TEST BANK for Fundamentals Of Nursing 10th Edition Potter Perry | All Chapters 1-50. by ACADEMIAMILL

Fundamentals of Nursing 10th Edition Potter Perry Test Bank Chapter 1. Nursing Today MULTIPLE CHOICE 1. Contemporary nursing practice is based on knowledge generated through nursing theories. Florence Nightingales theory introduced the concept that nursing care focuses on:

1 2

Psychological needs A maximal level of wellness

Health maintenance and restoration

Interpersonal interactions with the client

ANS: 3 Florence Nightingale believed the role of the nurse was to put the clients body in the best state in order to remain free of disease or to recover from disease. Although Florence Nightingale may have addressed meeting the psychological needs of her clients, it is not the focus of her theory. The goal of Nightingales theory is to facilitate the bodys reparative processes by manipulating the clients environment. Florence Nightingale thought the human body had reparative properties of its own if it was cared for in a way to recover from disease. Her theory did not focus on achieving a maximal level of wellness. Florence Nightingale believed the nurse was in charge of the clients health. Although she interacted with her clients by reading to them, her theory of nursing care did not focus upon interpersonal interactions. DIF: A REF: 2 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care 2. Nursing education programs in the United States may seek voluntary accreditation by the appropriate accrediting commission council of the:

National League for Nursing

American Nurses Association

Congress for Nursing Practice International Council of Nurses

ANS: 1 The National League for Nursing (NLN) is the professional nursing organization concerned with nursing education. The NLN provides accreditation to nursing programs that seek and meet the NLN accreditation requirements. The American Nurses Association (ANA) is concerned with the nursing profession and issues affecting health care, including standards of care.

The Congress for Nursing Practice is the part of the ANA concerned with determining the legal aspects of nursing practice, the public recognition of the importance of nursing, and the impact of trends in health care on nursing practice. The International Council of Nurses (ICN) is concerned about issues of health care and the nursing profession, including the provision of an international power base for nurses. DIF: A REF: 8 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care 3. The minimum educational requirement for a nurse practitioner is:

1 2

Diploma in nursing Masters in nursing

Doctorate in nursing

Baccalaureate in nursing

ANS: 2 A masters degree is nursing is required to become a nurse practitioner. Diploma programs in nursing require 3 years of education after which the graduate may become a registered nurse, but not a nurse practitioner. Doctoral programs focus on the application of research findings to clinical practice. The doctoral degree is beyond the masters degree. The baccalaureate degree program generally requires 4 years of study in a college or university, after which the graduate may become a registered nurse, not a nurse practitioner. DIF: A REF: 8 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care 4. A group that lobbies at the state and federal level for advancement of nursings role, economic interest, and health care is the:

State Board of Nursing

American Nurses Association

American Hospital Association

National Student Nurses Association

ANS: 2 The American Nurses Association (ANA) hires lobbyists at the state and federal level to promote the advancement of health care and the economic and general welfare of nurses. State Boards of Nursing primarily focus on licensure of nurses within their own state. The American Hospital Association does not focus on nurses economic issues and the advancement of the role of nurses. The National Student Nurses Association focuses on issues of importance for nursing students.

DIF: A REF: 8 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care 5. A nurse moves from Seattle to Boston and begins working in a hospital. The most important factor for the nurse to consider when moving to another state is the:

Massachusetts Nurse Practice Act

Standard for nursing practice in Boston Clinical ladder of mobility in the new hospital

3 4

Requirement for continuing education units (CEU) in Massachusetts

ANS: 1 Although most states have similar practice acts, each individual state has its own Nurse Practice Act that regulates the licensure and practice of nursing within that state. Knowledge of the Nurse Practice Act is necessary to provide safe and legal nursing care. Standards of nursing practice are not specific to a city, but rather to the profession itself. Although the clinical ladder of mobility may be of interest in regard to professional advancement, it is not the most important factor when practicing nursing in another state. Knowledge of the Nurse Practice Act in order to provide safe and legal nursing care is of higher importance. Regardless of where a nurse practices, the nurse should strive to remain current. DIF: C REF: 8 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care 6. A nurse is caring for a client who has chronic renal failure. The nurse states, We will do everything possible to return you to the optimum level of self-care possible. In coordinating an approach to best meet the needs of this client, the nurse is fulfilling the role of:

Manager

Educator

Counselor

Communicator

ANS: 1 The nurse, in caring for this client, will coordinate the activities of other members of the health care team. This client may require the assistance of a nursing assistant to provide personal care until the client is less fatigued. A nutritionist may be necessary for diet evaluation, planning, and teaching. A nurse may provide education on the dialysis therapy and perform the skill necessary until the client is able to do so independently.

The nurse may include patient teaching in the clients care, but more is required to meet the needs of this client. The nurse is not performing in the role of counselor. Clear communication will be necessary for the client to understand self-care measures regarding dialysis. The role of communicator does not, however, entirely meet the clients physical needs at this time. DIF: A REF: 10 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care 7. Nurses have the opportunity to work in a wide variety of health care agencies around the world. The practice setting where the majority of nurses continue to work is:

1 2

Acute care Home care

Long-term care

Ambulatory care

ANS: 1 Most nurses provide direct client care in the hospital setting. Although opportunities for providing patient care in the clients home are increasing, the majority of nurses are not employed in this setting. The majority of nurses do not work in nursing homes or extended care settings. Significantly fewer nurses work in an ambulatory care setting. DIF: A REF: 10 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care 8. A client is receiving Dilantin to prevent seizure activity. To which allied health care professional should the nurse refer this client in order to minimize the challenges this condition creates?

Physical therapist

Physicians assistant

Respiratory therapist Occupational therapist

ANS: 4 An occupational therapist is a person who provides assessment and intervention to ameliorate physical and psychological deficits that interfere with the performance of activities and tasks of living, including ones employment. A physical therapist is responsible for the patients musculoskeletal system. A physical therapist may use exercises as an intervention to improve a clients mobility.

A respiratory therapist provides treatment to preserve or improve pulmonary function. A physicians assistant performs tasks usually done by physicians and works under the direction of a supervising physician. DIF: C OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care 9. The Goldmark Report concluded that:

1 2 3 4

Nursing roles and responsibilities required clarification A theory-based curriculum was necessary for accreditation Nursing education programs must be affiliated with universities Increased financial support should be provided for nursing education

ANS: 4 In 1923 the Goldmark Report identified the need for increased financial support to universitybased schools of nursing. The National Commission on Nursing and Nursing Education Report of 1965 recommended that nursing roles and responsibilities be clarified in relation to other health care professionals. In 1975 the National League for Nursing required theory-based curriculum for accreditation. The Brown Report of 1948 concluded that all nursing education programs should be affiliated with universities and should have their own budgets. DIF: A REF: 3 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care 10. In 1893 Lillian Wald and Mary Brewster made significant contributions to the nursing profession through their work involving the:

Henry Street Settlement in New York

First training school in Toronto, Canada

Training school at Johns Hopkins in Baltimore

Development of the American Journal of Nursing

ANS: 1 In 1893 Lillian Wald and Mary Brewster opened the Henry Street Settlement, which was the first community health service for the poor. The first nurses training school in Canada was founded in St. Catherines, Ontario, in 1874. In 1894 Isabel Hampton Robb was the first superintendent of the Johns Hopkins Training School in Baltimore, Maryland. Isabel Hampton Robb was one of the original founders of the American Journal of Nursing. DIF: A REF: 3 OBJ: Comprehension

TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care 11. To obtain a certification in a specialty area, the nurse will have to complete:

1 2

A request for state approval A graduate degree in nursing

An examination and the minimum practice requirements

A general examination given to all nurses seeking certification

ANS: 3 Set minimum practice requirements are based on the certification the nurse is seeking. After passing the initial examination, the nurse maintains certification by ongoing continuing education and clinical or administrative practice. Individual states do not grant certification by request. Certification in a specialty area requires passing the examination for certification in that area and meeting minimum practice requirements. A masters degree in nursing is not required for certification in a specialty area. A specialized examination is given according to the specific area of nursing practice in which certification is being sought. DIF: A REF: 9 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care 12. In the ANA Standards of Professional Performance, which one of the following is a specific measurement criterion for The nurses decisions and actions on behalf of clients are determined in an ethical manner?

Acts as client advocate

Participates in the collection of client data

Seeks experiences to maintain clinical skills Consults with appropriate health care providers

ANS: 1 As a client advocate, the nurse protects the clients human and legal rights and provides assistance in asserting those rights if the need arises. Performing in the role of patient advocate fulfills a measurement criterion for the professional performance standard of ethics. Participating in data collection is a measurement criterion for the professional performance standard of quality of practice. The nurse who seeks experiences to maintain clinical skills is fulfilling a measurement criterion for the professional performance standard of education. Consulting with health care providers is a measurement criterion for the professional performance standard of collaboration.

DIF: A REF: 7 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care 13. In looking at the nineteenth century, the growth of professional nursing was stimulated by:

1 2 3 4

The Civil War Federal legislation Florence Nightingale The womens suffrage movement

ANS: 1 The Civil War stimulated the growth of nursing in the United States. Nurses were in demand to tend to the soldiers of the battlefield. Throughout history, nurses and their professional organizations have lobbied for health care legislation to meet the needs of clients. However, legislation was not responsible for the growth of nursing in the nineteenth century. Although Florence Nightingale had great impact on the practice of nursing, she was not the cause for the growth of nursing in the United States during the nineteenth century. The womens movement has encouraged nurses to seek greater autonomy and responsibility in providing care, and has caused female clients to seek more control of their health and lives. The womens movement was not responsible for the growth of nursing in the nineteenth century. DIF: A REF: 3 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care 14. Which of the following educational activities is an example of in-service education?

A workshop given at a nursing convention on malpractice

A program on new cardiac medications provided at a local hospital

Credit courses in communication offered at the community college Noncredit courses on nursing issues available through the internet

ANS: 2 An in-service education program is instruction or training provided by a health care agency or institution for its employees. A workshop at a nursing convention is an example of a continuing education program. Credit courses at a college are examples of continuing education that could possibly by applied toward furthering ones degree. Noncredit courses offered via the internet are an example of a continuing education program.

DIF: A REF: 8 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care 15. Nurses need to be aware of current trends in the health care delivery system in order to respond in educational preparation and practice. A major trend that is influencing nursing practice today is:

Decreased client acuity

Increased hospital stays

Decreased emphasis on health promotion

Increased incidence of chronic disease processes

ANS: 4 In recent decades, there is a higher incidence of chronic, long-term illness. With shortened hospital stays, client acuity has increased, not decreased. Hospital stays have decreased, not increased. Lengths of stay have shortened with a trend toward home care, and health promotion and illness prevention. With increased public awareness and rising health care costs, greater emphasis has been placed on health promotion and illness prevention. DIF: A REF: 4 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care 16. The nurse assists the client in a health promotion activity that also reduces the cost of health care delivery when:

Administering medication

Treating a diabetic foot ulcer

Obtaining an operative consent

Discussing exercise and nutrition

ANS: 4 The nurse may educate the client in such areas as exercise, nutrition, and healthy lifestyles to assist the client in health promotion and illness prevention. By administering medication, the nurse is assisting to restore a person to health or maintain ones health. A nurse who treats a foot ulcer is assisting a client to restore their health, rather than promoting healthy behaviors. Obtaining an operative consent pertains to legal aspects of care and is not considered a health promotion activity. DIF: A REF: 5 OBJ: Comprehension TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance/Programs 17. The nurse is best able to provide quality care that benefits both client and family by:

1 2 3 4

Incorporating caring into the practice Making the client the center of the practice Integrating the science and art of nursing into the practice Being knowledgeable of the institutions standards of practice

ANS: 3 Nursing is an art and a science. As a professional nurse you will learn to deliver care artfully with compassion, caring, and a respect for each clients dignity and personhood. As a science, nursing is based on a body of knowledge that is continually changing with new discoveries and innovations. When you integrate the science and art of nursing into your practice, the quality of care you provide to your clients is at a level of excellence that benefits clients and their families. Caring is one part of the art of nursing. While the client is the focus of nursing practice, this focus is not the main contributor to quality care. Standards of care provide guidelines for the delivery of client care. Awareness of the standards does not guarantee quality care. DIF: C REF: 2 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care 18. Which of the following statements best reflects Nightingales nursing philosophy on health maintenance and restoration?

Did all the clients eat a good breakfast?

What is the client rating his pain level after his medication?

Have any clients developed a nosocomial infection last month?

Is anyone interested in volunteering to mentor our new graduates?

ANS: 3 Florence Nightingale studied and implemented methods to improve battlefield sanitation, which ultimately reduced illness, infection, and mortality (Cohen, 1984). Today nurses are active in determining the best practices for skin care management, pain control, nutritional management, and care of older adults. Infection control and its impact on disease prevention was a major outcome of her contributions to nursing. Awareness of the connection between hospital-acquired infections (nosocomial) and nursing practice is the best example of her nursing philosophy. Nutritional management and its impact on client health, while important does not reflect the best option offered.

Pain management while a vital client concern does not represent the best option offered While volunteering is certainly reflected in Nightingales practice it is not the best option offered. DIF: C REF: 2-3 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Disease Prevention 19. The twentieth century is recognized for which of the following nursing concepts?

1 2 3 4

Code of Nursing Ethics Hospital-based nursing care Specialized nursing textbooks were adopted. Formalized university-based nursing education

ANS: 4 In the early twentieth century a movement toward a scientific, research-based defined body of nursing knowledge and practice was evolving. Nurses began to assume expanded and advanced practice roles. Mary Adelaide Nutting was instrumental in the affiliation of nursing education with universities. In 1990 the American Nurses Association established the Center for Ethics and Human Rights. Nursing in hospitals expanded in the late nineteenth century. Isabel Hampton Robb helped found the Nurses Associated Alumnae of the United States and Canada in 1896. This organization became the American Nurses Association (ANA) in 1911. She authored many nursing textbooks, including Nursing: Its Principles and Practice for Hospital and Private Use (1894), Nursing Ethics (1900), and Educational Standards for Nurses (1907), and was one of the original founders of theAmerican Journal of Nursing (AJN). DIF: A REF: 4 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 20. The best example of the impact of the womens movement on health care is:

Improvement in breast cancer survival rates

Insurance coverage for well-woman check-ups

Women subjects to be included in all appropriate health research projects A single, teenage mother receiving Women, Infants, and Children (WIC) benefits

ANS: 3 The womens movement brought about many changes in society as women increasingly demanded economic, political, occupational, and educational equality. As a result, there is greater sensitivity to the health care needs of women and the role of women in health care research. There are emerging health care specialties dealing with the needs of women. These new

specialties expand from the traditional obstetrical specialty and address issues ranging from wellwomens examinations, to oncological subspecialties, to the management of menopause. Because of the prior lack of female subjects in biomedical research, the federal government now requires studies to routinely include women in research, unless specific exception criteria are met. For example, research focusing on management of prostatic cancer is an exception. Improved survival rates for female-oriented cancers is evident because of emphasis being placed on research. While important, increased insurance coverage is not the best option available because this action would be directly driven by research findings. While important, increased federal funding for female-oriented benefits does not represent the best option available because this action would be directly driven by research findings. DIF: C REF: 4 OBJ: Analysis TOP: Nursing Process: Comprehension MSC: NCLEX test plan designation: Health Promotion and Maintenance 21. The human rights movement most directly impacts nursing practice because:

Nurses act as advocates for all clients

2 3

Clients require someone to focus on their needs Caring for clients is the focus of nursing practice

Everyone deserves to be treated fairly and with respect

ANS: 1 Client advocacy is a nursing responsibility. The human rights movement changed the way society views the rights of all of its members, including minorities, clients with terminal illness, pregnant women, and older adults. Many groups have special health care needs, and nursing responds by respecting the human rights of all clients and their right to quality care. Nurses advocate the rights of all clients. Clients do require someone to focus on their needs; advocacy is a responsibility of the nurse but the concept of the nurse as an advocate was established well before the human rights movement. Caring for clients is the focus of nursing practice, but caring physically and emotionally for a client as a nursing responsibility was established well before the human rights movement. Everyone deserves to be treated fairly and with respect. The realization of that truth was impacted by the human rights movement; however, this option does not directly relate to nursing. DIF: C REF: 4-5 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care 22. Nurses are caring for clients from a variety of cultures primarily as a result of:

Increased ease of travel and mobility

Political unrest in many foreign countries

Increased incidence of contagious diseases

Poor health care in underdeveloped countries

ANS: 1 Because the worlds population is more mobile, both immigration and travel have shown an increase over the last decades. Nursing practice will require the management and delivery of care for clients from many different cultures. Although immigration to this country has been impacted by political strife in other countries, it is not the primary factor in an increasingly culturally diverse client population. Increased incidence of contagious diseases has little impact on the cultural diversity of the client population. Although poor health care services may contribute to some influx of foreign clients, it is not the primary factor in an increasingly culturally diverse client population. DIF: C REF: 5 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity 23. Risk for injury during client transfer is minimized most effectively by:

Implementation of lift teams

2 3

Yearly personnel training sessions Using mechanical lifts when possible

Use of evidence-based techniques

ANS: 4 Injuries to both caregiver and client occur during client transfer. The caregiver is at risk for musculoskeletal injuries. The client is at risk for falls as well as musculoskeletal injuries. There is a shift from ineffective, injury-prone client transfer techniques to evidence-based practices for safe client handling. The implementation of a lift team is directly supported by evidence-based research (EBR). Yearly training sessions are important but the specific training is determined first by EBR. The use of mechanical lifts is directly supported by evidence-based research (EBR). DIF: C REF: 6 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment/Accident Prevention MULTIPLE RESPONSE 1. Which of the following activities reflect the nurses role in health promotion and wellness? (Select all that apply.)

Screening the local homeless population for head lice

Monitoring blood pressures at a community health fair

Organizing a foot race to benefit national cancer research

Consulting a teenage mother on breast-feeding techniques

Providing literature on smoking cessation to client families

Presenting a nursing workshop on the care of diabetic ulcers

ANS: 1, 2, 4, 5 Nursing responds to this greater concern for health promotion by providing programs in the community such as health fairs and wellness programs; educational programs for specific diseases; and client and family teaching activities in hospitals, clinics, primary care facilities, and other health care settings. While admirable, organizing a benefit for cancer research is not an activity directed towards health promotion and wellness but rather towards research that will benefit the population as a whole rather than specific individuals. Presenting a workshop on a specific nursing intervention is not an activity directed toward health promotion and wellness but rather towards professional development of the nurses. DIF: A REF: 5 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Programs 2. Changes in recent population demographics that have impacted the delivery of nursing care include the following: (Select all that apply.)

Increased birth rates

2 3

Increased life expectancy Decreasing rural population

Expanding urban settlement

Advances in medical modalities

Availability of free public education

ANS: 2, 3, 4 Demographic changes affect the population. Changes influencing health care in recent decades include the population shift from rural areas to urban centers; the increased life span; the higher incidence of chronic, long-term illness; and the increased incidence of diseases such as alcoholism and lung cancer. Nursing responds to such changes by exploring new methods to provide care, by changing educational emphases, and by establishing practice standards. Recent birth rates have declined. Advances in medical modalities and availability of free public education do not reflect changes in population demographics but rather health care advances and social services. Chapter 2. Health Care Delivery System MULTIPLE CHOICE 1. Regulatory interventions were initiated to reduce the rise in health care costs. These interventions include:

Prospective payment systems

State limits on health care fees

Federal guidelines for treatment Court review of insurance coverage

ANS: 1 As a means to reduce health care costs, in 1983 Congress established the prospective payment system in which hospitals are reimbursed a set dollar amount for each diagnosis-related group, regardless of the length of stay or use of services in the hospital. State limits on health care fees have not been used nationwide to reduce health care costs. Federal guidelines for treatment have not been used to reduce the cost of health care. Rather, the focus has been on financial reimbursement. Court review of insurance coverage has not been a primary intervention to lower health care costs. DIF: A REF: 16 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care 2. Levels of prevention are used by the nurse to provide a framework or guide for nursing interventions. Focus is based on the clients needs and the care or service that is provided. An example of a true health promotion service is a(n):

Aerobic dance class Immunization clinic

Diabetic support group

Smoking cessation clinic

ANS: 1 Examples of health promotion activities include exercise classes, prenatal care, well-baby care, nutrition counseling, and family planning. An immunization clinic is an example of an illness prevention service. A diabetic support group may be an example of a rehabilitation service to adapt to a change in lifestyle. A smoking cessation clinic may be a part of rehabilitation or offered as an illness prevention service. DIF: A REF: 19 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care 3. There are many types of health care delivery agencies. An example of a secondary level care agency is a:

School

Nursing home

Drug rehabilitation center

State-owned psychiatric hospital

ANS: 4 A state-owned psychiatric hospital is an example of the secondary level of care in which clients who present with signs and symptoms of disease are diagnosed and treated. A school is an example of preventive or primary care. A nursing home is an example of continuing care. A drug rehabilitation center is an example of restorative care. DIF: A REF: 20 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care 4. Which of the following fits within the occupational safety and health categories?

Noise exposure

2 3

Firearms safety Swimming lessons

Motorcycle helmets

ANS: 1 Exposure to environmental hazards within the workplace, such as noise exposure, is one aspect of occupational safety and health. Firearms do not fit within the occupational safety and health category. Swimming lessons do no fit within the occupational safety and health category. Motorcycle helmets do not fit within the occupational safety and health category. DIF: A REF: 20 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care 5. A contractual agreement between a hospital and a corporation to pay the health care expenses of the corporations employees is an example of a(n):

PPO

HMO

Private insurance

Third-party payment

ANS: 1 A preferred provider organization (PPO) is characterized by a contractual agreement between a set of providers (e.g., hospitals, physicians, or clinics) and a purchaser (e.g., the corporations insurance plan). Comprehensive health services are provided at a discount to the companies

under contract. Enrollees are limited to a list of preferred hospitals, physicians, and providers. An enrollee pays more out-of-pocket expenses for using a provider not on the list. A Medicare HMO is the same as a managed care organization (all care provided by a primary care physician) but designed to cover costs of senior citizens. Private insurance is the traditional fee-for-service plan where payment is computed after services are provided based on the number of services used. Third-party payment is when an entity (other than the client or health care provider) reimburses health care expenses. Third-party payers include insurance companies, governmental agencies, and employers. DIF: A REF: 18 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care 6. The Medicaid insurance program is best described as:

Acute care hospital insurance for the older adult population

A funded health care program for older and disabled persons

A state-regulated health care program for persons of low income

A fee-for-service insurance plan that supports preventive health care

ANS: 3 Medicaid is a federally funded, state-operated program of medical assistance to people with low incomes. Individual states determine eligibility and benefits. This option describes Medicare. This option describes Medicare Part A. This option does not describe Medicaid. DIF: A REF: 18 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care 7. Quality health care is an innovative approach to delivering health care. The major factor for its success is that it:

Focuses on the nursing process

Uses outcomes to manage client care

Is used exclusively in the acute care setting Allows a high degree of flexibility delivering the care

ANS: 2 Health care providers are defining and measuring quality in terms of outcomes. An outcome is a measure of what actually does or does not happen as a result of a process of care.

