weight infants.
DIF: Cognitive Level: Comprehension
REF: p. 993
OBJ: 7 TOP:
Respiratory distress syndrome (RDS)
KEY: Nursing Process Step:
Implementation MSC:
NCLEX: Physiological
Integrity
10.
A 2-year-old child with laryngotracheobronchitis (LTB) is fussy and restless in the
oxygen tent. The oxygen level in the tent is 25%, and blood gases are normal. What
would be the correct action by the nurse?
a.
Restrain the child in the tent and notify the health care provider.
b.
Increase the oxygen concentration in the tent.
c.
Take the child out of the tent and into the playroom.
d.
Ask the mother for help in comforting the child.
ANS: B
The child with LTB should be placed in the mist tent with 30% oxygen. Restlessness is
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caused by poor oxygenation. The child should not be taken out of the oxygenated tent.
While the mother could be asked to help comfort the child, and the health care
provider may be notified, the priority is to set the oxygen at the correct level.
DIF: Cognitive Level: Analysis
TOP: Laryngotracheobronchitis (LTB)
REF: p. 997
OBJ: 7
KEY:
Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity
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11.
The mother of a child with acute laryngotracheobronchitis (LTB) asks why her child
must be kept NPO. Which responses would be the most correct?
a.
The epinephrine given causes nausea and vomiting.
b.
The child is being hydrated with IV fluids.
c.
The child is not hungry.
d.
The child‘s rapid respirations pose a risk for aspiration.
ANS: D
Rapid respirations predispose to aspiration. The child is kept hydrated with IV fluids,
but this is not the reason that the child must be kept NPO.
DIF: Cognitive Level: Application
REF: p. 998
TOP: Laryngotracheobronchitis (LTB)
OBJ: 7
KEY:
Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity
12.
What could suddenly occur in a child with acute epiglottitis?
a.
Increased carbon dioxide levels
b.
Airway obstruction
c.
Inability to swallow
d.
Bronchial collapse
ANS: B
In acute epiglottitis, the infected epiglottis becomes inflamed and causes total airway
obstruction. Immediate treatment of acute epiglottitis includes an artificial airway.
DIF:
Cognitive Level: Comprehension
REF: pp. 997-998
TOP: Epiglottitis
OBJ: 7
KEY: Nursing
Process Step: Assessment
MSC: NCLEX: Physiological Integrity
13.
When conducting a class for parents about sudden infant death syndrome (SIDS), the
nurse instructs the class that the infant should be placed in which position to sleep?
a.
Right side-lying
b.
Left side-lying
c.
Prone
d.
Supine
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ANS: D
The American Academy of Pediatrics recommends placing the infant on its back, or
supine, to sleep.
DIF: Cognitive Level: Comprehension
REF: p. 996
OBJ: 7 TOP:
Sudden infant death syndrome (SIDS)
KEY: Nursing Process Step:
Implementation MSC:
NCLEX: Physiological
Integrity
14.
When interacting with the parents of a SIDS infant, the nurse should attempt to assist the
parents with:
a.
encouraging the parents to have another baby.
b.
encouraging the parents to remain stoic.
c.
allaying feelings of guilt and blame.
d.
learning how the event could have been prevented.
ANS: C
As parents try to cope, they have feelings of guilt and blame.
DIF: Cognitive Level: Application
REF: p. 996
OBJ: 7 TOP:
Sudden infant death syndrome (SIDS)
KEY: Nursing Process Step:
Implementation MSC:
NCLEX: Psychosocial
Integrity
15.
The nurse educates the family of a newly admitted child with cystic fibrosis that the
treatment will be centered on what therapy?
a.
Chest physiotherapy
b.
Mucus-drying agents
c.
Prevention of diarrhea
d.
Insulin therapy
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ANS: A
Chest physiotherapy and aerosol medications are the center of treatment for cystic
fibrosis.
DIF: Cognitive Level: Application
TOP: Cystic fibrosis
REF: p. 1000 OBJ: 7
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
16.
What is the main characteristic of cystic fibrosis?
a.
Multiple upper respiratory infections
b.
An underproduction of exocrine glands
c.
Excessive, thick mucus
d.
An overproduction of thin mucus
ANS: C
The pathophysiology of cystic fibrosis includes excessive, thick mucus.
DIF: Cognitive Level: Comprehension REF: p. 999
TOP: Cystic fibrosis
OBJ: 7
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
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17.
What is the best time to administer pancreatic enzyme replacement?
a.
Before meals and snacks
b.
Before bedtime
c.
Early in the morning
d.
After meals and snacks
ANS: A
Pancreatic enzymes are administered before meals and snacks to digest carbohydrates, fats,
and proteins.
DIF: Cognitive Level: Application
TOP: Cystic fibrosis
REF: p. 1000 OBJ: 7
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
18.
Following surgical repair of a cleft palate, what should be used to prevent injury to the
suture line?
a.
Straw
b.
Spoon
c.
Syringe
d.
Cup
ANS: D
When feeding a child with a repaired cleft palate, the nurse should avoid utensils, straws,
droppers, and syringes.
DIF: Cognitive Level: Application
REF: p. 1005 OBJ: 8
TOP: Cleft lip and palate KEY: Nursing Process
Step: Planning MSC: NCLEX: Safe, Effective Care
Environment
19.
What is the priority patient problem for the parents of a newborn born with cleft lip and
palate?
a.
Parental role conflict
b.
Risk for delayed growth and development
c.
Risk for impaired attachment
d.
Anticipatory grieving
ANS: C
Parents of a child with cleft lip and palate may have difficulty bonding with their child
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due to the appearance of the child. The priority patient problem is risk for impaired
attachment. A goal is to promote bonding between parents and infant.
DIF: Cognitive Level: Analysis
REF: p. 1004 OBJ: 8
TOP: Cleft lip and palate KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
20.
Which is a long-term complication of cleft lip and palate?
a.
Cognitive impairment
b.
Altered growth and development
c.
Faulty dentition
d.
Physical abilities
ANS: C
The older child with cleft lip and palate may experience psychological difficulties
because of the cosmetic appearance of the defect, problems with impaired speech, and
faulty dentition.
DIF: Cognitive Level: Comprehension REF: p. 1005 OBJ: 8
TOP: Cleft lip and palate KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
21.
How should the nurse measure urinary output for an infant with dehydration?
a.
Attaching a urine collecting bag
b.
Wringing out the diaper
c.
Weighing the diaper
d.
Inserting a catheter
ANS: C
Wet diapers are weighed to assess the amount of output.
DIF: Cognitive Level: Application
REF: p. 1005
OBJ: 8 TOP:
Dehydration
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
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22.
Following a bout of diarrhea, which foods should be offered to the school-age child?
a.
Apricots and peaches
b.
Chocolate milk
c.
Applesauce and milk
d.
Bananas and rice
ANS: D
When rehydration has been completed, foods that are nonirritating to the bowel should
be offered to the child. Bananas and rice would be the least irritating to the bowel, as
fruits and milk could cause GI irritation.
DIF: Cognitive Level: Application
REF: p. 1006
OBJ: 8 TOP: Nutrition
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
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23.
How is the infant with gastroesophageal reflux (GER) typically treated?
a.
By making the infant NPO
b.
By thickening the formula or breast milk with cereal
c.
By placing the infant to sleep on the side
d.
By switching the infant to cow‘s milk
ANS: B
GER is treated with small feedings thickened with cereal. The infant should not be
made NPO or switched to cow‘s milk. Infants should only be placed on the back to
sleep due to the risk of SIDS.
DIF: Cognitive Level: Application
REF: p. 1008
OBJ: 8 TOP: Nutrition
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
24.
What should the nurse assess in an infant who has been diagnosed with hypertrophic
pyloric stenosis?
a.
A history of diarrhea following each feeding
b.
Gastric pain evidenced by vigorous crying
c.
Poor appetite due to a poor sucking reflex
d.
An olive-shaped mass right of the midline
ANS: D
Examination of the abdomen may assist in the diagnosis and reveal key signs of
hypertrophic pyloric stenosis. Visible peristaltic waves that move from left to right
across the epigastric region may be evident, and palpation may reveal an oliveshaped mass in this area to the right of the midline.
DIF: Cognitive Level: Application
TOP: Pyloric stenosis
REF: p. 1009 OBJ: 8
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
25.
What is the hallmark sign of intussusception?
a.
Mucus-like stools
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b.
Currant jelly–like stools
c.
Tarry, black stools
d.
Green, soft stools
ANS: B
The hallmark sign of intussusception is currant jelly stools.
DIF: Cognitive Level: Knowledge
TOP: Gastrointestinal disorders
REF: p. 1010 OBJ: 8
KEY: Nursing
Process Step: Assessment MSC: NCLEX:
Physiological Integrity
26.
Which is a causative factor of
Hirschsprung disease?
a.
Frequent evacuation of solids, liquid, and
gases
b.
Excessive peristaltic movement
c.
The absence of parasympathetic ganglion cells in a portion of the colon
d.
One portion of the bowel telescoping into another
ANS: C
The causative factor in Hirschsprung disease is the absence of parasympathetic ganglion
cells in a portion of the colon.
DIF: Cognitive Level: Comprehension REF: p. 1010 OBJ: 8
TOP: Gastrointestinal disorders
KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity
27.
What should the nurse caring for a 6-year-old child with acute glomerulonephritis
anticipate as the most difficult part of the care to implement?
a.
Forced fluids
b.
Increased feedings
c.
Bed rest
d.
Frequent position changes
ANS: C
During the acute phase of glomerulonephritis, bed rest is usually recommended. A
diet of restricted fluid, sodium, potassium, and phosphate is initially required. Bed
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rest can be very hard to implement with an active 6-year-old child.
DIF: Cognitive Level: Application
TOP: Genitourinary disorders
REF: p. 1014 OBJ: 10
KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity
28.
When selecting patient problems for the 4-year-old child with nephrosis, what should be a
priority for the nurse?
a.
Impaired body image
b.
Skin impairment
c.
Nutritional deficit
d.
Injury
ANS: B
Nephrosis is a clinical state characterized by gross edema, which makes skin care a
priority.
DIF: Cognitive Level: Analysis
TOP: Genitourinary disorders
REF: p. 1013 OBJ: 10
KEY: Nursing
Process Step: Assessment MSC: NCLEX:
Physiological Integrity
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29.
When caring for a 7-week-old infant with hypothyroidism, the nurse explains that the
prevention of what complication is dependent on the administration of oral thyroid
replacement therapy and is critical for the child?
a.
Excessive growth
b.
Cognitive impairment
c.
Damage to the nervous system
d.
Damage to the urinary system
ANS: B
The treatment of choice for congenital and acquired hypothyroidism is oral thyroid
hormone replacement therapy. Prompt treatment is especially critical in the infant
with congenital hypothyroidism to avoid permanent cognitive impairment.
DIF: Cognitive Level: Application
TOP: Hypothyroidism
REF: p. 1016 OBJ: 11
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
30.
The nurse explains to the parents of a child with developmental hip dysplasia that the
application of a Pavlik harness is necessary. In what position will the harness hold the
child‘s femurs?
a.
Abduction
b.
Adduction
c.
Flexion
d.
Extension
ANS: A
The use of the Pavlik harness maintains the hips in abduction for 4 to 6 months.
DIF: Cognitive Level: Application
TOP: Pavlik harness
REF: p. 1019 OBJ: 12
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
31.
A teenage girl has been placed in a brace for the treatment of scoliosis, the most
common skeletal deformity of adolescence. The family asks what they can do to be
more supportive. What suggestion of the nurse is the most appropriate?
a.
Enrolling her in a health club
b.
Taking her to the mall in a wheelchair
c.
Purchasing clothes to disguise the cast
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d.
Spending a majority of their time with her
ANS: C
The adolescent is trying to fit in with peers and has concerns about body image.
DIF: Cognitive Level: Analysis
REF:
p. 1023
KEY:
OBJ: 12 TOP: Scoliosis
Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
32.
A newborn has talipes and is wearing casts. How often should the casts be changed?
a.
Daily
b.
Weekly
c.
Biweekly
d.
Monthly
ANS: B
Treatment of talipes consists of manipulation and the application of a series of short
leg casts. The foot is gently manipulated into a more normal position and then placed
in a cast to maintain the correction. Casts are changed weekly to allow for further
manipulation and to accommodate the rapidly growing infant.
DIF: Cognitive Level: Application
REF:
p. 1023
KEY:
OBJ: 12 TOP: Club foot
Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
33.
A child with Duchenne muscular dystrophy rises from the floor by walking up the
thighs with the hands. How should the nurse record this observation?
a.
Hand assistance
b.
Leg crawling
c.
Gowers sign
d.
Bright sign
ANS: C
Using the hands to walk up the thighs is known as the Gowers sign.
DIF: Cognitive Level: Comprehension REF:
p. 1024
OBJ: 12 TOP:
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Duchenne muscular dystrophy (DMD)
KEY: Nursing Process Step: Assessment
34.
MSC: NCLEX: Physiological Integrity
Which signs/symptoms would be considered classical signs of meningeal irritation?
a.
Positive Kernig sign, diarrhea, and headache
b.
Negative Brudzinski sign, positive Kernig sign, and irritability
c.
Positive Brudzinski sign, positive Kernig sign, and photophobia
d.
Negative Kernig sign, vomiting, and fever
ANS: C
Classical manifestations of meningitis include positive Kernig and Brudzinski signs.
DIF: Cognitive Level: Comprehension REF:
p. 1026
OBJ: 13 TOP: Meningitis KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
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35.
The health care provider is treating a child with meningitis with a course of antibiotic
therapy. When should the nurse expect the child to be out of isolation?
a.
When the course of antibiotics is complete
b.
When a negative CNS culture is obtained
c.
When the antibiotics have been initiated for 24 hours
d.
When the child has no symptoms of the disease
ANS: C
The child with bacterial meningitis is isolated for at least 24 hours until antibiotic therapy
has been administered.
DIF: Cognitive Level: Application
p. 1030
REF:
OBJ: 13 TOP: Meningitis KEY:
Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
36.
What are priority nursing interventions designed to do for a 4-year-old child with cerebral
palsy?
a.
Assist with referral to specialized education.
b.
Support the child with independent toileting.
c.
Assist the child to develop effective communication.
d.
Encourage the child to ambulate independently.
ANS: D
A child with cerebral palsy is usually in need of support with communication,
locomotion, and self-help.
DIF: Cognitive Level: Application
TOP: Cerebral palsy
REF: p. 1032 OBJ: 13
KEY: Nursing Process
Step: Planning MSC: NCLEX: Physiological
Integrity
37.
The nurse is caring for a newborn with a myelomeningocele. Before surgery, what should
the nursing interventions include?
a.
Leaving the lesion uncovered and placing the infant supine
b.
Covering the lesion with a sterile, saline-soaked gauze
c.
Applying lotion to the lesion to keep it moist
d.
Covering the lesion with a dry, sterile gauze
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ANS: B
Nursing interventions for an infant with myelomeningocele include covering the lesion
with a sterile, saline-soaked gauze.
DIF: Cognitive Level: Application
p. 1028
Spina bifida
REF:
OBJ: 13 TOP:
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
38.
Which additional congenital malformation is expected in 80% of infants with a
myelomeningocele?
a.
Cerebral palsy
b.
Hydrocephalus
c.
Meningitis
d.
Neuroblastoma
ANS: B
Hydrocephalus is present in 80% of infants affected by a myelomeningocele.
DIF: Cognitive Level: Comprehension REF:
p. 1033
Spina bifida
OBJ: 13 TOP:
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
39.
When speaking to young parents, the nurse states that lead poisoning is one of the
most common preventable health problems affecting children. What condition
occurs when the level of lead ingested exceeds the amount that can be absorbed by
the bone?
a.
Malnutrition
b.
Anemia
c.
Bone pain
d.
Diarrhea
ANS: B
When the amount of lead ingested exceeds the amount that can be absorbed by the bone,
it leads to anemia.
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DIF: Cognitive Level: Application
TOP: Lead poisoning
REF: p. 1037 OBJ: 14
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
40.
An infant has been diagnosed with cradle cap. What is the correct intervention to treat the
scalp?
a.
Alcohol
b.
Mineral oil
c.
Calamine
d.
A&D ointment
ANS: B
Crusty patches can be removed with the application of mineral oil.
DIF: Cognitive Level: Application
TOP: Skin disorders
REF: p. 1039 OBJ: 15
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
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41.
An adolescent female asks the nurse about taking retinoic acid (Accutane). What
guidance should be provided by the nurse?
a.
The medication should be used only for 10 weeks.
b.
The medication requires that sexually active females use contraception.
c.
The medication lowers hemoglobin very quickly.
d.
The medication has few side effects.
ANS: B
Accutane has many side effects and can produce birth defects. Effective
contraception is necessary during treatment and for 1 month after the 20 weeks it is
to be taken.
DIF: Cognitive Level: Application
REF:
p. 1040
KEY:
OBJ: 15 TOP: Acne
Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
42.
A new mother asks the clinic nurse if she must continue giving her baby nystatin for
thrush since the white lesions on his tongue have disappeared. What response by the
nurse is most appropriate?
a.
―No. When the lesions have gone you may stop the nystatin.‖
b.
―Yes. You should continue it for the full 7 days.‖
c.
―No. Thrush is a self-limiting disorder and nystatin is given for comfort only.‖
d.
―Yes. The medication should be refilled for a second week of therapy.‖
ANS: B
Nystatin should be given for the full 7 days even if the lesions are no longer present.
DIF: Cognitive Level: Analysis
TOP: Skin disorders
REF: p. 1042 OBJ: 15
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
43.
What are early signs of varicella disease?
a.
High fever over 101°F (38.3°C)
b.
General malaise
c.
Increased appetite
d.
Crusty sores
ANS: B
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Early signs of varicella will develop during the prodromal period and are mainly lowgrade fever, malaise, and anorexia. Lesions do not appear until later.
DIF: Cognitive Level: Comprehension REF: p. 1044 OBJ: 15
TOP: Skin disorders
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
44.
The mother of a child who has been diagnosed with varicella asks the nurse when the
child can return to school. When is the child no longer contagious?
a.
When the fever dissipates
b.
After the incubation period
c.
When the lesions have healed
d.
When the lesions are crusted over
ANS: D
Varicella is no longer contagious when the lesions are dry.
DIF: Cognitive Level: Application
TOP: Skin disorders
REF: p. 1036 OBJ: 15
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
45.
A child has developed a diaper rash, and the parents are using zinc oxide to treat
it. What does the nurse suggest to aid in the removal of the zinc oxide?
a.
Mild soap and water
b.
A cotton ball
c.
Mineral oil
d.
Alcohol swabs
ANS: C
To completely remove ointment, especially zinc oxide, mineral oil should be used.
DIF: Cognitive Level: Application
p. 1042
REF:
OBJ: 15 TOP: Diaper rash KEY:
Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
46.
The nurse instructs the parents of a child who has had a myringotomy to place the child in
which position?
a.
Supine
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b.
On the affected side
c.
On the unaffected side
d.
In a Trendelenburg‘s position
ANS: B
Lying on the affected side facilitates ear drainage following a myringotomy.
DIF: Cognitive Level: Application
TOP: Myringotomy
REF: p. 1042 OBJ: 16
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
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47.
What are the clinical manifestations of otitis media?
a.
Earache, wheezing, vomiting
b.
Coughing, rhinorrhea, headache
c.
Fever, irritability, pulling on ear
d.
Wheezing, cough, drainage in ear canal
ANS: C
Clinical manifestations of otitis media include fever, irritability, and pulling on the ear.
DIF: Cognitive Level: Comprehension REF:
p. 982
Otitis media
OBJ: 16 TOP:
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
48.
The nurse instructs the mother of a child with a ventricular septal defect that she can
expect the child to become cyanotic when the child does what?
a.
Experiences an elevation in temperature.
b.
Sleeps on the left side.
c.
Cries vigorously.
d.
Eats.
ANS: C
Crying vigorously will increase the pressure in the right ventricle, which will allow
unoxygenated blood to enter the circulating volume.
DIF: Cognitive Level: Analysis
TOP: Septal defects
REF: p. 1048 OBJ: 1
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
49.
Parents of a 5-year-old child diagnosed as cognitively impaired have come to the
nurse to discuss different approaches to the ongoing care of their child. The nurse
should suggest focusing on what activity?
a.
Acquiring job skills
b.
Making decisions
c.
Performing self-care activities
d.
Reading and doing simple math
ANS: C
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The cognitively impaired young child should be encouraged to learn simple skills for
doing self-care.
DIF: Cognitive Level: Application
REF: p. 1048 OBJ: 19
TOP: Cognitive impairment KEY: Nursing Process
Step: Implementation MSC: NCLEX: Psychosocial
Integrity
50.
The nurse explains that cognitive impairment is categorized by four levels that
depend on the intelligence quotient (IQ). How is a child with an IQ of 45 classified?
a.
Within the normal low range
b.
Educable
c.
Trainable
d.
Severe
ANS: C
The category of trainable is identified on the basis of an IQ of 35 to 55.
DIF: Cognitive Level: Application
REF: p. 1048 OBJ: 17
TOP: Cognitive impairment KEY: Nursing Process
Step: Implementation MSC: NCLEX: Psychosocial
Integrity
51.
What is the major criterion for diagnosing a child as cognitively impaired?
a.
An IQ of 75 or less
b.
Subaverage functioning
c.
An IQ of 70 or less
d.
Onset before 18
ANS: C
Cognitive impairment is based upon IQs from 20 to 70.
DIF: Cognitive Level: Application
REF: p. 1048 OBJ: 17
TOP: Cognitive impairment KEY: Nursing Process
Step: Assessment MSC: NCLEX: Health Promotion
and Maintenance
52.
Which is a priority nursing intervention for the cognitively impaired child?
a.
The family will provide good nutrition.
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b.
The family will provide loving interactions.
c.
Stimulation will improve.
d.
There will be contact with peers.
ANS: B
Nursing interventions focus on promoting optimal development and loving interactions
with family.
DIF: Cognitive Level: Application
REF: p. 977
OBJ: 19
TOP: Cognitive impairment KEY: Nursing Process
Step: Implementation MSC: NCLEX: Health Promotion
and Maintenance
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53.
Which statement correctly explains the etiology of Down syndrome?
a.
There is an extra chromosome on the 21st pair.
b.
There is a missing chromosome on the 21st pair.
c.
There are two pairs of the 21st chromosome.
d.
The chromosome‘s 21st pair is missing.
ANS: A
Down syndrome is attributed to an extra chromosome on the 21st pair.
DIF: Cognitive Level: Comprehension REF: p. 1050 OBJ: 18
TOP: Cognitive impairment KEY: Nursing Process
Step: Evaluation MSC: NCLEX: Health Promotion
and Maintenance
54.
What other congenital defects are common in children with Down syndrome?
a.
Hypospadias
b.
Pyloric stenosis
c.
Heart defects
d.
Hip dysplasia
ANS: C
Many children with Down syndrome have congenital heart defects.
DIF: Cognitive Level: Comprehension REF: p. 1050 OBJ: 18
TOP: Congenital impairment KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological
Integrity
55.
What assessment findings should lead the nurse to suspect Down syndrome in a
newborn?
a.
Hypertonia and dark skin
b.
Low-set ears and a simian crease
c.
Inner epicanthal folds and a high, domed forehead
d.
Long, thin fingers and excessive hair
ANS: B
Manifestations of the Down syndrome infant include low-set ears, simian crease,
protruding tongue, and hypotonic extremities.
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DIF: Cognitive Level: Analysis
REF: p. 1052 OBJ: 18
TOP: Congenital impairment KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
56.
Parents of a school-age child ask the nurse for suggestions in helping the child who is
demonstrating school avoidance. What is an appropriate suggestion by the nurse?
a.
Take the child to the health care provider for testing.
b.
Be firm and insist the child go to school.
c.
Allow the child to stay home and rest.
d.
Consult with the teacher at school.
ANS: B
Parents should be firm and insist the child go to school.
DIF: Cognitive Level: Application
REF: p. 1053 OBJ: 20
TOP: Nursing interventions KEY: Nursing Process
Step: Implementation MSC: NCLEX: Psychosocial
Integrity
57.
The nurse is caring for a child who has been diagnosed as having an attention deficit
hyperactivity disorder (ADHD). What is the most important intervention for the
nurse?
a.
Have the child enrolled in a special education class.
b.
Allay any feelings of guilt the parents may have.
c.
Counsel the parents that the medications are lifelong.
d.
Teach the parents to set limits.
ANS: B
It is most important to allay any feelings of guilt the parents may have.
DIF: Cognitive Level: Application
p. 1053
REF:
OBJ: 21 TOP:
Attention deficit hyperactivity disorder
(ADHD)
KEY: Nursing Process Step:
Implementation MSC:
NCLEX: Psychosocial
Integrity
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58.
Since children with attention deficit hyperactivity disorder (ADHD) take medication
for long periods of time, side effects must be considered. How often should children
be assessed for side effects of the drug therapy?
a.
Every 2 months
b.
Every 4 months
c.
Every 6 months
d.
Every 8 months
ANS: C
Children should be checked for medication side effects every 6 months.
DIF: Cognitive Level: Application
p. 1053
REF:
OBJ: 21 TOP:
Attention deficit hyperactivity disorder
(ADHD)
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
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59.
The parents of a child suffering from depression ask the nurse what causes depression
in children. Which answer is an appropriate response by the nurse?
a.
The causes of major depression are unknown.
b.
Major affective disorders in parents increase depression in children.
c.
Boys are more likely than girls to be depressed.
d.
The prevalence rate is higher in prepubescent children.
ANS: A
The causes of depression have not been established. However, many studies have
shown that children have a three times greater rate of suffering from depression if their
parents have a major affective disorder.
DIF: Cognitive Level: Application
p. 1053
REF:
OBJ: 22 TOP: Depression KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity
60.