The focus in quality health care is on the outcome, not the process. Quality health care is not used exclusively in the acute care setting. It may be used in various health care settings. Because quality health care is based on achieving outcomes, it does not allow a high degree of flexibility for the nurse in delivering care. DIF: A REF: 27 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care 8. Case management is one strategy for coordinating health care services. What best describes this caregiving approach?

Continuity of care is the primary concern.

This focus of care may be more expensive.

The physician is the coordinator of client care.

It is designed to provide minimal to moderate levels of care.

ANS: 1 With the case management model of care, the case manager coordinates the efforts of all disciplines to achieve the most efficient and appropriate plan of care. Continuity of care is of primary importance. If the efforts of all disciplines are well managed, repetition or delays may be avoided with a resultant shortened hospital stay. Therefore this focus of care may not be more expensive. The physician may or may not be the coordinator of client care. The case manager typically is a nurse or social worker. Case management is not entirely based on the level of care required. DIF: A REF: 21 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care/ Case Management 9. The payment mechanism that Medicare uses within its health care financing is:

Capitation

Fixed payments

Direct contracting

Prospective payment

ANS: 2 Inpatient hospital services for Medicare clients are reimbursed a set amount for each DRG, regardless of the clients length of stay or use of services in the hospital. Capitation is the payment mechanism in which providers receive a fixed amount per enrollee of a health care plan.

The payment mechanism that Medicare uses is not direct contracting. Medicare is not based on fixed payments, but rather on a set dollar amount according to the DRG. DIF: A REF: 27 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care 10. A student nurse visiting a nurse-managed clinic should expect to see which of the following services offered?

1 2 3 4

Physical therapy Same-day surgery Family support services Ongoing psychiatric therapy

ANS: 3 Nurse-managed clinics focus on health promotion and health education, disease prevention, chronic disease management, and support for self-care and caregivers. Physical therapy is not typically offered in a nurse-managed clinic. Same-day surgery is not offered in a nurse-managed clinic. Psychiatric therapy is not offered in a nurse-managed clinic. DIF: A REF: 21 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care 11. A disabled client requiring restorative care should be referred to a(n):

Nursing home

Subacute care unit

Home health care agency Ambulatory health center

ANS: 3 A home health care agency provides health services to individuals and families in their home to promote, maintain, or restore health, or to maximize the level of independence while minimizing the effects of disability and illness. A nursing home is a long-term care setting in which clients receive 24-hour intermediate and custodial care. A subacute care unit is not the best referral for restorative care. An ambulatory health center is not the best referral for restorative care. DIF: A REF: 16 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care

12. Which of the following is an appropriate referral for an older client who requires some assistance with daily activities within a partially protective environment?

1 2 3 4

Respite care Extended care Assisted living Rehabilitative care

ANS: 3 The appropriate response is assisted living. A group of residents live together, each resident having his or her own room, yet sharing dining and social activity areas. Respite care is a service that provides short-term relief for persons providing home care to the ill or disabled. An extended care facility provides intermediate medical, nursing, or custodial care for clients recovering from acute or chronic illness or disabilities. Rehabilitative care includes physical, occupational and speech therapy, and social services to help restore clients to their fullest ability. DIF: A REF: 20 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care 13. Discharge planning for clients begins:

After a diagnosis has been established

Once the long-term needs are identified

Upon admission to a health care facility When the acute care therapies are completed

ANS: 3 Discharge planning should begin at the time of admission to the hospital, using the strengths and resources of the client, providing resources to meet the clients limitations, and focusing on improving the clients long-term outcomes. The clients diagnosis does not have to be established before discharge planning can begin. Discharge planning should include preparation for long-term needs of the client. Acute care therapies may impact a clients discharge and should be a part of the plan from the beginning. DIF: A REF: 23 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care 14. A client states that she does not understand managed care organization (MCO) health insurance. The nurse responds most appropriately by explaining that the MCO:

Reimburses nursing home funding

Focuses on health maintenance and primary care

Allows the individual to go to any physician that he desires

Requires a contractual agreement between the health provider and clients employer

ANS: 2 In a managed care organization (MCO), a primary care physician provides all care and the focus is on health maintenance and primary care. Medicaid reimburses nursing home funding. In a managed care organization, referral by the primary care physician is necessary for access to specialists and for hospitalization. A PPO is limited to a contractual agreement between a set of providers and one or more purchasers. DIF: A REF: 25 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care 15. Which form of health care is of primary importance when dealing with managed care?

Health promotion

Disease prevention

Tertiary treatment

Secondary treatment

ANS: 1 If people stay healthy, the cost of medical care declines. Systems of managed care focus on containing or reducing costs, increasing client satisfaction, and improving the health or functional status of the individual (Sultz and Young, 2004). Health promotion: Activities that develop human attitudes and behaviors to maintain or enhance well-being. Disease prevention: Activities that protect people from becoming ill because of actual or potential health threats. Tertiary prevention: Care that prevents further progression of disease. Secondary prevention: Early diagnosis and treatment of illness (e.g., screening for hypertension). DIF: C REF: 21 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care 16. A nurse is consulting with a homeless family who has a 12-year-old disabled child. The nurse suggests which of the following services to best assist with the childs health care needs?

1 2

Medicare Medicaid

Long-term care insurance

An extended care faculty

ANS: 2 Medicaid is a federally funded, state-operated program that provides (1) health insurance to lowincome families and (2) health assistance to low-income people with long-term care (LTC) disabilities. Chapter 3. Community-Based Nursing Practice MULTIPLE CHOICE 1. The student nurse is investigating different types of practice settings. In looking at community health nursing, the student recognizes that it:

Is the same as public health nursing

Focuses on the incidence of disease

Requires graduate-level educational preparation

Includes direct care and services to subpopulations

ANS: 4 Community health nursing strives to safeguard and improve the health of populations in the community as well as providing direct care services to subpopulations within a community. Public health nursing is concerned with trends and patterns influencing the incidence of disease within populations. A community health nurse may be involved in direct client care for disease within a community. Public health nursing focuses on the needs of populations. Community health nursing has a broader focus, with an emphasis on the health of a community. The community health nurse merges public health knowledge with nursing theory. The community health nurse considers the needs of populations and is prepared to provide direct care services to subpopulations within a community. Nurses who become expert in community health practice may have advanced nursing degrees, yet the baccalaureate-prepared generalist also can become quite competent in formulating and applying population-focused assessments and interventions. DIF: A REF: 34 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 2. As a community health nurse assisting the client and family with nutritional needs the nurse should first:

Identify for the client the best foods to buy

Purchase foods at the lowest cost for the client

Ask the client and family what they think they should eat

Provide information on stores with the most reasonable pricing

ANS: 3

With the goal of helping clients assume responsibility for their own health care, the community health nurse must assess a clients learning needs and readiness to learn within the context of the individual, the systems the individual interacts with, and the resources available for support. Asking the client about what foods he or she thinks should be eaten may help the nurse assess the clients level of knowledge regarding nutrition as well as the clients food preferences. It also enables the client to become a participant in his or her care. Telling the client what foods to buy does not encourage the client to assume responsibility for managing his or her health care. The nurse should first assess the resources available, and then encourage the client to do his or her own shopping. Providing information on food sources and stores with reasonable pricing may be appropriate after the nurse has determined what information the client requires to meet nutritional needs. DIF: C REF: 40 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 3. Which one of the following clients from a vulnerable population currently appears to be at the greatest risk?

A physically abused client in a shelter

A schizophrenic client in outpatient therapy

An older adult taking medication for hypertension

A substance abuser who shares drug paraphernalia

ANS: 4 A client with substance abuse has health and socioeconomic problems. These clients frequently may avoid health care for fear of judgmental attitudes by health care providers and concern over being turned in to criminal authorities. An abused client in a shelter has sought protection so currently should be at less risk. Although considered to be a member of a vulnerable population, the older adult who takes medication for a chronic disease, such as hypertension, is taking measures to maintain health. A schizophrenic client in outpatient therapy is currently at less risk because he or she is receiving treatment. DIF: C REF: 36 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 4. A client with a history of a gastrointestinal disorder eats a well-balanced diet that keeps his GI symptoms suppressed. Which level of prevention corresponds to his dietary management?

Health promotion

Primary prevention

Tertiary prevention Secondary prevention

ANS: 3 The goal of tertiary prevention is to preclude further deterioration of physical and mental function in a person who has an existing illness, and to have the client use whatever residual function is available for maximum enjoyment of and participation in lifes activities. Health promotion is aimed at reducing the incidence of disease and its impact on people. Primary prevention is aimed at general health promotion. Secondary prevention is aimed at early recognition and treatment of disease. DIF: A REF: 37 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Health Promotion and Maintenance 5. Which of the following statements by the home health nurse best reflects client advocacy in response to the clients concern over the expense of the therapy?

1 2

Have you considered the possibility of a renal transplant? This peritoneal dialysis is less expensive than hemodialysis.

You must feel awful about this situation, but this is the best course of treatment for you.

Lets call the regional dialysis center and explore options for reducing the cost of your home dialysis.

ANS: 4 Calling the regional dialysis center and exploring options for reducing cost demonstrates the nurse acting as client advocate by identifying and assisting the client in contacting the appropriate agency for information and resources to meet the clients needs. Asking the client whether he has considered renal transplantation does not demonstrate client advocacy. Pointing out the difference in cost for dialysis in the home versus the hospital does not meet the clients need to reduce the expenses of his therapy. The nurse is not demonstrating patient advocacy. Telling the client that this is the best treatment for him does not address his financial concerns. The nurse is not demonstrating patient advocacy with this response. DIF: C REF: 40 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 6. In assessing the structure of the community in order to identify the needs of its population, the nurse will focus on:

Collecting demographic data on age distribution

Visiting neighborhood schools to review health records

Interviewing clients to determine the cultural composition of the subgroups

Observing locations where services, such as water sanitation, are provided

ANS: 4 When assessing the structure or locale of a community, the nurse should travel around the neighborhood or community and observe its design; the location of services, such as water and sanitation; and the locations where residents congregate. Collecting demographic data on age distribution would be an assessment of the communitys population. Visiting neighborhood schools to review health records is an example of assessing a social system within a community. Interviewing clients to determine the cultural composition of subgroups is an example of assessing the population within a community. DIF: A REF: 41 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 7. To facilitate change within a community, the nurse working as an effective change agent should:

Inform community members how to effectively manage their health needs

Work with clients and groups to select alternative health care sites and treatments

Formulate decisions for individual clients regarding their health care options

Provide instruction in the way the community should address health issues

ANS: 2 As a change agent, the nurse seeks to implement new and more effective approaches to problems. The nurse creates change by working with and empowering individuals and their families to solve problems or to become instrumental in changing aspects affecting their health care. Telling community members how to manage their health care needs may meet resistance. It also does not enable clients and their families to take responsibility for their health care. Making decisions for clients does not enable individuals to assume responsibility for their health care decisions. The community-based nurse acting as a change agent may be an excellent resource for health information to members of the community. Ultimately; however, the community members will take an active role to create change for themselves and will assume responsibility for their health care decisions. DIF: A REF: 39-40 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance

8. The client is being discharged from an acute care facility following a total hip replacement. She will need follow-up for her rehabilitation and exercise plan. In addition to a home health care nurse, what referral should be discussed?

Dietitian

2 3

Social worker Physical therapist

Respiratory therapist

ANS: 3 Directing clients to appropriate resources and improving continuity of care require the nurse to know those resources well. A physical therapist is responsible for the clients movement system and is likely to be needed following hip replacement surgery. A social worker may or may not be necessary. A dietitian may or may not be necessary. A respiratory therapist would not be necessary unless the client experienced a respiratory complication or had a preexisting respiratory condition. DIF: A OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 9. The nurse recognizes which of the following as the largest contributing factor for the rise in the need and use of home care?

Government funding of the home care setting has increased greatly.

Clients are more acutely ill when discharged from the acute care facility. There are 7 days/week services for the elderly in home care agencies.

3 4

The existence of more single-income families has increased the need for their elderly relatives to receive care in the home.

ANS: 2 Because hospital stays are being shortened to control health care costs, clients are returning home more acutely ill. This is the largest contributing factor for the rise in the need and use of home care. Government funding of home care is not the largest contributing factor for the rise in the need and use of home care. There are 7 days/week services for the elderly in a variety of settings, such as in acute care or long-term care, not just in the home care setting. Being able to provide daily services for the elderly in the home care setting is not the largest contributing factor for the rise in the need and use of home care. The existence of more single-income families is not the largest contributing factor for the rise in the need and use of home care. DIF: C REF: Chapter 2, 22 OBJ: Analysis

TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 10. One of the overall goals of Healthy People 2010 is to:

1 2

Increase life expectancy Decrease health care costs

Promote managed care organizations

Establish the credentials of service providers

ANS: 1 The overall goals of Healthy People 2010 are to increase the life expectancy and quality of life and to eliminate health disparities. The initiative of Healthy People 2010 is to improve the delivery of health care services to the general public. The overall goal did not focus on reducing health care costs. Although managed care organizations may increase in number, this was not a goal of the Healthy People 2010 initiative. Establishing the credentials of care providers was not a goal of Healthy People 2010. DIF: A REF: 33 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 11. When assessing members of a vulnerable population, the community health nurse should realize that the primary need is to:

Provide culturally competent assessment.

Organize in your mind exactly what you need to ask.

Create a comfortable, nonthreatening environment. Be alert for indications of mental and physical abuse.

ANS: 3 In order to be successful in assessing a member of a vulnerable population, the nurse must first create an environment that is encourages the client to cooperate with and actively participate in the assessment process While it is important that the nurse be cultural considerate of the client, it is not the primary need of those offered as options. While organization to thought is important to the effective use of time needed for an assessment, it is not the primary need of those offered as options. While vulnerable populations may be more susceptible to both mental and physical abuse making observation for signs of abuse important, it is not the primary need of those offered as options DIF: C REF: 35 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance

12. The nurse working in a free clinic often utilized by Hispanic immigrants is assessing a client who reports a cough and malaise. The client is hearing impaired, speaks very little English and is currently living in a homeless shelter. The nurses primary concerns should be the clients:

Language barrier

2 3

Risk for tuberculosis Hearing impairment

Lack of health care resources

ANS: 2 Risk for tuberculosis presents the greatest risk since it is supported by the physical signs, is highly contagious and a risk factor among the homeless and some immigrant populations. The language barrier is a concern since it impacts the communication between the nurse and the client but it is not the primary concern among the options offered. The clients hearing impairment is a concern because it has an impact on the communication between the nurse and the client but it is not the primary concern among the options offered. The clients lack of insurance is a concern because it affects the treatment plan necessary for the clients recovery, but it is not the primary concern among the options offered. DIF: C REF: 36 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 13. A nurse is planning interventions for the clients of a homeless shelter. Which of the activities represents a primary level intervention regarding sexually transmitted diseases?

HIV screening for all residents

Sex education for teenage residents

Treatment for residents diagnosed with AIDS

Gynecological referrals for female residences

ANS: 2 Primary level interventions are directed a preventing the disease. Educational programming is generally considered a primary intervention. Screening a disease is generally considered a secondary level intervention. Treatment of the disease is generally considered a tertiary level intervention. Referrals are generally considered a secondary intervention. DIF: A REF: 36 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 14. The nurse working in a free clinic is caring for a homeless client diagnosed with paranoid schizophrenia who has reported that, I hurt my foot running away from them. It hurts so bad I can hardly walk now. On assessment the nurse notices bruising on the clients back, arms, and

thighs, a red rash on both neck and face, and poor personal hygiene, in addition to edema of the left ankle. The nurse should first realize that this client is at risk for:

1 2 3 4

Physical abuse and assault Drug addiction relating to pain Communicable immune disorders Hospitalization due to mental disorder

ANS: 1 When a client has a severe mental illness such as schizophrenia there are multiple health and socioeconomic problems you will need to explore. Many clients with pervasive mental illnesses are homeless or live in poverty. In addition, mentally ill clients are at greater risk of abuse and assault. This clients reported foot injury and observable bruising support the possibility of abuse/ assault. While drug abuse may be a consideration, it does not represent the best option offered for this item because there is not indication that the client is drug seeking. Contacting communicable diseases is a risk factor for such a client but it does not represent the best option offered for this item because there are several factors that may indicate abuse/assault. Hospitalization may be required but it does not represent the best option offered for this item because there is no indication that the client is experiencing a psychiatric crisis. DIF: C REF: 37 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 15. A community nurse has identified a need for educational programming among the residents of an assistive living facility dealing with osteoarthritis. The best example of such programming is:

Planning the best exercise program for you.

Recognizing how arthritis has affected your life.

Proper self administration of antiinflammatory medication

Be an informed consumerdont fall for false arthritis cures.

ANS: 4 Thorough assessment and appropriate community based interventions provide an opportunity to improve the lifestyle and quality of life of older adults in general. The focus is on broad-based needs not specific client needs. Answer 4 offers information applicable to the entire resident population diagnoses with osteoarthritis. DIF: C REF: Chapter 2, 19 OBJ: Analysis TOP: Nursing Process: Planning/Implementation MSC: NCLEX test plan designation: Health Promotion and Maintenance 16. A homeless client has presented in the ED with a bacterial infection in a hand wound. The nurse has cleansed and dressed the wound, and an initial dose of an antibiotic has been

administered. The client will need the antibiotic prescription filled and a dressing change in 3 days. In order to ensure that the client will receive the appropriate follow-up care, the nurse must first act as the clients:

Educator

2 3

Advocate Caregiver

Counselor

ANS: 2 Client advocacy perhaps is more important today because of the confusion surrounding access to health care services. Your clients often need someone to help them walk through the system, identify where to go for services and tell them how to reach the individuals with the appropriate authority, what services to request, and how to follow through with the information they received. The role of the educator is to help the client assume responsibility for his or her own health care. This client has been educated to the needs related to caring for the infection but needs the nurse advocate to assist with facilitating the care. As caregiver, the nurse manages and cares for the clients health. You apply the nursing process (see Unit III) in a critical thinking approach to ensure appropriate, individualized nursing care for specific clients and their families. This clients nursing care has been appropriated delivered and so that nursing role has been fulfilled. A counselor assists clients in identifying and clarifying health problems and in choosing appropriate courses of action to solve those problems. The client is first in need of assistance in dealing with the obstacles to the care of the identified probleminfection. DIF: C REF: 37-38 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Health Promotion and Maintenance 17. A nurse is discussing the need to use a specific cleansing agent when redressing an infected hand. The client prefers using, plain old soap and water. The nurse knows that the primary factor that will affect client compliance is:

The ease with which the client can use the special agent

The clients acceptance of the need for the specialized care

The availability and cost of the prescribed cleansing agent

The introduction of an incentive to prompt client to comply

ANS: 2 Client must perceive the innovation or change as more advantageous than other alternatives or they will not make the change. Client education is essential in bringing about the change in attitude necessary for change. While the client is more likely to adapt the change if it is perceived as being easy, it is not the primary factor in achieving client compliance provided among the options available because client compliance is primarily a result of the clients understanding of

the need for change. While cost to the client is a factor, it is not the primary factor in achieving client compliance provided among the options available since client compliance is primarily a result of the clients understanding of the need for change. An incentive is sometimes necessary, but it is not the primary factor in achieving client compliance provided among the options available, because client compliance is primarily a result of the clients understanding of the need for change. DIF: C REF: 39 OBJ: Analysis TOP: Nursing Process: Planning/Implementation MSC: NCLEX test plan designation: Health Promotion and Maintenance 18. The nurse is assessing a client diagnosed with chronic bronchitis who has been experiencing an increase in dyspnea. The client lives within 2 blocks of a factory that emits pollution into the air. In light of this information, the nurse is primarily concerned with:

Performing a complete client health history and physical assessment

Providing the client with assess to all the required breathing treatments

Identifying a correlation between the pollution and the clients increased dyspnea

Determining the availability of alternate housing for the client away from the factory

ANS: 3 There may be many factors that are affecting the clients breathing. Determining the clients exposure to the pollution and its affects of the clients breathing would be the nurses primary concern for this client. The assessment and history is important but is not the best option available regarding the effects of air pollution on the clients respirations. The availability of required breathing treatments is important but it is not the best option regarding the effects of air pollution of the clients respirations. It may be necessary for the client to consider moving but only if it is determined that the pollution is responsible of the increase in the dyspnea. DIF: A REF: 40 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance MULTIPLE RESPONSE 1. Which of the following clients is a concern for the community health nurse? (Select all that apply.)

The homeless woman with a history of congestive heart failure

The elderly gentleman who fell while disembarking from a bus

The child of itinerant workers who has a developed asthma

A client diagnosed with HIV who recently lost her insurance

A 15-year-old who was injured while at a public swimming pool

A retired service veteran who has a chronic psychiatric disorder

ANS: 1, 3, 4 Community-based health care occurs outside traditional health care institutions, such as hospitals. It provides services for acute and chronic conditions to individuals and families with in the community (Stanhope and Lancaster, 2006). Some of these problems include an increase in homeless and immigrant populations, an increase in sexually transmitted diseases, underimmunization of infants and children, and life-threatening diseases (e.g., clients living with HIV and other emerging infections). All of these clients possess risk factors that are community based DIF: C REF: 40 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 2. A nurse working with clients at or below the poverty level recognizes that the life expectancy of these clients is lower than the general population because of: (select all that apply.)

Inadequate nutritional diets

High-risk work environments

Hazardous living environments Addictive and abusive lifestyles

4 5 6

Predisposition to chronic diseases Ineffective decision making abilities

ANS: 1, 2, 3, 4 People who live in poverty are more likely to live in hazardous environments, work at high-risk jobs, eat less nutritious diets, abuse substances, and have multiple stressors in their life. When researchers compared the life expectancies of European Americans and African-Americans, the causes of the differences were related to low socioeconomic status rather than ethnicity. Predisposition to chronic disease in part is genetic in nature and research has confirmed no such link between poverty and chronic disease. Decision-making ability is not the only factor affecting decision making. Poverty negatively affects the individuals ability to access recourses and adds stressors such as finding shelter that can alter the decision-making process. Chapter 4. Theoretical Foundations of Nursing Practice MULTIPLE CHOICE

1. In preparing to review different theories, the nurse reviews basic information to assist in understanding the material. Theories are defined as:

1 2

Mental formulations of objects or events Aspects of reality that can be consciously sensed

Statements that describe concepts or connect concepts

Concepts or propositions that project a systematic view of phenomena

ANS: 4 A theory is a set of concepts, definitions, relationships, and assumptions that project a systematic view of phenomena. Mental formulations of objects or events are called concepts. Aspects of reality that can be consciously sensed are called phenomena. Statements that describe concepts or connect concepts are called assumptions. DIF: A REF: 46 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 2. There are different types of theories that may be used by nurses seeking to study the basis of nursing practice. When the goal of a theory is to speculate on why phenomena occur, it is termed a:

Grand theory

Prescriptive theory

Descriptive theory

Middle range theory

ANS: 3 Descriptive theories describe phenomena, speculate on why phenomena occur, and describe the consequences of phenomena. Grand theories provide the structural framework for broad, abstract ideas about nursing. Prescriptive theories address nursing interventions and predict the consequence of a specific nursing intervention. Middle range theories address specific phenomena or concepts and reflect practice. DIF: A REF: 47 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance

3. Which one of the four linkages of interest in the nursing paradigm refers to factors in the home or school?

1 2 3 4

Person Health Nursing care Environment

ANS: 4 Environment/situation includes all possible conditions affecting the client and the setting in which health care needs occur, such as the home, school, workplace, or community. Person refers to the recipient of nursing care, including individual clients, families, and the community. Health is the goal of nursing care. Nursing care refers to the diagnosis and treatment of human responses to actual or potential health problems (ANA, 1995). DIF: A REF: 45 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 4. The nurse is working within a health care system that employs Neumans theory. A client is having difficulty breathing and requires oxygen and medication. Within Neumans theory, the nurse approaches the client to:

Achieve the 14 basic needs

Promote attainment of biological self-care requisites

Assist in physiological adaptation to internal changes

Strengthen the line of defenses at the secondary level of prevention

ANS: 4 Neumans framework for practice included nursing actions as primary, secondary, or tertiary levels of prevention in caring for clients holistically. Secondary prevention strengthens internal defenses and resources by establishing priorities and treatment plans for identified symptoms. In Hendersons theory, nurses help the client to perform 14 basic needs. The goal of Orems theory is to promote attainment of self-care. Roys theory focuses on adaptation. DIF: A REF: 49 OBJ: Comprehension

TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 5. Although there are similarities in the different nursing theories, there are key elements that distinguish one from another. The emphasis of Jean Watsons conceptual model is that:

1 2 3 4

Self-care maintains wholeness Stimuli disrupt an adaptive system Subsystems exist in dynamic stability Caring is central to the essence of nursing

ANS: 4 Like Benner and Wrubels theory, Watson emphasized caring in her theory. Watsons model is designed around the caring process, assisting clients in attaining or maintaining health or in dying peacefully. The key emphasis of her theory is that caring is the moral ideal: mind-bodysoul engagement with another. Self-care is central to Orems theory. The key emphasis of Roys theory is that stimuli disrupt an adaptive system. The key emphasis of Johnsons theory is that subsystems exist in dynamic stability. DIF: A REF: 50-51 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 6. A community health nurse is working with a variety of clients and decides to use a systems theory approach to assist them to meet their health care needs. In using this approach, the nurse focuses on the:

Hierarchy of the clients human needs

Clients interaction with the environment

Clients attitudes toward health behaviors

Response of the client to the process of growth and development

ANS: 2 According to systems theory, a system is made up of parts that rely on one another, are interrelated, share a common purpose, and together form a whole. A clients interaction with the environment is an example of an open system. The nurse understands factors that change the environment can also have an impact on the system. Maslows hierarchy of human needs is an interdisciplinary theory useful in planning individualized care.

Determining a clients attitudes toward health behaviors follows a health-and-wellness theoretical model. Focusing on the response of a client to the process of growth and development is consistent with developmental theories. DIF: A REF: 47 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 7. While working on a postoperative unit, the nurse is applying the elements of the self-care theory. The nurse who assists the client to manage or attain self-care in wound management is using the theory developed by:

Imogene King

2 3

Dorothea Orem Virginia Henderson

Florence Nightingale

ANS: 2 The goal of Orems theory is to help the client perform self-care. The goal of Kings theory is to use communication to help the client reestablish positive adaptation to the environment. The goal of Hendersons theory is to work independently with other health care workers assisting the client to gain independence as quickly as possible. The goal of Nightingales theory is to facilitate the bodys reparative processes by manipulating the clients environment. DIF: A REF: 50 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 8. Martha Rogers theory has a framework for practice that includes the:

Manipulation of the clients environment

21 nursing problems within 4 major client needs

Seven categories of behavior and behavioral balance Unitary human being in continuous interaction with the environment

ANS: 4

The framework for practice according to Martha Rogers theory is the unitary human continuously changing and coexisting with the environment. Nightingales theory includes manipulation of the clients environment (i.e., appropriate noise, nutrition, hygiene, light, comfort, socialization, and hope) in the framework for practice. Abdellahs nursing theory includes 21 nursing problems within 4 major client needs in the framework for practice. Johnsons theory includes seven categories of behavior and behavioral balance in the framework for practice. DIF: A REF: 50 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 9. The nurse plans to apply a theory that focused on stress reduction. A theory proposed by which one of the following individuals should be selected?

1 2 3 4

Parse Peplau Neuman Orlando

ANS: 3 Stress reduction is the goal of the systems model of nursing practice according to Neumans theory. Parses theory focuses on indivisible beings and the environment co-creating health. Peplaus theory focuses on the interpersonal process as the maturing force for personality. Orlandos theory focuses on the interpersonal process to alleviate distress. DIF: A REF: 49 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 10. A similarity between the theories of Leininger and of Benner and Wrubel is:

Caring as a central focus

The clients adaptation to demands

An emphasis on the maximum level of wellness Dynamic interpersonal communication

4 ANS: 1

Leininger states that care is the essence of nursing and the dominant, distinctive, and unifying feature of nursing. Caring is also central to the theory of Benner and Wrubel, depicting personal concern as an inherent feature of nursing practice. The theories of Roy and Johnson focused on the clients adaptation to demands. Neumans theory places emphasis on achieving a maximum level of wellness. Abdellahs theory also addressed the person as a whole. Kings theory and Peplaus theory share a similarity with a focus on interpersonal communication. DIF: A REF: 50-51 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 11. The nurse is working with a client diagnosed with multiple sclerosis. The goal is that the client will be capable of living independently. The nursing theory that best supports this clients situation is:

Orems theory

Neumans theory

Abdellahs theory

Hendersons theory

ANS: 1 According to Orem, the goal of nursing is to increase the clients ability to independently meet biological, psychological, developmental, or social needs. Neumans theory is concerned with the whole person. According to Neuman, the focus of nursing is on the variables affecting the clients response to a stressor. Abdellahs theory emphasizes the delivery of nursing care for the whole person. According to Henderson, nurses help clients to perform 14 basic needs. DIF: A REF: 50 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 12. While the nurse realizes that the definition of health is unique to the client, the most universal factor is that health is:

Dynamic and ever-changing

Affected and managed by the nurse

Determined by internal and external forces Perceived and defined by the individual

ANS: 1 Health has different meanings for each client, the clinical setting, and the health care profession (see Chapter 6). Health is dynamic and continuously changing. Your challenge is to provide the best possible care based on the clients level of health and health care needs at the time of care delivery. While the other options may be true, they are not universally true to all individuals because not everyone is involved in a nurse-client relationship, wellness can be affected by internal factors, external factors, or a combination of both, and not everyone is capable of perceiving and defining their own wellness. DIF: C REF: 45 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 13. Which of the following statements by the nurse best defines nursing diagnoses for a client?

1 2 3 4

It is the basis for a clients care plan. It is what we nurses use to plan your care. It is one of a set of standardized client oriented problems. It is the way nurses identify what specific needs a client has.

ANS: 4 In medicine, physicians diagnose and treat disease. In contrast, nursing is the diagnosis and treatment of human responses to actual or potential health problems (ANA, 2003). The scope of nursing is broad. For example, a nurse does not medically diagnose the clients heart condition but instead assesses the clients response to the disease and may develop nursing diagnoses of fatigue, change in body image, and altered coping. From these nursing diagnoses, the nurse creates an individualized plan of care for each of the clients health problems. Although the other statements are correct, they are not the best options available because they do not fully explain the function of a nursing diagnosis. DIF: C REF: 45 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 14. The nurse is caring for a client newly diagnosed with type 2 diabetes mellitus. Which of the following nursing interventions best reflects Orems nursing theory?

Arranging for a consult with a certified diabetic nurse educator

Demonstrating proper documentation of glucose testing results

Explaining the role of A1C values in the management of glucose levels

Preparing discharge teaching to reinforce proper finger-stick technique

ANS: 4 If a nurse uses Orems theory in practice, the nurse assesses and interprets the data to determine the clients self-care needs, self-care deficits, and self-care abilities in the management of a disease. The theory then guides the design of individualized nursing interventions. While the other interventions are appropriate and will ultimately affect effective client self-care/ management of the diabetes, they are not the correct option because they are not directly involved in determining client self-care needs. DIF: C REF: 50 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 15. Swansons theory of caring is best demonstrated when the nurse:

Demonstrates efficiency when performing ordered treatments

Offers to stay with the client during a painful bedside procedure

Administers the clients pain medication promptly when requested

Frequently updates a family regarding a clients status during surgery

ANS: 2 Swansons theory of caring defines five components of caring: knowing, being with, doing for, enabling, and maintaining belief. These components provide a foundation of knowledge for the direction and delivery of caring nursing practice. This theory provides a basis for identifying and testing nurse caring behaviors to determine if caring improves client health outcomes. Offering to stay with the client is an intervention directly reflected of being with the client. Efficiency is a component of caring but it is not the best option available because it is not exclusively directed toward Swansons theory. Administering pain medication promptly reflects effective nursing care as well as a clients right. It is a component of caring but it is not the best option available because it is not exclusively directed towards Swansons theory. Effective nursing care and caring for the family is important, but it is not the best option available because it is not directed towards the client. DIF: C REF: 46 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance

16. Which of the following responses observed in a client recently diagnosed with lung cancer is most directly addressed by the Neuman System Model?

The client asks for a consult with the hospital clergy.

The client is observed crying after his family has left for the day.

The client asks for pictures of his children to be brought to him in the hospital. The client is heard saying, I trust my health team, and Ill do what they suggest.

ANS: 2 Examples of phenomena of nursing include caring, self-care, and client responses to stress. In the Neuman Systems Model (1995), phenomena include all client responses, environmental factors, and nursing actions. Crying is reflective of a clients response to stress to a second level need (Maslows) and so is directly related to Neumans model. While consulting with clergy is reflective of a client need, it is higher on Maslows hierarchy and so not the best option available. While requesting family photos is reflective of a client need, it is higher on Maslows hierarchy and so not the best option available. The client stating that he/she will trust the health team is reflective of a client response, it is less reflective of a need and so not the best option available. DIF: C REF: 49 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 17. A client diagnosed with type 2 diabetes mellitus reports poor glucose control since starting her new stressful job. The nurse uses Neumans theory to focus on the:

Identification of new stressors and improve dietary choices

Acquisition of appropriate interpersonal communication skills

Learning of effective coping methods and relaxation techniques Implementation of both aerobic and anaerobic exercise routines

ANS: 1

The Neuman Systems Model uses a systems approach to describe how clients deal with stressors in their internal or external environments. Nurses using Neumans theory in practice focus their care on client responses to the stressors (Meleis, 2006). For example, when a client takes on a new role within their employment, they may react to the stress by eating an improper diet. In this situation the nurse focuses on the client response to the stressors and designs interventions related to improving nutritional intake, both actions directed towards improving glucose control. While acquiring good interpersonal communication skills may help minimize the stress the client is currently experiencing, it does not address identifying the source of the stress or the management of the type 2 diabetes. While acquiring effective coping and relaxation skills may help manage the stress the client is currently experiencing, it does not address identifying the source of the stress or the management of the type 2 diabetes. While implementing effective exercise routines may help in the management of the type 2 diabetes, it does not address identifying the source of the stress or the thorough management of the type 2 diabetes. DIF: C REF: 46 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 18. The best example of an appropriate nursing assumption is:

Clients will make their needs and wants known to the staff

Clients require a quiet, darkened environment in which to sleep

Prompt administration of pain medication is an expectation of a postoperative client

A client recently diagnosed with cancer will want family present when discussing treatment options

ANS: 3 Assumptions are the taken for granted statements that explain the nature of the concepts, definitions, purpose, relationships, and structure of a theory (Meleis, 2006; Chinn and Kramer, 2004). It is a reasonable assumption that a client who recently underwent surgery would require and expect prompt administration of medications to manage that pain. Not all clients will openly communicate their needs/wants to the staff so this option is not the best example offered. While most clients will rest effectively in a quiet, darken environment, it is not required by all clients so this option is not the best example offered.

While many clients will want family present in this situation, not all will. Therefore this option is not the best example offered because an incorrect assumption would result in a violation of a clients right to privacy. DIF: C REF: 46 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 19. An example of a nursing activity directed towards providing input to the nursing process is:

Assessing a client who has just reported being nauseated

Discussing various ways to increase calcium intake with a client

Asking the client to identify when she would like to be ambulated

Documenting a clients pain level 30 minutes after being medicated

ANS: 1 Input for the nursing process is the data or information that comes from a clients assessment (i.e., how the client interacts with the environment and the clients physiological function). This is an example of the nursing process content: the information about the nursing care for clients with specific health care problems. Feedback serves to inform a system about how it functions: how the client responds to the intervention. Output is the end product of a system and in the case of the nursing process it is whether the clients health status improves or remains stable as a result of nursing care. DIF: C REF: 47 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 20. The nurse realizes that which of the following stated client needs has the highest priority?

A clients reaction to facial scarring after an automobile accident

A client who is crying hysterically upon hearing of her sons death

A homeless clients fear that his belongings will be stolen while he is hospitalized

An asthmatic clients concern regarding the lack of insurance to pay for her medications

ANS: 4 The second level of Maslows hierarchy includes safety and security needs, which involve physical and psychological security. The clients concern about securing the medication needed to minimize the potential for breathing problems has the highest priority of the options available. The fourth level encompasses esteem and self-esteem needs, which involve self-confidence, usefulness, achievement, and self-worth. Although important, a clients concern regarding her appearance would not have priority over the other options available. The third level contains love and belonging needs, including friendship, social relationships, and sexual love. Although important, a clients reaction to the loss of a loved one does not have priority over the other options available. The second level of Maslows hierarchy includes safety and security needs, which involve physical and psychological security. While the clients concern for the safety of his belongs is on the same level, it does not take priority over the client whose concern relates to potential breathing problems. DIF: C REF: Chapter 6, 72 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 21. Which of the following statements best expresses the primary goal of nursing practice?

To identify client needs in order to facilitate improved health and wellness

To tend to the physical and psychosocial needs of both the client and his family

To provide effective, research-based nursing care specifically tailored to each clients needs

To perform the required treatments and interventions directed towards client recovery from illness

ANS: 3 Providing excellent, evidenced-based nursing care is an expectation for all nurses and the care they provide. Although other options are reflective of an appropriate nursing outcome, they are not the best descriptions of nursings primary goal. Chapter 5. Evidence-Based Practice MULTIPLE CHOICE

1. Which of the following research approaches is an example of an exploratory type of research?

1 2

Establishing facts and relationships of past events Testing how well a program, practice, or policy is working

Refining a hypothesis on the relationships among phenomena

Portraying the characteristics of persons, situations, or groups

ANS: 3 An example of an exploratory type of research is to develop or refine a hypothesis about the relationships among phenomena. An example of a historical type of research is to establish facts and relationships concerning past events. An example of an evaluation type of research is to test how well a program, practice, or policy is working. An example of a descriptive type of research is to accurately portray characteristics of persons, situations, or groups and the frequency with which certain events or characteristics occur. PTS: 1 DIF: A REF: 62 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 2. The Health Information Portability and Accountability Act (HIPAA), implemented in 2003, may influence nursing research in the area of:

The cost of the study

Where the study may be published

What type of study may be conducted

How the data will be obtained and protected

ANS: 4 HIPAA regulations identify how protected health information of potential research subjects is to be managed. The researcher must be able to ensure that the data will be protected and used only by the researcher. HIPAA regulations should not influence the area of cost in nursing research. The focus of HIPAA regulations is not on where a study may be published. HIPAA regulations should not influence the type of study conducted. PTS: 1 DIF: A OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment

3. The expected research role for the baccalaureate-prepared nurse is to:

1 2

Assume the role of a clinical expert Acquire funding for research projects

Identify clinical nursing problems in practice

Develop methods of inquiry relevant to nursing

ANS: 3 Nurses with a baccalaureate degree are prepared to read research critically and use existing standards to determine the readiness of the findings for clinical practice. They also participate in research activities through identification of clinical problems in nursing practice. Nurses with a masters degree assume the role of clinical expert and are able to create a climate in which research-based change can be implemented into practice. Doctorally-prepared nurses are responsible for acquiring funding for research from public and private sources. Doctorally-prepared nurses are prepared to design studies independently including the development of methods of inquiry relevant to nursing. PTS: 1 DIF: A REF: 55 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 4. When a nurse researcher distributes an explanatory information sheet to subjects solicited for participation in her study, which of the following ethical principles that guide research is this researcher using?

Informed consent

Freedom from harm

Protection of subjects

Confidentiality of subjects

ANS: 1 As a component of informed consent, research subjects are given full and complete information about the purpose of the study, procedures, data collection, potential harm and benefits, and alternative methods of treatment. Research aspects such as minimizing the risk to participants, allowing reasonable risk to participants in relation to anticipated benefits, and monitoring the research to ensure the safety of participants follow the ethical standard of freedom from harm. In the case of research, institutions have Health Information Portability and Accountability Act (HIPAA) regulations that identify how protected health information of research subjects is to be

managed. The nurse researcher who follows HIPAA guidelines is following the principle of protection of subjects. Confidentiality guarantees that any information provided by the subject will not be reported in any manner that identifies the subject and will not be made accessible to people outside the research team. Describing how confidentiality is maintained is a component of informed consent. PTS: 1 DIF: A REF: 63 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 5. The nurse takes on ethical responsibilities when conducting research with human subjects. Which of the following violates an ethical responsibility associated with informed consent?

Adhering to verbal and written agreements

Using data obtained before the initiation of the study Explaining the possibility of unknown risks when appropriate

3 4

Providing alternatives, including the right of refusal and standard practices

ANS: 2 Using data obtained before the initiation of the study would be a breach of privacy because the participant has not yet given informed consent for use of those data. Adhering to verbal and written agreements is central to informed consent and the implementation of ethical research. One component of informed consent is the inclusion of informing the research subject of the potential harm and benefits. This would include the risks to the subject (including financial risks) and the potential for no benefit. Within the consent document, the researcher must outline alternative methods of treatment and alternatives to participation, including the right to withdraw from the study at any given time. PTS: 1 DIF: A REF: 63 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 6. Nurses need to become familiar with the elements of a research publication. A brief explanation of the type of measurement to be used is found in which section of a study?

Results

Methods

Conclusion

Introduction

ANS: 2 The methods section of a study includes the description of the sample (what or who was studied), type of data collected, and the device or instrument used to measure empirical information. The results section contains a description of the results obtained in the study, including appropriate statistical tests used to analyze the data. The conclusion consists of the author summarizing implications that can be drawn from the study. The introduction section presents the purpose, a summary of literature used to formulate the study, and the hypothesis tested or the research questions posed. PTS: 1 DIF: A REF: 59 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 7. After identifying the problem, the next step in the research process is to:

1 2

Select the population Review the literature

Obtain approval to conduct the study

Identify the instrument to use for data analysis

ANS: 2 After identifying the problem, the next step in the research process is to review the literature to determine what is known about the problem. Following identification of the problem and review of the literature, the researcher will design the study protocol. Selecting the population is a component of this phase of the research process. Obtaining necessary approvals is part of conducting the study, which follows the design phase in the research process. Identifying the instrument to use for data analysis occurs during the process of designing the study protocol. This step would occur during the study design phase of the research process after problem identification and literature review have taken place. PTS: 1 DIF: A REF: 58 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 8. A sample of orthopedic clients varies greatly in their requests for postsurgical analgesics. Which type of nursing research would best examine a prospective group of clients in determining what factors affect their alterations in comfort?

Historical research

Evaluation research

Correlational research

Experimental research

ANS: 3 Correlational research explores the interrelationships among variables of interest (such as factors affecting client comfort) without any active intervention by the researcher. Historical research is designed to establish facts and relationships concerning past events. It would not use prospective groups of clients. Evaluation research tests how well a program, practice, or policy is working. In experimental research, the investigator controls the study variable and randomly assigns subjects to different conditions. PTS: 1 DIF: A REF: 62 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 9. Which of the following research topics best lends itself to the experimental research process method?

The effects of therapeutic touch on a geriatric client diagnosed with Alzheimers disease

Prioritizing three nursing diagnoses for a newly admitted client with diabetes mellitus

Employing humor as an intervention with clients who are recovering from orthopedic surgery

Determining the blood pressure patterns of a client who recently experienced a cerebrovascular accident (i.e., stroke)

ANS: 3 In experimental research, the investigator controls the study variable (use of humor) and randomly assigns subjects to different conditions (those who receive humor as an intervention, and those who do not). The effect of therapeutic touch on a geriatric client with Alzheimers disease lends itself to the nursing process as a nursing intervention to perhaps assist a client in meeting a goal of preventing social isolation. To use the experimental research process, there would have to be other clients involved (i.e., a group of clients with Alzheimers disease who receive therapeutic touch, and a group of clients with Alzheimers disease who do not receive therapeutic touch) to determine whether or not therapeutic touch had any effect. Prioritizing nursing diagnoses for client care is an example of using the nursing process.

Determining the blood pressure patterns of a client who recently had a cerebrovascular accident is a part of the assessment phase of the nursing process. In contrast to an experimental research study, no variable is being controlled by the nurse. PTS: 1 DIF: A REF: 62 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 10. The nurse is looking at different strategies for learning and incorporating new information into practice. A strategy that uses problem-solving is demonstrated by:

Repeatedly practicing vital signs until competence is achieved

Seeking information from the nurse manager on the clients status Reviewing Maslows hierarchy either in a textbook or on the internet

3 4

Trying different types of colostomy dressings for maximum therapeutic effect

ANS: 4 Trying various ways of resolving clients health care needs or evaluating health care products, as in trying different types of colostomy dressings for maximum effect, is an example of the problem-solving strategy for knowledge acquisition. Practicing skills is an example of gaining experience to increase ones knowledge. Information-seeking is a strategy used to obtain knowledge from experts in a particular field. Reviewing Maslows hierarchy in a reference textbook or on the internet is another example of acquiring knowledge through information-seeking. PTS: 1 DIF: A REF: 55 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 11. A nurse researcher has completed a study involving the use of intravenous analgesics for postsurgical discomfort. The description of the 16 clients used for the study would best be written in which part of the research report?