When the nurse performs the initial assessment of an adolescent with depression, what is
the most important question to ask?
a.
―What is making you depressed?‖
b.
―Have you ever thought about suicide?‖
c.
―What could we do to make you happy?‖
d.
―Would you like your friends to visit?‖
ANS: B
Ask direct questions about suicidal thoughts. The discovery of whether the person has
an actual plan is an indicator of the seriousness of the situation.
DIF: Cognitive Level: Analysis
REF:
p. 1054
KEY:
OBJ: 23 TOP: Suicide
Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity
61.
What is the most common method of attempted suicide?
a.
Hanging
b.
Drug overdose
c.
Gunshot
d.
Slashing the wrists
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ANS: B
Drug overdose is the most common method of attempted suicide.
DIF: Cognitive Level: Knowledge
REF:
p. 1054
KEY:
OBJ: 23 TOP: Suicide
Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity
62.
Recurrent abdominal pain (RAP) is most often seen in school-age or adolescent
children. The nurse should assess closely for what potential problems?
a.
Physical problems
b.
Relational problems
c.
Eating disorders
d.
Emotional problems
ANS: D
RAP is often related to emotional factors in the child.
DIF: Cognitive Level: Application
TOP: Recurrent abdominal pain (RAP)
REF: p. 1056 OBJ: 22
KEY:
Nursing Process Step: Assessment MSC: NCLEX:
Psychosocial Integrity
63.
When performing an assessment of a child with recurrent abdominal pain (RAP),
the nurse recognizes the child will most likely experience what symptom?
a.
Increased temperature
b.
Constipation
c.
Right quadrant pain
d.
Exercise-associated pain
ANS: B
The child may be constipated with periumbilical pain unrelated to eating, defecation, or
exercise.
DIF: Cognitive Level: Analysis
TOP: Recurrent abdominal pain (RAP)
REF: p. 1056 OBJ: 22
KEY:
Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
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64.
The nurse is recording a history for a child who has been diagnosed with recurrent
abdominal pain (RAP). What is a finding that is characteristic of this disorder?
a.
Morning headaches
b.
Pain for 3 consecutive months
c.
Febrile episodes in the late afternoon
d.
Diaphoresis when attacks occur
ANS: B
Recurrent abdominal pain occurring consecutively for 3 months supports a diagnosis
of RAP once other causes have been ruled out.
DIF: Cognitive Level: Application
TOP: Recurrent abdominal pain (RAP)
REF: p. 1056 OBJ: 22
KEY:
Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
MULTIPLE RESPONSE
1.
When assessing the laboratory values of a child with nephrosis, the nurse anticipates
which results? (Select all that apply.)
a.
High levels of protein in the urine
b.
High serum lipid levels
c.
Low serum protein levels
d.
Low hemoglobin
e.
High white blood cell count
ANS: A, B, C
A patient with nephrotic syndrome has high levels of serum lipids, low serum protein,
and albumin in urine that is dark and frothy with a high specific gravity. The
hemoglobin and WBC are usually normal.
DIF: Cognitive Level: Application
p. 1014
REF:
OBJ: 10 TOP: Nephrosis KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
2.
The nurse explains that which diagnostic studies are needed for the diagnosis of cognitive
impairment? (Select all that apply.)
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a.
Denver Developmental Screening Test
b.
Stanford-Binet Intelligence Scale
c.
Wechsler Intelligence Scale
d.
Miller‘s Analogies
e.
Strong Personality Assessment
ANS: A, B, C
The Denver, Stanford-Binet, and Wechsler are standard intelligence tests that aid in the
diagnosis of a cognitively impaired child.
DIF: Cognitive Level: Analysis
TOP: Intelligence tests
REF: p. 1048 OBJ: 17
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
COMPLETION
1.
When the mother of a child with gastroesophageal reflux calls the clinic nurse to
report that her baby is vomiting small amounts of blood, the nurse explains that the
esophagus has been irritated by gastric
.
ANS:
acid
Gastric acid that has repeatedly come in contact with the esophageal mucosa will erode
the mucosa, and bleeding will result.
DIF: Cognitive Level: Application
TOP: Gastroesophageal reflux (GER)
REF: p. 1008 OBJ: 8
KEY:
Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity
2.
The nurse reassures the anxious mother of a child with pyloric stenosis who is to have
surgery that the surgical procedure, called a
, is quickly done and the child recovers almost immediately.
ANS:
pyloromyotomy
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When the muscle is cut, the obstruction is immediately relieved and the child who is
hungry will begin to eat and keep food down.
DIF: Cognitive Level: Comprehension REF: p. 1009 OBJ: 8
TOP: Pyloromyotomy
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
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3.
The nurse anticipates that the cerebrospinal fluid (CSF) taken from a child with bacterial
meningitis would have a low _
level.
ANS:
glucose
The glucose level in the CSF of a child with bacterial meningitis is low because the
bacteria in the fluid have digested the glucose.
DIF: Cognitive Level: Analysis
TOP: Cerebrospinal fluid (CSF)
REF: p. 1026 OBJ: 13
KEY: Nursing
Process Step: Assessment MSC: NCLEX:
Physiological Integrity
4.
Autism is typically diagnosed between
and 3 years of age.
ANS:
2
Autistic is typically diagnosed between 2 and 3 years of age.
DIF: Cognitive Level: Knowledge
REF:
p. 1050
KEY:
OBJ: 19 TOP: Autism
Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
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Chapter 33: Health Promotion and Care of the
Older Adult Cooper: Foundations and Adult
Health Nursing, 9th Edition
MULTIPLE
CHOICE
1.
When discussing aging, to whom does the term older adulthood apply?
a.
Age 55 and above
b.
Age 65 and above
c.
Age 70 and above
d.
Age 75 and above
ANS: B
Older adulthood begins at about age 65.
DIF: Cognitive Level: Knowledge
REF: p. 1060
OBJ: 1 TOP: Aging
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
2.
When the nurse discusses prevention of cardiac disease, falls, and depression with a
group of older adults, the benefits of what are important to stress?
a.
Nutrition
b.
Medications
c.
Exercise
d.
Sleep
ANS: C
Primary prevention stresses exercise for the prevention of cardiac disease, falls, and
depression.
DIF: Cognitive Level: Comprehension REF: p. 1061 OBJ: 1
TOP: Health promotion
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
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Maintenance
3.
When was the Social Security Act, which was the first major legislation providing
financial security for older adults, passed?
a.
1930
b.
1935
c.
1940
d.
1945
ANS: B
The first major legislation to provide financial security for older adults was the Social
Security Act of 1935.
DIF: Cognitive Level: Knowledge
REF: p. 1064
OBJ: 1 TOP: Legislation
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
4.
When assessing the skin of an older adult patient who is complaining of pruritus, what
should the nurse advise the patient to avoid to reduce further drying of her skin?
a.
Perfumed soap
b.
Hard-milled soap
c.
Antibacterial soap
d.
Lotion soap
ANS: C
Antibacterial soap is very drying.
DIF: Cognitive Level: Application
TOP: Integumentary alterations
REF: p. 1067 OBJ: 8
KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity
5.
Because thin skin and lack of subcutaneous fat predisposes the older adult to
pressure injuries, the nurse alters the care plan to include turning the bedfast patient
how often?
a.
Once every shift
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b.
Every 4 hours
c.
Each evening
d.
Every 2 hours
ANS: D
Pressure injuries can be avoided by repositioning the patient every 2 hours.
DIF: Cognitive Level: Application
TOP: Integumentary alterations
REF: p. 1067 OBJ: 8
KEY: Nursing
Process Step: Planning MSC: NCLEX: Health
Promotion and Maintenance
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6.
At mealtime, the older adult seems to be eating less food than would be adequate.
Compared to the younger adult, what is a requirement for the older adult?
a.
More fluids
b.
Less calcium
c.
Fewer calories
d.
More vitamins
ANS: C
The older adult requires 30 calories per kilogram of body weight, whereas the younger
adult requires 40 calories.
DIF: Cognitive Level: Application
TOP: Gastrointestinal alterations
REF: p. 1069 OBJ: 5
KEY: Nursing
Process Step: Assessment MSC: NCLEX: Health
Promotion and Maintenance
7.
The older patient informs the nurse that food has no taste and therefore the patient has
no appetite. What is this most likely caused by?
a.
Tasteless food
b.
Overuse of salt
c.
Lack of variety
d.
Loss of taste buds
ANS: D
Older adults may experience a loss of appetite. Change in taste as a result of decreased
saliva production and a decreased number of taste buds may make food unappealing.
DIF: Cognitive Level: Application
TOP: Gastrointestinal alterations
REF: p. 1070 OBJ: 5
KEY: Nursing
Process Step: Assessment MSC: NCLEX:
Physiological Integrity
8.
An older adult is having difficulty swallowing. What position should the nurse
recommend to aid in swallowing?
a.
Chin parallel
b.
Chin upward
c.
Chin down
d.
Chin to the side
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ANS: C
The upright position, leaning slightly forward with the chin down, improves swallowing
with the assistance of gravity.
DIF: Cognitive Level: Application
TOP: Gastrointestinal alterations
REF: p. 1071 OBJ: 8
KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity
9.
The patient complains to the nurse about a newly developed intolerance to milk.
What should the nurse suggest to fulfill calcium needs?
a.
Rye bread
b.
Yogurt
c.
Apples
d.
Raisins
ANS: B
Lactose, primarily found in milk, is a common source of food intolerance. Dairy
products are an important source of calcium, which is needed to prevent
osteoporosis. Lactose-intolerant individuals need to replace milk with cheese and
yogurt, which are processed and digested more easily.
DIF: Cognitive Level: Application
TOP: Gastrointestinal alterations
REF: p. 1070 OBJ: 8
KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity
10.
The older adult patient complains to the nurse about nocturia. This problem is most likely
related to:
a.
loss of bladder tone.
b.
decrease in testosterone.
c.
decrease in bladder capacity.
d.
intake of caffeine.
ANS: C
At least 50% of older men and 70% of older women must get up two or more times
during the night to empty their bladders, a condition known as nocturia (excessive
urination at night). The most significant age-related change is the decrease in bladder
capacity.
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DIF: Cognitive Level: Application
REF: p. 1073
OBJ: 5 TOP:
Incontinence KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
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11.
The older adult female patient is concerned about incontinence when she sneezes.
What is the correct terminology for this type of incontinence?
a.
Urge incontinence
b.
Stress incontinence
c.
Overflow incontinence
d.
Functional incontinence
ANS: B
Stress incontinence results from increased abdominal pressure, which occurs with
coughing or sneezing. Urge incontinence occurs after a sudden urge to void and is
associated with cystitis, tumors, stones, and CNS disorders. Overflow incontinence is
associated with diabetic neuropathy and spinal cord injuries. Functional incontinence
results from unwillingness or inability to get to the toilet.
DIF: Cognitive Level: Comprehension
REF: p. 1073
OBJ: 5 TOP:
Incontinence KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
12.
A change of aging related to the circulatory system includes decreased blood vessel
elasticity. For what should the nurse assess?
a.
Confusion
b.
Tachycardia
c.
Hypertension
d.
Retained secretions
ANS: C
The blood vessels become less elastic because of aging and may lead to increased blood
pressure.
DIF: Cognitive Level: Application
REF: p. 1074 OBJ: 5
TOP: Circulatory alterations KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
13.
What should be suggested to a patient to aid with the pain of claudication?
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a.
Rest
b.
Exercise
c.
Cross legs
d.
Stand
ANS: A
A nursing intervention to relieve pain is to recommend the patient rest periodically
until the pain subsides. Exercise and standing for long periods of time can exacerbate
the pain. Crossing the legs can limit blood flow to the extremities and increase pain.
DIF:
Cognitive Level: Application
REF: pp. 1075-1076 OBJ:
8
TOP: Circulatory
alterations
KEY: Nursing Process Step:
Implementation MSC:
NCLEX: Physiological
Integrity
14.
The nurse recommends a breathing technique to help a patient with chronic
obstructive pulmonary disease (COPD) to empty the lungs of used air and to
promote inhalation of adequate oxygen. What is this method of breathing called?
a.
Pursed-lip breathing
b.
Increased inspiration
c.
Vital capacity
d.
Decreased expiration
ANS: A
Pursed-lip breathing can help empty the lungs of used air and promote inhalation of
additional oxygen.
DIF: Cognitive Level: Comprehension
REF: p. 1077
OBJ: 8 TOP:
Chronic obstructive pulmonary disease
(COPD)
KEY: Nursing Process Step:
Implementation MSC:
NCLEX: Physiological
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Integrity
15.
The nurse reminds the 80-year-old patient that her respiratory system has decreased
resistance to respiratory infections. For what is this patient at increased risk?
a.
COPD
b.
Bronchitis
c.
Pneumonia
d.
Atelectasis
ANS: C
Decreased resistance to respiratory infections places older adults at higher risk for
pneumonia.
DIF: Cognitive Level: Application
REF: p. 1077 OBJ: 5
TOP: Respiratory alterations KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
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16.
The nurse recognizes that an older adult patient with COPD has a higher incidence of
developing which age-related skeletal change that will alter the ability to exchange air
effectively?
a.
Osteoporosis
b.
Arthritis
c.
Kyphosis
d.
Osteomyelitis
ANS: C
Kyphosis, usually caused by osteoporosis, is a curvature of the spine that alters
respiration and air exchange.
DIF: Cognitive Level: Application
TOP: Musculoskeletal alterations
REF: p. 1076 OBJ: 5
KEY: Nursing
Process Step: Assessment MSC: NCLEX:
Physiological Integrity
17.
What is a major difference between rheumatoid arthritis and osteoarthritis?
a.
Rheumatoid arthritis is degenerative.
b.
Rheumatoid arthritis only affects patients over 40 years of age.
c.
Rheumatoid arthritis is inflammatory.
d.
Rheumatoid arthritis is curable.
ANS: C
Rheumatoid arthritis is an inflammatory disease; osteoarthritis is degenerative. Rheumatoid
arthritis can affect patients at any age. Neither type of arthritis is curable.
DIF:
Cognitive Level: Application REF: pp. 1078-1079
OBJ: 5
TOP: Arthritis KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological
Integrity
18.
For what is the older adult patient at increased risk because of age-related changes in the
musculoskeletal system?
a.
Fractures due to poor uptake of calcium
b.
Heart attacks due to increased effort to ambulate
c.
Respiratory failure due to kyphosis
d.
Falls related to posture changes
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ANS: D
Falls are the leading cause of accidental death in individuals over 65, in part because of
posture changes brought on by aging.
DIF: Cognitive Level: Analysis
TOP: Musculoskeletal alterations
REF: p. 1091 OBJ: 7
KEY: Nursing
Process Step: Implementation MSC: NCLEX: Health
Promotion and Maintenance
19.
The nurse is assisting an older adult patient out of bed when suddenly the patient begins
to fall. What is the likely cause of the fall?
a.
Fever
b.
Orthostatic hypotension
c.
Dehydration
d.
A decrease in venous return
ANS: B
Orthostatic hypotension occurs when the patient changes position. In the older adult, the
loss of elasticity in the vessels slows the vascular accommodation to sudden postural
changes to a standing position.
DIF: Cognitive Level: Application
TOP: Musculoskeletal alterations
REF: p. 1091 OBJ: 10
KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity
20.
To help prevent falls related to muscle weakness, what type of exercises should be
selected for the aging patient?
a.
Daily
b.
Running
c.
Weight-bearing
d.
Aerobic
ANS: C
Appropriate interventions to increase muscle strength begin with weight-bearing
exercises. They do not have to be done daily to be effective. Running and aerobic
exercise would not be appropriate or effective for the aging patient.
DIF: Cognitive Level: Application
REF: p. 1080 OBJ: 8
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TOP: Musculoskeletal alterations
KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity
21.
What is the best test to identify the risk of osteoporosis in postmenopausal women?
a.
Skeletal x-ray
b.
Bone density scan
c.
Calcium blood level
d.
CAT scan
ANS: B
Bone density testing can identify women at risk for fractures.
DIF: Cognitive Level: Comprehension REF: p. 1080 OBJ: 5
TOP: Osteoporosis
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
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22.
When an older female patient complains of painful sexual intercourse, what should the
nurse recognize as the probable cause?
a.
Urinary incontinence
b.
Arthritic joints
c.
Kyphosis
d.
Mucosal drying
ANS: D
Sexual intercourse may be uncomfortable because of drying of the mucosa of the vagina.
DIF:
Cognitive Level: Application REF:
p. 1082 | p. 1083 OBJ: 5
TOP:
Reproductive alterations
KEY: Nursing Process Step:
Implementation MSC:
NCLEX: Physiological
Integrity
23.
What is age-related vision change caused by the loss of elasticity of the lens called?
a.
Nearsightedness
b.
Cataracts
c.
Presbyopia
d.
Blepharitis
ANS: C
Age-related changes include presbyopia and farsightedness resulting from a loss
of elasticity of the lens. Cataracts are due to opacity of the lens.
DIF: Cognitive Level: Comprehension REF: p. 1084 OBJ: 5
TOP: Sensory alterations KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
24.
When communicating with an older adult patient who has difficulty hearing, how should
the nurse change her speech?
a.
Speak very loudly
b.
Speak rapidly
c.
Lower the tone of the voice
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d.
Raise the tone of the voice
ANS: C
To communicate with a patient with a hearing loss, the nurse should lower the tone of the
voice.
DIF: Cognitive Level: Application
REF: p. 1086 OBJ: 8
TOP: Sensory alterations KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
25.
Which symptom of diabetes distorts tactile sensation?
a.
Proprioception
b.
Loss of visual acuity
c.
Progressive paresis
d.
Peripheral neuropathy
ANS: D
Peripheral neuropathy is the presence of abnormal sensation and it distorts tactile
sensation.
DIF: Cognitive Level: Comprehension
REF: p. 1085
OBJ: 4 TOP: Diabetes
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
26.
What is the result of a slowing of the impulse transmission in the nervous system?
a.
Hypertension
b.
Hearing deficit
c.
Decrease in tactile sensations
d.
Longer reaction time
ANS: D
When nerve impulses in the nervous system of an older adult slow down, the result is a
longer reaction time.
DIF: Cognitive Level: Application
REF: p. 1086 OBJ: 5
TOP: Neurologic alterations KEY: Nursing Process
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Step: Assessment MSC: NCLEX: Physiological
Integrity
27.
What is the most common cause of dementia?
a.
Multi infarct
b.
Medications
c.
Alzheimer‘s disease
d.
Parkinson disease
ANS: C
Alzheimer‘s disease is the most common cause of dementia.
DIF: Cognitive Level: Knowledge
REF: p. 1088
OBJ: 9 TOP: Dementia
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Health Promotion and Maintenance
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28.
What is one positive aspect of Parkinson disease?
a.
The disease does not alter ability to communicate.
b.
Anti-Parkinson drugs have few side effects.
c.
Intellectual function is not impaired.
d.
Involuntary movements can be controlled.
ANS: C
Parkinson disease does not impair the intellect. The disease does alter the ability to
communicate. Anti-Parkinson drugs have many side effects. The involuntary
movements associated with the disease cannot be controlled.
DIF: Cognitive Level: Application
TOP: Parkinson disease
REF: p. 1090 OBJ: 4
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
29.
When should family members of a stroke victim expect to see some of the neurologic
involvement disappear?
a.
Within 2 to 3 weeks
b.
Within 1 to 2 months
c.
Within 3 to 6 months
d.
Within 6 to 9 months
ANS: C
Some of the initial neurologic deficits of a cerebrovascular accident may disappear in 3 to
6 months.
DIF: Cognitive Level: Application
REF: p. 1090
OBJ: 4 TOP: Stroke
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
30.
When communicating with an older adult patient, the nurse becomes aware of the
fact that the patient is well satisfied with his accomplishments over a lifetime and
has no regrets concerning aging. Which of Erikson‘s developmental stages has the
patient achieved?
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a.
Acceptance
b.
Withdrawal
c.
Ego integrity
d.
Interaction
ANS: C
The last stage of life is acceptance of life and it results in ego integrity.
DIF: Cognitive Level: Analysis
REF: p. 1064
OBJ: 3 TOP: Aging
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Psychosocial Integrity
31.
Which areas are affected only minimally by age?
a.
Physical activity
b.
Productivity
c.
Cognition
d.
Sexuality
ANS: C
Aging has little influence on cognition. Only through disease processes is cognition
altered.
DIF: Cognitive Level: Comprehension
REF: p. 1086
OBJ: 5 TOP: Aging
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Psychosocial Integrity
32.
How often does a 76-year-old need a screening for preventive health?
a.
Every 2 years
b.
Every 6 months
c.
Every 3 years
d.
Every year
ANS: D
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A complete physical is recommended annually after 75.
DIF: Cognitive Level: Comprehension REF: p. 1062 OBJ: 6
TOP: Health promotion
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
33.
When assessing the older adult, the nurse considers which aspect of the patient‘s routine
as a possible contributor to constipation?
a.
Intake of antacids several times a day
b.
Taking a laxative once a week
c.
Excessive exercise routine
d.
Eating two apples a day
ANS: A
Intake of antacids is constipating. All other options decrease the risk of constipation.
DIF: Cognitive Level: Analysis
REF: p. 1071
OBJ: 8 TOP:
Constipation KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
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MULTIPLE RESPONSE
1.
What should the nurse do to help the dysphagic patient? (Select all that apply.)
a.
Sit the patient upright.
b.
Reduce distraction during mealtime.
c.
Offer fluid from a straw.
d.
Thicken liquids.
e.
Cue the patient to swallow.
ANS: A, B, D, E
Offering fluids using a straw increases the possibility of choking or aspiration.
All other options would be beneficial to the dysphagic patient.
DIF: Cognitive Level: Application
TOP: Gastrointestinal alterations
REF: p. 1071 OBJ: 8
KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity
2.
Which statements are myths that have been disproved concerning aging? (Select all that
apply.)
a.
All older adults are senile.
b.
Most older adults live in their own homes.
c.
Older adults are poor.
d.
Older adults have frequent contact with family members.
e.
Older adults are disabled.
ANS: A, C, E
All older adults are not senile; this is a myth. Mental decline is not inevitable. Older
adults are not all poor; this is a myth. Older adults have a lower poverty rate than
younger adults. Older adults are not all disabled; this is a myth. Most are able to
manage their own care. Most older adults do live in their own homes and have
frequent contact with family members.
DIF: Cognitive Level: Comprehension REF: p. 1064 OBJ: 2
TOP: Aging myths
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
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3.
Which approaches should be included when teaching medication safety to an older,
homebound adult? (Select all that apply.)
a.
Always dispose of expired medications in the toilet or
the sink; never throw them in the trash can.
b.
Never share medications with others.
c.
If a medication is not finished as prescribed, save it for future use.
d.
Keep medications in their original containers.
e.
Always request childproof containers, even if the
patient has trouble opening the lids.
ANS: A, B, D
Expired medications should always be disposed of in the toilet or sink; they should
never be thrown in the trash where they could be retrieved by others. Medications
should never be shared with anyone else. Medications should always be stored in their
original containers. A prescription should always be taken as prescribed by the health
care provider. Medications should never be saved for future use. If an older adult has
trouble opening childproof medication containers, he should request non-childproof
lids.
DIF: Cognitive Level: Application
TOP: Medication practices
REF: p. 1093 OBJ: 8
KEY: Nursing Process
Step: Implementation MSC: NCLEX: Health Promotion
and Maintenance
COMPLETION
1.
When bathing an 80-year-old woman who lives on a farm, the nurse assesses brown
macules on the patient‘s hands and forearms. The nurse recognizes these as .
ANS:
lentigo
Lentigo is a term that refers to brown-pigmented lesions on the skin of the older person
who has spent a great deal of time in the sun. These macules are also called ―age
spots.‖
DIF: Cognitive Level: Comprehension REF: p. 1066 OBJ: 5
TOP: Integumentary alterations
KEY: Nursing
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Process Step: Assessment MSC: NCLEX:
Physiological Integrity
2.
The nurse initiates the application of a draw sheet on every bedfast patient on her unit to
facilitate lifting and to prevent
forces.
ANS:
shearing
Shearing forces cause skin damage by friction; for instance, when a patient is dragged
across bed linens during a position change.
DIF: Cognitive Level: Knowledge
TOP: Integumentary alterations
REF: p. 1067 OBJ: 8
KEY: Nursing
Process Step: Planning MSC: NCLEX:
Physiological Integrity
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3.
The nurse recognizes that a term referring to mechanical difficulty of swallowing is
.
ANS:
dysphagia
Dysphagia is a term that refers to mechanical difficulties in swallowing.
DIF: Cognitive Level: Knowledge
TOP: Gastrointestinal alterations
REF: p. 1071 OBJ: 5
KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity
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Chapter 34: Concepts of Mental Health
Cooper: Foundations and Adult Health Nursing, 9th Edition
MULTIPLE
CHOICE
1.
What is the mental health nurse referring to when using the term behavior?
a.
An isolated incident
b.
The manner in which a person performs
c.
A product of a coping strategy
d.
Failure to adapt
ANS: B
Behavior may be defined as the manner in which a person performs any or all of the
activities of daily living.
DIF: Cognitive Level: Knowledge
TOP: Mental health
REF: p. 1100 OBJ: 1
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
2.
What definition should the nurse use to clarify the concept of ―mental health‖?
a.
A wellness of attitude
b.
A person‘s response to disease and dysfunction
c.
The ability to cope and adjust to everyday stresses
d.
How the person performs activities of daily living
ANS: C
Mental health can be defined as a person‘s ability to cope and adjust to everyday stresses.
DIF: Cognitive Level: Comprehension REF: p. 1100 OBJ: 1
TOP: Mental health
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
3.
How should the nurse document the behavior of a patient with mental illness?
a.
Very disruptive to a person in society
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b.