Results section

Methods section

Discussion section

Introduction section

ANS: 2 A description of the clients used is found in the methods section of the research study. The results section contains a description of the results obtained in the study, including appropriate statistical tests used to analyze the data. The discussion section presents the authors interpretation of the results, including conclusions and implications that can be drawn from the study. The introductory section presents the purpose of the study, a summary of literature, and the hypotheses tested or questions posed. PTS: 1 DIF: A REF: 59 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 12. A nurse reads about a case study involving the potential positive effects of the early stimulation of posthead-injury clients. Which of the following questions should be a priority consideration before use of the research results?

What was the cost of the study?

2 3

Were ethical principles maintained? Were the results of this study published in other journals?

Are the clients in the study similar to clients I work with?

ANS: 4 Determination of whether the subjects and environment in the study are similar to the clients for whom the nurse provides care in the particular practice setting is necessary before research can be considered for use in practice. Although cost may be a consideration in determining the feasibility of applying research findings, it is not the priority consideration for research utilization. The research findings would first have to be applicable to the practice setting and client population. Even though research may indicate ethical principles were maintained, it does not necessarily mean that it is feasible to apply the findings in practice. For example, cost issues may limit the use of research findings. The number of journals that published the research results of the study should not be the priority consideration in implementation of its findings. To judge the scientific worth of the study; however, it is important to examine the amount of supportive evidence provided by other scientific studies that have obtained similar results. PTS: 1 DIF: C REF: 59 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 13. An example of a predictive type of question that a nurse might use for research is which of the following?

What creates an increase in stress levels?

2 3

How often does the stress reaction occur? What does guided imagery mean to clients?

If guided imagery is used, will stress levels be reduced?

ANS: 4 Questioning whether stress will be reduced is an example of a predictive type of question because it connects stress reduction with the use of guided imagery. Asking what increases stress explores factors that impact a phenomenon. It is not a predictive type of question. Asking how often stress increases does not predict any outcome, but rather focuses on frequency of a response, which could be used in data collection. Asking what guided imagery means does not predict any type of outcome, but rather explores meaning in order to gain understanding. PTS: 1 DIF: A REF: 55 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 14. A nurse routinely uses therapeutic touch when caring for postoperative clients with incisional pain. Occasionally a client will show reluctance when the intervention is offered. The nurses best response in such a situation is to:

Research for alternative interventions that will be better received by the client

Suggest that the client allow the intervention just once before making a final decision Respect the clients wishes and rely on pain medication to help with managing the pain

3 4

Inform the client that the intervention has been found to be effective during several research projects

ANS: 1 Evidence-based practice is a problem-solving approach to clinical practice that integrates the conscientious use of best evidence in combination with a clinicians expertise and client preferences and values in making decisions about client care. If the client is not receptive to an intervention, the best nursing response is to search for an alternative evidence-based therapy that the client will accept.

Suggesting the client allow intervention once before making a decision may be considered as long as there is no pressure placed on the client to accept the intervention, but it is not the best option provided because there is no guarantee that the client will be receptive to the intervention, and the problem regarding incisional pain would then go unaddressed. Chapter 6. Health and Wellness MULTIPLE CHOICE 1. When formulating a definition of health, the nurse should consider that health, within its current definition, is:

The absence of disease

A function of the physiological state

The ability to pursue activities of daily living

A state of well-being involving the whole person

ANS: 4 When formulating a definition of health, a person should consider the total person, as well as the environment in which the person lives. Health generally implies a state of well-being that is ultimately defined in terms of the individual. Health is considered to be more than merely the absence of disease. The definition of health has broadened beyond the physiological state to include mental, social, and spiritual well-being. An individual who has the ability to pursue activities of daily living may not define himself or herself as being healthy. Life conditions such as environment, diet, and lifestyle practices may negatively impact ones health long before the person is unable to perform activities of daily living. DIF: A REF: 69 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 2. Which one of the following is the main, overarching goal for Healthy People 2010?

Reduction of health care costs

Elimination of health disparities

Investigation of substance abuse Determination of acceptable morbidity rates

ANS: 2 Two overarching goals for Healthy People 2010 are (1) to increase quality and years of healthy life and (2) to eliminate health disparities.

Reducing health care costs was not a goal for Healthy People 2010. Investigation of substance abuse was not one of the main, overarching goals for Healthy People 2010. Determining acceptable morbidity rates was not one of the main, overarching goals for Healthy People 2010. DIF: A REF: 69 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 3. A nurse is using a holistic approach when caring for a client. To incorporate all of the factors that may influence the client, which of the following nursing responses is most therapeutic?

I would like you to perform this exercise once a day.

Your physician has left orders that you are to follow.

The laboratory tests reveal the need to reduce your daily percentage of fat intake.

Adapting to a low-fat diet and increasing your activity will help lower your blood glucose levels.

ANS: 4 Using a holistic approach involves consideration of all factors that may impact a clients level of well-being in all dimensions, not just physical health. Factors such as diet and exercise can influence ones level of health. Directing the client to exercise does not address the many factors that may impact ones level of health. This response does not facilitate the client in seeing the connection between lifestyle choices and well-being. Directing the client to follow physicians orders, though important, does not describe a holistic approach of nursing care. A holistic approach may include a discussion of diet and exercise and the effect these factors have on blood glucose level. The aim is for the client to take responsibility for their health and choices that may impact their health. Viewing laboratory test results is a part of the nursing assessment. To approach the client holistically, the nurse would need to also assess the clients diet and activity level. DIF: C REF: 72 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Health Promotion and Maintenance 4. The client states, Heart disease runs in our family. My blood pressure has always been high. The nurse determines that this is an example of the clients:

Risk factors

Active strategy

Health beliefs Negative health behavior

ANS: 1 Risk factors are anything that increases the vulnerability of an individual or group to an illness or accident. This client is identifying the physical risk factor of genetic predisposition to heart disease. An example of an active strategy would be weight reduction or smoking cessation, where the client is actively involved in measures to improve their present and future levels of wellness. Health beliefs are a persons ideas, convictions, and attitudes about health and illness. An example of a health belief would be if the client stated, Heart disease runs in our family. I know I will have heart disease anyway, so why exercise? A negative health behavior is a behavior that may negatively impact ones health. An example of a negative health behavior would be consistently drinking alcohol in excess. DIF: A REF: 77 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 5. A client is discharged following a heart attack. In using the Stages of Health Behavior Change as a guide, the nurse recognizes that the client is most likely to begin to accept information on diet changes and an exercise program during which stage?

Action

Preparation

Maintenance

Contemplation

ANS: 4 During the contemplation stage, the client is considering a change within the next 6 months. The client may be ambivalent initially, but will more likely accept information as he or she develops more belief in the value of change. During the action stage, the client is actively engaged in strategies to change behavior. During the preparation stage, the client is making small changes in preparation for a change in the next month. At this point, the client believes advantages outweigh disadvantages in behavior change. During the maintenance stage, the client has sustained change over time. DIF: A REF: 78 OBJ: Knowledge

TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 6. When assessing the external variables that influence a clients health beliefs and practices, the nurse must consider his:

1 2 3 4

Income status Religious practices Educational background Reaction to the heart disease

ANS: 1 External variables influencing a persons health beliefs and practices include family practices, cultural background, and socioeconomic factors, such as income. Economic variables may affect a clients level of health by increasing the risk for disease and influencing how or at what point the client enters the health care system. A persons compliance with the treatment to maintain or improve health is also affected by economic status. Religious practices are one way that people exercise spirituality. Spirituality is considered to be an internal variable. Educational background is an internal variable that can influence the health beliefs and practices of a client. An example of an internal variable that can influence health beliefs and practices of a client includes emotional factors, such as the reaction to heart disease. DIF: A REF: 74 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 7. A paraplegic client is admitted for an electrolyte imbalance. Based on the levels of prevention, the client is receiving care at the level of:

Health promotion

Primary prevention

Tertiary prevention

Secondary prevention

ANS: 4 The secondary prevention level focuses on early diagnosis and prompt treatment as well as disability limitations. Adequate treatment for the electrolyte imbalance is sought to prevent further complications. Health promotion is a focus of the primary prevention level.

The primary prevention level focuses on health promotion and specific protection measures such as immunizations and personal hygiene. The tertiary prevention level focuses on restoration and rehabilitation. DIF: A REF: 75 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 8. Which of the following nursing activities is an example of tertiary level caregiving?

Teaching a client how to irrigate a new colostomy

Providing a class on hygiene for an elementary school class

Informing a client that her infant can be immunized at the health department

Arranging for a hospice nurse to visit with the family of a client with lung cancer

ANS: 4 Tertiary prevention occurs when a defect or disability is permanent and irreversible. Care of the hospice nurse at this level aims to help the client and the clients family achieve as high a level of functioning as possible despite the limitations caused by the cancer. Teaching a client how to irrigate a new colostomy would be an example of secondary prevention. If the colostomy is to be permanent, care may later move to the tertiary level of prevention. Providing a class on hygiene for an elementary school class would be an example of the primary level of prevention. Informing a client about available immunizations would be an example of primary prevention. DIF: A REF: 75-76 OBJ: Comprehension TOP: Nursing Process: Planning/Implementation MSC: NCLEX test plan designation: Health Promotion and Maintenance 9. Which one of the following client assessment findings indicates a lifestyle risk factor to the nurse?

Obesity

Sunbathing

Overcrowded housing

Industrial-based occupation

ANS: 2 Excessive sunbathing is a lifestyle risk factor for skin cancer.

Obesity is a physiological risk factor. Overcrowded housing is an environmental risk factor. An industrial-based occupation is an environmental risk factor. DIF: A REF: 77-78 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 10. In the Health Belief Model, the nurse recognizes that the focus is placed on the:

1 2

Basic human needs for survival Functioning of the individual in all dimensions

Relationship of perceptions and compliance with therapy

Multidimensional nature of clients and their interaction with the environment

ANS: 3 In the Health Belief Model, the nurse focuses on the relationship between a persons beliefs and health behaviors. By focusing on the clients perceptions of health, the nurse is better able to understand and predict how a client will comply with health care therapies. Basic human needs for survival is a component of Maslows hierarchy of needs model. The nurse who focuses on the functioning of the individual in all dimensions is following a holistic health model. In the health promotion model, the nurse focuses on the multidimensional nature of clients and their interaction with the environment. DIF: A REF: 70 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 11. The client who recently received a kidney transplant is worried about her husband since he has taken over the physical tasks of running their home. The client is in the process of adapting to a change in:

Body image

Self-concept

Illness behavior

Family dynamics

ANS: 4

The effects of illness on the client and family have created a change in family dynamics. Family dynamics is the process by which the family functions, makes decisions, gives support to individual members, and copes with everyday changes and challenges. Body image is the subjective concept of physical appearance. The client did not express concerns regarding body image. Self-concept is a mental self-image of strengths and weaknesses in all aspects of personality. The client did not express a change in self-concept. Illness behavior refers to how people monitor their bodies, define and interpret their symptoms, take remedial actions, and use the health care system. The client did not express change in illness behavior. DIF: A REF: 81 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 12. Client assessment provides the nurse with necessary information for the development of an effective plan of care. When determining the influence of an internal variable on the clients health status, the nurse will specifically look for:

Anxiety level present

2 3

Family remedies used Location and type of occupation

Available health insurance coverage

ANS: 1 Emotional factors, such as the clients degree of anxiety, is an internal variable that can influence the clients health status. An example of an external variable that can influence the clients health status is the use of family remedies. Socioeconomic factors, such as location and type of occupation, are external variables that can influence the clients health status. Available health insurance coverage is an example of an external socioeconomic factor that can influence the clients health status. DIF: C REF: 73-74 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 13. A nurse understands that illness behavior means:

1 2 3 4

Each distinct illness will cause the client to behave in a specific manner Nursing care provides interventions that are behavior oriented The clients behaviors will have a direct impact on his illness When ill, a clients perception of illness will result in unique behaviors

ANS: 4 Medical sociologists call the reaction to illness, illness behavior. Nurses who understand how clients react to illness can minimize the effects of illness and assist clients and their families in maintaining or returning to the highest level of functioning. While the other options may be true, they do not define illness behavior. DIF: A REF: 79 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 14. A client tells the nurse that his illness is a result of his failure to live a good life. The nurse recognizes this statement as an example of the clients:

Risk factor

Health belief

Illness behavior Negative health behavior

ANS: 2 Health beliefs are a persons ideas, convictions, and attitudes about health and illness. A risk factor is any situation, habit, social or environmental condition, physiological or psychological condition, developmental or intellectual condition, or spiritual or other variable that increases the vulnerability of an individual or group to an illness or accident. Illness behavior is the unique manner in which a client reacts to illness. Negative health behaviors include practices actually or potentially harmful to health, such as smoking, drug or alcohol abuse, poor diet, and refusal to take necessary medications. DIF: A REF: 70 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 15. Which of the following client statements best relates to the third component of the Health Belief Model?

My blood cholesterol is only a little high.

2 3

No one in my family is susceptible to the flu. Ill just avoid the food that causes the problem.

By losing weight my blood pressure may come down.

ANS: 4 The third componentthe likelihood that a person will take preventive actionresults from the persons perception of the benefits of and barriers to taking action. Preventive action may include lifestyle changes, increased adherence to medical therapies, or a search for medical advice or treatment. The second component is the individuals perception of the seriousness of the illness. The first component of this model involves the individuals perception of susceptibility to an illness. Increased incidence of chronic disease processes. DIF: C REF: 70 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 16. The goal of Penders Health Promotion theory is best reflected in which of the following nursing interventions?

Suggesting the client experience a variety of exercise routines before settling on the one to adapt

Arranging for a client to attend a support group for individuals who also have severe burn scars Playing soft, classical music when a client diagnosed with Alzheimers becomes physically agitated

3 4

Providing a client with a history of stress-induced respiratory problems with detailed explanations regarding her care

ANS: 1 Health-promoting behaviors should result in improved health, enhanced functional ability, and better quality of life. According to the Basic Human Needs model, certain human needs are more basic than others; that is, some needs must be met before other needs (i.e., fulfilling the physiological needs before the needs of love and belonging). Self-actualization is the highest expression of ones individual potential and allows for continual discovery of self. Maslows model takes into account individual experiences, always unique to the individual.

Nurses using the holistic nursing model recognize the natural healing abilities of the body and incorporate complementary and alternative interventions, such as music therapy, reminiscence, relaxation therapy, therapeutic touch, and guided imagery, because they are effective, economical, noninvasive, nonpharmacological complements to traditional medical care. The holistic nursing model considers the emotional and spiritual well-being, as well as other dimensions of an individual, as important aspects of physical wellness. DIF: C REF: 71 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 17. The nurse knows that the greatest internal factor to consider when educating an adult client concerning health promotion activities is the clients:

1 2 3 4

Emotional wellness Developmental stage Professed spirituality Intellectual background

ANS: 4 A persons beliefs about health are shaped in part by the persons knowledge, lack of knowledge, or incorrect information about body functions and illnesses; educational background; and past experiences. These variables influence how a client thinks about health. In addition, cognitive abilities shape the way a person thinks, including the ability to understand factors involved in illness and to apply knowledge of health and illness to personal health practices. The clients ability to understand and accept the importance of the teaching is the primary nursing consideration. The clients degree of stress, depression, or fear, for example, can influence health beliefs and practices. The manner in which a person handles stress throughout each phase of life will influence the way the person reacts to illness, but this option is not the best choice available. A persons thought and behavior patterns change throughout life. The nurse must consider the clients level of growth and development when using his or her health beliefs and practices as a basis for planning care, but the client has been identified as being adult and so the developmental stage has been determined. Spirituality is reflected in how a person lives his or her life, including the values and beliefs exercised, the relationships established with family and friends, and the ability to find hope and meaning in life. However, this is not the best option available. DIF: C REF: 23 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance

18. The nurse is caring for a terminally ill client who recently immigrated to the United States. To provide quality end-of-life care, the nurse must initially:

1 2 3 4

Make every effort to involve the client and his family in the end-of-life care Understand the clients personal and cultural views regarding death and dying Arrange for end-of-life care to be provided by personnel familiar with the clients culture Share the clients concerns regarding the dying process with his interdisciplinary care team

ANS: 2 Differences in beliefs, values, and traditional health care practices are relevant when planning end-of-life care. It is the nurses responsibility to become familiar with the clients personal and cultural views so as to provide the most effective and appropriate end-of-life care. While this is important, it is not the best available option because understanding the clients cultural and personal views will facilitate all other offered options. This may not be either practical or possible. While this is important, it is not the best available option because understanding the clients cultural and personal views will facilitate all other offered options. DIF: C REF: 74 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 19. Which of the following nursing interventions is the best example of a primary care prevention strategy regarding the flu?

Staffing a flu immunization clinic at a senior citizens center

Providing flu prevention literature for distribution to visitors

Reminding client care personnel of the importance of the flu shot

Getting a drug manufacturer to donate flu vaccine for the homeless

ANS: 4 Primary prevention is true prevention; it precedes disease or dysfunction and is applied to clients considered physically and emotionally healthy. Primary prevention aimed at health promotion

includes health education programs, immunizations, and physical and nutritional fitness activities. This option is the best example because it facilitates the availability of a service to clients to whom it might otherwise be unavailable. This is a good example of primary care, but it is not the best one available because it facilitates a service that is already available. While this is an example of primary care, it is not the best because it does not ensure the facilitation of the needed service. While this is an example of primary care, it is not the best because it does not ensure the facilitation of the needed service. DIF: C REF: 75 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 20. The nurse can best discuss the impact of a known risk factor on a clients health by stating:

It doesnt mean youll get the disease just that the odds are greater for you.

Now you know that the possibility is there, you can take steps to prevent it.

The risk factor can be managed by making a change in your lifestyle.

Youre lucky because you have the benefit of being able to do something about it.

ANS: 1 The presence of risk factors does not mean that a disease will develop, but risk factors increase the chances that the individual will experience a particular disease or dysfunction. While this response is not incorrect, it does not address the impact of a risk factor on the clients health. This is not always true, and so it is not the best option. This option minimizes the clients concern and does not address the impact of a risk factor on the clients health. DIF: C REF: 77 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 21. When caring for a client with a spouse and two adolescent children, the nurse knows that the family unit must first:

Be viewed as a client

Change traditional roles

Provide support for the ailing mother Seek help to fulfill day-to-day needs

ANS: 1 The nurse must view the whole family as a client under stress, planning care to help the family regain the maximal level of functioning and well-being. While the illness of a family member requires role reassignment in order for the family to continue to function, the initial focus is to be viewed as a unit in need of care. While the family should provide support to the ailing member, the initial focus is to be viewed as a unit in need of care. Chapter 7. Caring in Nursing Practice MULTIPLE CHOICE 1. The nurse recognizes that the client symptomatology typical of the acute cancer survival phase includes:

Fear and anxiety Despair and anger

Lethargy and alopecia

Dyspnea and tachycardia

ANS: 1 The acute survival phase starts with the diagnosis of cancer. Diagnostic and therapeutic efforts dominate. Fear and anxiety are constant elements of this phase. Despair and anger are more representative of the stages of grief and loss according to KblerRoss. Extended survival is the period during which a client has ended the basic, rigorous course of treatment and is dealing with the physical side effects of the treatment, such as lethargy and alopecia. Dyspnea and tachycardia may represent a clients unique individualized symptomatology but they are not recognized as general signs of the acute phase. DIF: A REF: 85 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Illness Management 2. Since being treated for leukemia in her early twenties, a client has experienced bilateral mastectomies and has been diagnosed with osteoporosis and hypothyroidism. This health history best reflects the lifelong impact of:

Cancer on a clients health and wellness

2 3

Cancer treatments on future health status Specific cancers on the health status of survivors

Genetic susceptibility on the reoccurrence of cancer

ANS: 2 The impact of cancer treatment on future health status is the correct response. The increased risk for developing a second cancer is due to cancer treatment, genetic or other susceptibility, or an interaction between treatment and susceptibility. The risk for treatment related problems is associated with the complexity of the cancer itself (e.g., type of tumor and stage of disease); the type, variety, and intensity of treatments used; and the age and underlying health status of the client. While cancer itself affects the clients immediate health and wellness status, it is secondary to the long-term effects of the cancer treatments used. Although some health effects are related to specific forms of cancer, this is not the best option available because it is much less likely to be the cause of lifelong health issues. While genetic predisposition is a factor in cancer development it is not the most likely factor affecting lifelong health issues for the cancer survivor. DIF: C REF: 86 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Illness Management 3. In the geriatric population, the primary reason cancer is diagnosed in its later stage is:

Health care benefit coverage is often inadequate

Symptoms are often masked by the effects of aging

Clients are reluctant to seek help for the early symptoms Symptoms are often attributed to the aging process

ANS: 4 Most cancer survivors (61%) are over the age of 65 (IOM, 2006). Often health care providers wrongly attribute the symptoms of cancer or the symptoms from the side effects of treatment to aging. This often leads to late diagnosis or a failure to provide aggressive and effective treatment of symptoms. While the geriatric population may have a problem with adequate health care coverage, it is not the primary cause of delayed cancer diagnosis in that population. While symptoms may be masked by the effects of aging, it is not the primary cause of delayed cancer diagnosis in this population.

While symptoms can be attributed to the aging process for individual geriatric clients, it is not the primary cause of delayed cancer diagnosis in this population. DIF: C REF: 86 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Illness Management 4. Which of the following clients is most likely to experience cancer treatment-related problems in the future?