Differing from socially acceptable behavior
c.
Causing the person to be involved in problems
d.
Resulting from an inability to exercise control
ANS: B
Mental illness can cause behavior that deviates from socially and culturally acceptable
behavior.
DIF: Cognitive Level: Analysis
TOP: Mental health
REF: p. 1101 OBJ: 2
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
How many people in the United States will develop a mental disorder during their
4.
lifetime?
a.
One in two
b.
One in five
c.
One in eight
d.
One in ten
ANS: A
It is estimated that 50% of people in the United States will develop a mental disorder
during their lifetime.
DIF: Cognitive Level: Comprehension REF: p. 1101 OBJ: 2
TOP: Mental health
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
5.
During the 17th and 18th centuries, care of patients with mental illness often was
cruel. What type of care was used by Dr. Philippe Pinel to bring about change?
a.
Personal care
b.
Individual care
c.
Behavior care
d.
Humane care
ANS: D
Dr. Philippe Pinel advocated humane care.
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DIF: Cognitive Level: Comprehension REF:
p. 1102
OBJ: 1 TOP:
Mental health
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
6.
When was psychiatric training for nurses initially offered?
a.
1852
b.
1882
c.
1902
d.
1922
ANS: B
In 1882, McLean Hospital in Waverly, Massachusetts, provided the first psychiatric
training school for nurses.
DIF: Cognitive Level: Knowledge
REF:
p. 1102
OBJ: 1 TOP:
Mental health
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
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7.
Using the mental health continuum as a guide, the nurse observes behavior that
usually places an individual on the illness end of the continuum. What is true of this
behavior?
a.
It causes extreme concern about health.
b.
It results in inability to function in society.
c.
It demonstrates that the person is out of touch with reality.
d.
It results in inability to interact with people.
ANS: C
On the illness end of the mental health continuum, the person is rarely in touch with
reality.
DIF: Cognitive Level: Application
TOP: Mental health
REF: p. 1103 OBJ: 1
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
8.
The majority of people function in a relatively healthy manner. What can diminish their
functional capacity?
a.
Lack of a support system
b.
Periods of crisis
c.
Nutritional deficits
d.
A physical disease process
ANS: B
Periods of crisis can decrease functional capacity, moving a person toward the illness end
of the continuum.
DIF: Cognitive Level: Application
REF:
p. 1103
OBJ: 1 TOP:
Mental health
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
9.
What is the basis for classifying a person as having a mental illness?
a.
Behavior exhibited and the context
b.
Response of society to the behavior
c.
Ability of the patient to conform
d.
Patient‘s history and previous behavior
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ANS: A
A person is deemed to be mentally ill by the behavior exhibited and the context in which
that behavior occurs.
DIF: Cognitive Level: Application
REF:
p. 1104
OBJ: 2 TOP:
Mental health
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
10.
Using Freud‘s personality theory, what action by a patient identifies the influence of the
superego?
a.
Eating an entire chocolate pie
b.
Becoming anxious about having no visitors
c.
Monopolizing the attention of the health care provider
d.
Returning a $5 bill that another patient left on the table
ANS: D
The superego is the mediator between right and wrong (the conscience).
DIF: Cognitive Level: Analysis
TOP: Mental health
REF: p. 1104 OBJ: 3
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
11.
Using Freud‘s personality theory, what action by a patient indicates a strong ego?
a.
Laughs at himself for being foolish.
b.
Continually boasts of his accomplishments.
c.
Apologizes continually.
d.
Insists that the TV channel stay tuned to CNN.
ANS: A
Ego is the reality tester. Laughing at oneself shows that the patient can compare his own
foolish behavior to the norm.
DIF: Cognitive Level: Analysis
TOP: Mental health
REF: p. 1104 OBJ: 3
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
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12.
Which theorist believed that personality development was based on task mastery?
a.
Sigmund Freud
b.
Erik Erikson
c.
Jean Piaget
d.
Friedrich Nietzsche
ANS: B
Erik Erikson provided a framework for understanding personality development in terms of
task mastery. Sigmund Freud described personality development as having three parts: id,
ego, and superego. Jean Piaget theorized that development was based on how humans
acquire and utilize knowledge. Friedrich Nietzsche‘s theories had more to do with
morality than personality development.
DIF: Cognitive Level: Comprehension REF:
p. 1104
OBJ: 2 TOP:
Mental health
KEY: Nursing
Process Step: N/A MSC: NCLEX: Psychosocial
Integrity
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13.
Which role is an example of an ascribed role?
a.
Sex
b.
Occupation
c.
Manner of dealing with stress
d.
Attitude toward homosexuality
ANS: A
Ascribed roles are those that a person takes on, but had no personal choice in the
matter. Ethnicity, sex, and nationality are examples of ascribed roles.
DIF: Cognitive Level: Comprehension REF: p. 1105 OBJ: 3
TOP: Mental health
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
14.
The nurse is assessing a young woman who is a teacher, happily married, raising two
children, taking care of her disabled mother, and going to school to get a master‘s
degree. How should the behavior of the young woman be classified?
a.
Ego-centered
b.
Role integrated
c.
High-level wellness
d.
Unbounded energy
ANS: B
Role integration is performing several ascribed roles at the same time.
DIF: Cognitive Level: Analysis
TOP: Mental health
REF: p. 1105 OBJ: 3
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
15.
What action consistently done by a patient should indicate to a nurse that the patient has a
poor self-concept?
a.
Wears bright-colored clothing.
b.
Demands the attention of staff.
c.
Apologizes to others repeatedly.
d.
Becomes angry when frustrated.
ANS: C
Apologizing repeatedly is indicative of self-effacement. Anger, demanding attention, and
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wearing attention-getting clothing are not characteristics of a poor self-concept.
DIF:
Cognitive Level: Analysis
p. 1103 | p. 1104 OBJ: 2
REF:
TOP: Mental
health
KEY: Nursing Process Step: Assessment
16.
MSC: NCLEX: Psychosocial Integrity
What does any event that requires change stimulate?
a.
Anger
b.
Depression
c.
Stress
d.
Anxiety
ANS: C
Any event that requires change leads to stress, which is the nonspecific response of the
body to any demand.
DIF: Cognitive Level: Comprehension REF: p. 1105 OBJ: 7
TOP: Mental health
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
17.
A nurse tearfully confides to the head nurse that being assigned to care for eight
patients is stressful and overwhelming. What demonstrates the use of a healthy
coping mechanism?
a.
Writing down long lists of needed interventions before starting the day‘s work
b.
Delegating appropriate care assignments to unlicensed assistive personnel
c.
Asking a coworker to take one of her patients
d.
Asking for the day off
ANS: B
The use of delegation is an effective coping mechanism. The other options are not
healthy as they either delay or avoid dealing with the stress.
DIF:
Cognitive Level: Analysis
p. 1105 | p. 1106 OBJ: 2
REF:
TOP: Mental
health
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity
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18.
A perceived threat to self causes what emotion?
a.
Fear
b.
Anger
c.
Depression
d.
Anxiety
ANS: D
Anxiety can be defined as a vague feeling of apprehension resulting from a perceived
threat to self.
DIF: Cognitive Level: Knowledge
TOP: Mental health
REF: p. 1105 OBJ: 7
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
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19.
What action by a student before taking a test should indicate to a nursing
instructor that the student is demonstrating signs of moderate anxiety?
a.
Studies for 6 hours
b.
Sleeps 6 hours because of fatigue
c.
Vomits
d.
Argues about the scheduling of the test
ANS: C
Symptoms of anxiety include the following: vocal changes, rapid speech, increased pulse,
respirations, and blood pressure, tremors, restlessness, increased perspiration, nausea,
decreased appetite, diarrhea, frequent urination, and vomiting.
DIF: Cognitive Level: Application
TOP: Mental health
REF: p. 1105 OBJ: 7
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
20.
What coping mechanism demonstrated by a patient should indicate to the nurse that
the patient is seeking ways to deal with and resolve stress?
a.
Projection
b.
Adaptation
c.
Reaction formation
d.
Compensation
ANS: B
An individual who develops ways to deal with stress and resolve it has adapted.
DIF: Cognitive Level: Application
TOP: Mental health
REF: p. 1106 OBJ: 9
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
21.
A 40-year-old patient cries and has a tantrum when the health care provider refuses
to give her a prescription for diet pills. The nurse realizes that this is the use of
which defense mechanism?
a.
Compensation
b.
Denial
c.
Regression
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d.
Repression
ANS: C
Regression is a behavior that reflects the return to an earlier form of coping.
DIF: Cognitive Level: Application
TOP: Mental health
REF: p. 1107 OBJ: 6
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
22.
When the patient who overeats insists that weight gain is related to retained fluids,
the nurse recognizes the patient is using which defense mechanism?
a.
Compensation
b.
Rationalization
c.
Sublimation
d.
Regression
ANS: B
Defense mechanisms are unconscious reactions that offer protection to the self from
stressful situations. Rationalization offers a reasonable explanation for an event rather
than facing reality.
DIF: Cognitive Level: Application
TOP: Mental health
REF: p. 1106 OBJ: 6
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
23.
After finding the patient with diabetes eating candy, the nurse reminds the patient
that the candy will elevate blood sugar levels. The patient‘s response is: ―It‘s only a
little bit, and it won‘t do anything.‖ Which defense mechanism is the patient using?
a.
Conversion
b.
Denial
c.
Repression
d.
Regression
ANS: B
The patient is using denial as a defense mechanism. Reality is denied.
DIF:
Cognitive Level: Application REF:
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p. 1107 | p. 1109 OBJ: 6
TOP: Mental
health
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity
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24.
The patient complains to the nurse that the health care provider does not like him
and wants him to fail at following the diet prescribed. The nurse recognizes that
the patient is using which defense mechanism?
a.
Conversion
b.
Projection
c.
Introjection
d.
Repression
ANS: B
Projection is attributing to other‘s characteristics that the person does not want to
acknowledge.
DIF: Cognitive Level: Application
TOP: Mental health
REF: p. 1107 OBJ: 6
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
25.
The nurse is sensitive to the fact that patients lose control over their lives when
admitted to the hospital. In what does this loss of control frequently result?
a.
Anger
b.
Depression
c.
Fear
d.
Anxiety
ANS: D
Loss of control may result in feelings of apprehension and uncertainty.
DIF: Cognitive Level: Application
TOP: Mental health
REF: p. 1106 OBJ: 5
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
26.
The patient admitted to the hospital may adjust to illness by assuming a role in which
everyday responsibilities are avoided. What is this role called?
a.
Patient role
b.
Illness role
c.
Sick role
d.
Dependent role
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ANS: C
The sick role allows the patient to be excused from everyday responsibilities.
DIF: Cognitive Level: Comprehension REF: p. 1108 OBJ: 8
TOP: Mental health
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
27.
Why is it important for the nurse to be observant of patient behavior?
a.
Behavior is preformed.
b.
Behavior is important.
c.
Behavior is learned.
d.
Behavior is repeated.
ANS: C
Behavior is learned and has meaning.
DIF: Cognitive Level: Comprehension REF: p. 1109 OBJ: 9
TOP: Mental health
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
28.
What is a nursing intervention that helps to build trust, encourages the patient to
have faith in the care being received, and meets psychosocial needs?
a.
Developing a care plan
b.
Implementing nurse orders
c.
Patient education
d.
Meeting patient goals
ANS: C
One of the steps to meet the psychosocial needs of the patient is patient education.
DIF: Cognitive Level: Application
TOP: Mental health
REF: p. 1108 OBJ: 10
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
29.
A family is informed that the brain damage to their daughter is irreversible. The father
is later overheard making vacation plans and discussing what the family will do when
his daughter leaves the hospital. The nurse recognizes the father is in which crisis
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stage?
a.
High anxiety
b.
Denial
c.
Reconciliation
d.
Adaptation
ANS: B
The father is exhibiting signs of denial. Once the reality of the situation becomes evident,
anger and confusion follow.
DIF:
Cognitive Level: Application REF:
p. 1107 | p. 1109 OBJ: 9
TOP: Mental
health
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity
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30.
When developing a care plan for a mentally ill patient, what should the nurse assess first?
a.
Coping strategies
b.
Emotional status
c.
Medications taken
d.
Nutritional status
ANS: B
The nurse‘s first priority would be to assess the emotional status of the mentally ill
patient.
DIF: Cognitive Level: Comprehension REF: p. 1110 OBJ: 9
TOP: Mental health
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
31.
When the patient is told that his insurance will no longer pay for his physical therapy,
the nurse is aware that this obstruction to his goal may result in which concept?
a.
Conflict
b.
Adaptation
c.
Frustration
d.
Anxiety
ANS: C
Frustration refers to anything that interferes with goal-directed activity.
DIF: Cognitive Level: Application
TOP: Mental health
REF: p. 1106 OBJ: 9
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
32.
What is the most likely result when an attempt at adaptation fails?
a.
Depression
b.
Anger
c.
Frustration
d.
Anxiety
ANS: D
When adaptive behavior fails, anxiety increases.
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DIF: Cognitive Level: Application
TOP: Mental health
REF: p. 1106 OBJ: 5
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
33.
The nurse is assessing a nervous 18-year-old patient who has vital signs of P 120, R
30, and BP 160/90. The patient states that he feels something bad is about to happen.
Based on this data alone, how should the nurse identify the patient‘s level of anxiety?
a.
Mild
b.
Moderate
c.
Severe
d.
Panic
ANS: C
Severe anxiety may be manifested by elevated blood pressure, pulse, and respiratory
rate, a feeling of impending danger, and feelings of fatigue.
DIF: Cognitive Level: Analysis
TOP: Mental health
REF: p. 1105 OBJ: 9
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
34.
When assisting the older adult who is despondent about the need to leave his home, what
technique should the nurse use?
a.
Ask him if he has a drinking problem.
b.
Explore the option of his moving in with someone.
c.
Reminisce with the patient and review his life.
d.
Assess for hopelessness and helplessness.
ANS: C
Reminiscence and life review are effective techniques to help older adults deal with
changing life circumstances.
DIF: Cognitive Level: Application
TOP: Mental health
REF: p. 1108 OBJ: 10
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
35.
A patient admitted to the hospital after a motorcycle crash that has left him
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paralyzed from the waist down tells the nurse he has feelings of helplessness and
hopelessness. What other feelings may the patient have that should be recognized?
a.
Isolation
b.
Suicidal ideation
c.
Fear
d.
Anger
ANS: B
Hopelessness and helplessness can lead to possible thoughts of suicide.
DIF: Cognitive Level: Application
TOP: Mental health
REF: p. 1108 OBJ: 9
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
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36.
Which event in the mental health care movement occurred first?
a.
Establishment of Pennsylvania Hospital
b.
Deinstitutionalization movement
c.
Formation of Committee for Mental Health
d.
Passage of Omnibus Budget Reconciliation Act (OBRA)
e.
Dorothea Dix awakens public awareness of plight of mentally ill
ANS: A
Pennsylvania Hospital—1731, Dorothea Dix—1882, Committee for Mental Health—
1909, deinstitutionalization movement—1960, OBRA—1981.
DIF: Cognitive Level: Application
REF:
p. 1102
OBJ: 1 TOP:
Mental health
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
MULTIPLE RESPONSE
1.
The nurse uses a diagram to show how the four parts of ―self‖ fit together. What are the
four parts? (Select all that apply.)
a.
Body image
b.
Ego
c.
Self-esteem
d.
Role
e.
Identity
ANS: A, C, D, E
The four parts of the ―self‖ are body image, self-esteem, role, and identity.
DIF: Cognitive Level: Comprehension REF: p. 1104 OBJ: 3
TOP: Mental health
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
2.
A variety of factors influence the level of anxiety experienced by the patient faced by
a stressful situation. Which would the nurse outline? (Select all that apply.)
a.
How others perceive the event
b.
The number of stressors present at one time
c.
Degree of change the stressors require
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d.
Present role assumption
e.
Previous experience with a similar situation
ANS: B, C, D, E
The number of stressors present at one time, the degree of change the stressors require,
present role assumption, and previous experience with a similar situation are all factors
that can influence the level of anxiety experienced when faced with a stressful situation.
The level of anxiety experienced is also influenced by how the event is perceived by the
individual, not how the event is perceived by others.
DIF: Cognitive Level: Analysis
TOP: Mental health
REF: p. 1106 OBJ: 7
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
COMPLETION
1.
The situation in which a parent must choose between attending a daughter‘s ballet
recital or a son‘s baseball game is an example of a
.
ANS:
conflict
Conflict occurs when there is a presence of simultaneous goals, only one of which can be
met.
DIF: Cognitive Level: Application
TOP: Mental health
REF: p. 1106 OBJ: 7
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
2.
In the movie Gone With the Wind, Scarlett O‘Hara says, ―I‘ll think about that
tomorrow. Tomorrow is another day.‖ The nurse recognizes the defense mechanism
of
.
ANS:
repression
Repression is an unconscious barring of anxiety-producing thoughts.
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DIF: Cognitive Level: Comprehension REF: p. 1107 OBJ: 6
TOP: Mental health
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
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Chapter 35: Care of the Patient with a Psychiatric
Disorder Cooper: Foundations and Adult Health
Nursing, 9th Edition
MULTIPLE
CHOICE
1.
The nurse is discussing the differences between a patient with a neurosis and one
with a psychosis. What is true of the patient experiencing a neurosis?
a.
The patient experiences a flight from reality.
b.
The patient usually needs hospitalization.
c.
The patient has insight that there is an emotional problem.
d.
The patient has severe personality deterioration.
ANS: C
An individual with a neurosis has insight that he has an emotional problem. A person
with psychosis is out of touch with reality and has severe personality deterioration.
Treatment for neurosis is usually completed in the outpatient setting, while treatment
for psychosis often requires hospitalization.
DIF: Cognitive Level: Application
TOP: Mental illness
REF: p. 1113 OBJ: 2
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
2.
When the patient with a psychosis is thought to be a danger to self or others, by what
method should the patient be admitted to the hospital?
a.
Probating
b.
Nurse‘s request
c.
Health care provider‘s order
d.
Family request
ANS: A
Probating can be done if the individual is thought to be a danger to self or others.
DIF: Cognitive Level: Comprehension REF: p. 1113 OBJ: 4
TOP: Mental illness
KEY: Nursing Process Step:
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Implementation MSC: NCLEX: Psychosocial Integrity
3.
The Diagnostic and Statistical Manual of Psychiatric Disorders, V (DSM-V), is used
by most hospitals and is the current tool used to examine mental health and illness.
What approach does the DSM-V use to classify mental disorders?
a.
Holistic system
b.
Hierarchical system
c.
Multiaxial system
d.
Evaluation system
ANS: C
The DSM-V is a multiaxial system.
DIF: Cognitive Level: Comprehension REF:
p. 1113
OBJ: 1 TOP:
Mental illness
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
4.
When all five axes of the Diagnostic and Statistical Manual of Psychiatric
Disorders, V, are used, it provides what type of assessment approach to
comprehensive care?
a.
Personalized
b.
Individualized
c.
Holistic
d.
Organic
ANS: C
Using all five axes of the DSM-V provides a holistic assessment.
DIF:
Cognitive Level: Comprehension REF: NIT
TOP: Mental illness
OBJ: 1
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
5.
A young man with malaria spikes a temperature of 105°F (40.5°C) and begins to
hallucinate. How should the nurse assess this?
a.
Delirium
b.
Psychotic break
c.
Possible stroke
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d.
Anxiety disorder
ANS: A
Delirium is an organic mental disorder that is frequently brought on by a severe physical
illness, such as fever.
DIF: Cognitive Level: Application
TOP: Mental illness
REF: p. 1114 OBJ: 2
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
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6.
A patient admitted for delirium demonstrates increased disorientation and agitation
only during the evening and nighttime. What is the term applied to this type of
delirium?
a.
Disordered thinking
b.
Schizophrenia
c.
Dementia
d.
Sundowning syndrome
ANS: D
A patient with sundowning syndrome displays increased disorientation and agitation
only during evening and nighttime. Disordered thinking occurs when an individual is
not able to interpret information being received in the brain. Disordered thinking is
one characteristic of schizophrenia, which is a large group of psychotic disorders that
includes nonreality-based thinking.
Dementia is an altered mental state secondary to cerebral disease.
DIF: Cognitive Level: Application
TOP: Mental illness
REF: p. 1114 OBJ: 2
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
7.
Dementia is an organic mental disease secondary to what problem?
a.
Chemical imbalance
b.
Emotional problems
c.
Circulatory impairment
d.
Cerebral disease
ANS: D
Dementia describes an altered mental state secondary to cerebral disease.
DIF: Cognitive Level: Knowledge
TOP: Mental illness
REF: p. 1114 OBJ: 2
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
8.
A profound, disabling mental illness is characterized by bizarre, nonreality thinking.
What is the illness?
a.
Manic depressive
b.
Schizophrenia
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c.
Paranoia
d.
Bipolar
ANS: B
Schizophrenia, a thought process disorder, is one of the most profoundly disabling mental
illnesses.
DIF: Cognitive Level: Knowledge
TOP: Mental illness
REF: p. 1114 OBJ: 2
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
9.
A patient believes himself to be the president of the United States and that terrorists
are trying to kidnap him. The nurse records these observations as which type of
behavior?
a.
Absent behavior
b.
Positive behavior
c.
Negative behavior
d.
False behavior
ANS: B
The behaviors of schizophrenic individuals can be categorized as positive (or
excessive) or negative (or absent). Examples of positive behaviors include
hallucinations, delusions, and disordered thinking. Examples of negative behaviors
include apathy, social withdrawal, and flat affect.
DIF: Cognitive Level: Application
TOP: Mental illness
REF: p. 1114 OBJ: 2
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
10.
The patient talks with his dead brother and arranges furniture so that his brother
will have a place to sit. How should the nurse document this behavior?
a.
Disordered thinking
b.
Anhedonia
c.
Hallucination
d.
Alogia
ANS: C
A hallucination is a sensory experience without a stimulus trigger. Disordered thinking
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occurs when the individual is not able to interpret information being received in the
brain. Anhedonia describes lack of expressed feelings. Alogia is reduced content of
speech.
DIF: Cognitive Level: Application
TOP: Mental illness
REF: p. 1120 OBJ: 2
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
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11.
What is the prognosis for a schizophrenic patient who is exhibiting positive behaviors?
a.
Guarded
b.
Poor
c.
Good
d.
Repeatable
ANS: C
Prognosis for schizophrenic patients who are exhibiting positive behavior patterns is
good.
DIF: Cognitive Level: Comprehension REF: p. 1114 OBJ: 2
TOP: Mental illness
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
12.
The nurse cautions a patient to watch his step. What response indicates concrete thinking?
a.
The patient fixedly begins to watch his feet.
b.
The patient immediately examines his watch.
c.
The patient begins to watch the nurse‘s feet.
d.
The patient stands rigidly in one place without moving.
ANS: A
Concreteness is an indication of disordered thinking. The patient is unable to translate
any words except by a very concrete definition.
DIF: Cognitive Level: Application
TOP: Mental illness
REF: p. 1120 OBJ: 2
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
13.
The nurse asks a patient with schizophrenia if he had any visitors on Sunday. Which
response indicates loose association?
a.
―No.‖
b.
―Yes! I had 90 visitors who came from every state in the union.‖
c.
―Sunday is the Sabbath. Do we have visitors on the Sabbath?‖
d.
―We visited Yellowstone Park last summer.‖
ANS: D
Loose association is a type of disordered thinking that occurs when the individual
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cannot interpret information and the conversation does not flow.
DIF: Cognitive Level: Application
TOP: Mental illness
REF: p. 1120 OBJ: 2
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
14.
The nurse is caring for a patient with a diagnosis of catatonic schizophrenia. What
behavior is consistent with this diagnosis?
a.
Talks excitedly about going home.
b.
Suspiciously watches the staff.
c.
Stands on one foot for 15 minutes.
d.
States he has a cat under his bed that talks to him.
ANS: C
Maintaining a rigid pose for long periods of time is an example of behavior expected with
catatonic schizophrenia.
DIF: Cognitive Level: Application
TOP: Mental illness
REF: p. 1120 OBJ: 2
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
15.
What is the term used for the beginning stage of schizophrenia, characterized by a
lack of energy and complaints of multiple physical problems?
a.
Prepsychotic
b.
Residual
c.
Acute
d.
Prodromal
ANS: D
The prodromal phase is the beginning stage of schizophrenia. Hallucinations and
delusions sometimes occur in the prepsychotic stage. In the acute phase, individuals
often lose touch with reality. The residual phase follows the acute phase and the
symptoms of that phase are similar to those of the prodromal stage.
DIF: Cognitive Level: Application
TOP: Mental illness
REF: p. 1120 OBJ: 2
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
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Integrity
16.
For the past 3 weeks, the nurse has observed a patient interacting with staff and other
patients, helping decorate the dining room for a party, and leading the singing in the
activity room. Today, the patient tearfully refuses to dress or get out of bed. The
nurse recognizes these behaviors as evidence of which psychiatric disorder?
a.
Unipolar depression
b.
Dysthymic disorder
c.
Hypomanic episode
d.
Bipolar disorder
ANS: D
Bipolar disorder can cause the patient to experience a sudden shift in emotion from one
extreme to the other.
DIF: Cognitive Level: Application
TOP: Mental illness
REF: p. 1121 OBJ: 2
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
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17.
The nurse recognizes that researchers have identified that hereditary factors account for
what percentage of mood disorders?
a.
10% to 15%
b.
20% to 30%
c.
35% to 50%
d.
60% to 80%
ANS: D
Research indicates that hereditary factors account for 60% to 80% of mood disorders.
DIF: Cognitive Level: Comprehension REF: p. 1121 OBJ: 2
TOP: Mental illness
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
18.
A home health nurse has a patient who is taking lithium. What should be included in the
teaching plan?
a.
Examine her skin closely for eruptions.
b.
Take her blood pressure twice a day to check for hypertension.
c.
Have her drug blood level checked every month.
d.
Avoid aged cheese and red wine.
ANS: C
Lithium has a very narrow therapeutic window. The drug blood levels should be closely
monitored.
DIF: Cognitive Level: Application
TOP: Mental illness
REF: p. 1122 OBJ: 6
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
19.
The nurse alters the care plan for a patient with depression to include what type of
activity?
a.
Domino game with three other patients
b.
Ping-Pong game with one other patient
c.
Group outing to view wildflowers
d.
Magazine to read alone
ANS: C
The quiet, noncompetitive trip to view wildflowers would be the best option.
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Depressed people should not be put in situations where they must concentrate or
compete.
DIF: Cognitive Level: Analysis
TOP: Mental illness
REF: p. 1121 OBJ: 5
KEY: Nursing Process
Step: Planning MSC: NCLEX: Psychosocial
Integrity
20.
The nurse is assessing a female patient who has become rapidly and exceedingly
anxious because her fingernail polish is chipped. What type of anxiety should the
nurse conclude that the patient is exhibiting?
a.
Signal anxiety
b.
General anxiety
c.
Anxiety traits
d.
Panic disorder
ANS: C
An individual with anxiety traits has anxious reactions to relatively nonstressful
events. Signal anxiety is a learned response to an event such as test taking. An
individual with general anxiety worries over many things. A panic attack occurs
suddenly and typically peaks within 10 minutes.
DIF: Cognitive Level: Application
TOP: Mental illness
REF: p. 1122 OBJ: 2
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
21.
The home health nurse assesses a patient who creates elaborate excuses for not
leaving home. Further questioning reveals the patient had not left home for 6
months. How should this be documented?
a.
Mania
b.
Depression
c.
Agoraphobia
d.
Anxiety
ANS: C
Agoraphobia is a high level of anxiety in which an anxiety attack could occur in
individuals who avoid other people, places, or events.
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DIF: Cognitive Level: Application
TOP: Mental illness
REF: p. 1125 OBJ: 2
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
22.
When a patient demonstrates accelerated heart rate, trembling, choking, and
chest pain along with acute, intense, and overwhelming anxiety, the nurse
should recognize that the patient is most likely experiencing what condition?
a.
Terror
b.
Fright
c.
Fear
d.
Panic
ANS: D
Panic can be defined as an attack of acute, intense, and overwhelming anxiety.
DIF: Cognitive Level: Application
TOP: Mental illness
REF: p. 1122 OBJ: 2
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
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23.
When a patient is experiencing a panic attack, how should the nurse best assist the
patient?
a.
Assist with reality orientation.
b.
Aid in decision making.
c.
Assist with rational thought.
d.
Coach in deep breathing.
ANS: D
Coaching in relaxation techniques such as deep breathing is an effective
intervention for a patient who is experiencing a panic attack.
DIF: Cognitive Level: Application
TOP: Mental illness
REF: p. 1117 OBJ: 5
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
24.
A patient is frequently late for appointments because he goes back to his room
numerous times to assure himself that none of his belongings have been stolen. What
does this behavior represent?
a.
Senseless behavior
b.
Controlled repetition
c.
Obsessive-compulsive
d.
Anxiety tension
ANS: C
Obsessive-compulsive disorders have two features: thoughts that are recurrent, intrusive,
and senseless; and behaviors that are performed repeatedly and ritualistically.
DIF: Cognitive Level: Application
TOP: Mental illness
REF: p. 1125 OBJ: 2
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
25.
A 14-year-old survivor of a school shooting screams and dives under a table when
firecrackers go off. What does this behavior represent?
a.
Phobia
b.
Posttraumatic stress disorder
c.
Obsessive-compulsive disorder
d.
Disordered thinking
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ANS: B
Posttraumatic stress disorder describes a response to an intense traumatic
experience that is beyond the usual range of human experience.
DIF: Cognitive Level: Application
TOP: Mental illness
REF: p. 1126 OBJ: 2
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
26.
What should the nurse preparing a patient for a scheduled appointment for
electroconvulsive therapy (ECT) remind the patient to do?
a.
Drink plenty of fluids before ECT to ensure adequate hydration.
b.
Bring a change of clothes in case of incontinence.
c.
Be prepared for visual disturbances after the treatment.
d.
Arrange for transportation to and from the appointment.
ANS: D
If the patient has not arranged for adequate transportation to and from the
appointment, the treatment will be canceled because driving after ECT is
dangerous. The patient is typically NPO before the procedure. Incontinence and
visual disturbances are not common following the procedure.
DIF: Cognitive Level: Application
TOP: Mental illness
REF: p. 1123 OBJ: 5
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
27.
The nurse is told that a patient believes he was born into the wrong body. What is the
correct terminology for the desire to have the body of the opposite sex?
a.
Homosexuality
b.
Transsexualism
c.
Heterosexuality
d.
Bisexuality
ANS: B
Transsexualism is a persistent desire to be the opposite sex and to have the body of the
opposite sex.
DIF: Cognitive Level: Comprehension REF: p. 1127 OBJ: 2
TOP: Mental illness
KEY: Nursing Process
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Step: Assessment MSC: NCLEX: Psychosocial
Integrity
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28.
The patient complains of recurrent, multiple physical ailments for which there is no
organic cause. How should the nurse assess this?
a.
Obsessive-compulsive disorder
b.
Phobia anxiety disorder
c.
Somatic symptom disorder
d.
Delusional disorder
ANS: C
Somatic symptom disorder is characterized by recurrent, multiple physical complaints for
which there is no organic cause.
DIF: Cognitive Level: Application
TOP: Mental illness
REF: p. 1127 OBJ: 2
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
29.
What disorder is a severe form of self-starvation that can lead to death?
a.
Bulimia nervosa
b.
Anorexia nervosa
c.
Teenage nervosa
d.
Obesity nervosa
ANS: B
Anorexia nervosa is a severe form of self-starvation that can lead to death.
DIF: Cognitive Level: Knowledge
TOP: Mental illness
REF: p. 1128 OBJ: 2
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
30.
The patient is concerned about confidentiality and asks the nurse not to tell anyone
what is said. What is the best response by the nurse?
a.
―I am required to report any intent to hurt yourself or others.‖
b.
―Conversations between patient and nurse are confidential.‖
c.
―What we say can be secret. What I write in the
chart is available to the health team.‖
d.
―I can‘t help you unless you trust me.‖
ANS: A
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No secrets are allowed to be kept by a member of the health care team.
DIF: Cognitive Level: Application
TOP: Mental illness
REF: p. 1132 OBJ: 5
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
31.
What is the term for a long-term and intense form of psychotherapy developed
by Sigmund Freud that allows a patient‘s unconscious thoughts to be brought
to the surface?
a.
Adjunctive
b.
Behavior
c.
Psychoanalysis
d.
Cognitive
ANS: C
Psychoanalysis technique was developed by Sigmund Freud and is a long-term and
intense therapy.
DIF: Cognitive Level: Comprehension REF:
p. 1132
OBJ: 5 TOP:
Psychotherapy
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
32.
What is the typical schedule for electroconvulsive therapy (ECT)?
a.
3 treatments over 2 weeks
b.
6 treatments over 2 months
c.
8 treatments over several weeks
d.
10 treatments over several weeks
ANS: D
ECT is done as a treatment for depression, mania, and schizoaffective disorders that
have not responded to other treatments. The usual protocol is 10 treatments over
several weeks.
DIF: Cognitive Level: Comprehension REF: p. 1132 OBJ: 5
TOP: Mental illness
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
33.
A patient who is taking a monoamine oxidase inhibitor (MAOI) asks the nurse about
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the addition of St. John‘s wort to help with his depression. What would be the best
response of the nurse?
a.
―That is a great idea. Alternative therapies can be very helpful.‖
b.
―You will feel better sooner if you include phenylalanine.‖
c.
―Did you know that St. John‘s wort can raise your blood pressure dramatically?‖
d.
―You will need to drink lots of water.‖
ANS: C
St. John‘s wort can raise blood pressure dramatically in people who are also taking
MAOIs.
DIF: Cognitive Level: Analysis
REF: p. 1136 OBJ: 6
TOP: Psychopharmacology KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological
Integrity
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MULTIPLE RESPONSE
1.
Adjunctive therapies are used for which reasons? (Select all that apply.)
a.
To increase self-esteem
b.
To promote positive interaction
c.
To enhance reality orientation
d.
To stimulate communication
e.
To increase energy
ANS: A, B, C
The purpose of adjunctive therapies is to increase self-esteem, promote positive interaction,
and enhance reality orientation.
DIF: Cognitive Level: Comprehension REF: p. 1132 OBJ: 6
TOP: Mental illness
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
2.
What are considered warning signs of suicide? (Select all that apply.)
a.
Talking about suicide
b.
Increased interactions with friends and family
c.
Drug or alcohol abuse
d.
Difficulty concentrating on work or school
e.
Personality changes
ANS: A, C, D, E
Warning signs of suicide include talking about suicide, decreased interactions with
friends and family, drug/alcohol abuse, difficulty concentrating on work or school,
and personality changes.
DIF: Cognitive Level: Comprehension
REF: p. 1121
OBJ: 3 TOP: Suicide
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Psychosocial Integrity
COMPLETION
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1.
The nurse instructs a patient who has just been prescribed a protocol of fluoxetine
HCl (Prozac) that the drug takes 2 to 4
to take effect.
ANS:
weeks
Antidepressants of this type take 2 to 4 weeks before any effect is felt by the patient.
DIF: Cognitive Level: Comprehension REF: p. 1122 OBJ: 5
TOP: Mental illness
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
2.
The nurse explains that an alternative therapy that uses essential oils and scented
candles to help a patient relax and focuses on the atmosphere of the moment is
.
ANS:
aromatherapy
Aromatherapy uses essential oils and scented candles to soothe the senses and make
people aware of the here and now of the pleasant environment.
DIF: Cognitive Level: Comprehension REF: p. 1136 OBJ: 6
TOP: Mental illness
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
3.
The nurse recognizes that stress can cause an ulcer, which is classified as a symptom
illness.
ANS:
Somatic
Somatic symptom illness addresses the stress-related problems that can result in physical
signs and symptoms. Psychophysiologic disorders are thought to have an emotional basis,
manifested as a physical illness.
DIF: Cognitive Level: Comprehension REF: p. 1127 OBJ: 2
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TOP: Mental illness
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
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Chapter 36: Care of the Patient with an
Addictive Personality Cooper: Foundations
and Adult Health Nursing, 9th Edition
MULTIPLE
CHOICE
1.
A 60-year-old man was admitted for cholecystitis that resulted in a cholecystectomy.
On his third day of hospitalization, he begins to sweat profusely, tremble, and has a
blood pressure of 160/100. Based on these findings, what focused assessment should
the nurse complete?
a.
Cardiac problems
b.
Respiratory problems
c.
Withdrawal problems
d.
Circulatory problems
ANS: C
Diaphoresis, tremors, and hypertension are all symptoms of withdrawal from alcohol
consumption. The nurse, concerned about the patient‘s medical condition, may not
consider substance abuse until withdrawal symptoms appear.
DIF: Cognitive Level: Analysis
REF: p. 1143
OBJ: 4 TOP: Addiction
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
2.
What age of onset of alcohol consumption is most predictive of alcohol addiction?
a.
8 or younger
b.
10 or younger
c.
12 or younger
d.
14 or younger
ANS: D
Forty-four percent of those who start drinking at the age of 14 or younger will develop
alcoholism.
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DIF: Cognitive Level: Comprehension
REF: p. 1141
OBJ: 4 TOP: Alcoholism
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
3.
Alcohol is involved in motor vehicle accidents, suicides, and homicides.
Approximately how many deaths each year are related to alcohol consumption?
a.
58,000
b.
78,000
c.
88,000
d.
108,000
ANS: C
About 88,000 deaths each year are related to alcohol consumption.
DIF: Cognitive Level: Knowledge
REF: p. 1141 OBJ: 4
TOP: Alcoholism
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
4.
What stage of dependence is described by a patient when he tells the nurse that he
has tried to stop his drug habit, but he does not feel ―normal‖ without it?
a.
Early
b.
Prodromal
c.
Middle
d.
Late
ANS: C
In the middle stage, the user shows signs of withdrawal with abstinence and must use the
drug to feel normal.
DIF: Cognitive Level: Comprehension
REF: p. 1142
OBJ: 2 TOP: Addiction
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Psychosocial Integrity
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5.
What must a patient in the late stages of dependence do in order to recover?
a.
Gain insight into the addiction.
b.
Receive treatment for substance abuse.
c.
Pledge to lead a completely different lifestyle.
d.
Seek a nondrug-oriented support system.
ANS: B
Very few people in the late stage of dependence will recover without treatment. The
other options may aid in the recovery, but it is the treatment that is essential for
recovery.
DIF: Cognitive Level: Application
REF: p. 1142
OBJ: 2 TOP: Addiction
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Psychosocial Integrity
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6.
What is the best response by a nurse when a patient inquires how alcohol acts so quickly
on his system?
a.
Alcohol is digested quickly.
b.
Alcohol is converted to glycogen immediately.
c.
Alcohol is metabolized into ethanol rapidly.
d.
Alcohol is excreted in urine slowly.
ANS: C
Alcohol is not digested or converted into glycogen, but it is metabolized quickly by the
liver to ethanol.
DIF: Cognitive Level: Analysis
REF: p. 1143
OBJ: 4 TOP: Alcoholism
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
7.
The nurse reminds a group of high school students that most states have laws limiting
blood alcohol levels of drivers. What is the legal blood alcohol serum level in most
states?
a.
0.08%
b.
0.20%
c.
0.40%
d.
0.50%
ANS: A
Most states designate blood alcohol serum levels of 0.08% as the legal limit for driving a
motor vehicle.
DIF: Cognitive Level: Comprehension
REF: p. 1143
OBJ: 3 TOP: Alcoholism
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
8.
A pregnant adolescent tells the nurse that she ―only drinks a little.‖ How many
drinks per day can cause an adverse effect in an infant?
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a.
One drink a day
b.
Two drinks a day
c.
Three drinks a day
d.
Four drinks a day
ANS: B
As few as two drinks per day may cause adverse effects in an infant.
DIF: Cognitive Level: Comprehension
REF: p. 1143
OBJ: 4 TOP: Alcoholism
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
9.
The nurse assesses an alcoholic patient carefully for signs of withdrawal. How soon
after cessation of alcohol intake do withdrawal symptoms usually appear?
a.
3 hours
b.
4 hours
c.
5 hours
d.
6 hours
ANS: D
Withdrawal signs can occur as early as 6 hours after cessation of alcohol intake and
sometimes last for 3 to 5 days.
DIF: Cognitive Level: Comprehension
REF: p. 1143
OBJ: 4 TOP: Alcoholism
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
10.
The nurse is performing an initial assessment on an alcoholic patient. Which of the
following actions by the nurse would best ensure honest answers?
a.
Not asking personal questions
b.
Having a nonjudgmental attitude
c.
Including the family
d.
Promising the patient not to tell anyone
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ANS: B
Maintaining a nonjudgmental attitude may reassure the patient and allow him to be more
honest in his responses to the admission assessment.
DIF: Cognitive Level: Application
REF: p. 1144
OBJ: 5 TOP: Alcoholism
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Psychosocial Integrity
11.
During the detoxification period, what does the nurse aim to achieve when designing
interventions?
a.
Enroll the patient in Alcoholics Anonymous (AA).
b.
Keep the patient safe from aspiration and seizure.
c.
Help the patient interact in nonaddictive activities.
d.
Help the patient gain insight into the addiction.
ANS: B
Care for the addicted patient starts with detoxification and is focused on keeping the
patient safe from the symptoms of withdrawal. Enrolling the patient in AA, helping the
patient interact in nonaddictive activities, and helping the patient gain insight into the
addiction would be part of the rehabilitation process.
DIF: Cognitive Level: Application
REF: p. 1145
OBJ: 5 TOP: Addiction
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
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12.
What should the entire health team focus on during the rehabilitation phase?
a.
Establishing a support system
b.
Seeking and maintaining employment
c.
Abstaining from drug use
d.
Addressing the problems related to addiction
ANS: C
The focus of rehabilitation is for the patient to abstain from drug use.
DIF: Cognitive Level: Application
REF: p. 1145
OBJ: 5 TOP: Addiction
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Psychosocial Integrity
13.
What should the nurse do to decrease the patient‘s disorientation at night during the
detoxification period?
a.
Place the patient in a room with another recovering patient.
b.
Instruct the patient to orient himself to his surroundings at bedtime.
c.
Wake the patient up every 4 hours to eat a small snack.
d.
Use nightlights and remove extra furniture from the room.
ANS: D
Use of nightlights and removing extra furniture that could be misidentified will reduce
disorientation. The patient should not be woken up to eat, but if he is awake, small
snacks can be offered. The nurse should orient the patient to his surroundings.
DIF: Cognitive Level: Application
REF: p. 1145
OBJ: 5 TOP: Addiction
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Psychosocial Integrity
14.
The nurse explains that Alcoholics Anonymous (AA) consists of abstinent alcoholics
who help other alcoholics become and stay sober. What is the foundation of AA?
a.
Psychotherapy
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b.
A 12-step program
c.
Treatment center
d.
Individual counseling
ANS: B
The foundation of AA is a 12-step program.
DIF: Cognitive Level: Knowledge
REF: p. 1147
OBJ: 5 TOP: Alcoholism
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
15.
What severe side effect will occur if an alcoholic patient consumes alcohol while taking
disulfiram (Antabuse)?
a.
Nausea
b.
Blackouts
c.
Headaches
d.
Hypertension
ANS: A
When a person who is taking Antabuse consumes alcohol, severe nausea, tachycardia,
shortness of breath, confusion, and dizziness are experienced. The drug is used as a
form of aversion therapy.
DIF: Cognitive Level: Comprehension
REF: p. 1145
OBJ: 5 TOP: Addiction
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
16.
If the patient tells the nurse, ―I‘m not an alcoholic. I can stop whenever I want to,‖
what should be the nurse‘s most therapeutic response?
a.
―Well, why don‘t you?‖
b.
―Hasn‘t alcohol use interfered with your employment?‖
c.
―A positive attitude like that is a good start.‖
d.
―What would you call alcoholism?‖
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ANS: B
When the addicted person presents in denial, the nurse should use techniques to set limits
on that behavior.
DIF: Cognitive Level: Analysis
REF: p. 1146
OBJ: 1 TOP: Addiction
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Psychosocial Integrity
17.
When a patient denies any problems related to addiction, what is the nurse‘s most
therapeutic response?
a.
―What do you call this hospitalization?‖
b.
―How can anybody help you if you don‘t see a problem?‖
c.
―Would your family agree that you have no problems?‖
d.
―Can you think of any time your behavior created an
unpleasant situation in your life?‖
ANS: D
When the patient denies that his behavior is problematic, the nurse should ask the
patient to recount incidences when the behavior had unpleasant consequences.
DIF: Cognitive Level: Analysis
REF: p. 1146
OBJ: 1 TOP: Addiction
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Psychosocial Integrity
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18.
Which drug is often used in date rape?
a.
Dalmane
b.
Xanax
c.
Narcan
d.
Rohypnol
ANS: D
Rohypnol has been abused as a date-rape drug and has not been approved for use in the
United States.
DIF: Cognitive Level: Comprehension |
Cognitive Level: Knowledge REF: p. 1149
OBJ: 6
TOP: Addiction
KEY: Nursing Process Step: Assessment
19.
MSC: NCLEX: Psychosocial Integrity
A patient seems bewildered when he confides in the nurse that all of his friends
and leisure time have been centered on a drug culture. Which would be the best
response by the nurse?
a.
―What other sort of activities might you enjoy?‖
b.
―You will need to get new friends.‖
c.
―Returning to those activities will get you back here and in trouble.‖
d.
―You need to get a hobby.‖
ANS: A
Encouraging the patient to imagine new activities is a start toward seeking them. Giving
advice is not therapeutic.
DIF: Cognitive Level: Analysis
REF: p. 1146
OBJ: 1 TOP: Addiction
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Psychosocial Integrity
20.
When a patient is admitted with an overdose of an opioid narcotic, the nurse should
anticipate an order for which drug to reverse the effects of the narcotic?
a.
Clonidine
b.
Narcan
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c.
Orlaam
d.
Methadone
ANS: B
Opioid overdose treatment involves administering Narcan as prescribed to reverse the
effects of the narcotic.
DIF: Cognitive Level: Application
REF: p. 1149
OBJ: 6 TOP: Addiction
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
21.
The nurse concludes that a significant goal of the care plan for an alcoholic patient
has been met when the patient makes which statement?
a.
―I drink because I‘m lonely.‖
b.
―All my difficulties are related to my drinking.‖
c.
―I wouldn‘t need to drink if I had my family back.‖
d.
―My drinking helps me cope with the stress of my job.‖
ANS: B
A major goal for the successful treatment of alcoholics is to have them express
responsibility for their behavior.
DIF: Cognitive Level: Application
REF: p. 1146
OBJ: 5 TOP: Addiction
KEY: Nursing Process Step:
Evaluation
MSC: NCLEX: Psychosocial Integrity
22.
While creating a methadone protocol for a patient rehabilitating from heroin
addiction, the nurse explains that the patient will take methadone for what length of
time?
a.
Daily for the rest of his life.
b.
Daily until stabilized, then gradually reduce the dose to zero.
c.
Weekly for at least 6 months, then decrease the dose to once a month.
d.
Monthly for 6 to 10 months, then decrease the dose to zero.
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ANS: B
Methadone is given daily until the patient is stabilized. The methadone is reduced
gradually until the patient does not need to take any.
DIF: Cognitive Level: Application
REF: p. 1150
OBJ: 5 TOP: Addiction
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Psychosocial Integrity
23.
A 22-year-old patient presents in the emergency department with the characteristics of
severe Parkinson disease. The nurse should suspect an overdose of what drug?
a.
Marijuana
b.
Cocaine
c.
Amphetamines
d.
Valium
ANS: C
Over time, dopamine depletion in the brain can cause Parkinson-like symptoms to occur
in people who abuse amphetamines.
DIF: Cognitive Level: Comprehension
REF: p. 1151
OBJ: 6 TOP: Addiction
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
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24.
A college student has brought his hallucinating roommate to the college clinic.
The young man says his roommate has been experimenting with phencyclidine
(PCP). How long should the nurse expect the hallucinations to last?
a.
30 to 60 minutes
b.
1 to 4 hours
c.
4 to 6 hours
d.
6 to 12 hours
ANS: D
Some hallucinogenic effects of PCP can last 6 to 12 hours.
DIF: Cognitive Level: Comprehension
REF: p. 1151
OBJ: 6 TOP: Addiction
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
25.
The mother of a young woman being treated for amphetamine overdose asks the nurse
when the manifestations will subside. What would be the most correct answer by the
nurse?
a.
―Usually in 8 to 10 hours.‖
b.
―She will snap out of it in a day or two.‖
c.
―Usually in about 2 hours, but the effects will return in 2 to 3 days.‖
d.
―The manifestations may be permanent.‖
ANS: D
The manifestations of overdose of amphetamines are frequently permanent.
DIF: Cognitive Level: Comprehension
REF: p. 1151
OBJ: 6 TOP: Addiction
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Psychosocial Integrity
26.
What nursing intervention should be included in the plan of care for a baby born to a
drug-addicted mother?
a. Swaddle the baby closely.
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b.
Place the baby in a brightly lit area.
c.
Hold and rock the baby frequently.
d.
Place the baby in a busy part of the nursery for stimulation.
ANS: A
A baby born to a drug-addicted mother should be swaddled, placed in an area of low
stimulation, and minimally handled.
DIF: Cognitive Level: Application
REF: p. 1151
OBJ: 6 TOP: Addiction
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
27.
What is the greatest problem with lysergic acid diethylamide (LSD) use?
a.
The drug is addictive.
b.
The drug stimulates drug-seeking behavior.
c.
The drug causes flashbacks.
d.
The drug sets off hypertensive episodes.
ANS: C
LSD causes flashbacks, or ―bad trips,‖ unpredictably, and the flashbacks may occur years
after ingestion of the drug. LSD is not considered an addictive drug and does not stimulate
drug-seeking behavior. Hypertension is not a typical side effect of LSD.
DIF: Cognitive Level: Application
REF: p. 1151
OBJ: 6 TOP: Addiction
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Psychosocial Integrity
28.
What should the nurse do to decrease the damage of bruxism seen in a patient who has
been abusing the drug ecstasy?
a.
Turn the patient to his right side.
b.
Elevate the head of the bed 30 degrees.
c.
Provide the patient with a pacifier.
d.
Administer a muscle relaxant.
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ANS: C
The use of an infant pacifier will reduce the damage to the teeth for a patient who is
manifesting bruxism (grinding of the teeth).
DIF: Cognitive Level: Application
REF: p. 1151
OBJ: 6 TOP: Addiction
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
29.
What should the nurse do when suspecting a coworker of abusing drugs while at work?
a.
Confront the abuser.
b.
Report observations to a supervisor.
c.
Call the state board of nursing.
d.
Discuss the problem with another coworker.
ANS: B
The nurse‘s observations should be reported objectively, preferably in writing, to the
supervisor.
DIF: Cognitive Level: Application
TOP: Impaired nurse
REF: p. 1153 OBJ: 7
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
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30.
Which statement describes the impaired nurse who is in a peer assistance program?
a.
The nurse has a revoked nursing license.
b.
The nurse does not have to notify her employer.
c.
The nurse will be allowed to work as a nurse under supervision.
d.
The nurse will be reported to the Healthcare Integrity and Protection Data Bank.