1 2 3 4

A 73-year-old client with heart problems An otherwise healthy 6-year-old child A 25-year-old professional tennis player A 39-year-old with a history of depression

ANS: 2 The risk for treatment-related problems is associated with the complexity of the cancer itself (e.g., type of tumor and stage of disease); the type, variety, and intensity of treatments used; and the age and underlying health status of the client. The 6-year-old child is at greatest risk because the primary cancer occurred at such a young age and during a critical physiological developmental stage. Because the pivotal factors for cancer treatment-related problems are age and development, the 73-year-old with heart problems does not present the greatest risk. Because the pivotal factors for cancer treatment related problems are age and development, 25year-old professional tennis players chronic health issues do not present the greatest risk. While depression may have a negative health effect, a 39-year-old with a history of depression does not present the greatest risk for cancer treatment related problems since the pivotal factors are age and developmental stage. DIF: C REF: 86-87 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Illness Management 5. Eleven months after being treated for breast cancer, a client reports difficulty sleeping and the associated fatigue while denying any other signs/symptoms. The nurse recognizes that the client may be experiencing:

Situational depression

Normal remission symptoms

Post-traumatic stress disorder Delayed effects of chemotherapy drugs

ANS: 1 Survivors feelings of distress range along a continuum from sadness to disabling depression (Vachon, 2006). The long-term presence of fatigue and sleep disturbances, for example, is often associated with anxiety and depression in many cancer survivors (Barton-Burke, 2006). Sleep disorders and fatigue would not necessarily be expected at this point in the remission stage. Posttraumatic stress disorder (PTSD) is a psychiatric disorder characterized by an acute emotional response to a traumatic event or situation. Cancer survivors experience symptoms of PTSD (e.g., grief, nightmares, panic attacks, or fear) at a rate of 4% to 19%, as a result of their diagnosis, treatment, or a past traumatic episode. While chemotherapy drugs can produce side effects, sleep disorders are not a typical complaint. DIF: C REF: 88 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Illness Management 6. A client, who recently completed treatment for cancer, shares with the nurse that she is, a little depressed, but I guess I will be OK. The foremost reason the nurse encourages the client to discuss this situation with her primary health care provider is that the nurse realizes that:

The depression will not improve by itself

The medications can help resolve the depression

Depression can decrease the clients chances of recovery

The depression is a result of concerns about the cancer reoccurring

ANS: 3 Research has associated depression with decreased cancer survivorship. A study conducted by Brown and colleagues (2003) suggested that a cancer diagnosis and its effects predispose people to distress, which if maintained over time will enhance disease progression. While depression may not improve by itself, it is not the primary reason for the nurse to encourage the client in cancer remission to seek medical advice. Chronic depression can adversely affect the chances of long-term survivorship. While medications can help resolve depression, it is not the primary reason for the nurse to encourage the client in cancer remission to seek medical advice. Chronic depression can adversely affect the chances of long-term survivorship. While may be a result of concerns about the cancer reoccurring, it is not the primary reason for the nurse to encourage the client in cancer remission to seek medical advice. Chronic depression can adversely affect the chances of long-term survivorship. DIF: C REF: 87 OBJ: Analysis TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Adaptation/Illness Management 7. The nurse knows that the primary factor affecting a cancer survivors quality of life is:

1 2

The clients precancer physical and mental health status The presence of a strong support system

The quality and type of cancer treatment received

The type and number of cancer-related risk factors the client possesses

ANS: 2 Mellon and colleagues (2006) interviewed cancer survivors and their family caregivers, finding that two of the strongest predictors for cancer survivors quality of life (enjoyment of life) were family stressors and social support. Precancer physical and mental health status may affect the survivors physical recovery regarding the treatment but not their quality of life (enjoyment of life). The quality and type of cancer treatment received may affect the survivors chances of survival but not their quality of life (enjoyment of life). The type and number of cancer-related risk factors the client possesses may affect the survivors chances of survival but not their quality of life (enjoyment of life). DIF: C REF: 85-86 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Illness Management 8. A client, who is a 7-year breast cancer survivor, tells the nurse, My husband will help me bathe when he gets here. The nurse interprets this statement to mean that the client:

Is reluctant to have the staff see her chest scar

Prefers to protect her modesty and privacy

Has a healthy self-image regarding her husband

Is not comfortable with the care she is receiving

ANS: 3 Self-image and intimacy may be negatively affected after cancer surgery. It is a positive sign that the client is comfortable having her husband perform this task for her. Although the client may be reluctant to have staff see her chest scar, the clients history of cancer surgery should direct you to the more related option. While the client may prefer to protect her modesty and privacy, the clients history of cancer surgery should direct you to the more related option.

Although the client may not be comfortable with the care she is receiving, it is not as likely as the other options and the clients history of cancer surgery should direct you to the more related option. DIF: C REF: 88 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Illness Management 9. The nurse understands the primary focus of education for a client who has just received a diagnosis of cancer is to:

Introduce self-care measures to support health

2 3

Discuss the management of treatment-related side effects Reinforce the explanation of the risks of proposed treatments

Formulate long-term lifestyle changes to minimize risk factors

ANS: 3 When caring for clients with an initial diagnosis of cancer, the immediate focus of client education should be the reinforcement of their health care providers explanations of the risks related to their cancer as well as the benefits and risks related to the proposed treatment options. This should then be followed by instructions on what they need to self-monitor (i.e., appetite and weight, effects of fatigue and sleeplessness), and what to discuss with health care providers in the future. Potential for treatment effects; such as pain, neuropathy, or cognitive change; also should be addressed since clients are more likely to report their symptoms if they are educated on their likelihood. Survivors need to learn how to manage problems related to persistent symptoms. Because survivors are at an increased risk for developing a second cancer and/or chronic illness, it is important to educate them about lifestyle behaviors that will improve the quality of their life. While introducing self-care measures to support health is an appropriate topic for client education, it should be addressed after the client is informed of the risks related to their cancer as well as the benefits and risks related to the proposed treatment options. Although discussing the management of treatment-related side effects is an appropriate topic for client education, it should be addressed after the client is informed of the risks related to their cancer as well as the benefits and risks related to the proposed treatment options. While formulating long-term lifestyle changes to minimize risk factors is an appropriate topic for client education, it should be addressed after the client is informed of the risks related to the cancer as well as the benefits and risks related to the proposed treatment options. DIF: C REF: 91 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 10. Which of the following assessment data best confirms the possibility of cognitive impairment in a client with a diagnosis of lung cancer?

Client is observed writing questions to ask his oncologist.

2 3

Client states, I seem to be a little more forgetful lately. Clients wife states, I have to remind him of everything.

Client overheard asking son, Where did I put my glasses?

ANS: 2 Cognitive changes are a set of physical symptoms very common in survivors that develop from their disease, treatment, the complications of treatment, underlying medical conditions, and psychological responses to the diagnosis of cancer (Nail, 2006). Cognitive changes can occur during all phases of the cancer experience, from small deficits in information processing to acute delirium. Often the cognitive impairments survivors experience are not evident to someone else but are apparent to the person experiencing them, especially in relation to work performance with high cognitive demands (Anderson-Hanley and others, 2003). The clients personal evaluation of his memory is the best indicator of cognitive impairment. While writing down questions to ask the oncologist may be motivated by poor memory, it is not uncommon for clients to prepare a list of questions before a meeting with their health care provider. Although the clients spouse reminding the client of things may indicate impaired cognitive ability, it is not as strong an indicator as a statement from the client. Although not being able to locate an item may indicate impaired memory, it is not uncommon for individuals to misplace personal items. DIF: C REF: 86-87 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Illness Management 11. Which of the following cancer survivors is at greatest risk for post-treatment symptoms and poor treatment outcomes?

An Asian dishwasher

A Hispanic truck driver

A Caucasian factory worker

An African-American carpenter

ANS: 1 There is evidence to suggest that survivors among racial and ethnic minorities and other underserved populations have more post-treatment symptoms and poorer treatment outcomes than Caucasians (CDC, 2004). The disparities in health among ethnic groups are related to a complex interplay of economic, social, and cultural factors, with poverty being a key factor. The

Asian dishwasher is both a member of a racial minority and likely the poorest paid of the survivors. While being a member of an ethnic group is a risk factor, a Hispanic truck driver is not likely to be the poorest of the survivors. The Caucasian factory worker has the least risk because he is not a member of an ethnic or racial minority nor is there a likelihood of him being the poorest of the survivors. While being a member of a racial minority is a risk factor, an African-American carpenter is not likely to be the poorest of the survivors. DIF: C REF: 85 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Illness Management 12. When assessing cancer survivors regarding the stressors of cancer, the nurse should first ask clients:

1 2 3 4

If they feel they are stressed by the cancer How they believe cancer has affected their life What they are doing to cope with the stress of having experienced cancer What assistance they need to successfully manage the stressors of dealing with cancer

ANS: 2 As a nurse, learn to assess the many ways in which cancer affects the lives of clients who are survivors. It is through their perception of how cancer impacts their lives, that therapeutic nursing interventions can be implemented. Clients may not be comfortable identifying themselves as being stressed. An open-ended question regarding the effects of cancer on the clients life is likely to be more informative. Asking a client what they are doing to cope with stress assumes the client is experiencing stress, and it may be uncomfortable for the client to answer. An open-ended question regarding the effects of cancer on the clients life is likely to be more informative. Asking a client about assistance needed to manage stress assumes the client is experiencing stress, and it may be uncomfortable for the client to answer. An open-ended question regarding the effects of cancer on the clients life is likely to be more informative. DIF: C REF: 91 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Illness Management 13. A 78-year-old woman presents at the emergency department with complaints of shortness of breath. She has a history of radiation therapy for a lung mass 7 years ago. When the client asks the nurse if it could be cancer again, the most therapeutic response would be:

At your age, shortness of breath could be a result of any number of things.

That is a possibility but it could also be a result of your radiation therapy. What makes you think that? Shortness of breath can have many different causes.

3 4

I wouldnt jump to that conclusion. Lets just see what your health care provider thinks.

ANS: 2 Cancer survivors are at increased risk for cancer (either a recurrence of the cancer for which they were treated or a second cancer) and for a wide range of treatment-related problems (IOM, 2006). While shortness of breath could be caused by many things, it does not address the clients concern regarding reoccurring cancer. While shortness of breath could be caused by many things, it does not address the clients concern regarding reoccurring cancer. Telling the client not to jump to conclusions minimizes the clients concern. Chapter 8. Caring for Patients with Chronic Illness MULTIPLE CHOICE 1. When caring for an older patient with hypertension who has been hospitalized after a transient ischemic (TIA), which topic is the most important for the nurse to include in the discharge teaching?

Effect of atherosclerosis on blood vessels

Mechanism of action of anticoagulant drug therapy

Symptoms indicating that the patient should contact the health care provider Impact of the patients family history on likelihood of developing a serious stroke

ANS: C One of the tasks for patients with chronic illnesses is to prevent and manage a crisis. The patient needs instruction on recognition of symptoms of hypertension and TIA and appropriate actions to take if these symptoms occur. The other information also may be included in patient teaching but is not as essential in the patients self-management of the illness.

DIF: Cognitive Level: Apply (application) REF: 63 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 2. The nurse performs a comprehensive geriatric assessment of a patient who is being assessed for admission to an assisted living facility. Which question is the most important for the nurse to ask?

Have you had any recent infections?

b. c.

How frequently do you see a doctor? Do you have a history of heart disease?

Are you able to prepare your own meals?

ANS: D The patients functional abilities, rather than the presence of an acute or chronic illness, are more useful in determining how well the patient might adapt to an assisted living situation. The other questions will also provide helpful information but are not as useful in providing a basis for determining patient needs or for developing interventions for the older patient. DIF: Cognitive Level: Apply (application) REF: 71 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 3. An older patient who takes multiple medications for chronic cardiac and pulmonary diseases is alert and lives with a daughter who works during the day. During a clinic visit, the patient verbalizes to the nurse that she has a strained relationship with her daughter and does not enjoy being alone all day. Which nursing diagnosis should the nurse assign as the priority for this patient?

Risk for injury related to drug interactions

Social isolation related to weakness and fatigue

Compromised family coping related to the patients many care needs

Caregiver role strain related to need to adjust family employment schedule

ANS: A The patients age and multiple medications indicate a risk for injury caused by interactions between the multiple drugs being taken and a decreased drug metabolism rate. Problems with social isolation, caregiver role strain, or compromised family coping are not physiologic priorities. Drug-drug interactions could cause the most harm to the patient and is therefore the priority.

DIF: Cognitive Level: Apply (application) REF: 73-74 TOP: Nursing Process: Diagnosis MSC: NCLEX: Health Promotion and Maintenance 4. The nurse plans to complete a thorough assessment of an older patient. Which method should the nurse use to gather the most complete information?

Use a geriatric assessment instrument to evaluate the patient.

Ask the patient to write down medical problems and medications.

Interview both the patient and the primary caregiver for the patient. Review the patients medical record for a history of medical problems.

ANS: A The most complete information about the patient will be obtained through the use of an assessment instrument specific to the geriatric population, which includes information about both medical diagnoses and treatments and about functional health patterns and abilities. A review of the medical record, interviews with the patient and caregiver, and written information by the patient are all included in a comprehensive geriatric assessment. DIF: Cognitive Level: Apply (application) REF: 71 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 5. An older patient is hospitalized with pneumonia. Which intervention should the nurse implement to provide optimal care for this patient?

Use a standardized geriatric nursing care plan.

Minimize activity level during hospitalization.

Plan for transfer to a long-term care facility upon discharge. Consider the preadmission functional abilities when setting patient goals.

ANS: D The plan of care for older adults should be individualized and based on the patients current functional abilities. A standardized geriatric nursing care plan will not address individual patient needs and strengths. A patients need for discharge to a long-term care facility is variable. Activity level should be designed to allow the patient to retain functional abilities while hospitalized and also to allow any additional rest needed for recovery from the acute process. DIF: Cognitive Level: Apply (application) REF: 71

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 6. The nurse cares for an older adult patient who lives in a rural area. Which intervention should the nurse plan to implement to best meet this patients needs?

Suggest that the patient move to an urban area.

Assess the patient for chronic diseases that are unique to rural areas. Ensure transportation to appointments with the health care provider.

c. d.

Obtain adequate medications for the patient to last for 4 to 6 months.

ANS: C Transportation can be a barrier to accessing health services in rural areas. The patient living in a rural area may lose the benefits of a familiar situation and social support by moving to an urban area. There are no chronic diseases unique to rural areas. Because medications may change, the nurse should help the patient plan for obtaining medications through alternate means such as the mail or delivery services, not by purchasing large quantities of the medications. DIF: Cognitive Level: Apply (application) REF: 66-67 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 7. Which nursing action will be most helpful in decreasing the risk for drug-drug interactions in an older adult?

Teach the patient to have all prescriptions filled at the same pharmacy.

Instruct the patient to avoid taking over-the-counter (OTC) medications.

Make a schedule for the patient as a reminder of when to take each medication. Have the patient bring all medications, supplements, and herbs to each appointment.

ANS: D The most information about drug use and possible interactions is obtained when the patient brings all prescribed medications, OTC medications, and supplements to every health care appointment. The patient should discuss the use of any OTC medications with the health care provider and obtain all prescribed medications from the same pharmacy, but use of supplements

and herbal medications also need to be considered in order to prevent drug-drug interactions. Use of a medication schedule will help the patient take medications as scheduled but will not prevent drug-drug interactions. DIF: Cognitive Level: Understand (comprehension) REF: 74 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 8. A patient who has just moved to a long-term care facility has a nursing diagnosis of relocation stress syndrome. Which action should the nurse include in the plan of care?

Remind the patient that making changes is usually stressful.

Discuss the reason for the move to the facility with the patient.

Restrict family visits until the patient is accustomed to the facility.

Have staff members write notes welcoming the patient to the facility.

ANS: D Having staff members write notes will make the patient feel more welcome and comfortable at the long-term care facility. Discussing the reason for the move and reminding the patient that change is usually stressful will not decrease the patients stress about the move. Family member visits will decrease the patients sense of stress about the relocation. DIF: Cognitive Level: Apply (application) REF: 70 TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity 9. An older patient complains of having no energy and feeling increasingly weak. The patient has had a 12-pound weight loss over the last year. Which action should the nurse take initially?

Ask the patient about daily dietary intake.

Schedule regular range-of-motion exercise.

Discuss long-term care placement with the patient.

Describe normal changes associated with aging to the patient.

ANS: A In a frail older patient, nutrition is frequently compromised, and the nurses initial action should be to assess the patients nutritional status. Active range of motion may be helpful in improving the patients strength and endurance, but nutritional assessment is the priority because the patient has had a significant weight loss. The patient may be a candidate for long-term care placement, but more assessment is needed before this can be determined. The patients assessment data are not consistent with normal changes associated with aging.

DIF: Cognitive Level: Apply (application) REF: 67 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 10. The nurse admits an acutely ill, older patient to the hospital. Which action should the nurse take first?

Speak slowly and loudly while facing the patient.

Obtain a detailed medical history from the patient.

Perform the physical assessment before interviewing the patient.

Ask a family member to go home and retrieve the patients cane.

ANS: C When a patient is acutely ill, the physical assessment should be accomplished first to detect any physiologic changes that require immediate action. Not all older patients have hearing deficits, and it is insensitive of the nurse to speak loudly and slowly to all older patients. To avoid tiring the patient, much of the medical history can be obtained from medical records. After the initial physical assessment to determine the patients current condition, then the nurse could ask someone to obtain any assistive devices for the patient if applicable. DIF: Cognitive Level: Apply (application) REF: 71 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 11. The nurse cares for an alert, homeless older adult patient who was admitted to the hospital with a chronic foot infection. Which intervention is the most appropriate for the nurse to include in the discharge plan for this patient?

Refer the patient to social services for further assessment.

Teach the patient how to assess and care for the foot infection.

Schedule the patient to return to outpatient services for foot care. Give the patient written information about shelters and meal sites.

ANS: A An interdisciplinary approach, including social services, is needed when caring for homeless older adults. Even with appropriate teaching, a homeless individual may not be able to maintain

adequate foot care because of a lack of supplies or a suitable place to accomplish care. Older homeless individuals are less likely to use shelters or meal sites. A homeless person may fail to keep appointments for outpatient services because of factors such as fear of institutionalization or lack of transportation. DIF: Cognitive Level: Apply (application) REF: 67 TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 12. The home health nurse cares for an older adult patient who lives alone and takes several different prescribed medications for chronic health problems. Which intervention, if implemented by the nurse, would best encourage medication compliance?

a. b. c. d.

Use a marked pillbox to set up the patients medications. Discuss the option of moving to an assisted living facility. Remind the patient about the importance of taking medications. Visit the patient daily to administer the prescribed medications.

ANS: A Because forgetting to take medications is a common cause of medication errors in older adults, the use of medication reminder devices is helpful when older adults have multiple medications to take. There is no indication that the patient needs to move to assisted living or that the patient does not understand the importance of medication compliance. Home health care is not designed for the patient who needs ongoing assistance with activities of daily living (ADLs) or instrumental ADLs (IADLs). DIF: Cognitive Level: Apply (application) REF: 65 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 13. The home health nurse visits an older patient with mild forgetfulness. The nurse is most concerned if which information is obtained?

The patient tells the nurse that a close friend recently died.

The patient has lost 10 pounds (4.5 kg) during the last month.

The patient is cared for by a daughter during the day and stays with a son at night.

The patients son uses a marked pillbox to set up the patients medications weekly.

ANS: B

A 10-pound weight loss may be an indication of elder neglect or depression and requires further assessment by the nurse. The use of a marked pillbox and planning by the family for 24-hour care are appropriate for this patient. It is not unusual that an 86-year-old would have friends who have died. DIF: Cognitive Level: Apply (application) REF: 67 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 14. Which statement, if made by an older adult patient, would be of most concern to the nurse?

I prefer to manage my life without much help from other people.

I take three different medications for my heart and joint problems.

I dont go on daily walks anymore since I had pneumonia 3 months ago.

I set up my medications in a marked pillbox so I dont forget to take them.

ANS: C Inactivity and immobility lead rapidly to loss of function in older adults. The nurse should develop a plan to prevent further deconditioning and restore function for the patient. Selfmanagement is appropriate for independently living older adults. On average, an older adult takes seven different medications so the use of three medications is not unusual for this patient. The use of memory devices to assist with safe medication administration is recommended for older adults. DIF: Cognitive Level: Apply (application) REF: 73 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 15. The nurse assesses an older patient who takes diuretics and has a possible urinary tract infection (UTI). Which action should the nurse take first?

Palpate over the suprapubic area.

Inspect for abdominal distention.

Question the patient about hematuria. Invite the patient to use the bathroom.

ANS: D Before beginning the assessment of an older patient with a UTI and on diuretics, the nurse should have the patient empty the bladder because bladder fullness or discomfort will distract

from the patients ability to provide accurate information. The patient may seem disoriented if distracted by pain or urgency. The physical assessment data are obtained after the patient is as comfortable as possible. DIF: Cognitive Level: Apply (application) REF: 71 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 16. Which patient is most likely to need long-term nursing care management?

72-year-old who had a hip replacement after a fall at home

64-year-old who developed sepsis after a ruptured peptic ulcer

76-year-old who had a cholecystectomy and bile duct drainage

63-year-old with bilateral knee osteoarthritis who weighs 350 lb (159 kg)

ANS: D Osteoarthritis and obesity are chronic problems that will require planning for long-term interventions such as physical therapy and nutrition counseling. The other patients have acute problems that are not likely to require long-term management. DIF: Cognitive Level: Apply (application) REF: 70 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 17. When completing an admission assessment on an older adult, the nurse gives the patient a high fall risk score. Which action should the nurse take first?

Use a bed alarm system on the patients bed.

Administer the prescribed PRN sedative medication.

Ask the health care provider to order a vest restraint. Place the patient in a geri-chair near the nurses station.

ANS: A The use of the least restrictive restraint alternative is required. Physical or chemical restraints may be necessary, but the nurses first action should be an alternative such as a bed alarm. DIF: Cognitive Level: Apply (application) REF: 75 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

18. An older adult patient presents with a broken arm and visible scattered bruises healing at different stages. Which action should the nurse take first?

a. b. c. d.

Notify an elder protective services agency about the possible abuse. Make a referral for a home assessment visit by the home health nurse. Have the family member stay in the waiting area while the patient is assessed. Ask the patient how the injury occurred and observe the family members reaction.

ANS: C The initial action should be assessment and interviewing of the patient. The patient should be interviewed alone because the patient will be unlikely to give accurate information if the abuser is present. If abuse is occurring, the patient should not be discharged home for a later assessment by a home health nurse. The nurse needs to collect and document data before notifying the elder protective services agency. DIF: Cognitive Level: Apply (application) REF: 68-69 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment 19. The family of an older patient with chronic health problems and increasing weakness is considering placement in a long-term care (LTC) facility. Which action by the nurse will be most helpful in assisting the patient to make this transition?

Have the family select a LTC facility that is relatively new.

Obtain the patients input about the choice of a LTC facility.

Ask that the patient be placed in a private room at the facility. Explain the reasons for the need to live in LTC to the patient.

ANS: B The stress of relocation is likely to be less when the patient has input into the choice of the facility. The age of the long-term care facility does not indicate a better fit for the patient or better quality of care. Although some patients may prefer a private room, others may adjust better when given a well-suited roommate. The patient should understand the reasons for the move but will make the best adjustment when involved with the choice to move and the choice of the facility.

DIF: Cognitive Level: Apply (application) REF: 70 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 20. The nurse manages the care of older adults in an adult health day care center. Which action can the nurse delegate to unlicensed assistive personnel (UAP)?

a. b. c. d.

Obtain information about food and medication allergies from patients. Take blood pressures daily and document in individual patient records. Choose social activities based on the individual patient needs and desires. Teach family members how to cope with patients who are cognitively impaired.