ANS: C
The peer assistance program allows the nurse to retain licensure and continue to work
under supervision, although possibly in an area where access to controlled drugs is
difficult. It is necessary for the employer to have information regarding the peer
assistance assignment. Action is not reported to the Healthcare Integrity and
Protection Data Bank until final adverse actions are taken, allowing the nurse to
complete the peer assistance program.
DIF: Cognitive Level: Application
REF:
p. 1155
OBJ: 7 TOP:
Impaired nurse
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
MULTIPLE RESPONSE
1.
During the initial intake assessment of a drug user, the nurse should attempt to obtain
which subjective data? (Select all that apply.)
a.
Usual pattern of use
b.
Specific drug
c.
Previous arrests
d.
Amount of drug used
e.
Time of last use
ANS: A, B, D, E
Determining the drug, strength, frequency, last use, and pattern of use is the basic
database on a substance abuser.
DIF: Cognitive Level: Application
REF: p. 1144
OBJ: 4 TOP: Addiction
KEY: Nursing Process Step:
Assessment
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MSC: NCLEX: Psychosocial Integrity
2.
The nurse should assess a patient for which criteria of addiction? (Select all that apply.)
a.
Excessive use of the substance
b.
Increase in social function
c.
Uncontrollable consumption
d.
Increase in economic function
e.
Psychological disturbances
ANS: A, C, E
Criteria for addiction include excessive use of the substance, a decrease in social
function, uncontrollable consumption, a decrease in economic function, and
psychological disturbances.
DIF: Cognitive Level: Application
REF: p. 1140
OBJ: 1 TOP: Addiction
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Psychosocial Integrity
3.
A nurse suspects here a coworker is abusing drugs. Which of the following symptoms,
noticed in the coworker, would contribute to the suspicions? (Select all that apply.)
a.
Spending more time with coworkers
b.
Frequently absent from the unit
c.
Rapid changes in mood and performance
d.
Increased somatic complaints
e.
Patients report they did not receive their medications
ANS: B, C, D, E
Signs of drug abuse in a nurse include the nurse becoming more isolated from
coworkers, being frequently absent from the unit, rapidly changing mood and
performance, increasing somatic complaints, and patients reporting they did not
receive their medications.
DIF: Cognitive Level: Comprehension REF: p. 1153 OBJ: 7
TOP: Mental illness
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
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COMPLETION
1.
When assessing an alcoholic patient, the nurse notes short-term memory loss, painful
extremities, foot drop, and muttered incoherent responses to questions. The nurse
recognizes these symptoms as most likely related to a condition caused by long-term
alcohol abuse, which is known as
syndrome.
ANS:
Korsakoff
Korsakoff syndrome is a permanent condition caused by long-term alcohol use. The
patient mutters incoherently and experiences short-term memory loss, painful
extremities, and foot drop.
DIF: Cognitive Level: Comprehension
REF: p. 1143
OBJ: 4 TOP: Addiction
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
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2.
The nurse uses the CAGE questionnaire to assess a patient. The nurse suspects the
patient is an alcoholic if there are affirmative answers for
items on the
questionnaire.
ANS:
tw
o
2
An affirmative answer on two or more questions on the CAGE questionnaire is reason
to assess more closely for possible alcohol abuse.
DIF: Cognitive Level: Comprehension
REF: p. 1144
OBJ: 4 TOP: Addiction
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Psychosocial Integrity
3.
The nurse cautions that a person who chronically abuses drugs may experience mental
impairment. The area of the brain that can be affected and permanently damaged is the
system.
ANS:
limbic
The most commonly abused drugs act on the limbic system of the brain and can cause
permanent damage.
DIF: Cognitive Level: Comprehension
REF: p. 1148
OBJ: 4 TOP: Addiction
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
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Chapter 37: Home Health Nursing
Cooper: Foundations and Adult Health Nursing, 9th Edition
MULTIPLE
CHOICE
1.
What became effective in 1966 by an act of legislation that revolutionized home care?
a.
Life insurance
b.
Medicare
c.
Private insurance
d.
Social Security
ANS: B
When Medicare became effective in 1966, it revolutionized home care by changing it
to a medical rather than nursing model of practice, defining and limiting services it
would reimburse, and changing the payment source and even changing the reason
home care was provided.
DIF: Cognitive Level: Comprehension REF: p. 1160 OBJ: 2
TOP: Home health KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
2.
A major change to Medicare reimbursement was implemented in 1983. The new
system paid a set rate according to diagnosis. What was the new payment system
based upon?
a.
Interim payment systems
b.
Diagnosis-related groups
c.
Title XVIII
d.
Title XIX
ANS: B
The new payment system introduced in 1983 provided reimbursement based
upon set rates that were determined by diagnosis-related groups (DRGs).
DIF: Cognitive Level: Application
REF: p. 1160 OBJ: 2
TOP: Home health KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
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3.
How often must the home care treatment plan be recertified in order for the patient to
continue to receive services?
a.
Every 3 days
b.
Every 60 days
c.
Every 10 days
d.
Every 2 weeks
ANS: B
Medicare and Medicaid home care services are based on the medical model of
treatment and depend on the health care provider for entry into the formalized system.
Medicare requires a plan of treatment signed by the health care provider, outlining all
disciplines, treatment, frequency, and duration. These orders must be recertified every
60 days.
DIF: Cognitive Level: Knowledge
REF: p. 1164 OBJ: 2
TOP: Home health KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
4.
Nurses who work in home settings rather than a hospital setting require a different
level of ability to be technically proficient, self-motivated, and innovative. This
requires a higher level of what quality?
a.
Knowledge
b.
Performance
c.
Independence
d.
Cooperation
ANS: C
The independence of home care practice can be difficult for nurses who depend on the
security of the institutional setting.
DIF: Cognitive Level: Application
REF: p. 1164 OBJ: 7
TOP: Home health KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
5.
The LPN/LVN may provide many services to the patient in the home including highlevel skills. Under whose supervision should these high-level skills be directed and
performed?
a.
Health care provider
b.
Family
c.
Facility supervisor
d.
RN
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ANS: D
The LPN/LVN must always work under the supervision of an RN.
DIF: Cognitive Level: Comprehension REF: p. 1164 OBJ: 7
TOP: Home health KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
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6.
For physical therapy services to be reimbursed by Medicare, what must be the goal of the
therapy?
a.
Preventive
b.
Restorative
c.
Maintenance
d.
Educational
ANS: B
The goals of treatment must be restorative in order for Medicare to provide
reimbursement. In some cases, the goals can be preventive or maintenance for other
payer sources.
DIF: Cognitive Level: Comprehension REF: p. 1164 OBJ: 5
TOP: Services
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
7.
Speech therapy goals include minimizing speech disorders and maximizing
rehabilitation of speech abilities. To be reimbursed by Medicare, who must provide
these services?
a.
Bachelor‘s-level clinician
b.
Speech therapist
c.
Master‘s-level clinician
d.
Physiatrist
ANS: C
To be reimbursed by Medicare, speech therapy must be provided by a master‘sprepared clinician. Other payers will sometimes reimburse services provided by a
bachelor‘s-level clinician.
DIF: Cognitive Level: Comprehension REF: p. 1166 OBJ: 5
TOP: Services
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
8.
Medical social services focus on the emotional and social aspects of illness. What is
another area of service?
a.
Home problems
b.
Marriage problems
c.
Crisis intervention
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d.
Work problems
ANS: C
Coping with stress and crisis intervention are also part of medical social workers‘
services.
DIF: Cognitive Level: Comprehension REF: p. 1166 OBJ: 5
TOP: Services
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
9.
Medicare will not cover home health aide visits for the sole reason of:
a.
Physical assistance
b.
Health care provider orders
c.
Personal care
d.
Household chores
ANS: D
Medicare will not pay for visits made solely for household chores.
DIF: Cognitive Level: Comprehension REF: p. 1166 OBJ: 5
TOP: Services
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
10.
The patient, family, social service agency, hospital, health care provider, or another
agency all can provide the entry point to the home health care system. What is the
entry point for the home health care system called?
a.
Recommendation
b.
Survey
c.
Referral
d.
In-taking
ANS: C
The entry point for home health care system is by referral. This can come from the
patient, family, social service agency, hospital, health care provider, or another
agency.
DIF: Cognitive Level: Knowledge
REF: p. 1167 OBJ: 5
TOP: Home health KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
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11.
The initial evaluation and admission visit is made by an RN, who has been provided
with general orders by a health care provider before the visit. This visit must be made
within how many hours of the referral?
a.
4 to 8
b.
12 to 15
c.
18 to 24
d.
24 to 48
ANS: D
The initial evaluation and admission visit made by an RN must be made within 24 to
48 hours of the referral. In some cases, if nursing will not be providing any services,
the physical therapist may conduct the admission visit.
DIF: Cognitive Level: Application
REF: p. 1167 OBJ: 8
TOP: Home health KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
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12.
The evaluation and admission process for entry to the home health care system
includes physical and psychosocial examination, explanation of the patient‘s rights,
and evaluation of family, home, and nursing interventions. What is the normal
minimum time for the admission visit?
a.
30 minutes
b.
1 hour
c.
2 hours
d.
3 hours
ANS: B
The admission process typically takes a minimum of 1 hour.
DIF: Cognitive Level: Knowledge
REF: p. 1167 OBJ: 8
TOP: Home health KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
13.
After the patient is admitted to the home health services system, a treatment plan is
drafted cooperatively with the health care provider and is signed. A separate,
detailed care plan is always required for which disciplines?
a.
Registered nurse
b.
Physical therapist
c.
Home health aide
d.
LPN/LVN
ANS: C
A separate, detailed care plan is always required for the home health aide.
DIF: Cognitive Level: Application | Cognitive Level: Knowledge
REF: p. 1167
OBJ: 5 TOP: Home health KEY:
Nursing Process Step: N/A MSC: NCLEX: N/A
14.
How long is the average home health care visit by the skilled nurse?
a.
10 to 15 minutes
b.
20 to 30 minutes
c.
30 to 45 minutes
d.
45 to 60 minutes
ANS: C
Skilled nursing visits typically take 30 to 45 minutes.
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DIF: Cognitive Level: Knowledge
REF: p. 1167 OBJ: 6
TOP: Home health KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
15.
Complete documentation is essential and must include an accurate picture of the
type and quality of care given, as well as the effectiveness of the plan of care.
Which model should be followed to best provide adequate documentation?
a.
Caretaker
b.
Nursing process
c.
Home health care
d.
Nursing efficiency
ANS: B
Documentation that follows the nursing process model provides an accurate picture of the
type and quality of care.
DIF: Cognitive Level: Comprehension REF: p. 1168 OBJ: 8
TOP: Home health KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
16.
When should discharge planning begin for a patient receiving home care services?
a.
A week before discharge
b.
Two days before discharge
c.
The day of discharge
d.
On admission
ANS: D
Discharge planning for home care begins on admission.
DIF: Cognitive Level: Knowledge
REF: p. 1168 OBJ: 8
TOP: Discharge
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
17.
When implementing quality assurance–specific criteria, measurements are developed
for three criteria: structural, process, and outcome. How is this method of
assessment different from previous methods?
a.
It is objective.
b.
It is specific.
c.
It is subjective.
d.
It is generalized.
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ANS: A
In the past, measurements of quality in an agency, the care delivered, and the staff
were all subjective. The quality assurance–specific criteria measurements are
objective.
DIF: Cognitive Level: Comprehension REF:
p. 1169
OBJ: 4 TOP:
Quality assurance
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
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18.
What is an eligibility requirement for an individual to qualify for Medicare services?
a.
Retired
b.
At least 65 years old
c.
Low-income
d.
Poor health
ANS: B
Beneficiaries of service must be at least 65 years of age.
DIF: Cognitive Level: Knowledge
REF:
p. 1169
OBJ: 9 TOP:
Reimbursement
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
19.
Medicaid pays for home care services for people who have low incomes. Who
administers the Medicaid program?
a.
Federal government
b.
City government
c.
State government
d.
County government
ANS: C
Medicaid is administered by the state. Medicare is a federal program.
DIF: Cognitive Level: Comprehension REF:
p. 1169
OBJ: 9 TOP:
Reimbursement
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
20.
During a time of acute illness, the family may become extremely distressed and
neglect the needs of other family members. On what does the family seem to focus?
a.
The outcomes
b.
The disease
c.
The health care provider
d.
The patient
ANS: D
During times of acute illness, the family may become extremely distressed and focus only
on the patient. The nurse can refer family members to an appropriate resource.
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DIF: Cognitive Level: Application
REF:
p. 1171
OBJ: 8 TOP:
Nursing process
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
21.
What should be the focus when the family and the patient work with the nurse to plan
interventions?
a.
Determining actions
b.
Participating in care
c.
Setting goals
d.
Celebrating achievements
ANS: C
When planning interventions, it is important that the nurse work with the patient and the
family on setting goals.
DIF: Cognitive Level: Application
TOP: Nursing process
REF: p. 1171 OBJ: 8
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
22.
The nurse should provide the patient and family with accurate health information
concerning diagnoses and progress. What will accurate information help the family
to become?
a.
Active participants
b.
Effective caregivers
c.
Encouraged supporters
d.
Active providers
ANS: B
Providing accurate information about the diagnosis and progress helps the family to be
effective caregivers.
DIF: Cognitive Level: Application
TOP: Nursing process
REF: p. 1171 OBJ: 8
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
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23.
Because many illnesses are now controlled rather than cured, the number of
people with chronic, debilitating illnesses has increased. What do home care
nurses prevent by providing?
a.
Deaths
b.
Increased morbidity
c.
Increased hospitalization
d.
Acute episodes
ANS: D
Home care provides assessment and evaluation of chronic illnesses to prevent acute
episodes.
DIF: Cognitive Level: Application
REF: p. 1172
OBJ: 8 TOP:
Home health KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Health Promotion and Maintenance
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24.
What is the fastest-growing group in the US population today?
a.
30- to 40-year-olds
b.
40- to 50-year-olds
c.
50- to 65-year-olds
d.
Those 85 and older
ANS: D
The age group older than 85 is the fastest-growing group in the United States today.
DIF: Cognitive Level: Knowledge
REF: p. 1172 OBJ: 8
TOP: Aging KEY: Nursing Process Step: N/A
25.
MSC: NCLEX: N/A
By offering enteral, parenteral, intravenous, and blood transfusion therapies, what can
home care services prevent?
a.
Morbidity
b.
Hospitalization
c.
Hospice care
d.
Mortality
ANS: B
Home care services can prevent hospitalization by offering enteral, parenteral,
intravenous, and blood transfusion therapies. Morbidity, mortality, and hospice care
cannot be prevented.
DIF: Cognitive Level: Comprehension REF: p. 1172 OBJ: 6
TOP: Home health KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
26.
What has been influenced by the increase in home health providers supporting
healthy living and illness prevention, and a movement toward
deinstitutionalization of technology-dependent children and adults?
a.
Criteria for admission
b.
Age of eligibility
c.
Reimbursement criteria
d.
Length of financial support
ANS: C
The increase in home health providers supporting healthy living and illness
prevention and the movement toward deinstitutionalization of technology-dependent
children and adults resulted from Medicare and third-party payers changing
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reimbursement criteria.
DIF: Cognitive Level: Application
REF: p. 1172 OBJ: 9
TOP: Home health KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
27.
The licensed nurse can delegate which tasks to the home health assistive personnel?
a.
Bathing the patient
b.
Assessing ability to void
c.
Administering an injection
d.
Teaching about medications
ANS: A
Bathing the patient is a task that can be delegated safely to the home health assistive
personnel. Home health assistive personnel cannot assess, teach, or administer
injections.
DIF: Cognitive Level: Comprehension
REF: p. 1167
OBJ: 5 TOP:
Home health KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1.
The home health nurse plans interventions to meet which general service goals? (Select
all that apply.)
a.
Restore function as is appropriate.
b.
Improve level of function.
c.
Maintain current health level.
d.
Ensure return of health.
e.
Teach healthy lifestyle.
ANS: A, B, C, E
The general service goals are restoration, improvement, maintenance, and promotion of
health.
DIF: Cognitive Level: Application
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REF: p. 1166
OBJ: 8 TOP:
Home health KEY: Nursing Process Step:
Planning
MSC: NCLEX: Health Promotion and Maintenance
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COMPLETION
1.
The nurse describes a new technological service to the patient that will monitor
several assessments remotely. This new intervention is known as
services.
ANS:
telehealth
A newer method of home care delivery is telehealth services. This approach allows for
patient and care provider interaction and monitoring using telephone, computers,
television, and two-way monitors.
DIF: Cognitive Level: Comprehension REF: p. 1161 OBJ: 3
TOP: Telehealth services KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
2.
When the decision is made with the family to place the patient on hospice
care, the home health nurse explains that the reimbursement changes from
―fee per visit‖ to ―fee per
.‖
ANS:
diem
Medicare-supported hospice care is billed on a fee per diem.
DIF: Cognitive Level: Comprehension
REF: p. 1163
OBJ: 9 TOP: Hospice
KEY: Nursing Process Step:
Planning
MSC: NCLEX: Health Promotion and Maintenance
3.
The nurse can best confirm that the patient understands the communication by obtaining
from the patient.
ANS:
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feedback
Feedback confirms that the patient has understood the communication.
DIF: Cognitive Level: Application
TOP: Communication
REF: p. 1167 OBJ: 4
KEY: Nursing Process
Step: Evaluation MSC: NCLEX: Health Promotion
and Maintenance
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Chapter 38: Long-Term Care
Cooper: Foundations and Adult Health Nursing, 9th Edition
MULTIPLE
CHOICE
1.
The home health nurse is assisting a family to select a long-term care facility for an
80-year-old widow in good health who no longer drives, loves to play cards, can
ambulate with a walker, and is oriented. Which facility would be the best selection
for this patient?
a.
Subacute unit setting
b.
Long-term care facility (nursing home)
c.
Assisted living center
d.
Continuing care retirement center (CCRC)
ANS: C
The assisted living center provides meals, transportation, social interaction, and a
homelike quality without the intrusion of the medical model. The patient‘s age does not
make her a reasonable candidate for a CCRC. The patient does not require acute skilled
nursing care.
DIF: Cognitive Level: Analysis
TOP: Long-term care
REF: p. 1179 OBJ: 2
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Health Promotion
and Maintenance
2.
The home health nurse helps an older adult couple plan changes in their home that
will facilitate care in their home as they age. What fraction of the US population
live in a home setting?
a.
1/4
b.
1/2
c.
1/3
d.
3/4
ANS: B
Approximately (11.3 million) of the US population over the age of 65 live in a home or
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family setting.
DIF: Cognitive Level: Comprehension REF: p. 1176 OBJ: 2
TOP: Long-term care
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Health Promotion
and Maintenance
3.
The nurse confirms that the cost of caring for a relatively unimpaired older adult in a
private home is approximately what fraction of the cost of placing the older adult in a
long-term care facility?
a.
1/4
b.
1/3
c.
1/2
d.
2/3
ANS: C
It costs approximately half as much to care for an older adult at home as it would cost in a
long-term care facility.
DIF: Cognitive Level: Comprehension REF: p. 1177 OBJ: 4
TOP: Long-term care
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Health Promotion
and Maintenance
4.
What is the goal for services provided by home health care agencies?
a.
Self-care
b.
Assisted living
c.
Rehabilitation
d.
Improved function
ANS: C
Services provided by home health care agencies are aimed at rehabilitation.
DIF: Cognitive Level: Comprehension
REF: p. 1177
OBJ: 8 TOP:
Home health KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
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5.
The nurse clarifies to the family of a patient that one of the roles of the LPN/LVN in
the home care setting is to evaluate the care provided to the patient by which
provider?
a.
The family
b.
Other licensed care providers
c.
Nonlicensed staff.
d.
The health care provider
ANS: C
One of the roles of the LPN/LVN in the home care setting may be to evaluate the care
provided by CNAs, HHAs, homemakers, and personal care attendants.
DIF: Cognitive Level: Application |
Cognitive Level: Comprehension REF: p.
1178
OBJ: 7
TOP: Home
health
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
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6.
The family caring for an older adult in their home feels that they need assistance
from a hospice service. What is necessary for hospice service to be initiated?
a.
A family request
b.
A patient request
c.
Medical certification
d.
A referral by a hospice nurse
ANS: C
Hospice agencies provide care at the end of life. Medical certification is required for
terminal care.
DIF: Cognitive Level: Application
REF: p. 1178
OBJ: 8 TOP: Hospice
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
7.
The nurse suggests to a family caring for a member with early Alzheimer‘s disease in
their home that they investigate the services of an adult day care center. What is a
major benefit of adult day care centers?
a.
It takes the patient out on recreational outings.
b.
It can provide daily hygiene.
c.
It expands social interaction.
d.
It is free to the public.
ANS: C
Adult day care centers are open a large part of the day and offer several modalities to
enhance social interaction and also give the family respite.
DIF: Cognitive Level: Application
TOP: Adult day care
REF: p. 1179 OBJ: 8
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
8.
What differentiates the services of a long-term care facility from that of an assisted living
facility?
a.
Skilled nursing care
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b.
Personal care services
c.
Weekly visits by the staff health care provider
d.
Intensive rehabilitation services
ANS: B
Assisted living is a type of residential care setting where the resident receives personal
care services.
DIF: Cognitive Level: Application
TOP: Long-term care
REF: p. 1179 OBJ: 8
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
9.
What would be the most appropriate guidance the nurse could provide an older adult
couple that is considering a continuing care retirement community (CCRC)?
a.
Admittance is limited to people who are relatively unimpaired.
b.
A contract is usually a lifetime commitment.
c.
A contract is an acceptable tax shelter.
d.
Contracts can be signed on a month-to-month basis.
ANS: B
CCRCs offer a complete range of health care services, from independent living to 24-hour
skilled nursing. In most cases, signing a contract with a CCRC is a lifetime commitment.
DIF: Cognitive Level: Application
TOP: Long-term care
REF: p. 1180 OBJ: 8
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Health Promotion
and Maintenance
10.
An 82-year-old patient recovering from a hip replacement could be expected to move
from the acute care hospital to which setting for rehabilitation?
a.
A subacute care unit
b.
An assisted living center
c.
An adult day care center
d.
A continuing care retirement community
ANS: A
Subacute units have a strong rehabilitative focus and a shorter length of stay than a longterm care center.
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DIF: Cognitive Level: Application
REF: p. 1180
OBJ: 1 TOP: Subacute
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Health Promotion and Maintenance
11.
What is the correct term for people who live in long-term care facilities?
a.
Patients, because they will be receiving acute care.
b.
Residents, because the facility has become their home.
c.
Patients, because they seek professional medical services.
d.
Customers, because they are purchasing care service.
ANS: B
The older adult in a long-term care facility is referred to as a resident to reinforce the
homelike environment.
DIF: Cognitive Level: Knowledge
TOP: Long-term care
REF: p. 1175 OBJ: 2
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
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12.
Which statement is true concerning a 50-year-old patient recovering from a stroke
who is going to a long-term care facility for a short stay?
a.
Her regular hospitalization insurance will pay for the care.
b.
She will still have daily health care provider visits.
c.
She will need to contract outside physical therapy services.
d.
She will probably be discharged within 6 months.
ANS: D
A short-stay resident in a long-term care facility for rehabilitation will have residential
physical therapy services and will usually be discharged within 6 months. Regular
hospitalization insurance does not cover long-term care. Daily health care provider
visits do not occur in the long-term care facility.
DIF: Cognitive Level: Application
TOP: Long-term care
REF: p. 1181 OBJ: 2
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Health Promotion
and Maintenance
13.
In the long-term care facility, health care professionals work together to meet the
needs of older adults and to go over the care plan with the resident and family
members. What is this approach called?
a.
Team approach
b.
Individualized approach
c.
Interdisciplinary approach
d.
Outgoing approach
ANS: C
The long-term care facility is an interdisciplinary setting.
DIF: Cognitive Level: Comprehension REF:
p. 1181
OBJ: 7 TOP: Long-
term care
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
14.
What is the time limit for the legal administration of medications?
a.
30 minutes
b.
1 hour
c.
90 minutes
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d.
2 hours
ANS: D
In long-term care, there is a 2-hour window for legal administration of medications, 1
hour before and 1 hour after the official administration time.
DIF: Cognitive Level: Comprehension REF: p. 1182 OBJ: 3
TOP: Long-term care
KEY: Nursing Process
Step: Planning MSC: NCLEX: Health Promotion
and Maintenance
15.
The Omnibus Budget Reconciliation Act (OBRA) defines the requirements for which
aspect of care as it relates to long-term care?
a.
Nursing care
b.
Nutritional support
c.
Quality of care
d.
Staffing requirements
ANS: C
OBRA defines requirements for the quality of care given to residents of long-term care
facilities.
DIF: Cognitive Level: Comprehension REF: p. 1182 OBJ: 3
TOP: Long-term care
KEY: Nursing Process
Step: Planning MSC: NCLEX: Health Promotion
and Maintenance
16.
The Health Care Financing Administration (HCFA) conducts unannounced
institutional surveys annually to assess the quality of life for the patients. The
findings of the surveys are reported to:
a.
various licensing boards.
b.
facility administrators.
c.
the public.
d.
the US Department of Health and Human Services.
ANS: C
Surveyors are required by law to visit the long-term care facility unannounced, on an
annual basis and as needed, and the report is made public.
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DIF: Cognitive Level: Comprehension REF: p. 1182 OBJ: 3
TOP: Long-term care
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Health Promotion
and Maintenance
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17.
A 48-year-old long-term care facility resident expresses concern that the cost of his
care has used up his assets. For what program should the nurse suggest that the
resident apply to cover the continued cost of living in a long-term facility?
a.
Medicare
b.
Hospitalization insurance
c.
Medicaid
d.
Public health funds
ANS: C
When adults have used all of their assets, they may then qualify for Medicaid.
Medicaid is a federally funded, state-operated program of medical assistance for
people with low incomes.