ANS: B Measurement and documentation of vital signs are included in UAP education and scope of practice. Obtaining patient health history, planning activities based on the patient assessment, and patient education are all actions that require critical thinking and will be done by the registered nurse. DIF: Cognitive Level: Apply (application) REF: 72 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment MULTIPLE RESPONSE 1. Which nursing actions will the nurse take to assess for possible malnutrition in an older adult patient (select all that apply)?

Observe for depression.

Review laboratory results.

Assess teeth and oral mucosa.

Ask about transportation needs.

Determine food likes and dislikes.

ANS: A, B, C, D The laboratory results, especially albumin and cholesterol levels, may indicate chronic poor protein intake or high-fat/cholesterol intake. Transportation impacts patients ability to shop for groceries. Depression may lead to decreased appetite. Oral sores or teeth in poor condition may

decrease the ability to chew and swallow. Food likes and dislikes are not necessarily associated with malnutrition. Chapter 9. Cultural Competence MULTIPLE CHOICE 1. The nurse recognizes that ethnicity differs from race in that ethnicity:

Refers to subgroups within a race

2 3

Is a unique factor within a cultural group Includes more than biological identification

Is the set of conflicting values between races

ANS: 3 Ethnicity refers to a shared identity related to social and cultural heritage, such as values, language, geographical space, and racial characteristics. Race refers to biological attributes. Subcultures refer to subgroups within a race. A variant cultural pattern is a unique factor within a cultural group. Ethnocentrism is the root of biases and prejudices comprising beliefs and attitudes associating negative permanent characteristics with people who are perceived to be different from the valued group. DIF: A REF: 107 OBJ: Cognitive Level: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity 2. Within transcultural nursing, sensitivity to social organization is the recognition of the clients:

Language usage

Status and expected role in the family

Definition of health and health practices Psychological characteristics and coping mechanisms

ANS: 2 Cultural groups consist of units of social organization delineated by kinship, status hierarchy, and appropriate roles for their members. Sensitivity to social organization is the recognition of the clients status and role in the family. Sensitivity to communication patterns would be the recognition of the clients language usage. Culture is the framework used in defining social phenomena such as when a person is considered to be healthy or in need of intervention. The way an individual defines health and health practices needs to be understood by the nurse to best meet the needs of the client. Sensitivity to social organization is not met by recognizing the definition of health for an individual. Psychological characteristics and coping mechanisms may be expressed in a variety of ways across cultures. Sensitivity to social organization is not

demonstrated by the recognition of psychological characteristics and coping mechanisms of a particular culture. DIF: A REF: 116 OBJ: Cognitive Level: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity 3. Traditional Western medicine, in contrast to alternative therapy, uses:

Acupuncture

2 3

Herbal therapy Spiritual advising

Medication administration

ANS: 4 Traditional Western medicine uses medication administration as a method of treatment. Acupuncture is an alternative therapy often used in non-Western cultures such as the Chinese and Southeast Asians. Herbal therapy is an alternative therapy often used in non-Western cultures, but not in traditional Western medicine. Spiritual advising is not used in traditional Western medicine, but it may be seen in the African-American cultural group. DIF: A REF: 110 OBJ: Cognitive Level: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 4. The nurse is completing an assessment of an Asian-American client. Recognizing that there are commonly seen problems in individuals from this background, the nurse observes for particular signs and symptoms of:

Hypertension

Tuberculosis

Diabetes mellitus Lactose intolerance

ANS: 4 Lactose intolerance is frequently observed among Asians, Africans, and Hispanics. Hypertension is commonly seen in African Americans. Aboriginal Canadians descended from native North American Indians and living on reservations have a higher incidence of tuberculosis. Diabetes mellitus is commonly seen among Ute, Pima, and Papago Indians.

DIF: A REF: 116 OBJ: Cognitive Level: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 5. The nurse recognizes the following as an appropriate strategy for communicating with clients who are not fluent in English?

Speaking in a louder tone of voice

Incorporating hand gestures and pictures

Responding to the client by his or her first name

Interacting with an interpreter for all communication

ANS: 2 An appropriate strategy for communicating with clients who are not fluent in English is to incorporate hand gestures and pictures. Speaking in a louder tone of voice will not help the client understand the English language. Responding to the client by his or her first name may demonstrate a lack of respect. The nurse should introduce him or herself and then request the client to introduce himself or herself. An interpreter is not necessary for all communication. However, an interpreter must be used for communicating to the client information about his or her medical condition. It is not acceptable for family members to translate health care information, but they can assist with ongoing interaction during the clients care. DIF: A REF: 113 OBJ: Cognitive Level: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity 6. One aspect of a culture is invisible, or less observable, to others. A nurse wanting to develop an awareness of the practices of different cultures within that community would have which of the following as an example of this component?

Wearing an amulet or charm

Using prayer beads or candles

Using cotton garments for clothing Believing in supernatural influences

ANS: 4 An example of an invisible (less observable) component of a culture is having a belief in supernatural influences. An example of a visible (easily seen) component of culture is the wearing of an amulet or charm. An example of a visible (easily seen) component of culture is

using prayer beads or candles. Using cotton undergarments for clothing is a visible (easily seen) component of culture. DIF: A REF: 107 OBJ: Cognitive Level: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity 7. From culture to culture time often takes on different meanings. In exploring the relationship of time to nursing interventions, the nurse should:

Avoid using set times to do procedures, if possible

Maintain the set times for treatments and inform the client of the schedule

Maintain a flexible attitude when the client requests procedures to be done at specific times

Encourage clients to set the times when they would like the nurse to perform nursing care activities.

ANS: 3 Because time has different meanings from one culture to another, the nurse should maintain a flexible attitude and not become emotionally upset when the client requests procedures to be done at different times. When making appointments and referrals, anticipated barriers to time adherence should be explored and managed with the client. For organizational purposes, nurses should seek clients input and together the nurse and client may set a time to do procedures. Maintaining set times for treatments and informing the client of the schedule do not take into consideration the clients time orientation. Although the clients input should be sought, it is not realistic to have clients set their own times for nursing care activities regardless of the schedule. Some procedures may be required more frequently than the client would set, or the nurse may be unable to meet the needs of several clients on the unit at the same time. DIF: A REF: 118 OBJ: Cognitive Level: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity 8. The nurse recognizes that changes in demographics have an influence on health care delivery. One of the expectations in the United States by the year 2020 is:

Growth of the European-American population

Increases in the Hispanic and Latino populations

Reduction of the African-American population by 50%

Equal growth in the Hispanic-, Asian-, and African-American populations

ANS: 2 By 2020 the population of Hispanic and Latino populations is predicted to triple. Population projections beyond 2000 show Hispanics/Latinos, Asian-Americans, and African-Americans outpacing the growth of white, European-descended groups. The African-American group is projected to double by 2020. By 2020 the population of African Americans is predicted to double and that of Asian Americans and Hispanics/Latinos to triple. DIF: A REF: 107 OBJ: Cognitive Level: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 9. While going through the process of acculturation a client will be:

Identifying with 2 or more cultures

Adapting to and adopting a new culture

Showing favor to the dominant culture Socializing within their primary cultural group

ANS: 2 Acculturation is the process of adapting to and adopting a new culture. Biculturalism occurs when an individual identifies equally with two or more cultures. Assimilation occurs when an individual gives up his or her ethnic identity in favor of the dominant culture. Socialization into ones primary culture as a child is known as enculturation. DIF: A REF: 708 OBJ: Cognitive Level: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity 10. An example of a nurse imposing his/her own cultural beliefs on a client is evident in which of the following examples?

1 2 3

Adaptation of the clients room to accommodate family members Seeking information on gender-congruent care for an Egyptian client Administering less potent pain medication to an outpatient surgery client

Encouraging family members to assist with the clients feeding and hygiene care

ANS: 3 Holding back more potent pain medication for a client who had a minor procedure is an example of a cultural imposition of the nurse on a client. Adaptation of the clients room to accommodate extra family members is not an example of cultural imposition on a client, but rather is meeting the clients need by providing culturally congruent care. Seeking information on gendercongruent care for an Egyptian client is an example of the desire to provide culturally congruent care. Encouraging family to assist with the clients care is not an example of cultural imposition on a client. Western culture tends to follow a pattern of caring that focuses on self-care and selfdetermination, whereas non-Western cultures typically have care provided by others. DIF: A REF: 109 OBJ: Cognitive Level: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity 11. Following a surgical procedure, an older Chinese woman refuses to perform the range of motion and breathing exercises requested, in addition is hesitant to complete her hygienic care and grooming. The nurse recognizes that this is most likely related to:

Dependence on health care providers for care

Reliance upon family members to assist with care

Lack of personal motivation to participate in self-care

Reluctance to cooperate with traditional Western medical treatment

ANS: 2 Non-Western cultures traditionally rely heavily on family members to provide care. Although it may be related to dependence on health care providers for care, it is not as likely because nonWestern cultures depend on family members to assist with care. While it may be related to lack of personal motivation to participate in self-care, the clients behavior is more likely a result of her cultural background rather than a lack of motivation. While the clients behavior may be a result of reluctance to cooperate with Western medical treatments, it is more likely indicative of her cultural dependence on family members. DIF: C REF: 110 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness

12. When faced with a scenario where it is believed that a client from another cultural background is using herbal remedies along with the prescribed medication to treat her arthritis. The nurses first action should be to:

Educate the client concerning the danger of taking herbs and the prescribed medication

Inquire of the client as to the reason for using herbal remedies along with the prescribed medication Ask the client to identify what herbal remedies are being used along with the prescribed medications

3 4

Alert the physician to the clients use of herbal remedies in addition to the prescribed medications

ANS: 3 Rather than first dismissing the practice as dangerous and incompatible with Western medicine, practitioners need to investigate further whether the practice needs changing. Although educating the client may be appropriate, this cannot be determined until the herb has been identified and it is determined to be harmful in this situation. Asking the client why additional remedies are being used may make the client feel defensive. The nurse needs to first determine what herbs are being used. While alerting the physician is appropriate, it is not the first action to be taken by the nurse. The nurse should initially determine what herbs are being used. DIF: C REF: 110 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 13. Being cared for by a nurse of the opposite gender would be an especially important issue for women from which of the following cultures?

Afghan

Filipino

Native American

African American

ANS: 1 Modesty is a strong value among Afghan and Arab women. Modesty is not an especially important issue for Filipino women. Modesty is not an especially important issue for Native American women. Modesty is not an especially important issue for African American women.

DIF: A REF: 109 OBJ: Cognitive Level: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 14. An example of a culture where a male relative will regularly decline to observe the birth process is:

Pakistani

2 3

Hispanic Korean

Japanese

ANS: 1 Religious beliefs may prohibit the presence of males, including husbands, in the delivery room. This may be observed among devout Muslims, Hindus, and Orthodox Jews. Hispanic men typically do not have religious or cultural beliefs that would prohibit them from the delivery room. Korean men typically do not have religious or cultural beliefs that would prohibit them from the delivery room. Asian men typically do not have religious or cultural beliefs that would prohibit them from the delivery room. DIF: A REF: 111 OBJ: Cognitive Level: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 15. The nurse observes a religious charm hanging from the wrist of a client being prepared for surgery. The nurses best initial approach is to:

Remove the religious charm

Securely tape the charm in place

Ask the client to leave the charm with family members

Clarify whether the charm may remain in place during the procedure

ANS: 4 The nurse should first determine if it is permissible for the item to remain in place during the procedure. Removing the bracelet may create unnecessary stress for the client. Initially the nurse should determine if removal is necessary. Taping the bracelet in place may be appropriate after the nurse determines that the item may remain in place during the procedure. Asking the client to

remove the item may create unnecessary stress for the client. Initially the nurse should determine if removal is necessary. DIF: B REF: 109 OBJ: Cognitive Level: Application TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 16. The nurse recognizes that the family of a deceased Buddhist client will:

1 2 3 4

Bury before sundown Decline viewing the body Not move the body until it is cold Select cremation rather than burial

ANS: 3 Some Buddhists may refuse to move the dead body after death because of their belief that the spirit of the dead takes some time to leave the body. They define death as the absence of consciousness and loss of body warmth. Among Orthodox Jews, the body is generally buried before sundown. Some Asian Indians regard seeing the deceased as adding to the suffering of the family. Hindus and Buddhists believe that the soul lives on and the dead body without the soul is but an empty shell, and therefore may not want to see the body. Muslims prefer burial rather than cremation. DIF: A REF: 112-113 OBJ: Cognitive Level: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity 17. A nurse that has the knowledge of the biocultural history of clients and aware that individuals with a greater potential for and incidence of hypertension are:

Asians

Hispanics

Native Americans

African Americans

ANS: 4 Malignant hypertension is found more frequently in African Americans. Lactose intolerance is frequently observed among Asians. Hispanics have a higher incidence of lactose intolerance. Native Americans have a higher incidence of tuberculosis and diabetes mellitus.

DIF: A REF: 117 OBJ: Cognitive Level: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 18. There are cultural context of health and illness differences in comparing Western versus nonWestern cultures. The nurse is aware that in Western culture the overall treatment is:

Herbal

Holistic

Naturalistic

Specialty-specific

ANS: 4 The overall treatment in Western culture is specialty-specific. The treatment in some nonWestern cultures is herbal. The treatment in non-Western cultures is holistic in nature. Some nonWestern cultures use a naturalistic approach for the method of diagnosis. DIF: A REF: 109 OBJ: Cognitive Level: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 19. Regarding a client who is an Orthodox Jew and maintains a Kosher diet, the nurse will make sure that the clients menu does not include:

Beef

Eggs

Milk Shellfish

ANS: 4 Jewish clients who follow a Kosher diet will avoid meat from carnivores, pork products, and fish without scales or fins. Therefore shellfish should not be included in the menu of a client who is an Orthodox Jew and maintains a Kosher diet. Beef may be included in a Kosher diet. Eggs may be included in a Kosher diet. Milk may be included in a Kosher diet. DIF: A REF: 117 OBJ: Cognitive Level: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness

20. For a client who is a Buddhist and maintains a traditional diet, the nurse will make sure that a sufficient quantity of which of the following is included in the menu?

1 2 3 4

Beef Milk Fish Vegetables

ANS: 4 Many Buddhists are vegetarians. The nurse should ensure that a sufficient quantity of vegetables is included in the menu when caring for a Buddhist who maintains a traditional diet. Beef is not a traditional component of a Buddhists diet. A sufficient quantity of milk is not necessary for the traditional Buddhists diet. A sufficient quantity of fish is not necessary for the traditional Buddhists diet. DIF: A REF: 117 OBJ: Cognitive Level: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 21. Which of the following factors has the greatest impact on health care available to nonHispanic white minority groups in the United Sates?

Significant language barriers

Inappropriately high poverty rates

Genetically based disease processes Mistrust of Western medical practices

ANS: 2 Racial and ethnic minorities are more likely than non-Hispanic whites to be poor or near poor. In addition, Hispanics, African Americans, and some Asian subgroups are less likely than nonHispanic whites to have a high school education. In general, racial and ethnic minorities often experience poorer access to care and lower quality of preventive, primary, and specialty care. While language barriers may have an influence on the amount and type of health care services available to and sought out by minority groups, it is poverty that has the greatest negative influence. While genetically based disease processes may have an influence on the amount and type of health care services available to and sought out by minority groups, it is poverty that has the greatest negative influence. Although mistrust of Western medical practices may have an influence on the amount and type of health care services available to and sought out by minority groups, it is poverty that has the greatest negative influence.

DIF: C REF: 107 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 22. The nurse who is attempting to practice in a culturally sensitive manner must first realize that recognition of the visible signs of a clients culture:

Is essential to the establishment of a nurse-client relationship

Provides the basis for a sense of trust between client and nurse

Does not ensure understanding of the underlying cultural beliefs

Has little impact on the nurses ability to provide therapeutic care

ANS: 3 Culture has both visible (easily seen) and invisible (less observable) components. Nurses cannot appreciate the meanings and beliefs associated with these artifacts without further assessment. Recognition of visible signs of a clients culture will assist in the formation of a therapeutic nurseclient relationship because it conveys the nurses interest in the client as a person; it is not essential to the relationship process. Recognition of visible signs of a clients culture will assist in the formation of trust (a component of a therapeutic nurse-client relationship) because it conveys the nurses interest in the client as a person; it is not essential to the trust-establishing process. Recognition of visible signs of a clients culture will assist in the formation of a therapeutic nurseclient relationship, which is vital to the nurses ability to provide therapeutic care because it conveys the nurses interest in the client as a person. DIF: C REF: 107 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 23. Which of the following nursing interventions shows the greatest degree of culturally competent nursing care for a Muslim female client?

Notifying the chaplain of the clients religious preference

Notifying staff that the clients bath will be done by her sister

Drawing the curtains around the clients bed during prayer time

Facilitating a dietary consult to meet the clients nutritional concerns

ANS: 2 Cultural competence is the process of acquiring specific knowledge, skills, and attitudes that ensure delivery of culturally congruent care. By arranging for the family to assume responsibility for the clients hygiene, the nurse has shown a specific knowledge of the clients needs and acted upon that need. The other options are not as specific or as directly related to nursing care as notifying the staff that the clients bath will be done by her sister. DIF: C REF: 109 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 24. A nursing care assistant fails to report in a timely manner a request for pain medication from an African-American male client who is recovering from a stab wound. The nurses initial action is to evaluate the care assistants:

1 2

Feelings regarding this particular client Need for administrative disciplinary action

Understanding of the need for prompt reporting

Employment files for documentation of similar behavior

ANS: 1 Personal bias and prejudices when acted upon may interfere with the delivery of appropriate, effective nursing care. While all the options are appropriate, the nurses initial action is to determine the cause of the care assistants negligent behavior. Although all the options are appropriate, the nurses initial action is to determine the cause of the care assistants negligent behavior. DIF: C REF: 109 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 25. An Arab woman arrives in the emergency department reporting vaginal bleeding. It is determined that the client is 5 months pregnant with her second child and has had no prenatal care. The nurse realizes that the most likely reason for this lack of health care is that the client:

Cannot afford to seek health care

2 3

Views pregnancy as a normal life event Typically relies on same-culture healers

Lacks an understanding of available services

ANS: 2 Culture is the context in which groups of people interpret and define their experiences relevant to life transitions. This includes events such as birth, illness, and dying. It is the system of meanings by which people make sense of their experiences. Culture is how others define social phenomena such as when a person is healthy or requires intervention. Traditionally, in Arab culture, pregnancy is not a medical condition but rather a normal life transition; hence, a pregnant woman does not always go to a doctor unless she has a problem. While the other options may have been a factor, the most likely cause is that the Arab culture views pregnancy as a normal life event and care is sought only when a perceived problem exists. DIF: C REF: 109 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 26. An Asian-American client will accept hygiene care from only family members. The cultural origin of this behavior is most likely:

Valued privacy

Female modesty

Interdependency

Mistrust of strangers

ANS: 3 In collectivistic cultures that value group reliance and interdependence, such as traditional Asians, Hispanics, and Africans, caring behaviors require actively providing physical and psychosocial support for family or community members. While the other options may be individualized factors, culturally the most likely origin is that of group reliance and interdependency of the Asian culture. DIF: C REF: 110 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness

27. An older Chinese client experienced a stroke that left him with right-sided weakness and now refuses to participate in physical therapy until his son is present. The nurse should initially interpret this behavior as:

A sign of post-stroke depression

2 3

An illustration of cultural collectivism A response to the therapy-induced pain

An example of a healthy father-son relationship

ANS: 2 In collectivistic cultures that value group reliance and interdependence, such as traditional Asians, Hispanics, and Africans, caring behaviors require actively providing physical and psychosocial support for family or community members. The other options may be true; however, the more likely interpretation is the clients cultural inclination toward group reliance and family support systems. DIF: C REF: 110 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 28. While assessing an older Vietnamese client, the nurse notes several oval-shaped reddened areas on her back and arms. The clients daughter explains them to be the result of a traditional healing practice called cupping. The nurses immediate reaction should be to:

Report the finding to the authorities to rule out physical abuse

Ask the daughter to explain the practice in detail

Notify the clients health care provider to see if treatment is necessary Document the assessment findings in the nursing notes

ANS: 2 Many Southeast-Asian cultures practice folk remedies such as coining, cupping, pinching, and burning to relieve aches and pains and remove bad wind or noxious elements that cause illness. These remedies leave peculiar visible markings on the skin in the form of ecchymosis, superficial burns, strap marks, or local tenderness. Cultural ignorance causes a practitioner to call authorities for suspicion of abuse. Nurses need to investigate to determine the details of the practice in order to decide whether the practice needs to be changed. Consultation and collaboration with herbalists and other naturalistic practitioners will prevent unnecessary distress for the client. While reporting the finding to authorities should not be dismissed, the nurse should

first discuss the practice with the daughter to learn more of the details regarding the practice. The clients health care provider should be notified, however, the nurses assessment of the areas as reddened areas suggests that other options may have priority. Documentation of the assessment findings is certainly appropriate and is a nursing responsibility, but acquiring an explanation from the daughter who is present would have priority. DIF: C REF: 110 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 29. The nurse, caring for a comatose Muslim client who is dying, realizes that from a cultural standpoint, the most therapeutic intervention is to:

1 2

Facilitate the clients peaceful, pain-controlled death Become familiar with Muslim death and dying traditions

Approach the family to identify and discuss any needs that exist

Arrange for a private room so the family can grieve traditionally

ANS: 3 Be aware of religious and cultural preferences when helping clients and families prepare for death. Facilitating the clients peaceful, pain-controlled death is an appropriate intervention; it is not necessarily culturally oriented because nursing strives to facilitate a peaceful, pain-free death for all clients. Becoming familiar with cultural tradition is therapeutic and would have priority if the family were not present to be questioned directly regarding their needs. Arranging for a private room may be a therapeutic intervention because most cultures would prefer some degree of privacy when attending to the death of a loved one, but since the family is present the priority intervention is the one that identifies their needs. DIF: C REF: 112-113 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 30. A Hispanic client is diagnosed with inoperable brain cancer. The clients wife insists that any discussion about treatment options be postponed until all local family members are present. The nurse correctly views this as:

The familys attempt to facilitate a good death for the client

An invasion of the clients right of confidentiality by the family members

Appropriate because the cancer may have affected his decision-making abilities A cultural tradition that relieves the ill family member of the burden of decision making

ANS: 4 In some cultures, the group assumes decision making for a family member in these situations and is trusted to make the right decision for the individual. Indeed, some groups such as African Americans, Asian Americans, and Hispanics expect their family to make decisions for them, and family members prefer to protect the individual from unnecessary suffering by knowing the reality of imminent death. These cultures value group interdependence and view individual autonomy as an unnecessary burden for a loved one who is ill (Pacquiao, 2002, 2003a). The means by which the family provides a good death is first established through the process of group decision making. It may appear that the clients confidentiality is being invaded by a member of the Western nursing profession; it is a cultural norm for members of many Hispanic families. Although cancer may affect the clients abilities to make decisions, the origin of this behavior is more likely the cultural tradition of group decision making among Hispanics. DIF: C REF: 111 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 31. The nurse realizes that the primary goal of a cultural assessment is to:

Minimize client distress resulting from unmet cultural expectations

Provide care that is in concert with the clients cultural expectations

Identify cultural beliefs and traditions that are important to the client

Blend Western nursing practice with the clients cultural expectations

ANS: 2 The goal of cultural assessment is to gather significant information from the client that will enable the nurse to implement culturally congruent care. Minimizing distress is an achieved

outcome when the goal of culturally congruent care is met. Identifying beliefs and traditions is an assessment goal that helps identify the criteria for individualized, culturally congruent care. Blending Western nursing practice with cultural expectations will result in individualized, culturally congruent care. DIF: C REF: 108 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 32. The nurse caring for members of the Hispanic community recognizes which of the following situations as the best reflection of the cultures view of family caring?