DIF: Cognitive Level: Analysis
TOP: Long-term care
REF: p. 1182 OBJ: 3
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
18.
Although the Occupational Safety and Health Act (OSHA) increases the cost of care,
what is a benefit that it provides for long-term care?
a.
It ensures a safe environment for personnel.
b.
It ensures that medications are administered safely.
c.
It ensures that food is prepared safely.
d.
It ensures safe ambulation and transportation of patients.
ANS: A
The OSHA guidelines significantly increase costs, but they also ensure a safe
environment for personnel, which is mandatory today.
DIF: Cognitive Level: Comprehension REF:
p. 1183
OBJ: 3 TOP: Long-
term care
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
19.
A nurse helps a family understand that once hospice service is initiated, the
focus of care changes from rehabilitation and restoration to what type of care?
a.
Maintaining the patient at the optimal level
b.
Assisting with funeral planning
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c.
Relieving the family of care
d.
Maintaining comfort as death approaches
ANS: D
Hospice care is focused on the provision of comfort to the person who is approaching
death. While hospice will assist with funeral planning as needed, it is not the focus of
care. Hospice provides respite for the family, but hospice does not relieve the family
of care duties.
DIF: Cognitive Level: Application
REF: p. 1178
OBJ: 8 TOP: Hospice
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Psychosocial Integrity
20.
What is included when the LVN/LPN completes the Resident Assessment Instrument
(RAI)?
a.
Minimum Data Set (MDS) and the signature of the health care provider
b.
Resident Assessment Protocols (RAPs) and the drug list
c.
Minimum Data Set, Resident Assessment Protocols, and the RN‘s signature
d.
Resident Assessment Protocols and the signature of the administrator
ANS: C
The RAI must be signed by the RN and contain the RAPs and MDS.
DIF: Cognitive Level: Application
TOP: Long-term care
REF: p. 1183 OBJ: 3
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
21.
The nurse assesses a patient‘s ability to perform self-care activities, as well as more
complex social and household activities. What is provided from this assessment?
a.
Physical status
b.
Emotional status
c.
Health status
d.
Functional status
ANS: D
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The functional status is related to activities of daily living (ADLs) and instrumental
activities of daily living (IADLs).
DIF: Cognitive Level: Application
TOP: Long-term care
REF: p. 1184 OBJ: 2
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Health Promotion
and Maintenance
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22.
How often does the Omnibus Budget Reconciliation Act (OBRA) require that a
summary (including vital signs and weight) be obtained in the long-term care
setting?
a.
Daily
b.
Weekly
c.
Monthly
d.
Yearly
ANS: C
A summary, including vital signs and weight, is only required on a monthly basis.
DIF: Cognitive Level: Application
TOP: Long-term care
REF: p. 1182 OBJ: 3
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
23.
In a long-term care facility, the nurse takes an active part in formulating the
resident‘s plan of care. How often is the plan of care revised?
a.
Weekly
b.
Every 90 days
c.
Monthly
d.
Every 6 months
ANS: B
In long-term care, the resident‘s plan of care is reviewed by the interdisciplinary team
every 90 days for resolution of problems or revision of goals and interventions.
DIF: Cognitive Level: Application
TOP: Nursing process
REF: p. 1184 OBJ: 3
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Health Promotion
and Maintenance
24.
The nurse recognizes that an ongoing assessment will help set priorities in the nursing
care plan of a long-term care resident. What does this allow the planning process to
become?
a.
Timely
b.
Patient-centered
c.
Preferential
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d.
Categorized
ANS: B
The planning process must be patient-centered.
DIF: Cognitive Level: Application
TOP: Nursing process
REF: p. 1186 OBJ: 6
KEY: Nursing Process
Step: Planning MSC: NCLEX: Health Promotion
and Maintenance
25.
The long-term care facility nurse recognizes that visiting the resident, changing his
or her position, assessing for incontinence, providing skin care, and offering fluids
are part of the nurse‘s responsibility. What does the initiation of these
interventions provide?
a.
Continuity
b.
Safety
c.
Prevention
d.
Reassurance
ANS: B
Nursing interventions basic to long-term care include monitoring safety measures
such as changing the resident‘s position every 2 hours, assessing for incontinence,
providing skin care when needed, and offering fluids.
DIF: Cognitive Level: Application
TOP: Nursing process
REF: p. 1176 OBJ: 6
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
26.
How often should the long-term care facility nurse make rounds and monitor residents for
safety?
a.
Every 2 hours
b.
Every 4 hours
c.
Every 6 hours
d.
Once per shift
ANS: A
Nursing interventions related to long-term care include making rounds and monitoring for
resident safety every 2 hours.
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DIF: Cognitive Level: Application
TOP: Nursing process
REF: p. 1185 OBJ: 7
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
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27.
When a patient asks why he must be transferred to a subacute unit from the hospital,
what would be an appropriate response by the nurse?
a.
Reimbursement guidelines limit adults‘ stays in an acute setting.
b.
The health care provider can oversee care more closely in a subacute setting.
c.
Financial restrictions of insurance limit time spent in an acute care setting.
d.
Cost and services at the acute care setting are the same as at the hospital.
ANS: A
In the acute care setting, strict rules about length of stay and limitations in cost
reimbursement limit the amount of time adults can be hospitalized. These strict
reimbursement rules for acute care do not apply, however, to subacute care provided
in a skilled nursing facility setting.
DIF: Cognitive Level: Application
TOP: Nursing process
REF: p. 1180 OBJ: 3
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
28.
Two unique members of the care giving team in a long-term care facility are the certified
medication aide/technician and the
assistant.
a.
dental
b.
certified medication
c.
restorative nursing
d.
medical
ANS: C
These two members of the care team are unique to the long-term care facility. Both
have had extra training over and above that of the certified unlicensed assistive
personnel.
DIF: Cognitive Level: Knowledge
REF:
p. 1182
OBJ: 8 TOP: Long-
term care giving team
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
MULTIPLE
RESPONSE
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1.
The LPN/LVN performs which functions when working as a staffing coordinator of a
home health agency? (Select all that apply.)
a.
Scheduling appropriate care providers
b.
Reviewing documentation
c.
Verifying financial coverage
d.
Making referrals
e.
Performing comprehensive assessments
ANS: A, C
Reviewing documentation may be done by an LPN/LVN but not in the role of staffing
coordinator but as a medical chart auditor or reviewer. Scheduling care providers and
verifying financial coverage are among the duties of the staffing coordinator. Making
referrals and performing comprehensive assessments are duties of the RN.
DIF: Cognitive Level: Application
REF: p. 1182 OBJ: 8
TOP: Staffing coordinator KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
2.
The LPN/LVN suggests to the RN that the nursing care plan be modified to
include referral to an adult day care center. What benefits should the patient expect
to receive? (Select all that apply.)
a.
Overnight care
b.
Respite care for the family
c.
Social interaction for the patient
d.
Mental stimulation for the patient
e.
Supporting maintenance of the ADLs
ANS: B, C, D, E
Overnight care is usually not offered from a day care center.
DIF: Cognitive Level: Application
TOP: Adult day care
REF: p. 1178 OBJ: 8
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Health Promotion
and Maintenance
3.
A daughter is assessing a nursing home before placing her mother there for what she
feels will be a long-term stay. Which of the following are important aspects of
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quality to consider when selecting a nursing home? (Select all that apply.)
a.
Privacy is respected.
b.
Staff members are task-focused.
c.
The staff welcomes family visits.
d.
There is a homelike environment.
e.
Rooms are maintained like a hospital.
ANS: A, C, D
It is important that privacy is respected, family members are welcomed, and a
homelike environment is maintained. Staff members should be resident-focused, not
task-focused. Rooms should be maintained like a home instead of like a hospital.
DIF: Cognitive Level: Application
REF:
p. 1180
OBJ: 7 TOP:
Quality indicators
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
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4.
What impact will the Affordable Care Act have on nursing homes and long-term care
centers when fully implemented? (Select all that apply.)
a.
A weaker consumer complaint system
b.
Better training for state inspectors
c.
Program to support national criminal background checks
d.
Public disclosure of nursing home owners and operators
e.
Training of unlicensed assistive personnel in the care of people with dementia
ANS: B, C, D, E
The Affordable Care Act will result in a stronger consumer complaint system, better
training for state inspectors, a program to support national criminal background checks,
public disclosure of nursing home owners and operators, and training for unlicensed
assistive personnel in the care of people with dementia.
DIF: Cognitive Level: Comprehension REF:
p. 1183
OBJ: 3 TOP:
Federal regulations
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
COMPLETION
1.
The nurse explains to a patient that shopping, using a phone, and administering his own
medications are classified as
activities of daily living.
ANS:
instrumental
IADLs are more complex skills than ADLs and indicate a higher level of independent
functioning.
DIF: Cognitive Level: Application
REF: p. 1179
OBJ: 8 TOP:
Instrumental activities of daily living (IADLs)
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
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2.
When a resident who is a Muslim becomes concerned about his religiously dictated
dietary requirements, the nurse may refer this concern to the long-term care
department.
ANS:
dietary
Long-term facilities take into consideration the patient‘s individual needs, including diet
preferences. The dietary department is usually able to meet most requests.
DIF: Cognitive Level: Application
REF: p. 1176 OBJ: 7
TOP: Ethnic considerations KEY: Nursing Process
Step: Implementation MSC: NCLEX: Health Promotion
and Maintenance
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Chapter 39: Rehabilitation Nursing
Cooper: Foundations and Adult Health Nursing, 9th Edition
MULTIPLE
CHOICE
1.
The nurse who is part of a team focused on restoring an individual to the fullest
physical, mental, social, vocational, and economic capacity is practicing what type of
nursing?
a.
Holistic nursing
b.
Conscientious nursing
c.
Rehabilitation nursing
d.
Comprehensive nursing
ANS: C
Rehabilitation is the process of restoring an individual to the fullest physical, mental,
social, vocational, and economic capacity of which he or she is capable.
DIF: Cognitive Level: Comprehension REF:
p. 1188
OBJ: 1 TOP:
Rehabilitation
KEY: Nursing
Process Step: N/A MSC: NCLEX: Health
Promotion and Maintenance
2.
The nurse recognizes that the rehabilitation process involves the efforts of various
disciplines. The focus of rehabilitation is to build on which area?
a.
A person‘s losses
b.
A person‘s long-term plans
c.
A person‘s drives
d.
A person‘s abilities
ANS: D
The underlying philosophy of rehabilitation is to focus on the abilities of the patient.
DIF: Cognitive Level: Application
TOP: Rehabilitation
REF: p. 1188 OBJ: 1
KEY: Nursing Process Step:
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Implementation MSC: NCLEX: Health Promotion and
Maintenance
3.
The nurse should tell a paraplegic that the rehabilitation experience will consist of:
a.
relearning former skills.
b.
learning to walk.
c.
learning new skills to adapt to a different lifestyle.
d.
developing muscle strength.
ANS: C
The type and the focus of rehabilitation are individualized to the patient, the injury,
and abilities. Skills will be taught to enhance the patient‘s adaptation to a new
lifestyle.
DIF:
Cognitive Level: Application REF:
p. 1189 | p. 1190 OBJ: 3
TOP:
Rehabilitation
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and
Maintenance
4.
The nurse who helps a patient with a disability rejoice in the acquisition of the smallest
new skill is embracing which rehabilitation philosophy?
a.
Resolving impairments
b.
Removing disabilities
c.
Increasing quality of life
d.
Eliminating complications
ANS: C
A philosophy of rehabilitation is to increase the quality of life. Impairments may not
be able to be resolved, disabilities may not be able to be completely removed, and
complications may not be totally eliminated. However, with rehabilitation, the
individual can learn to adjust to the new lifestyle.
DIF: Cognitive Level: Application
TOP: Rehabilitation
REF: p. 1189 OBJ: 1
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
5.
A patient with quadriplegia resulting from a spinal cord injury says to the
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rehabilitation nurse, ―I‘m sick of this therapy! What is an occupational therapist going
to do for me? Can she give me an ‗occupation‘?‖ What response by the nurse would
be the most helpful?
a.
―No, but the occupational therapist can show you
how to enjoy some recreational activities.‖
b.
―Yes, in a way. The occupational therapist
provides training that strengthens muscles you can
still control.‖
c.
―Maybe. The occupational therapist recommends
adaptive equipment that will make you more
independent.‖
d.
―No, the voc-rehab counselor helps with employment.
The occupational therapist helps train you for
improved communication skills.‖
ANS: C
The occupational therapist recommends adaptive equipment or helps in modifying skills to
enhance independence.
DIF: Cognitive Level: Analysis
TOP: Rehabilitation
REF: p. 1192 OBJ: 4
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity
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6.
When caring for a patient with a disability, the rehabilitation nurse provides individual
treatment to help the patient stay focused on which goals?
a.
Returning to normal
b.
Independence
c.
Employment
d.
Promotion of health
ANS: B
The focus on rehabilitation is on enabling the individual to move from a totally dependent
state to a level of independence.
DIF: Cognitive Level: Application
TOP: Rehabilitation
REF: p. 1192 OBJ: 3
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
7.
Following admission, how soon must a comprehension rehabilitation plan of care be
implemented on a rehabilitation patient?
a.
12 hours
b.
24 hours
c.
3 days
d.
1 week
ANS: B
A comprehensive rehabilitation plan must be initiated within 24 hours of admission to
the rehabilitation service. The results of the interdisciplinary assessment provide the
basis for development of the plan of care. The team has 3 days from admission to
review and revise the plan of care.
DIF: Cognitive Level: Application
TOP: Rehabilitation
REF: p. 1190 OBJ: 4
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
8.
Which is a characteristic of the interdisciplinary approach to the rehabilitation team?
a.
Each discipline makes its own goals for the patient.
b.
There are clear boundaries between the disciplines.
c.
There is a combination of expanded problem
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solving beyond the boundaries of the individual
disciplines.
d.
Cross-trained people are used who have
functional ability in two or more disciplines.
ANS: C
In the interdisciplinary approach, the team collaborates on the goals for the patient.
In the multidisciplinary rehabilitation team approach, each discipline makes its own
goals for the patient and there are clear boundaries between the disciplines. The
transdisciplinary rehabilitation team is characterized by the blurring of boundaries
between disciplines and the cross-training and flexibility to reduce a duplication of
efforts.
DIF: Cognitive Level: Application
TOP: Rehabilitation
REF: p. 1191 OBJ: 4
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
9.
When planning care for children, the nurse uses a concept that recognizes the pivotal
role of the family in the lives of children with disabilities or other chronic conditions.
What is this philosophy called?
a.
Child-centered care
b.
Systems-centered care
c.
Family-centered care
d.
Individual-centered care
ANS: C
Family-centered care is an evolving concept that uses the family as equal partners in the
rehabilitation process.
DIF: Cognitive Level: Comprehension REF: p. 1193 OBJ: 6
TOP: Rehabilitation
KEY: Nursing Process
Step: Planning MSC: NCLEX: Health Promotion
and Maintenance
10.
What is the primary difference between the rehabilitation of children and the
rehabilitation of adults?
a.
Level of disability
b.
Body part involved
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c.
Degree of disability
d.
Developmental potential
ANS: D
The primary difference between rehabilitation of children and rehabilitation of adults is
the developmental potential of the child.
DIF: Cognitive Level: Knowledge
TOP: Rehabilitation
REF: p. 1200 OBJ: 10
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
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11.
The acquisition of adaptive skills and behaviors by an individual who has been disabled
since birth refers to:
a.
training.
b.
education.
c.
development.
d.
habilitation.
ANS: D
Habilitation refers to developing skills and behaviors in people who did not have the
skills originally. Children who are disabled from birth have no skills to relearn and are
habilitated rather than rehabilitated.
DIF: Cognitive Level: Comprehension REF:
p. 1200
OBJ: 10 TOP: Habilitation KEY:
Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
12.
The nurse who is engaged in gerontological rehabilitation nursing has a dual
challenge. The gerontological rehabilitation nurse must assess not only the
debilitating factors of disease but also which other factor?
a.
Advancing age
b.
Reduced ability to learn
c.
Limited energy
d.
Eroded interest level
ANS: A
Gerontological rehabilitation nursing focuses on the unique requirements of older
adult rehabilitation. The elderly, with their potential physical limitations, require
specialized care.
DIF:
Cognitive Level: Application REF:
p. 1200 | p. 1202 OBJ: 10 TOP:
Rehabilitation
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and
Maintenance
13.
The nurse explains that the main roles of the gerontological rehabilitation nurse are
to provide rehabilitative care and what other role?
a. Provide restoration.
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b.
Teach prevention.
c.
Teach adaptive skills.
d.
Provide positive reinforcement.
ANS: B
Teaching prevention is the dual role of the geriatric rehabilitation nurse. Restoration,
adaptive skills, and positive reinforcements are all part of providing rehabilitative
care.
DIF: Cognitive Level: Application
TOP: Rehabilitation
REF: p. 1202 OBJ: 10
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
14.
What should the nurse do to reduce the incidence of postural hypotension in a patient
with a spinal cord injury?
a.
Monitor diastolic blood pressure closely.
b.
Encourage the patient to remain in the bed.
c.
Raise the head of the bed for 15 to 20 minutes before transfer to a wheelchair.
d.
Encourage adequate intake of fluids to expand fluid volume.
ANS: C
Raising the head of the bed before transfer allows for gradual vessel accommodation
from the supine position to the upright position. It is important to check the patient‘s
blood pressure, but it will not reduce the incidence of postural hypotension. It is
important to encourage the patient to get out of bed. Postural hypotension is related to
a pooling of blood in the lower extremities and is not related to a fluid volume deficit.
DIF:
Cognitive Level: Application REF:
p. 1197 | p. 1199 OBJ: 7
TOP:
Rehabilitation
KEY: Nursing Process Step:
Implementation MSC:
NCLEX: Physiological
Integrity
15.
The nurse takes special care to be gentle in caring for patients with spinal cord injuries
to avoid stimulating the autonomic nervous system and triggering which condition?
a.
Paresis
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b.
Heterotopic ossification
c.
Postural hypotension
d.
Autonomic dysreflexia
ANS: D
Autonomic dysreflexia is a sudden and extreme elevation in blood pressure caused
by a reflex action of the autonomic nervous system. It is the result of stimulation of
the body below the level of the spinal cord injury.
DIF: Cognitive Level: Application
TOP: Rehabilitation
REF: p. 1199 OBJ: 7
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
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16.
The nurse instructs the mother of a 5-year-old who sustained a mild brain injury
that although all neurologic evaluations are normal, her child may exhibit
postconcussive syndrome. What are common characteristics of this syndrome?
a.
Convulsions and high fever
b.
Irritability and memory deficits
c.
Muscular twitching and muscle pain
d.
Paresis of limbs and fatigue
ANS: B
Mild brain injury is characterized by brief or no loss of consciousness. This type
constitutes the majority of head injuries. Neurologic examinations are often normal.
Postconcussive syndrome can persist for months, years, or indefinitely. Signs and
symptoms include fatigue, headache, vertigo, lethargy, irritability, personality changes,
cognitive deficits, decreased information processing speed and memory, understanding,
learning, and perceptual difficulties.
DIF: Cognitive Level: Application
TOP: Rehabilitation
REF: p. 1199 OBJ: 7
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
17.
When changing the position of a patient with a spinal cord injury at T4, the nurse
should recognize that what symptom is an indication of an episode of autonomic
dysreflexia?
a.
Nausea
b.
Pallor
c.
Goose bumps
d.
Dizziness
ANS: C
Patients with spinal cord lesions above T5 may experience sudden and extreme
elevations in blood pressure caused by a reflex action of the autonomic nervous
system. It is produced by stimulation of the body below the level of the injury,
usually by a distended bladder from a blocked catheter. Any stimulation can produce
the syndrome, including constipation, diarrhea, sexual activity, pressure injuries,
position changes (from lying to sitting), and even wrinkles in clothing or bed sheets.
Other symptoms may include diaphoresis, shivering, goose bumps, flushing of the
skin, and a severe pounding headache.
DIF: Cognitive Level: Analysis
REF: p. 1196 OBJ: 7
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TOP: Rehabilitation
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
18.
When assessing a patient with a traumatic brain injury, the nurse notes that his
memory is improving. The nurse should explain to the family that what other
symptom may occur with memory improvement?
a.
Decrease in learning ability
b.
Depression
c.
Anger
d.
Increased concentration
ANS: B
Generally, the more memory improves in a patient with a brain injury, the more the
patient becomes depressed.
DIF: Cognitive Level: Analysis
TOP: Rehabilitation
REF: p. 1200 OBJ: 7
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
19.
When caring for a 32-year-old Hispanic male who has become disabled, on what
should the rehabilitation team base the priority of treatment goals?
a.
Difficulty of the language barrier
b.
Cultural significance of the disability
c.
Depth of the patient‘s support system
d.
Attitude toward rehabilitation
ANS: B
Culture defines the significance of disease and disability. Although all of the options
must be addressed, the significance of the disability has highest priority.
DIF: Cognitive Level: Analysis
TOP: Rehabilitation
REF: p. 1194 OBJ: 2
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
20.
What is the best way to define a handicap?
a.
Any loss of function
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b.
A disability that interferes with one‘s normal functioning
c.
Any loss of ability to perform activities of daily living
d.
An irreversible lifelong impairment
ANS: B
A handicap is a disadvantage for a given individual from an impairment that limits his
or her role performance. A particular handicap for one person might not pose any
handicap for another with the same disability. An impairment is a loss of function. A
functional limitation is a disability that interferes with one‘s normal functioning. A
chronic illness is an irreversible lifelong impairment.
DIF: Cognitive Level: Comprehension REF: p. 1196 OBJ: 1
TOP: Rehabilitation
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
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21.
What should the nurse do to decrease the potential for a deep vein thrombosis (DVT)
in a patient who is a paraplegic from a spinal cord injury?
a.
Massage the patient‘s legs daily.
b.
Perform passive range-of-motion exercises.
c.
Encourage frequent warm baths.
d.
Allow the patient‘s legs to dangle for a period of 10 minutes several times a day.
ANS: B
DVTs are a problem for patients with a spinal cord injury. Passive range-ofmotion exercises manipulate the muscles, which improves venous return,
reducing the probability of DVT.
DIF: Cognitive Level: Application
TOP: Rehabilitation
REF: p. 1199 OBJ: 5
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
22.
When the nurse observes a patient experiencing a severe episode of autonomic
dysreflexia, what should be the initial intervention?
a.
Locate the cause of irritation.
b.
Assess the blood pressure.
c.
Cover the patient with several blankets.
d.
Raise the head of the bed to a high Fowler‘s position.
ANS: D
The head of the bed should be raised immediately. Raising the head of the bed will
reduce the blood pressure. Finding the cause of the episode is secondary to preventing
the possibility of a stroke from the hypertension.
DIF:
Cognitive Level: Analysis
p. 1197 | p. 1199 OBJ: 5
REF:
TOP:
Rehabilitation
KEY: Nursing Process Step:
Implementation MSC:
NCLEX: Physiological
Integrity
23.
When speaking to a group of high school students, the rehabilitation nurse states
that spinal cord injuries resulting in paralysis occur mainly as the result of
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traumatic accidents in which group of individuals?
a.
Middle-aged men
b.
Older adult females
c.
Young males
d.
Young females
ANS: C
Individuals paralyzed by spinal cord injuries are primarily young males.
DIF: Cognitive Level: Comprehension REF: p. 1196 OBJ: 2
TOP: Rehabilitation
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
24.
The spinal cord injury patient has paralysis of all extremities and bowel and bladder
disturbance. The nurse recognizes the injury as most likely occurring at what vertebral
level?
a.
C1 to C2
b.
C3 to C4
c.
C2 to C7
d.
C4 to C7
ANS: C
The vertebral level of injury for a cervical cord is C2 to C7 if the patient has paralysis
of all extremities and trunk, and has lost control of bowel and bladder function.
DIF: Cognitive Level: Application
TOP: Rehabilitation
REF: p. 1196 OBJ: 2
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
25.
The rehabilitation nurse can use basic rehabilitation skills regardless of the origin of
the disability. What intervention would be effective for a person with arthritis, a
person with a brain injury, or a person with a spinal cord injury?
a.
Encouraging large fluid intake
b.
Seeking spiritual support from a higher being
c.
Using the spouse as a support system
d.
Positioning to maintain alignment
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ANS: D
Alignment preservation is an implementation that is appropriate for a variety of
rehabilitation patients, regardless of the origin of their disability.
DIF:
Cognitive Level: Application
REF: pp. 1192-1193 OBJ:
5
TOP: Rehabilitation
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
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26.
What should a nurse explain to a patient as a cause of triggering autonomic dysreflexia?
a.
Loud sound
b.
Distended bladder
c.
Leg cramp
d.
Sudden chilling
ANS: B
Patients with spinal cord lesions above T5 may experience sudden and extreme
elevations in blood pressure caused by a reflex action of the autonomic nervous
system. It is produced by stimulation of the body below the level of the injury,
usually by a distended bladder from a blocked catheter. Any stimulation can produce
the syndrome, including constipation, diarrhea, sexual activity, pressure injuries,
position changes (from lying to sitting), and even wrinkles in clothing or bed sheets.
DIF: Cognitive Level: Comprehension REF: p. 1199 OBJ: 5
TOP: Rehabilitation
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity
27.
The rehabilitation nurse stresses to the family of a patient with a brain injury that
difficult and painful rehabilitation will probably be required for what length of time?
a.
1 to 2 years
b.
2 to 4 years
c.
5 to 10 years
d.
6 to 12 years
ANS: C
Most brain-related disabilities, including physical, cognitive, and psychosocial
difficulties, call for at least 5 to 10 years of difficult and painful rehabilitation; many
require lifelong treatment and attention.
DIF: Cognitive Level: Knowledge
TOP: Rehabilitation
REF: p. 1199 OBJ: 7
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and
Maintenance
28.
The rehabilitation nurse recognizes that the majority of patients with head injuries
show no abnormal neurologic findings and experience no loss of consciousness.
How should the nurse categorize this type of brain injury?
a. Mild
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b.
Moderate
c.
Severe
d.
Catastrophic
ANS: A
Mild brain injury is characterized by no loss of consciousness and no abnormal
neurologic findings.
DIF: Cognitive Level: Knowledge
TOP: Rehabilitation
REF: p. 1199 OBJ: 2
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
29.
A 33-year-old patient with a spinal cord injury says to the nurse, ―I‘ve let my family
down. I don‘t know what to do.‖ What would be the best response by the nurse?
a.
―After your rehabilitation starts, you‘ll feel better.‖
b.
―You should be grateful you are alive.‖
c.
―What does this injury mean to you?‖
d.
―Technological advances are changing the future for spinal cord injury victims.‖
ANS: C
The patient should be encouraged to express his or her feelings about the disability.
DIF: Cognitive Level: Analysis
TOP: Rehabilitation
REF: p. 1198 OBJ: 5
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychological
Integrity
30.
The nurse used a diagnosis of impaired cognition for a 40-year-old patient with a
brain injury. Which assessment data would support the diagnosis?
a.
Frequently becomes violent.
b.
Becomes easily fatigued.
c.
Is depressed.
d.
Cannot add three numbers in his head.
ANS: D
Impaired cognition includes problems in thinking, impaired concentration, and impaired
information processing.
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DIF: Cognitive Level: Analysis
TOP: Rehabilitation
REF: p. 1200 OBJ: 5
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
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31.
The patient with a brain injury is beginning to regain memory. The nurse explains to the
family that what will most likely occur?
a.
The patient will become less combative.
b.
The patient will become angrier.
c.
The patient will become more depressed.
d.
The patient will wish to retire.
ANS: C
Generally, the more the memory improves, the more the patient becomes depressed.
DIF: Cognitive Level: Comprehension REF: p. 1200 OBJ: 7
TOP: Rehabilitation
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
MULTIPLE RESPONSE
1.
The nurse explains that the Americans with Disabilities Act of 1990 defines a person
as disabled if which criteria are met? (Select all that apply.)
a.
The person has a physical or mental impairment.
b.
The person is limited in at least one major life activity.
c.
The person has a medical record of the impairment.
d.
The person is unemployed.
e.
The person needs assistance in completion of ADLs.
ANS: A, B, C
The definition is that a disabled person may have a physical or mental impairment that
limits the person in one or more major life activities and has a medical record of that
disability.
DIF: Cognitive Level: Comprehension
REF: p. 1196
OBJ: 2 TOP:
Americans with Disabilities Act (ADA)
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
2.
The nurse is caring for a victim of posttraumatic stress syndrome. The nurse identifies
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which techniques as examples of therapeutic communication? (Select all that apply.)
a.
Listening
b.
Reframing
c.
Characterizing
d.
Normalizing responses
e.
Working to develop trust
ANS: A, B, D, E
The techniques of therapeutic communication that are important to use with the PTSD
patient are listening, reframing, normalizing responses, and working to develop trust.
DIF: Cognitive Level: Comprehension
REF: p. 1196
OBJ: 9 TOP: PTSD
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
COMPLETION
1.
The rehabilitation nurse assesses localized edema around the knee of a patient with
paraplegia. The nurse suspects that this is the first sign of
ossification.
ANS:
heterotopic
Heterotopic ossification is a bony growth in joints of spinal cord injury patients below
the injury that ultimately limits range of motion.
DIF: Cognitive Level: Comprehension REF: p. 1199 OBJ: 7
TOP: Rehabilitation
KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological
Integrity
2.
A child who was struck by a car and suffered a closed head injury was
unconscious for 24 hours before waking. The nurse recognizes this as a
brain
injury.
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ANS:
moderate
A period of unconsciousness of 1 to 24 hours is characteristic of a moderate brain injury.
DIF: Cognitive Level: Application |
Cognitive Level: Comprehension REF: p.
1199
OBJ: 7
TOP:
Rehabilitation
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
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3.
The nurse who assesses for cultural influences, values cultural diversity, and
incorporates cultural knowledge in practice is said to be culturally
.
ANS:
competent
A culturally competent nurse includes knowledge of cultural values and influences in
their nursing practice.
DIF: Cognitive Level: Application
REF: p. 1194
OBJ: 5 TOP: Culture
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Health Promotion and Maintenance
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Chapter 40: Hospice Care
Cooper: Foundations and Adult Health Nursing, 9th Edition
MULTIPLE
CHOICE
1.
What is the overall objective of hospice service?
a.
Relieve symptoms of terminal disease.
b.
Educate the patient about the process of death.
c.
Keep the patient comfortable as death approaches.
d.
Relieve the family of the stress of death.
ANS: C
Hospice is a philosophy of care that provides support and comfort to patients who are
dying.
DIF: Cognitive Level: Comprehension
REF: p. 1204
OBJ: 1 TOP: Hospice
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Psychosocial Integrity
2.
Who was responsible for renewing the hospice philosophy in the 1960s?
a.
Cicely Saunders
b.
Lillian Wald
c.
Dorothea Dix
d.
Florence Nightingale
ANS: A
The idea of hospice is originated in Europe. Dame Cicely Saunders renewed the idea of
hospice in the 1960s.
DIF: Cognitive Level: Knowledge
REF: p. 1204 OBJ: 1
TOP: Hospice
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
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3.
The hospice nurse clarifies that hospice service is initiated when what type of treatment is
no longer effective?
a.
Proactive
b.
Palliative
c.
Alternative
d.
Curative
ANS: D
Hospice care is appropriate when curative treatment is no longer effective. Hospice
service is palliative, proactive, and an alternative to curative treatment.
DIF: Cognitive Level: Comprehension
REF: p. 1206
OBJ: 2 TOP: Hospice
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Psychosocial Integrity
4.
The nurse differentiates between curative and palliative care. What is true of curative
treatment?
a.
Curative treatment is centered on symptom control.
b.
Curative treatment is focused on prolonging life.
c.
Curative treatment is not concerned with dying.
d.
Curative treatment is the only care covered by health insurance.
ANS: B
Curative treatment is aggressive care that aims to cure disease and prolong life.
Palliative care is not curative in nature and is centered on symptom control. Both types
of care are typically covered by health insurance.
DIF: Cognitive Level: Application
REF: p. 1206
OBJ: 2 TOP: Hospice
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Psychosocial Integrity
5.
Because the family is confused about the meaning of palliative care, the hospice
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nurse needs to explain the focus of care. What is the focus of palliative care?
a.
An aggressive approach to prolong life
b.
A protocol of pain relief
c.
A form of organized care, which relieves the family of responsibility
d.
An integrated service of support for alleviation of symptoms
ANS: D
Palliative care is not curative but is an integrated plan designed to relieve pain and
control symptoms. The goal is not to prolong life. While pain relief may be one aspect
of hospice care, it is not what treatment is centered upon. The family is not relieved of
their responsibility.
DIF:
Cognitive Level: Analysis
OBJ: 2
REF: pp. 1205-1206
TOP: Hospice KEY: Nursing Process
Step: Implementation MSC: NCLEX: Psychosocial
Integrity
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6.
The hospice nurse explains that to qualify for admission to a hospice, the attending
health care provider must certify that the patient has a life expectancy of fewer than
how many months?
a.
2 months
b.
3 months
c.
4 months
d.
6 months
ANS: D
The patient must meet certain criteria to be admitted to hospice, such as a prognosis of 6
months or fewer to live.
DIF: Cognitive Level: Comprehension
REF: p. 1206
OBJ: 3 TOP: Hospice
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Psychosocial Integrity
7.
The hospice nurse requests that the patient designate a primary caregiver for himself.
What is true of the primary caregiver?
a.
Must be a relative.
b.
Has complete control over the patient‘s care.
c.
Assumes ongoing responsibility for health maintenance of the patient.
d.
Must have power of attorney.
ANS: C
A primary caregiver is one who assumes responsibility for health maintenance and
therapy. It is not necessary that the primary caregiver be a relative. The primary
caregiver does not have complete control over the patient‘s care, and it is not necessary
for the primary caregiver to have power of attorney.
DIF: Cognitive Level: Application
REF: p. 1207
OBJ: 3 TOP: Hospice
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Psychosocial Integrity
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8.
Why is it important for the hospice nurse to provide time to confer with the patient and
family?
a.
To show concern
b.
To report changes in the plan of care designed by the team
c.
To confirm the ongoing reimbursement
d.
To plan for changes in the scope of care
ANS: D
No changes should be made to the patient‘s plan of care without first discussing it with
the entire family. The family should be involved in planning the changes in the scope
of care.
DIF: Cognitive Level: Application
REF: p. 1209
OBJ: 1 TOP: Hospice
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Psychosocial Integrity
9.
The patient informs the hospice nurse, ―I‘m not sold on this hospice thing. I‘m not
looking for Jesus, I‘m just dying.‖ What would be the most therapeutic response by
the nurse?
a.
―Spiritualism is as you define it.‖
b.
―Rejecting the spiritual aspect of yourself may not be in your best interest.‖
c.
―Hospice service is about how to make your remaining time meaningful.‖
d.
―Based on what you say, hospice service may not answer your needs.‖
ANS: C
The holistic approach of hospice pertains to the total patient care including
physical, emotional, social, economic, and spiritual needs of the patient with no
particular emphasis on any one of those aspects.
DIF: Cognitive Level: Analysis
OBJ: 1
REF: p. 1206 | p. 1207
TOP: Hospice KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
10.
What is the role of the hospice medical director?
a.
To design and direct the plan of care
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b.
To evaluate the appropriateness of the care
c.
To function as mediator between the team and the attending health care provider
d.
To take the place of the patient‘s attending health care provider
ANS: C
The medical director is a mediator between the interdisciplinary team and the
attending health care provider. The interdisciplinary team designs the plan of care.
The primary team, along with the interdisciplinary team, evaluates the
appropriateness of care. The medical director does not take the place of the attending
health care provider, but instead acts as a consultant for the attending health care
provider.
DIF: Cognitive Level: Application
REF: p. 1208
OBJ: 4 TOP: Hospice
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Psychosocial Integrity
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11.
The hospice nurse tells the family that the nurse coordinator, an RN, will visit them. What
is the role of the nurse coordinator?
a.
Collect initial fees for the hospice service.
b.
Officially admit the patient to the hospice service.
c.
Assist with accessing community resources.
d.
Assist with funeral planning.
ANS: B
The role of the nurse coordinator is to do the initial assessment, admit the patient,
and develop the plan of care with the interdisciplinary team. The nurse coordinator
would not be responsible for collecting fees at the initiation of services. The social
worker would assist with community resources. The spiritual coordinator would
assist with funeral planning.
DIF:
Cognitive Level: Application REF: p. 1208 | p. 1209
OBJ: 4
TOP: Hospice KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
12.
The social worker evaluates and assesses the psychosocial needs of the patient. To
work in a hospice, the social worker must have at least which degree?
a.
Associate
b.
Bachelor‘s
c.
Master‘s
d.
Doctorate
ANS: B
The hospice social worker must have at least a bachelor‘s degree.
DIF: Cognitive Level: Knowledge
REF: p. 1208 OBJ: 4
TOP: Hospice
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
13.
The hospice spiritual coordinator can be affiliated with any religion, assists with the
spiritual assessment of the patient, and develops the plan of care regarding spiritual
matters. To work in a hospice, what degree should the spiritual coordinator possess?
a.
Bachelor‘s degree
b.
Master‘s degree
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c.
Seminary degree
d.
Associate degree
ANS: C
The hospice spiritual coordinator must have a seminary degree.
DIF: Cognitive Level: Knowledge
REF: p. 1208 OBJ: 4
TOP: Hospice
KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
14.
The hospice nurse introduced the family to the volunteer coordinator who will assign a
volunteer to the patient. What can a hospice volunteer do for a patient and caregiver?
a.
Give the family respite.
b.
Give necessary medication in the absence of the nurse.
c.
Be at the family‘s disposal 16 hours a week.
d.
Bathe the patient.
ANS: A
The volunteer coordinator assigns volunteers to the family to give the family
respite. The volunteer cannot give medication. A dedicated number of hours per
week are not mandated. It is not the role of the volunteer to provide personal care.
DIF:
Cognitive Level: Comprehension
OBJ: 4
REF: p. 1208 | p. 1209
TOP: Hospice KEY: Nursing Process
Step: Assessment MSC: NCLEX: Psychosocial
Integrity
15.
The hospice nurse instructs the family that they have access to a bereavement
coordinator who follows the plan of care focused on the caregiver after the death of
the patient. For how long of a period of time will the caregiver and family have
access to the bereavement coordinator?
a.
One week
b.
One month
c.
One year
d.
Two years
ANS: C
The bereavement coordinator follows the plan of care for the caregiver for at least a year
following the death of the patient.
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DIF: Cognitive Level: Comprehension
REF: p. 1210
OBJ: 4 TOP: Hospice
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Psychosocial Integrity
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16.
The hospice nurse instructs the family that they have access to a hospice pharmacist,
who is available for consultation on the drugs the hospice patient may be taking. What
other role does the hospice pharmacist fill?
a.
Administer all drugs necessary for pain alleviation.
b.
Evaluate drug interactions with food and other medications.
c.
Evaluate the safety of the drug storage in the patient‘s home.
d.
Monitor drug effectiveness by frequent phone interviews with the family.
ANS: B
The hospice pharmacist is available to consult about drug interactions with other drugs
or food. The pharmacist does not administer the drugs. The nurse would evaluate the
safety of drug storage in the home and monitor the drug effectiveness.
DIF: Cognitive Level: Analysis
REF: p. 1210
OBJ: 4 TOP: Hospice
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
17.
Who conducts the nutritional assessment at the time of admission to hospice care?
a.
Health care provider
b.
Hospice nurse
c.
Caregiver
d.
Unlicensed assistive personnel
ANS: B
The hospice nurse does the nutritional assessment during admission.
DIF: Cognitive Level: Comprehension
REF: p. 1210
OBJ: 4 TOP: Hospice
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
18.
When a deficiency in nutritional status of a patient is assessed, what action should be
taken by the hospice nurse?
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a.
Make a comprehensive grocery list for the caregiver.
b.
Alert the licensed medical nutritionist.
c.
Seek culturally appropriate methods to increase nutrition.
d.
Instruct the caregiver to give the patient multivitamins.
ANS: B
The hospice nurse can call on the nutritionist for assistance for the patient who is
assessed as having a nutritional deficit. The nutritionist can then provide assistance
with meal planning and diet counseling.
DIF: Cognitive Level: Analysis
REF: p. 1210
OBJ: 4 TOP: Hospice
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
19.
What symptom of hospice patients is the most dreaded and feared, and should be a
priority of symptom management?
a.
Fear
b.
Anger
c.
Grief
d.
Pain
ANS: D
While hospice patients experience all of these symptoms, pain is the most dreaded
and feared. Pain disrupts the quality, activities, and enjoyment of life. Pain should be
a priority of symptom management in hospice care.
DIF: Cognitive Level: Application
REF: p. 1211
OBJ: 5 TOP: Hospice
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Psychosocial Integrity
20.
During a pain assessment, the patient tells the nurse that the pain is aching, stabbing,
and throbbing. What type of pain is the patient describing?
a.
Visceral
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b.
Neuropathic
c.
Somatic
d.
Psychogenic
ANS: C
Somatic pain arises from the musculoskeletal system and is aching, stabbing, or
throbbing. Visceral pain arises from the internal organs and is described as cramping,
dull, or squeezing. Neuropathic pain arises from the neurologic system and is
described as tingling, burning, or shooting.
DIF: Cognitive Level: Application
REF: p. 1212
OBJ: 6 TOP: Hospice
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
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21.
What are the drugs of choice when caring for the hospice patient?
a.
Nonsteroidal antiinflammatory drugs
b.
Anticholinergic drugs
c.
Duragesic patches
d.
Morphine derivatives
ANS: D
Morphine derivatives are popular drugs of choice when dealing with the hospice
patient because they have a wide variety of modes of administration and provide good
pain control.
DIF: Cognitive Level: Application
REF: p. 1212
OBJ: 6 TOP: Pain
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
22.
The nurse should educate the patient and caregiver that large doses of narcotics are
required to control pain. What is the optimal dose for pain medications?
a.
The smallest amount possible to achieve some effects
b.
The dose that provides pain relief
c.
The dose that is not addictive
d.
The dose that works for most people
ANS: B
The patient and caregiver should understand that pain can be controlled and that using
large doses of opioids is common and necessary to achieve that control. It is good to
educate the patient and caregiver that the dose that works is the dose that works.
DIF:
Cognitive Level: Analysis
OBJ: 6
REF: p. 1212 | p. 1214
TOP: Hospice KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological
Integrity
23.
The nurse warns that nausea is a common side effect with opioid treatment. What
is the best treatment for nausea caused by opioids?
a.
Antiemetics
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b.
Ice chips
c.
Dry crackers
d.
Ginger ale
ANS: A
Rather than discontinuing the opioid, the nausea should be treated with an antiemetic.
DIF: Cognitive Level: Application
REF: p. 1214
OBJ: 6 TOP: Hospice
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
24.
When educating a patient concerning ways to prevent nausea, the nurse suggests that
eating slowly in a pleasant atmosphere will help, as well as taking an antiemetic
before meals. How many minutes before meals should the patient take the
antiemetic?
a.
10
b.
20
c.
30
d.
60
ANS: C
Taking an antiemetic 30 minutes before meals reduces nausea and increases appetite.
DIF: Cognitive Level: Application
REF: p. 1214
OBJ: 5 TOP: Hospice
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
25.
What is the most common problem of the terminally ill patient that is caused by
narcotics?
a.
Malnutrition
b.
Constipation
c.
Fluid retention
d.
Dehydration
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ANS: B
One of the most common opioid-induced problems of the terminally ill patient is
constipation.
DIF: Cognitive Level: Comprehension
REF: p. 1214
OBJ: 5 TOP: Hospice
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
26.
The hospice nurse documents an assessment finding of cachexia in the patient record.
What does cachexia describe?
a.
Deep sleep and unresponsiveness
b.
Marked weakness and emaciation
c.
Total addiction to opioids
d.
Renewed energy
ANS: B
Malnutrition marked by weakness and emaciation is called cachexia.
DIF: Cognitive Level: Knowledge
REF: p. 1215
OBJ: 5 TOP: Hospice
KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
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27.
Which of the following is an expected part of the end-of-dying process?
a.
Denial
b.
Despair
c.
Anorexia
d.
Depression
ANS: C
The nurse often has to reassure the patient and caregiver that anorexia is part of the endof-dying process.
DIF: Cognitive Level: Comprehension
REF: p. 1215
OBJ: 5 TOP: Hospice
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
28.
Which medication relaxes the patient‘s respiratory effort and thus increases the efficiency
of the patient‘s respiratory status?
a.
Aminophylline
b.
Theophylline
c.
Epinephrine
d.
Morphine
ANS: D
Respiratory distress may be relieved by morphine.
DIF: Cognitive Level: Application
REF: p. 1215
OBJ: 5 TOP: Hospice
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
29.
Why should the hospice nurse delay the use of oropharyngeal suctioning?
a.
It will decrease mucus production.
b.
It will be uncomfortable for the patient.
c.
It is not necessary.
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d.
It puts the patient at risk for infection.
ANS: B
Suctioning should only occur if the patient is choking because it causes an increase in
mucus production and is uncomfortable for the patient.
DIF: Cognitive Level: Application
REF: p. 1215
OBJ: 5 TOP: Hospice
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
30.
The hospice nurse recommends that the patient prepare the document that provides
guidance to the family concerning the patient‘s wishes regarding life-support
measures and organ donation. What is this document called?
a.
Power of attorney
b.
Living will
c.
Advance directive
d.
Conservatorship
ANS: C
An advance directive is a document prepared while the patient is alive and competent
that provides guidance to the family and health care team in the event the person can
no longer make decisions.
DIF: Cognitive Level: Knowledge
REF: p. 1217
OBJ: 8 TOP: Hospice
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Psychosocial Integrity
31.
The hospice nurse instructs caregivers in repositioning the patient because the
patient spends most of the time reclining. What problem can this cause?
a.
Contractures
b.
Pressure injuries
c.
Bruising
d.
Excoriation
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ANS: B
Increased weakness is noted in the last stages of a terminal illness. With increased
weakness, activity intolerance increases, and the patient spends most of the time
reclining. This leads to risk for skin impairment and the formation of pressure injuries.
DIF: Cognitive Level: Application
REF: p. 1216
OBJ: 5 TOP: Hospice
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
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MULTIPLE RESPONSE
1.
When air hunger is assessed in the dying patient, the nurse can perform which
interventions? (Select all that apply.)
a.
Circulate the air with a fan.
b.
Use a tranquilizer to decrease anxiety.
c.
Provide good oral hygiene.
d.
Perform careful suctioning.
e.
Raise the head of the bed 30 degrees.
ANS: A, B, C, E
Circulating the air with a fan, administering a tranquilizer to decrease anxiety,
providing good oral hygiene, and raising the head of the bed 30 degrees are all
interventions that can aid in relieving air hunger in the dying patient. Suctioning will
increase mucus production, which will make the dyspnea worse.
DIF: Cognitive Level: Application
REF: p. 1215
OBJ: 5 TOP: Hospice
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
2.
The hospice nurse educates the patient and family about the members of the
interdisciplinary team. Which caregivers are included?
(Select all that apply.)
a.
Medical director
b.
Nurse coordinator
c.
Social worker
d.
Spiritual coordinator
e.
Psychologist
ANS: A, B, C, D
The hospice interdisciplinary team includes the medical director, nurse coordinator, social
worker, and spiritual coordinator. The interdisciplinary team does not include a
psychologist.
DIF: Cognitive Level: Comprehension
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REF: p. 1207
OBJ: 4 TOP: Hospice
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
3.
Which are signs and symptoms of approaching death? (Select all that apply.)
a.
Mottled extremities
b.
Significant increase in urine output
c.
Increased restlessness and pulling at bed linens
d.
Alteration in rhythmic respiration
e.
Increased pulse rate
ANS: A, C, D, E
Mottled extremities, a significant decrease in urine output, an increased restlessness,
alteration in rhythmic respirations, and increased pulse rate are all symptoms of
approaching death.
DIF: Cognitive Level: Application
REF: p. 1217
OBJ: 7 TOP: Hospice
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
4.
What are the goals of hospice service? (Select all that apply.)
a.
Alleviating symptoms of approaching death
b.
Educating and supporting primary caregivers
c.
Using family input for designing a plan of care
d.
Encouraging patients and caregivers to enjoy life
e.
Focusing on the desires of the family in the plan of care
ANS: A, B, C, D
The plan of care should focus on the desires of the patient, not the desires of the family
members.
DIF: Cognitive Level: Application
REF: p. 1206
OBJ: 1 TOP: Hospice
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KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
COMPLETION
1. When the dying patient becomes confused, the nurse should him or her.
ANS:
reorient
Reorientation regarding time, date, and location is the least distressing to the dying
patient.
DIF: Cognitive Level: Application
REF: p. 1217
OBJ: 5 TOP: Hospice
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Psychosocial Integrity
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Chapter 41: Introduction to Anatomy and
Physiology Cooper: Foundations and Adult
Health Nursing, 9th Edition
MULTIPLE
CHOICE
1.
Which anatomic term means toward the midline.
a.
anterior
b.
posterior
c.
medial
d.
cranial
ANS: C
The term medial indicates an anatomic direction toward the midline.
DIF:
Cognitive Level: Knowledge
OBJ: 2 TOP:
Anatomic terminology KEY: Nursing Process Step:
Assessment
2.
MSC: NCLEX: Physiological Integrity
Which are the smallest living components in our body?
a.
Cells
b.
Organs
c.
Electrons
d.
Osmosis
ANS: A
Cells are considered to be the smallest living units of structure and function in our body.
DIF:
Cognitive Level: Knowledge OBJ: 6
TOP: Structural levels of organization
KEY: Nursing
Process Step: N/A MSC: NCLEX: Physiological
Integrity
3.
Which is the largest organelle, responsible for cell reproduction and control of other
organelles?
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a.
Nucleus
b.
Ribosome
c.
Mitochondrion
d.
Golgi apparatus
ANS: A
The nucleus is the largest organelle within the cell.
DIF:
Cognitive Level: Knowledge
OBJ: 8
TOP: Parts of the cell KEY:
Nursing Process Step: Assessment
MSC: NCLEX:
Physiological Integrity
4.
When the patient complains of pain in the bladder, this indicates a likely disorder in
which body cavity?
a.
Pelvic
b.
Mediastinum
c.
Dorsal
d.
Abdominal
ANS: A
A subdivision called the pelvic cavity contains the lower portion of the large intestine
(lower sigmoid colon, rectum), urinary bladder, and internal structures of the
reproductive system.
DIF:
Cognitive Level: Comprehension OBJ: 5
TOP: Body cavity KEY:
Nursing Process Step: Assessment
MSC: NCLEX:
Physiological Integrity
5.
The four phases of cell division all occur in which process?
a.
diffusion.
b.
mitosis.
c.
osmosis.
d.
filtration.
ANS: B
During mitosis, the cell goes through four phases: prophase, metaphase, anaphase, and
telophase.
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DIF:
Cognitive Level: Knowledge
OBJ: 9
TOP: Cell division KEY:
Nursing Process Step: N/A MSC: NCLEX:
Physiological Integrity
6.
Telophase is which phase of cell reproduction during mitosis?
a.
First phase
b.
Latent phase
c.
Final phase
d.
Spindle phase
ANS: C
During this final phase of cell division, the two nuclei appear and the chromosomes
disperse.