A husband calling each evening to tell his wife goodnight

Family members taking turns staying with the client at night The daughter bringing her fathers favorite soup to the hospital

3 4

The eldest son sending a huge floral arrangement to the hospital

ANS: 2 In collectivistic groups such as the Hispanic culture, the physical presence of loved ones with the client demonstrates caring. While the other options show caring, it is not the best option reflecting the Hispanic culture. DIF: C REF: 110 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 33. A nurse caring for the Arab community observes a client crying. The woman was recently informed that her radiation treatments may affect her ability to become pregnant. The nurse recognizes that the client is most likely reacting to a cultural attitude regarding:

The importance of children to an Arab family

The Arab view that infertility is grounds for divorce

Infertility is a punishment for unholy living The loss of status among other married Arab women

ANS: 2 Infertility in a woman is considered grounds for divorce and rejection among Arabs. Although infertility is grounds for divorce in Arab cultures, it is not the best option for this question.

Infertility as a punishment for unholy living may not be a generally accepted view, it is not the best option for this question. While the loss of status among other married Arab women may be true, it is not the best option for this question. DIF: C REF: 111 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 34. The primary problem with using English-speaking children of immigrant families as interpreters is that:

The adults may resent their dependence upon the child

The subjects discussed may be too disturbing to the child

Children can be easily distracted, thus making them unreliable translators

There are concerns about the childs ability to convey important information

ANS: 1 Assuming that children are ideal interpreters for their parents may in fact be an insult to the authority of the elder who has to take directions from a child. Although the other options may be true, it is not the primary reason for the concerns regarding using children as interpreters Chapter 10. Family Dynamics MULTIPLE CHOICE 1. Which of the following is a current trend in families or family living?

People marrying earlier

Reduction in the divorce rate

People having more children More people choosing to live alone

ANS: 4 The number of people living alone is expanding rapidly and represents approximately 26% of all households. People are marrying later, not earlier. The rate of divorce appears to have stabilized, with approximately 55% of marriages ending in divorce. Couples are choosing to have fewer children or none at all. DIF: A REF: 122 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics

2. Of the following trends, which one represents the greatest current health care challenge to nurses?

1 2 3 4

Homelessness Single parent families Alternative relationship patterns Sandwiched or middle generation

ANS: 1 Homelessness is identified as one of the greatest health care challenges to nurses. The trend of single parent families is not the greatest current health care challenge to nurses. The trend of alternate relationship patterns is not the greatest current health care challenge to nurses. The trend of a sandwiched or middle generation is not the greatest current health care challenge to nurses. DIF: A REF: 124 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 3. When working with families, the nurse may view the family as context or client. Which one of the following examples demonstrates the view of the family as context?

The familys ability to support the clients dietary and recreational needs

The clients ability to understand and manage his own personal dietary needs

The familys demands on the client that are based on the clients role performance The adjustment of both the client and the family to changes in diet and exercise

ANS: 2 When the nurse views the family as context, the primary focus is on the health and development of an individual member existing within the clients family. The clients ability to understand and manage his own dietary needs is an example of viewing the family as context. The familys ability to support the clients dietary and recreational needs is an example of viewing the family as client. The familys demands on the client based on his role performance is an example of viewing the family as client. The adjustment of the client and family to changes in diet and exercise is an example of viewing the family as system. DIF: A REF: 128 OBJ: Comprehension TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 4. What would a nurse expect to find in an assessment of a healthy family?

1 2

Change is viewed as detrimental to the family. There is a passive response to most stressors.

The structure is flexible enough to adapt to crises.

Minimum influence is being exerted on the environment.

ANS: 3 A healthy family has a flexible structure that allows adaptable performance of tasks and acceptance of help from outside the family system. The structure is flexible enough to allow adaptability but not so flexible that the family lacks cohesiveness and a sense of stability. The healthy family is able to integrate the need for stability with the need for growth and change. It does not view change as detrimental to family processes. The healthy family demonstrates control over the environment and does not passively respond to stressors. The healthy family exerts influence on the immediate environment of home, neighborhood, and school. DIF: A REF: 127 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 5. Initially, the nurse should begin by doing what in completing a clients family assessment?

Collecting health data from all the family members

Testing the familys ability to cope with normal stressors

Evaluating the familys interpersonal communication patterns Determining the clients definition of familiar structure and attitudes

ANS: 4 The nurse begins the family assessment by determining the clients definition of and attitude toward family and the extent to which the family may be incorporated into nursing care. The nurse also assesses family form and membership. Gathering health data from the family members is not the starting point for a family assessment. Testing a familys ability to cope is not where the nurse should begin a family assessment. Evaluating communication barriers would not be an initial action of the nurse when completing a clients family assessment. DIF: C REF: 126 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics

6. Post discharge, the client is returning to their home environment. In assisting the client with that, specifically in implementing family-centered care, the nurse:

1 2 3 4

Provides personal beliefs regarding problem-solving Assists the family members to assume dependent roles Works with the client to accept responsibility for role in discourse Offers both client and family information about necessary selfcare abilities

ANS: 4 When implementing family-centered care, the nurse adopts the role of educator and offers information about necessary self-care abilities. In family-centered care, the nurse guides the family in problem solving without providing his/her own beliefs. In family-centered care, the nurse assists clients to assume independent roles by increasing family members abilities in certain areas. In family-centered care, the nurse guides the family in problem solving, not in helping them accept blame. DIF: A REF: 129 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 7. A client is unable to independently perform colostomy care due to arthritis. The nurse should first:

Offer to assist the client to learn to manage the care

Arrange for home care services to care for the colostomy

Inquire as to family members who may be able to assist with the care

Suggest that the client attend a colostomy self-help support group

ANS: 3 The nurse should first find out if there is anyone else in the family or neighborhood who would or could assist with the colostomy care. Informing the client that management of the colostomy must be learned will not change the fact that the client has arthritis and needs assistance. The nurse should first determine whether there is someone else who could perform the task. If not, the nurse arranges for a home care service referral. A colostomy self-help support group may provide emotional support, but it will not meet the clients need for assistance with colostomy care. DIF: C REF: 131 OBJ: Analysis TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 8. The optimum goal of effective communication within the family, according to the nurse observing the family members and their interaction, is:

Problem solving and psychological support

Role development of individual members

Socialization among individual members

Better financial conditions for the family

ANS: 1 The optimum goal of effective communication within the family is to be able to problem solve and provide psychological support for its members. Role development is not the optimum goal of effective communication within the family. Socialization among individual family members is not the optimum goal of effective communication within the family. Improving financial conditions for the family is not the optimum goal of effective communication within the family. DIF: A REF: 129 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 9. Which of the following is a gerontological principle related to families?

Later-life families need not work on developmental tasks.

The caregivers are often not members of the clients family.

Role reversal is usually expected and well accepted by the older client. Support systems are likely to be different than those of younger age-groups.

ANS: 4 It is true that social support systems for older adults are likely to be different from those for clients in younger age-groups. Members of later-life families need to be working on developmental tasks. Caregivers for older adults are usually either spouses or middle-age children. Accepting shifting of generational roles is often difficult for the older client. DIF: A REF: 125 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 10. In assessing the roles and power structure of a clients nuclear family, the nurse should specifically ask the client:

Who decides where to go on vacation?

2 3

What type of health care insurance do you have? How many family members currently live in your home?

What types of social activities do you and your family enjoy?

ANS: 1 Asking, Who decides where to go on vacation? enables the nurse to determine the power structure and patterning of roles and tasks of the family. Asking about health insurance does not assess the roles and power structure of the family. Inquiring about family members living at home may be used to help determine family form, not the power structure and roles of the family. Asking about social activities may provide information on the interactive processes of the family and how time is spent, but it does not assess the roles and power structure of the family. DIF: C REF: 126 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 11. Needing assistance with daily living activities, an older adult with two grown children is being discharged home. Although both children live nearby, the daughter is expressing concern about handling her parents physical needs. The nurses initial response is to:

Work with the family on delegating responsibility

Suggest short-term nursing home placement to the client

Arrange for the client to remain hospitalized in the medical center Make decisions for the family on how to manage the care at home

ANS: 1 The nurse must consider caregiver strain and work with the family on delegating responsibility. Nursing home placement should not be the nurses initial response to caregiver strain. Arranging for the client to remain in the medical center is not always feasible and does not address the problem of caregiver strain. It should not be the nurses initial response in this situation. The nurse should not make decisions for the family, but rather work with the family to problem solve. DIF: C REF: 126 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 12. The nurse suspects that there is physical abuse present after visiting the client in the home. In recognition of the pattern of family violence, the nurse knows that:

Child abuse is declining in frequency

2 3

Spouses are the most frequent abusers Mental illness is a major cause of abuse

Abuse is primarily seen in lower income families

ANS: 2 In recognition of the pattern of family violence, the nurse knows that spouses are the most frequent abusers. Child abuse is increasing, not decreasing. Mental illness may increase the incidence of abuse within a family, but is not a major cause of abuse. Emotional, physical, and sexual abuse occurs across all social classes. DIF: A REF: 124 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 13. The primary goal of family-centered nursing is to:

Promote the wellness of the family and its members

Implement appropriate care for the family and its members

Provide support and care for the family and its individual members Identify physical and emotional problems affecting the family as a unit

ANS: 3 The goal of family-centered nursing care is to promote, support, and provide for the well-being and health of the family and individual family members. While the other options are appropriate goals, they are not the primary goal because promoting, supporting, and providing for the wellbeing and health of the family and individual family members will result in this option DIF: C REF: 122 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 14. A nurse who is sensitive to the care of families recognizes that the term family is primarily defined:

As individuals legally bound to the client

As people with biological connections to the client

In terms generally accepted by the majority of clients

By the client as individuals important to the client

ANS: 4 A nurse can think of the family as a set of relationships that the client identifies as family or as a network of individuals who influence each others lives. People related legally and biologically may be criterion used to determine family. General terms may not be correct in todays diversified world. DIF: C REF: 122 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 15. The nurse is preparing a new mother for discharge when the woman shares that she is worried about going back to work and its effects on my infant. The most therapeutic response by the nurse is:

Do you want to go back to work?

Just be sure you have an excellent baby sitter.

There is no proof that working will harm your baby.

Can your husband share in the child care responsibilities?

ANS: 3 Balancing employment and family life creates a variety of challenges in terms of child care and household work for both parents. There is no proof maternal employment is damaging for children (Shpancer and others, 2006; Hill, 2005). Although the other options may be true or attempt to offer a solution, they do not address her concerns regarding the effects on her child. DIF: C REF: 123 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 16. The greatest risk to a child of adolescent parents comes from the:

Increased family stressors resulting in domestic violence

Lack of appropriate parenting resources and role models

Statically high potential for physical and emotional abuse Parents inability to provide health care and economic support

ANS: 2 The greatest risk to a child of adolescent parents is derived from the parents strong potential to lack good parenting skills. This inability can result in both physical and emotional harm. Increased family stressors resulting in domestic violence and statically high potential for physical and emotional abuse often result from poor parenting and coping skills. The parents inability to provide health care and economic support is more likely in an adolescent-headed family resulting from limited marketable skills.

DIF: C REF: 123 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 17. Which of the following nursing statements has the greatest therapeutic value when counseling a sandwich generation client caring for a chronically ill parent?

I can help you in finding assistance with the in-home care.

What is the most stressful aspect of caring for your parent?

Im sure your children love having grandmother in the house.

What do you do for relaxation now that your mom lives with you?

ANS: 4 Assess for caregiver stress, such as tension in relationships with family and care recipient, changes in level of health, changes in mood, and anxiety and depression. Asking the caregiver about hobbies or other means of relaxation is a nonthreatening way to assess tension levels. Offering to help find assistance infers a need for help that may insult the caregiver. Assuming the caregiver is stressed or assuming the living situation is good may cause the caregiver to be reluctant to discuss existing problems. DIF: C REF: 133 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 18. The mother of a child receiving immunizations at a health clinic shares with the nurse that she and the child have not eaten today. Which of the following nursing interventions is best directed at impacting the immediate problem while being sensitive to the mothers sense of selfworth?

Notifying family services of the problem

Taking both mother and child to the cafeteria

Informing the mother that she is eligible for food stamps Providing her with contacts at the neighborhood food bank

ANS: 4 When caring for these families, the nurse needs to be sensitive to the familys desire for independence, but also help them with obtaining appropriate food, financial, and health care resources. Notifying family services may become necessary, but attempts to provide the mother with available means of assistance has priority. Taking them to the cafeteria would provide immediate food but does not address future needs or show sensitivity to the mother. Informing

the mother about local and state aid may become necessary, but it does not address the immediate need, nor does it show sensitivity to the mother. DIF: C REF: 124 OBJ: Analysis TOP: Nursing Process: Planning/Implementation MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 19. The nurse recognizes that the presence of an alcohol-abusing parent places a child at greatest risk for:

Homelessness

School truancy

Family violence

Accident-related injuries

ANS: 3 Factors such as alcohol and drug abuse increase the incidence of abuse within a family (Family Violence Prevention Fund, 2006b). While the other options are possible, they are not the greatest negative outcome. DIF: C REF: 124 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 20. The most important impact that truthful, timely communication between the nurse and the family of a critically ill client has is on the familys ability to:

Trust the nurse

Adjust to bad news

Be confident of the care the client is receiving

Make appropriate choices regarding client treatment

ANS: 1 Provide realistic assurance; giving false hope breaks the nurse-client trust. Being trustful of the information provided by the nurse will aid in the adjustment to bad news. Trust is the basis for confidence in the care being provided and for appropriate decision-making. DIF: C REF: 125 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 21. When caring for a terminally ill client, the nurse must also assess the family, because the primary benefit will be:

Effective use of time and resources in the end-of-life care of the client

Appropriate attention to the cultural beliefs and expectations of the family Added information regarding the care needs and preferences of the client

3 4

The ability to respond effectively to the family unit during the dying process

ANS: 4 The more you know about your clients family, how they interact with one another, their strengths, and their weaknesses, the better. Each family approaches and copes with end-of-life decisions differently. While the other responses may be true, they are not the primary benefit. DIF: C REF: 125 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 22. When attempting to meet the needs of the family, the nurse recognizes the central concept of the theory of family developmental stages is that:

Over time all families progress through developmental stages

Needs differ as the family progresses through the various stages

While each family is unique, they all tend to progress through similar stages The family will progress only when all the challenges of a particular stage are met

ANS: 3 Although families are far from identical to one another, they tend to go through certain stages. Nursing care can be delivered based on the assumption that all families progress through similar stages that present comparable challenges. DIF: C REF: 125 OBJ: Analysis TOP: Nursing Process: Assessment/Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 23. The nurse can primarily affect the effectiveness of a familys ability to cope with stress by encouraging:

Flexible roles

2 3

Distinct task assignment Individual independence

Variable parenting models

ANS: 1 A rigid structure specifically dictates who is able to accomplish a task, and may limit the number of persons inside as well as outside the immediate family who can assume these tasks. Sharing tasks allows for reassignment of tasks when the need arises. A rigid structure specifically dictates who is able to accomplish a task, and may limit the number of persons inside as well as outside the immediate family who can assume these tasks. Inability to reassign the tasks will impact the familys ability to adjust to stressors. Chapter 11. Developmental Theories MULTIPLE CHOICE 1. A nurse who wants to apply a theory that relates to moral development should read more from the work of:

Gould

Freud

Erikson

Kohlberg

ANS: 4 Kohlberg developed a theory on moral development. Gould developed a theory on psychosocial development. Freud developed a theory on psychosexual development. Erikson developed a theory on psychosocial development. DIF: A REF: 144 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 2. The nurse using Eriksons theory to assess a 20-year-old clients developmental status expects to find which of the following behaviors?

Coping with physical and social losses

Enjoys participating in the community

Applying self to learning skills Overcoming a sense of guilt or frustration

ANS: 2 According to Erikson, the young adult is in the intimacy versus isolation stage of development. This is the time in which the young adult can become fully participative in the community,

enjoying adult freedom and responsibility. Coping with physical and social losses is found in Eriksons integrity versus despair stage (old age) of development. Applying themselves to learning productive skills is a consistent behavior found in Eriksons industry versus inferiority stage (6 to 11 years) of development. According to Erikson, overcoming a sense of guilt or frustration is in the initiative versus guilt stage (3 to 6 years) of development. DIF: A REF: 140 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 3. The nurse recognizes that Freuds theory approaches development by looking at:

1 2

Moral reasoning. Logical maturity

Psychosexual aspects

Cognitive development

ANS: 3 Freuds theory of personality development approaches development by looking at psychosexual aspects. Kohlbergs theory approaches development by looking at moral reasoning. Goulds theory approaches development by looking at logical maturity. Piagets theory approaches development by looking at cognitive development. DIF: A REF: 138 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 4. According to Piaget, a preschool child (3 to 5 years old) who comes to the clinic is expected by the nurse to exhibit which of the following behaviors?

Far-reaching problem-solving

Exploration of the environment

Cooperation and sharing with others Thinking with the use of symbols and images

ANS: 4 According to Piaget, the preoperational child (age 2 to 7 years) is learning to think with the use of symbols and mental images. Organization of thoughts and far-reaching problem-solving are noted in Piagets formal operations (11 years to adulthood) stage of cognitive development. According to Piaget, the child explores the environment in the sensorimotor stage (birth to 2 years) of cognitive development. Cooperation and sharing are seen in Piagets concrete operations (age 7 to 11 years) stage of cognitive development. DIF: A REF: 142 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education

5. For an older adult client, an example of a common behavioral task or critical event is:

1 2

Selecting a mate Rearing children

Finding a congenial social group

Adjusting to decreasing physical strength

ANS: 4 A common behavioral task of the older adult client is adjusting to decreasing physical strength. Selecting a mate is a developmental task commonly seen in the early adult. Rearing children is a developmental task of the middle-early adult. Finding a congenial social group is a developmental task of the middle-early adult. DIF: A REF: 137 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 6. The nurse working in an adult medical clinic wishes to learn more about a developmental theory that focuses on the adult years. The nurse investigates different possibilities and selects the theory proposed by:

Gould

Piaget

Freud Chess and Thomas

ANS: 1 Goulds theory of psychosocial development specifically focuses on the adult years. Piagets theory focused on cognitive development throughout the life span. Freuds psychosexual theory focused on personality development throughout the life span. The theory of Chess and Thomas focused on development from childhood to early adulthood. DIF: A REF: 142 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 7. The nurse recognizes that which one of the following statements about growth and development is correct?

Development ends with adolescence.

Growth refers to qualitative events.

Developmental tasks are age-related achievements. Cognitive theories focus on emotional development.

4 ANS: 3

Developmental tasks are age-related achievements is a correct statement about growth and development. Human growth and development are orderly, predictable processes beginning with conception and continuing until death. Growth refers to quantitative events. Development refers to qualitative events. Cognitive theories focus on reasoning and thinking processes. DIF: A REF: 137 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 8. In Kohlbergs Moral Development theory, an individual who reaches level II (conventional thought) is expected to exhibit:

Absolute obedience to authority

2 3

Reasoning based on personal gain Personal internalization of others expectations

Self-chosen ethical principles, universality, and impartiality

ANS: 3 At level IIconventional thought, the person sees moral reasoning based on his or her own personal internalization of societal and others expectations. In stage 1, the childs response to a moral dilemma is in terms of absolute obedience to authority and rules. At level Ipreconventional thoughtthe person reflects on moral reasoning based on personal gain. According to Kohlberg, stage 6 is when a person has self-chosen ethical principles, universality, and impartiality. DIF: A REF: 144 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 9. According to Piaget, the infant is in the first period of development, which is characterized by:

Concrete operations

Preoperational thought

Sensorimotor intelligence Identity versus role confusion

ANS: 3 According to Piaget, the infant is in the first period of development, which is characterized by sensorimotor intelligence. According to Piaget, children ages 7 to 11 are in the concrete operations period of development, which is characterized by having the ability to perform mental operations, while children ages 2 to 7 are in the preoperational period of development, which is characterized by the child learning to think with the use of symbols and mental images. Identity versus role confusion is a developmental stage (puberty) according to Erikson. DIF: A REF: 142 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education

10. A childs understanding of the concept of ice becoming water, Piagets stage of cognitive development, is seen in:

1 2 3 4

Sensorimotor Preoperational Formal operations Concrete operations

ANS: 4 During Piagets concrete operations stage of cognitive development, the child is able to understand that objects or quantities remain the same despite a change in their physical appearance, such as when ice becomes water. During Piagets sensorimotor stage of cognitive development, the child is exploring the environment but is unable to understand the concept of ice becoming water. During Piagets preoperational stage of cognitive development, the child is learning to think with the use of symbols and mental images but is not able to understand the concept of ice becoming water. According to Piagets formal operations stage of cognitive development, the individuals thinking moves to abstract and theoretical subjects. DIF: A REF: 142-143 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 11. The nurse in a pediatric health care setting is using Kohlbergs developmental theory. A child is evaluated as having reached level I, the preconventional level, if the child:

Makes sure that he or she is not late for school

Cleans the blackboards after school for the teacher

Runs for school council in order to change policies

Stays away from peer groups that harass other children

ANS: 1 According to Kohlbergs developmental theory of moral development, at level I, the preconventional level, the childs reasoning is based on personal gain. The moral reason for acting relates to the consequences the person believes will occur. The child who makes sure not to be late for school may do so out of fear of punishment. Cleaning the blackboards after school for the teacher is an example of Kohlbergs stage 3, good boy-nice girl orientation. The child desires to win the teachers approval. Running for school council to change policies is an example of Kohlbergs stage 5 social contract orientation. Staying away from gangs at school that harass other children is an example of Kohlbergs stage 4 society-maintaining orientation. DIF: A REF: 144 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education

12. In applying Goulds developmental theory, the nurse anticipates that a client will have a greater concern for ones health within the following theme and age-group:

1 2 3 4

First theme (20s) Second theme (early 30s) Fourth theme (40s) Fifth theme (50s)

ANS: 4 During the fifth theme (50s), Gould finds a realization of mortality with a concern for ones state of health. During the first theme (20s), Gould finds individuals wanting to get away from their parents. During the second theme (30s), Gould finds young adults working to accept who they are and to accept their growing children as being unique and separate. During the fourth theme (40s), Gould finds resignation and the belief that possibilities are limited. DIF: A REF: 142 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 13. The nurse is working with a new mother who will require surgery. The follow-up treatment will interfere with bonding. In applying Freuds theory, the nurse recognizes that the stage of development that may be affected is the:

Oral stage

Anal stage

Phallic stage Latent stage

ANS: 1 According to Freud, disruption in the physical or emotional availability of the parent for the newborn (e.g., undergoing surgery) will affect the oral stage of development; the anal stage is from 12 to 18 months to 3 years, when the child is toilet-training; the phallic stage is from 3 to 6 years of age, when the child becomes interested in the genital organs; and the latent stage is from 6 to 12 years, when the child represses sexual urges and channels them into productive activities that are socially acceptable. DIF: A REF: 138 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 14. In accordance with Eriksons theory, it is expected by the nurse that a middle-aged adult client will be involved in the process of:

Developing a sense of identity

Searching for meaning in life

Enhancing ones capability to love others

Expanding personal and social involvement

ANS: 4 In accordance with Eriksons theory, the middle-aged adult client is involved in the process of expanding ones personal and social involvement. Middle-aged adults should be able to see beyond their needs and accomplishments to the needs of society. Developing a sense of identity is in accordance with Eriksons identity versus role confusion (puberty) stage of development. Searching for meaning in life is in accordance with Eriksons integrity versus despair (old age) stage of development. Enhancing ones capability to love others is in accordance with Eriksons intimacy versus isolation (young adult) stage of development. DIF: A REF: 140 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 15. The primary purpose for the nurse to understand human growth and development is to be best able to:

Identify deviations from normal

2 3

Select effective nursing interventions Be sensitive to age-appropriate needs

Enhance nurse-client communication

ANS: 1 Understanding normal growth and development helps nurses predict, prevent, and detect any deviations from clients normal expected patterns. While being familiar with the characteristics of the various stages of human growth and development and being able to apply that knowledge to the individual client do have a positive impact on determining the most appropriate nursing interventions, the primary purpose is to predict, prevent, and detect any deviations from the clients normal expected patterns. Although being familiar with the characteristics of the various stages of human growth and development and being able to apply that knowledge to the individual client do have a positive impact on identifying age-appropriate needs, the primary purpose is to predict, prevent, and detect any deviations from the clients normal expected patterns. While being familiar with the characteristics of the various stages of human growth and development and being able to apply that knowledge to the individual client do have a positive impact on the nurses ability to communicate with the client in an appropriate manner, the primary purpose is to predict, prevent, and detect any deviations from the clients normal expected patterns. DIF: C REF: 137 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 16. Which of the following should the nurse consider first when assessing the cognitive ability of an older adult?