DIF:
Cognitive Level: Knowledge
OBJ: 9
TOP: Cell division KEY:
Nursing Process Step: N/A MSC: NCLEX:
Physiological Integrity
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7.
The nurse is aware that which muscle group is both striated and involuntary?
a.
Skeletal
b.
Glial
c.
Cardiac
d.
Visceral
ANS: C
The cardiac muscle is both striated and involuntary.
DIF:
Cognitive Level: Knowledge
OBJ: 11
TOP: Tissues KEY:
Nursing Process Step: Planning
MSC:
NCLEX: Physiological Integrity
8.
Which is a group of several different kinds of tissues arranged so that together they
can perform a more complex function than any tissue alone?
a.
Organ
b.
System
c.
Cell
d.
Endoplasmic reticulum
ANS: A
When several kinds of tissues are united to perform a more complex function than any
tissue alone, they are called organs.
DIF:
Cognitive Level: Knowledge
OBJ: 7
TOP: Organs KEY:
Nursing Process Step: N/A MSC: NCLEX:
Physiological Integrity
9.
Which traits describe visceral muscles?
a.
Smooth and voluntary
b.
Smooth and involuntary
c.
Striated and voluntary
d.
Striated and involuntary
ANS: B
Visceral (smooth) muscles will not function at will; thus, they act involuntarily.
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DIF:
Cognitive Level: Knowledge
OBJ: 11
TOP: Tissues KEY:
Nursing Process Step: Assessment
MSC:
NCLEX: Physiological Integrity
10.
How are the thoracic and abdominal cavities separated?
a.
By the pleura
b.
By the diaphragm
c.
By the sagittal plane
d.
By the peritoneum
ANS: B
The diaphragm (a muscle directly beneath the lungs) separates the ventral cavity into the
thoracic (chest) and abdominal cavities.
DIF:
Cognitive Level: Knowledge
OBJ: 3
TOP: Ventral cavity KEY:
Nursing Process Step: Assessment
MSC: NCLEX:
Physiological Integrity
11.
Which is the broad section of biology dealing with the description of human structure?
a.
Hematology
b.
Anatomy
c.
Kinesiology
d.
Physiology
ANS: B
Anatomy is the study, classification, and description of the structure and organs of the
body.
DIF:
Cognitive Level: Knowledge
OBJ: 1
TOP: Terminology KEY:
Nursing Process Step: N/A MSC: NCLEX:
Physiological Integrity
12.
Which term explains the processes and functions of many structures of the body and how
they interact with one another?.
a.
Anatomy
b.
Mitosis
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c.
Filtration
d.
Physiology
ANS: D
Physiology explains the processes and functions of the various structures and how they
interrelate with one another.
DIF:
Cognitive Level: Knowledge
OBJ: 1
TOP: Terminology KEY:
Nursing Process Step: N/A MSC: NCLEX:
Physiological Integrity
13.
Which anatomic structure(s) is/are NOT in the thoracic cavity?
a.
heart
b.
lungs
c.
blood vessels
d.
transverse colon
ANS: D
The transverse colon is located in the abdominal cavity.
DIF:
Cognitive Level: Comprehension OBJ: 5
TOP: Thoracic cavity KEY:
Nursing Process Step: Assessment
MSC: NCLEX:
Physiological Integrity
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14.
When several organs and parts are grouped together for certain functions, which is
formed?
a.
tissues.
b.
systems.
c.
cells.
d.
membranes.
ANS: B
A system is an organization of varying numbers and kinds of organs arranged so that
together they can perform complex functions for the body.
DIF:
Cognitive Level: Knowledge
OBJ: 7
TOP: Systems KEY:
Nursing Process Step: Assessment
MSC:
NCLEX: Physiological Integrity
15.
Which are the distinct surface proteins of the plasma membrane essential in determining?
a.
Tissue typing
b.
Blood count
c.
Effectiveness of a drug
d.
Sexual maturity
ANS: A
The plasma membrane has distinct surface proteins as coming from one individual.
This is the basis for the procedure of tissue typing to determine compatibility before an
organ transplant.
DIF:
Cognitive Level: Comprehension OBJ: 12
TOP: Cells KEY:
Nursing Process Step: Assessment
MSC:
NCLEX: Physiological Integrity
16.
In anatomic terminology, posterior means toward which body part?
a.
tail.
b.
head.
c.
back.
d.
trunk.
ANS: C
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The posterior is toward the back.
DIF:
Cognitive Level: Knowledge
OBJ: 2 TOP:
Anatomic terminology KEY: Nursing Process Step:
Assessment
17.
MSC: NCLEX: Physiological Integrity
What does the transverse body plane
divide?
a.
The front and back (coronal) of the
body
b.
The body lengthwise (two equal
halves)
c.
The superior and inferior portions of the body
d.
The body into axial and appendicular
ANS: C
The transverse plane cuts the body horizontally into the sagittal and the frontal planes,
dividing the body into caudal and cranial portions.
DIF:
Cognitive Level: Knowledge
OBJ: 3
TOP: Body planes KEY:
Nursing Process Step: Assessment
MSC: NCLEX:
Physiological Integrity
18.
Caudal is defined as toward which direction?
a.
head
b.
feet
c.
tail
d.
chest
ANS: C
Caudal is a directional word that indicates toward the ―tail,‖ the distal portion of the
spine.
DIF:
Cognitive Level: Knowledge
OBJ: 3 TOP:
Anatomic terminology KEY: Nursing Process Step:
Assessment
19.
MSC: NCLEX: Physiological Integrity
Which is the term for movement of water from an area of lower solute concentration to an
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area of higher solute concentration?
a.
Absorption
b.
Filtration
c.
Diffusion
d.
Osmosis
ANS: D
Osmosis is the passage of water from less concentrated solution to more concentrated
solution.
DIF:
Cognitive Level: Knowledge
OBJ: 10
TOP: Transport process
KEY: Nursing Process Step: Assessment
MSC:
NCLEX: Physiological Integrity
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20.
Which is the type of tissue composed of cells that contract in response to a message from
the brain or spinal cord?
a.
Epithelial
b.
Connective
c.
Membrane
d.
Muscle
ANS: D
Muscle tissue is composed of cells that contract in response to a message from the brain
or spinal cord.
DIF:
Cognitive Level: Knowledge
OBJ: 7
TOP: Tissues KEY:
Nursing Process Step: Assessment
MSC:
NCLEX: Physiological Integrity
21.
Which is the type of tissue associated with the storage of fat?
a.
Areolar tissue
b.
Adipose tissue
c.
Osseous tissue
d.
Muscle tissue
ANS: B
Adipose tissue is associated with the important function of storing fat.
DIF:
Cognitive Level: Knowledge
OBJ: 11
TOP: Tissues KEY:
Nursing Process Step: Assessment
MSC:
NCLEX: Physiological Integrity
22.
Which are the tissues that lubricate and line the body surfaces that open to the outside
environment?
a.
Mucous membranes
b.
Serous membranes
c.
Cytoplasm
d.
Involuntary visceral muscles
ANS: A
Mucous membranes secrete mucus. They line the body surfaces that open to the outside
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environment.
DIF:
Cognitive Level: Knowledge
OBJ: 12
TOP: Tissues KEY:
Nursing Process Step: Assessment
MSC:
NCLEX: Physiological Integrity
23.
Which is the process by which a cell digests a foreign material by surrounding it?
a.
Pinocytosis
b.
Phagocytosis
c.
Absorption
d.
Diffusion
ANS: B
Phagocytosis is the process that permits a cell to engulf or surround any foreign material
and digest it.
DIF:
Cognitive Level: Knowledge
OBJ: 10
TOP: Active transport processes
KEY: Nursing Process Step: Assessment
MSC: NCLEX:
Physiological Integrity
24.
Active transport in the movement of ions and other water-soluble particles across cell
membranes requires that the body uses which process?
a.
rapid filtration.
b.
charged diffusion.
c.
a chemical pump.
d.
osmosis.
ANS: C
Active transport of ions and other water-soluble particles of the cell membrane require a
chemical pump, such as insulin, to move glucose into the cell.
DIF:
Cognitive Level: Comprehension OBJ: 10
TOP: Active transport processes
KEY: Nursing Process Step: Assessment
MSC: NCLEX:
Physiological Integrity
25.
Which is the term for the passage of water containing dissolved materials through a
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membrane as the result of a greater mechanical force on one side?
a.
Metabolism
b.
Mitosis
c.
Filtration
d.
Osmosis
ANS: C
Filtration is the movement of water and particles through a membrane by a force from
either pressure or gravity.
DIF:
Cognitive Level: Knowledge
OBJ: 10
TOP:
Passive transport processes KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiological Integrity
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26.
The nurse is aware that when a patient complains of pain in the epigastric region,
the source of the pain is most likely to be a disorder involving which organ?
a.
gallbladder.
b.
transverse colon.
c.
stomach.
d.
appendix.
ANS: C
The epigastric region of the abdomen is comprised of parts of the right and left lobes of
the liver and a large portion of the stomach.
DIF: Cognitive Level: Comprehension OBJ: 5 TOP:
Epigastric region KEY: Nursing Process Step:
Assessment
27.
MSC: NCLEX: Physiological Integrity
Which are tissues that cover the outside of the body and some internal structures?
a.
Connective
b.
Epithelial
c.
Nerve
d.
Muscle
ANS: B
Epithelial tissue covers the outside of the body and some of the internal structures.
DIF: Cognitive Level: Knowledge
OBJ: 7
TOP: Tissues KEY:
Nursing Process Step: Assessment
MSC:
NCLEX: Physiological Integrity
28.
When the nurse assesses an arm in proximal to distal order, the assessment is performed
in which manner?
a.
From the shoulder to the fingers.
b.
From the front to the back.
c.
From the fingers to the center of the body.
d.
From the center of the body to the fingers.
ANS: A
Proximal is nearest the origin of the structure. Distal is farthest from the origin of the
structure.
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DIF: Cognitive Level: Comprehension OBJ: 3 TOP:
Anatomic terminology KEY: Nursing Process Step:
Assessment
29.
MSC: NCLEX: Physiological Integrity
Which is the function of epithelial membranes?
a.
Secretes mucus, lines ends of bones, and lines bursae.
b.
Lines ends of bones, secretes synovial fluid, and lines internal surfaces of organs.
c.
Covers the wall of lower digestive tract,
secretes mucus, and lines lungs, peritoneum,
and pericardium.
d.
Lines lungs, peritoneum, and pericardium, and secretes synovial fluid.
ANS: C
The epithelial membrane secretes mucus, lines the lungs, peritoneum, and
pericardium, and covers the wall of the lower digestive tract. The synovial membrane
secretes synovial fluid to prevent friction between joints and the ends of bones, and
lines the bursae found between moving body parts.
DIF: Cognitive Level: Knowledge
OBJ: 7
TOP: Tissues KEY:
Nursing Process Step: Assessment
MSC:
NCLEX: Physiological Integrity
30.
The nurse explains that pinocytosis is a process by which cells perform which action?
a.
divide.
b.
take in extracellular fluid.
c.
use a chemical pump.
d.
convert mitochondria.
ANS: B
Pinocytosis is a process by which the cell wall makes an indentation allowing
extracellular fluid to fill in, then encloses it into the cell.
DIF: Cognitive Level: Comprehension OBJ: 10
TOP: Pinocytosis KEY:
Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
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31.
Which is the most complex structural level of organization of the body?
a.
Body as a whole
b.
Cellular
c.
Organs
d.
Chemical
ANS: A
The structural levels of organization progress from the least complex (chemical)
through cells, tissues, organs, systems to the most complex (the body as a whole).
DIF: Cognitive Level: Comprehension
OBJ: 6
TOP: Structural levels of organization
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
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32.
Which structure forms the outer boundary of the cell?
a.
The nucleus
b.
The cytoplasm
c.
The plasma membrane
d.
The endoplasmic reticulum
ANS: C
The plasma membrane encloses the cytoplasm and forms the outer boundary of the cell.
The nucleus, cytoplasm and endoplasmic reticulum are internal structures in the cell.
DIF:
Cognitive Level: Knowledge OBJ: 8
TOP: Protective covering of nucleus
KEY: Nursing
Process Step: N/A MSC: NCLEX: Physiological
Integrity
MULTIPLE
RESPONSE
1.
Which are among the 11 body systems? (Select all that apply.)
a.
Lymphatic
b.
Cellular
c.
Digestive
d.
Reproductive
e.
Accessory
f.
Spinal cord
ANS: A, C, D
There are 11 body systems: integumentary, respiratory, skeletal, digestive, muscular,
nervous, endocrine, urinary, reproductive, cardiovascular, and lymphatic.
DIF:
Cognitive Level: Knowledge
OBJ: 13
TOP: Body systems KEY:
Nursing Process Step: Assessment
MSC: NCLEX:
Physiological Integrity
2.
Which are characteristics of visceral muscles? (Select all that apply.)
a.
Involuntary
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b.
Smooth
c.
Striated
d.
Independent from the spinal cord
e.
Voluntary
f.
Present in the blood vessels
ANS: A, B, F
Smooth muscles are smooth, involuntary, and respond to messages from the spinal cord.
DIF:
Cognitive Level: Application
OBJ: 7
TOP: Muscle Tissue KEY:
Nursing Process Step: Assessment
MSC: NCLEX:
Physiological Integrity
3.
Which are passive transport mechanisms that move material across the cell membranes?
(Select all that apply.)
a.
Diffusion
b.
Evaporation
c.
Filtration
d.
Osmosis
e.
Mitosis
f.
Anaphase
ANS: A, C, D
The passive transport systems are diffusion, filtration, and osmosis.
DIF:
Cognitive Level: Comprehension OBJ: 10
TOP: Passive transport system
KEY: Nursing Process Step: Assessment
MSC: NCLEX:
Physiological Integrity
4.
Which organs can be found in the dorsal cavity? (Select all that apply.)
a.
Descending colon
b.
Kidneys
c.
Gallbladder
d.
Brain
e.
Pancreas
f.
Spinal cavities
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ANS: D, F
The dorsal cavity is composed of the brain and the spinal cavities. The spinal cavities
hold the cord and the meninges.
DIF:
Cognitive Level: Comprehension OBJ: 3
TOP: Dorsal cavity KEY:
Nursing Process Step: N/A MSC: NCLEX:
Physiological Integrity
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COMPLETION
1.
The nurse clarifies that the three functions of epithelial tissue are protection,
, and
secretion.
ANS:
absorption
The function of epithelial tissue is protection by covering the body and preventing
invasion; absorption by absorbing material; and secretion by secreting mucus to line and
moisten the body surfaces.
DIF:
Cognitive Level: Comprehension OBJ: 7 TOP:
Epithelial tissue function KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
2.
The nurse explains that are small saclike structures inside the cell that digest compounds
that have invaded the cell.
ANS:
lysosomes
Lysosomes are small saclike structures inside the cell that digest compounds that have
invaded the cell.
DIF:
Cognitive Level: Knowledge
OBJ: 8
TOP: Lysosomes KEY:
Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
3.
The body plane that divides the body into the ventral and dorsal section is the
plane.
ANS:
coronal
The coronal plane divides the body into ventral and dorsal (front and back) sections.
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DIF:
Cognitive Level: Comprehension OBJ: 3
TOP: Coronal plane KEY:
Nursing Process Step: Assessment
MSC: NCLEX:
Physiological Integrity
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Chapter 42: Care of the Surgical Patient
Cooper: Foundations and Adult Health Nursing, 9th Edition
MULTIPLE
CHOICE
1.
The patient who had a nephrectomy yesterday has not used the patient-controlled
analgesia (PCA) delivery system but admits to being in pain but fearful of addiction.
Which is the nurse‘s response?
a.
―Modern analgesic drugs do not cause addiction.‖
b.
―Pain relief is worth a short period of addiction.‖
c.
―Addiction rarely occurs in the brief time postsurgical analgesia is required.‖
d.
―Addiction could be a real concern.‖
ANS: C
Addiction rarely occurs in the short time that it is required after surgery. Modern, or
older drugs, can cause addiction, but not generally in the brief post- operative time frame.
Postsurgical analgesia, because of its brief application, does not usually produce a
physical or a psychological dependence. The patient should be taught that addiction is
not usually a concern after surgery.
DIF:
Cognitive Level: Applying
OBJ: 13
TOP: Fear of addiction
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
2.
A 73-year-old patient with diabetes was admitted for below the knee amputation of
his right leg. Removal of his right leg is an example of which type of surgery?
a.
Palliative
b.
Diagnostic
c.
Reconstructive
d.
Ablative
ANS: D
Ablative is a type of surgery where an amputation, excision of any part of the body, or
removal of a growth and harmful substance is performed.
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DIF:
Cognitive Level: Understanding
OBJ: 2 TOP:
Types of surgeries KEY: Nursing Process Step: Data
Collection
MSC: NCLEX: Physiological Integrity
3.
A patient is in need of appendix removal surgery. In which situation might surgery be
delayed?
a.
The patient has taken antiseizure medication today.
b.
An illegible signature is on the consent form.
c.
The patient is still taking anticoagulants.
d.
The admission office is unable to confirm insurance coverage.
ANS: C
Anticoagulant therapy increases the threat of hemorrhage and may be a cause for
delay. All medications should be cancelled before surgery, except for drugs such as
antiseizure medication. If the signature is illegible, the consent form may need to be
signed again. Inability to confirm insurance coverage is not a medical reason to delay
the surgery, especially if the case is urgent.
DIF:
Cognitive Level: Knowledge
OBJ: 7 TOP:
Anticoagulant therapy KEY: Nursing Process Step: Data
Collection
MSC: NCLEX: Physiological Integrity
4.
Which circumstance could prevent the patient from signing an informed consent form for
a cholecystectomy?
a.
The patient complains of pain radiating to the scapula.
b.
The patient received an injection of antianxiety medication 1 hour ago.
c.
The patient is 85 years of age.
d.
The patient is concerned over his lack of insurance coverage.
ANS: B
Informed consent should not be obtained if the patient is disoriented and under the
influence of sedatives. Age, illegibility, and lack of insurance coverage do not prevent
signing the consent. Pain into the scapula is a symptom of colitis.
DIF:
Cognitive Level: Applying
OBJ: 7 TOP:
Informed consent KEY: Nursing Process Step: Data
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Collection
MSC: NCLEX: Physiological Integrity
5.
The nurse anticipates that the patient will be given which type of anesthesia because
of the extensive tissue manipulation involved in a hysterectomy?
a.
general
b.
regional
c.
specific
d.
preoperative
ANS: A
An anesthesiologist gives general anesthetics by IV and inhalation routes through
four stages of anesthesia when the procedure requires extensive tissue
manipulation. Regional anesthesia would not be sufficient in this case. The terms
―specific‖ and ―preoperative‖ are not terms associated with types of anesthesia.
DIF:
Cognitive Level: Knowledge
OBJ: 9
TOP: Anesthesia KEY:
Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity
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6.
The nurse caring for a patient who had spinal anesthesia for a vaginal repair
should be alert for which sign of a serious complication?
a.
a flushing of the face and torso.
b.
numbness of the perineum.
c.
complaint of thirst.
d.
a sudden drop in blood pressure.
ANS: D
Spinal anesthesia may cause a sudden drop in blood pressure or respiratory difficulty
as the anesthetic agent moves up in the spinal cord. Elevating the patient‘s torso may
prevent respiratory paralysis. Flushing of the face and torso may be a response to
vasodilation, but it is not as serious a concern as hypotension. Numbness of the
perineum is a desired response so that surgery can be performed without pain. A
complaint of thirst is not as serious a concern as hypotension.
DIF:
Cognitive Level: Understanding
OBJ: 9
TOP: Epidural block KEY:
Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity
7.
Why might the older adult patient not respond to surgical treatment as well as a younger
adult patient?
a.
Poor skin turgor
b.
Fear of the unknown
c.
Response to physiologic changes
d.
Decreased peristalsis related to anesthesia
ANS: C
Of specific concern in older adults is the body‘s response to temperature changes,
cardiovascular shifts, respiratory needs, and renal function. Poor skin turgor is not a
reason an older adult does not respond well to surgical treatment. Fear of the
unknown and decreased peristalsis are common to all ages.
DIF:
Cognitive Level: Applying
OBJ: 5 TOP:
Older adult patients KEY: Nursing Process Step:
Planning
MSC: NCLEX: Physiological
Integrity
8. Which postoperative nursing
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has had a repair of a cerebral aneurysm?
a.
coughing every 2 hours.
b.
turning every 2 hours.
c.
monitoring intravenous therapy at 50 mL/hr.
d.
assessing vital signs every 2 hours.
ANS: A
After brain, head, neck, spinal or eye surgery, coughing is not performed. Coughing
can increase intracranial pressure. The patient is still able to turn every 2 hours.
Intravenous therapy is administered at the rate prescribed. Vital sign measurement is
not contraindicated, and should be obtained as prescribed.
DIF:
Cognitive Level: Analyzing
OBJ: 13
TOP:
Postoperative complications KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
9.
The nurse acting as a circulating nurse has a responsibility for which activity?
a.
Observing for breaks in sterile technique.
b.
Performing surgical hand scrub
c.
assisting with surgical draping of the patient.
d.
maintaining count of sponges, needles, and instruments during surgery.
ANS: A
The circulating nurse is responsible for observing breaks in sterile technique. The
scrub nurse performs a surgical hand scrub, , drapes the patient, and maintains
needle and sponge count during surgery, then does a final sponge and needle check
with the circulating nurse before closing.
DIF:
Cognitive Level: Understanding
OBJ: 11
TOP: Duties of circulating nurse
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Safe, Effective Care Environment
10.
Which statement made by a patient during a preoperative assessment would be
significant to report to the charge nurse and surgeon?
a.
―I have been taking an herbal product of feverfew for my migraines.‖
b.
―I exercise for 3 hours a day.‖
c.
―I drink 2 cups of coffee a day.‖
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d.
―I use eye drops for redness every day.‖
ANS: A
The herbal remedy of feverfew acts as an anticoagulant and increases the possibility of
hemorrhage. The drug should be stopped before surgery, and bleeding and clotting
times should be evaluated. Exercising does not need to be reported. Two cups of coffee
every day or eye drops for redness would not need to be reported.
DIF:
Cognitive Level: Applying
OBJ: 4 TOP:
Preoperative assessment KEY: Nursing Process Step: Data
Collection
MSC: NCLEX: Physiological Integrity
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11.
A patient is on postoperative day 2 after a nephrectomy. Which intervention is an
effective way to increase peristalsis?
a.
Ambulation
b.
An enema
c.
Encouraging hot liquids
d.
Administering a laxative
ANS: A
Encouraging activity (turning every 2 hours, early ambulation) assists GI activity.
An enema or a laxative would be used only if ambulation did not increase the
peristalsis. Hot liquids could cause a burn injury; warm liquids are encouraged.
DIF: Cognitive Level: Understanding
OBJ: 13
TOP:
Postoperative complications KEY: Nursing Process Step:
Planning
MSC: NCLEX: Physiological
Integrity
12.
A patient is transferred from the operating room to the recovery room after
undergoing an open reduction and internal fixation (ORIF) of his left ankle. Which
is the first assessment to make?
a.
Check ankle dressings for hemorrhage.
b.
Check airway for patency.
c.
Check intravenous site.
d.
Check pedal pulse.
ANS: B
Evaluation of the patient follows the ABCs of immediate postoperative observation:
airway, breathing, consciousness, and circulation. While assessing for hemorrhage,
IV site infiltration and pedal pulse is important, the priority assessment is the patency
of the airway.
DIF: Cognitive Level: Applying
OBJ: 12
TOP: Nursing assessment
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance
13.
Frequent assessment of a postoperative patient is essential. Which are the first signs and
symptoms of hemorrhage?
a. Increasing blood pressure
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b.
Decreasing pulse
c.
Restlessness
d.
Weakness, apathy
ANS: C
Restlessness is the first sign of hemorrhage, due to lack of oxygen flow to the brain.
A pulse that increases and becomes thready combined with a declining blood
pressure, cool and clammy skin, and reduced urine output may signal hypovolemic
shock.
DIF: Cognitive Level: Understanding
OBJ: 12
TOP:
Postoperative complications KEY: Nursing Process Step: Data
Collection
MSC: NCLEX: Physiological Integrity
14.
The nurse instructing a postsurgical patient in the use of thrombolytic deterrent stockings
will include which instruction?
a.
Disregard appearance of edema above the stocking.
b.
Massage legs to smooth wrinkles out of stockings.
c.
Wring stockings thoroughly before hanging to dry.
d.
Hand wash stockings in warm water and mild soap.
ANS: D
Stockings should be hand washed gently in warm water and mild soap and laid over a
surface to dry. They should not be wrung out or hung. Massaging legs may dislodge a
clot The appearance of edema indicates the stockings are too restrictive.
DIF: Cognitive Level: Understanding
OBJ: 13
TOP: Thrombolytic deterrent stockings
KEY:
Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity
15.
The patient is brought into PACU still unconscious. Which action will the nurse take
FIRST when the nurse assesses a temperature of 94°F?
a.
Notify the charge nurse immediately.
b.
Offer warm fluids through a straw.
c.
Do nothing, this is a normal reaction to anesthesia.
d.
Cover with a warm blanket.
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ANS: D
Hypothermia is a frequent assessment postsurgery. A warm blanket or a ventilated cover
would be applied to bring up the temperature. While the charge nurse does need to be
notified, the first action should be to apply a warm blanket. A patient who is unconscious
should not be given fluids, due to risk of aspiration. Hypothermia, especially marked
hypothermia, needs immediate intervention.
DIF: Cognitive Level: Analyzing
OBJ: 13
TOP: Hypothermia KEY:
Nursing Process Step: Planning
MSC:
NCLEX: Physiological Integrity
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16.
In which location are guidelines for ensuring that all nursing interventions on the