A life-long bachelor

2 3

Orphaned at age 12 History of a chronic disease process

Recent immigration to the United States

ANS: 4 Cognitive processes comprise changes in intelligence, ability to understand and use language, and the development of thinking that shapes an individuals attitudes, beliefs, and behaviors. Recent immigration to the United States would present language and life experiences that should be considered by the nurse. Socioemotional processes consist of the variations that occur in an individuals personality, emotions, and relationships with others during their lifetime. Being a bachelor and not having experienced a marital relationship should be considered by the nurse. Socioemotional processes consist of the variations that occur in an individuals personality, emotions, and relationships with others during their lifetime. Being orphaned at a young age should be considered by the nurse. Biological processes produce changes in an individuals physical growth and development. A chronic disease process should be considered by the nurse. DIF: C REF: 142 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 17. A nurse caring for a 78-year-old client recently diagnosed with pneumonia will find Eriksons psychosocial development theory most helpful in determining:

Which needs the client will typically develop

Which coping mechanisms the client will likely use

How the client will respond to the respiratory problem How the client and his family will adjust to the stressors

ANS: 3 Developmental theories are important in helping nurses assess and treat a persons response to an illness. Understanding and being able to apply the concepts of the theory will enable the nurse to determine a variety of generalized information that will assist in providing appropriate nursing care. The other options are only one area of information that is made available when applying Eriksons psychosocial development theory. DIF: C REF: 140 OBJ: Analysis TOP: Nursing Process: Assessment/Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 18. As described by Freud, the nurse recognizes that a young adult best shows a well-developed superego when he:

Tells a friend that hell help him stop smoking

Returns a lost wallet to a stranger who dropped it

Arranges for a cab ride home after consuming alcohol Has 10% of his salary automatically transferred to savings

ANS: 3 Components of the human personality develop through Freuds developmental stages. Freud believed that the functions of these components regulate behavior. These components are the id, the ego, and the superego. The superego performs regulating, restraining, and prohibiting actions. Often referred to as the conscience, the superego is influenced by the standards of outside social forces (i.e., the law). The ego represents the reality component mediating conflicts between the environment and the forces of the id. The ego helps us judge reality accurately, regulate impulses, and make good decisions. DIF: C REF: 139 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 19. A nurse is preparing to discharge an 11-month-old child after a hospitalization for a viral infection. The nurse uses anticipatory guidance most effectively when:

1 2 3 4

Encouraging the parents to limit visitors for 14 days Providing the parents with written discharge instructions Arranging the follow-up pediatrician appointment for the parents Informing the parents that the child may cry when taken to daycare

ANS: 4 A nurses use of anticipatory guidance (derived from an understanding of the characteristics shown by clients in the trust versus mistrust phase of development) will help parents cope with the hospitalization of an infant and the infants behaviors when discharged to home. The childs sense of trust may be challenged during hospitalization and may need support from parents when returning home. Encouraging the parents to limit visitors for 14 days is more educational and related to the childs physical recovery. Providing the parents with written discharge instructions is more educational and designed to reinforce the information. Arranging the follow-up pediatrician appointment for the parents is an action included in the discharge planning. DIF: C REF: 139 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 20. Which of the following situations/statements best depicts Goulds fourth theme of adult development?

When I made that decision, I didnt expect it to turn out like it did.

I have to take the opportunity to be my own boss and not rely on others. I think you can do anything if only you have your health and good friends.

3 4

As much as Id love to open my own shop, I just cant take that kind of chance.

ANS: 4 The fourth theme, identified in the 40s and called the die is cast, indicates resignation and the belief that possibilities are limited. The personality is set. Individuals believe changes in career are less likely to be successful. Parents are blamed for their lack of choices. Individuals face regret for mistakes made with children. The second theme occurs during the early 30s and asks, Is what I am the only way for me to be? This question occurs when young adults experience the consequences of the decisions of their independence. Goulds development themes start when individuals are in their 20s with, I have to get away from my parents. This is challenged in minor ways before the end of high school but ends as young persons begin to live away from home. The move away from parental influence is gradual as young adults establish themselves as adults. During the 50s a decrease in negativism occurs. Gould finds a realization of mortality with a concern for ones state of health. DIF: C REF: 142 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 21. The nurse is caring for an older adult client who has reported symptoms suggestive of depression. Which of the following questions asked by the nurse is most therapeutic in assessing the clients perception of the impact depression has had on her life?

What does it mean to be depressed?

How does being depressed make you feel?

Were you happy before becoming depressed?

What makes you think that you are depressed?

ANS: 1 Understanding the older persons concept of depression assists nurses in explaining complementary and alternative treatment measures. Asking how depression make the client feel or whether the client was previously happy are best saved until the client defines depression and is open to the possibility of being depressed. Asking what makes the client think they are depressed could be interpreted as being somewhat threatening and may interfere with the clients desire to talk about the situation.

DIF: C REF: 141 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 22. The nurse is caring for a 6-year-old child who is scheduled for outpatient surgery. Piagets theory of cognitive development suggests that the nurse can help the child cope with the stressors of this hospital experience best by:

Arranging for the parents to be with the child until the anesthetic takes affect

Explaining the entire process with the child using ageappropriate language

Using play as a means of familiarizing the child with the events he will experience

Providing the child with a coloring book that shows the events he will be experiencing

ANS: 3 Play becomes a primary means by which children foster their cognitive development and learn about the world. Nursing interventions during this period will recognize the use of play as the way the child understands the events taking place. You will assist parents in the use of play materials such as thermometers, blood pressure equipment, and play needles that will allow children to communicate feelings about health care procedures they experience. Arranging for the parents to be with the child until the anesthetic takes affect may be an appropriate intervention but it does not reflect effective care suggested by Piagets theory of cognitive development. Explaining the entire process with the child using age-appropriate language would be more appropriate for the older child. Providing the child with a coloring book that shows the events he will be experiencing DIF: C REF: 142 OBJ: Analysis TOP: Nursing Process: Planning/Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 23. Which of the following nursing responses is most therapeutic when made in response to a parents concern about her 3-year-old childs tendency to break the rules?

Just keep reminding her of the rules.

Daycare will help her learn to play fair.

She will begin to understand that concept in a year or so.

Add an age appropriate punishment for breaking the rules.

ANS: 3 The first stage, heteronomous morality, occurs between 4 and 7 years and is characterized by a belief that rules are unchangeable and that when a rule is broken, there is imminent justice.

Before that stage, the child is not able to fully understand rules or other moral issues. While telling the client to keep reminding her of the rules may be useful, it does not help assure the parent that the child is displaying normal, age-appropriate behavior. While socialization will often have a positive effect on a childs sense of fair play, this option does not help assure the parent that the child is displaying normal, age-appropriate behavior. The child is too young to understand the concept that makes punishment effective in acquiring fair play. DIF: C REF: 144 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 24. To help a comatose clients family make a moral decision regarding the termination of life support, the nurse must first:

Refrain from expressing his/her personal beliefs concerning the life support issue

Provide the family with information regarding the process of terminating life support Determine whether the client had expressed any written or oral wishes regarding the issue

3 4

Facilitate the familys decision-making process by providing them with a quiet, private space for discussion

ANS: 1 Nurses need to know their own moral reasoning level. Recognizing ones own moral developmental level is essential in separating your own beliefs from others when helping clients with their moral decision-making process. Information regarding the process of terminating life support should be provided only after the family makes their decision or has asked for the information. To not influence the family, the nurse must first refrain from interjecting any personal feelings about the termination of life support measures. DIF: C REF: 145 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 25. Which of the following best describes a nurse thinking at stage 5 of Kohlbergs Moral Developmental Theory?

The client has a right to decide whether or not to proceed with the treatment plan.

The hospitals policies and procedures are excellent tools for making client oriented decisions. It wont be fair to expect to get every weekend and holiday off, so Ill certainly work my share.

If you dont keep client information confidential you could be terminated immediately.

ANS: 1 The individual also recognizes that different social groups have different values but believes that all rational people would agree on basic rights, such as liberty and life. (Stage 5: Social Contract Orientation). Moral decisions take into account societal perspectives. Right behavior is doing ones duty, showing respect for authority, and maintaining the social order. (Stage 4: SocietyMaintaining Orientation). The principles of justice require the individual to treat everyone in an impartial manner, respecting the basic dignity of all people, and guides the individual to base decisions on an equal respect for all. (Stage 6: Universal Ethical Principle Orientation). Avoidance of punishment or the unquestioning deference to authority is the characteristic motivation to behave. (Stage 1: Punishment and Obedience Orientation) DIF: C REF: 144 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 26. Which of the following client statements made by an older adult best reflects an understanding of the decrease in physical strength and stamina in this developmental stage?

I know Im not as young as I use to be.

2 3

I just hire help with jobs I cant do myself. You get older you cant do as much, thats life.

I have to ask my son for help with the yard work.

ANS: 2 A common behavioral task of the older adult client is adjusting to decreasing physical strength. This option reflects the best adjustment because the client has developed a plan for coping. While the other options appear to address the issue, they do not present any proof of the clients healthy acceptance or adjustment to the decrease in physical strength and stamina. Chapter 12. Conception Through Adolescence MULTIPLE CHOICE 1. Which of the following data is the most important for the nurse to assess when caring for a woman in her second trimester of pregnancy?

Detection of fetal movement

Observation that the uterus is below the pubis

Confirmation of the desire to breast- or bottle-feed

Determination of the presence of morning sickness

ANS: 1 During the second trimester, between 16 and 20 weeks gestation, the mother begins to feel fetal movement. During the second trimester, the uterus should be above the level of the symphysis

pubis. Confirmation of the desire to breast- or bottle-feed is more likely to take place during the third trimester. Morning sickness is most likely to occur during the first trimester. DIF: C REF: 151 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments 2. Which one of the following newborn reflexes should the nurse be able to elicit at a 6-month well-baby visit?

1 2

Moro Startle

Babinski

Extrusion

ANS: 3 The Babinski reflex is a normal reflex found in a 6-month-old infant. The Moro reflex is seen in the newborn. The startle reflex is seen in the newborn. Before 6 months of age, the extrusion reflex causes food to be pushed out of the mouth. It is normally present from birth to 4 months. DIF: A OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments 3. In evaluating an infants physical status and growth, the nurse expects to find:

Birth weight triples by 6 months

Anterior fontanel closes 4 to 8 weeks after birth

Chest circumference is larger than head circumference at 12 months Birth height increases 1 inch each month for the first 6 months

ANS: 4 Height increases an average of 1 inch during each of the first 6 months and inch the next 6 months. Birth weight doubles in approximately 5 months and triples by 12 months. The anterior fontanel closes at about 12 to 18 months. The head and chest circumference are equal at 1 year of age. DIF: A REF: 155 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments

4. Upon evaluation of a 6-month-old infants developmental status, the nurse expects that the child at this age will be able to:

1 2 3 4

Completely roll over Pull self to a standing position Creep on all four extremities Assume a sitting position independently

ANS: 1 A 6-month-old infant is able to roll over. A 9-month-old infant is able to pull self to a standing position, creep on all four extremities, and attain a sitting position independently. DIF: A OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments 5. For a 2-year-old child, cognitive development is characterized by:

Recognizing right and wrong

Initiating play with other children

Having a vocabulary of at least 1000 words

Using short sentences to express independence

ANS: 4 A 2-year-old child uses short sentences to express independence and control, does not understand the concepts of right and wrong, may engage in solitary play and begin to participate in parallel play, may initiate play with other children, and has a vocabulary up to 300 words. DIF: A REF: 159 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments 6. In planning nursing care for an 18-month-old child, the nurse should know that the predominant developmental characteristic of children this age is:

Parallel play

Peer pressure

Mutilation anxiety Imaginary playmates

ANS: 1 During toddlerhood, the child begins to participate in parallel play, which is playing beside rather than with another child. Peer pressure is seen with the school-age child. A fear of the preschool child is bodily harm. The preschool child may have imaginary playmates.

DIF: A REF: 159 OBJ: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments 7. The nurse, in working with children of this age, plans to allow a 5-year-old boy who was admitted to the surgical center to have his tonsils removed to:

Perform his own preoperative hygienic care

Have alone time to relax before the procedure

Handle the equipment when taking his blood pressure

Have access to age-appropriate magazines and puzzles for diversion

ANS: 3 Preschool children may cooperate if they are allowed to manipulate the equipment. A preschooler is unable to take responsibility for his or her own preoperative hygienic care. Leaving the preschooler alone may increase the childs anxiety. Magazines and puzzles would be more appropriate activities for the older child. The preschool child likes to engage in pretend play, using their imagination and imitating adult behavior. DIF: A REF: 160 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments 8. A parent of a 3-year-old boy states that she is concerned because he was potty trained long before hospitalization but now refuses to use the toilet. What is the correct response by the nurse?

Your son is probably feeling neglected, and you should make an effort to spend more time with him.

This is common behavior that is expressed when the hospitalized child is stressed or anxious. You may need to include discipline because children easily lose the ability to be toilet trained during hospitalization.

3 4

Your son was probably not ready to be potty trained, and you may want to continue the training for the next 6 months.

ANS: 2 During times of stress or illness, preschoolers may revert to bed-wetting or thumb-sucking and want the parent to feed, dress, and hold them. Reassuring the parent that this is normal coping behavior may help alleviate their concern. Reverting to a prior level of functioning, such as a

child who was potty trained now refusing to use the toilet, does not indicate the child is feeling neglected. The behavior demonstrates that the child is experiencing stress and this is a coping behavior. Disciplining the child would not be a correct response. The child should be provided with experiences he or she can master. Such successes help the child to return to their prior level of independent functioning. Reverting to a prior level of functioning, such as a child who was potty trained now refusing to use the toilet, does not indicate the child was unready to be potty trained. The behavior more likely demonstrates that the child is experiencing stress, and this is a coping behavior. DIF: A REF: 161 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments 9. A 4 1/2-year-old child is crying from pain related to her fractured leg. Which of the following is the most appropriate nursing response to her alteration in comfort?

1 2 3 4

Please try to not move your leg and that will make it feel better. Ill give you a shot of medicine that will help take the pain away. Its okay if you need to cry. Would you like to hold your favorite doll? Would you like to tell me now where you want me to give you your shot?

ANS: 3 Telling the child its okay to cry and hold a toy informs the child what they can do, and involves an age-appropriate familiar toy to provide comfort. Telling the child not to move when they are in pain is unlikely to be effective. A preschool child may have difficulty in understanding the request. Telling the child they are going to get a shot may increase their anxiety, as they fear bodily harm. If a child is allowed to determine the site for administration of an injection, specific sites should be offered as choices. However, the nurse needs to avoid allowing procrastination by the child. DIF: A REF: 160 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments 10. When teaching basic infant safety to the parents of a 3-month-old, the nurse should emphasize:

Placing gates at stairways

Keeping bathroom doors closed

Giving large, hard teething biscuits

Removing feeding bibs at bedtime

ANS: 4 Bibs should be removed at bedtime to avoid suffocation. Placing gates or fences at stairways is an appropriate safety measure to prevent falls of the 8- to 12-month-old infant. Keeping bathroom doors closed is an appropriate safety measure to prevent drowning of the 8- to 12month-old infant. Caution should be exercised when giving teething biscuits to a 4- to 7-monthold infant because large chunks may be broken off and aspirated. Teething biscuits are typically not given to a 3-month-old. DIF: A REF: 156 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments 11. The parents of a 3-month-old ask the nurse what behavior they should expect. The nurse informs the parents that the child will be able to:

Say Da-da

Smile responsively

Differentiate strangers

Play social peekaboo games

ANS: 2 Two- and 3-month-old infants begin to smile responsively rather than reflexively. By 1 year of age, infants have two- or three-word vocabularies such as Da-da. By 8 months, most infants can differentiate a stranger from a familiar person. By 9 months, infants play simple social games such as patty-cake and peekaboo. DIF: A REF: 155 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments 12. A client in her first trimester of pregnancy asks the nurse about how the baby is growing. The nurse responds correctly by telling the client that:

The sex of the baby can be determined.

2 3

There is a fine hair that covers the body. Fingers and toes are differentiated clearly.

The organ systems are beginning to develop.

ANS: 4

During the first trimester of pregnancy, the organ systems are beginning to develop. During the second trimester of pregnancy, the sex of the fetus can be determined, and fine hair, called lanugo, covers most of the body of the fetus. Also during the second trimester of pregnancy, fingers and toes are differentiated. DIF: A REF: 150 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments 13. The nurse assists the family of a 9-year-old with nutritional information. A recommended after-school snack for a child this age is:

1 2

Milk shakes Potato chips

Plain popcorn

Bite-size candy

ANS: 3 Plain popcorn, fresh fruit, raw vegetables, cheese, skim-milk pudding, and hot chocolate are appropriate after-school snacks. Thick milk shakes would be high in fat and calories. There are better food choices for after-school snacks. Potato chips should be discouraged as a snack because they are high in fat and low in nutritional value. Candy bars should be discouraged as a snack because they are high in fat and calories, are low in nutrition, and are cariogenic. DIF: A REF: 168 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments 14. The elementary school nurse is responsible for evaluating each childs overall physical development. During the school-age years, the nurse anticipates that:

The childs body weight will almost triple

There will be few physical differences among children

The child will grow an average of 1 to 2 inches per year

Body fat will gradually increase, contributing to a heavier appearance

ANS: 3 During the school-age years, the child will grow an average of 1 to 2 inches per year and gain an average of 4 to 7 pounds a year. Many children double, not triple, their weight during these middle childhood years. Growth accelerates at different times for different children. There will

be many physical differences apparent among children at the end of middle childhood. The school-age child appears slimmer as a result of changes in fat distribution and thickness. DIF: A REF: 164 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments 15. A 6-year-old is hospitalized for asthma. Which of the following activities would be appropriate to help this child resolve the crisis of hospitalization?

Crayons and a coloring book

A 1000-piece puzzle to complete

A CD player with soothing CDs

A Nerf football to throw around the room

ANS: 1 Providing a 6-year-old with crayons and a book to color in would be an age-appropriate activity to help the child with the crisis of hospitalization. Painting, drawing, playing computer games, and making models allow children to practice and improve newly refined skills. A 1000-piece puzzle would be too much for a 6-year-old to complete. A CD player with soothing CDs would not be an age-appropriate activity for a 6-year-old. Throwing a Nerf football around the room may not be appropriate for a hospitalized child with asthma. DIF: A REF: 164 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments 16. Which one of the following statements is correct regarding the preadolescence developmental stage?

It appears 2 years earlier in boys than in girls.

Intimate feelings are confided in the parents.

Interest in the opposite sex is not a factor for this group. It signals the development of secondary sex characteristics.

ANS: 4 The preadolescence developmental stage (puberty) signals the development of secondary sex characteristics. Physical changes often begin 2 years earlier in girls than in boys. Preadolescents usually develop best friends with whom they share intimate feelings. New interest in the opposite sex develops in the preadolescence developmental stage. DIF: A REF: 167 OBJ: Knowledge TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments 17. The nurse is teaching parents about probable warning signs that a teenager is considering suicide and tells parents to be alert to:

An increase in appetite

A sudden interest in school activities

An unexplained increase in sleepiness

Talking about death and personal harm

ANS: 4 A warning sign that a teenager is considering suicide includes verbalization of suicidal thoughts. Appetite disturbances, usually a decrease in appetite, may be a warning sign that a teenager is considering suicide. A decrease in school performance and loss of initiative are possible warning signs that a teenager is considering suicide. Sleep disturbances, such as the inability to sleep, are a warning sign for suicide. DIF: A REF: 172 OBJ: Knowledge TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments 18. In order to obtain the most information, which of the following is the most appropriate question asked of a 14-year-old female who is visiting the county health center for birth control help?

Have you told your parents that you are sexually active?

Are any of your friends participating in sexual behaviors?

What can you tell me about any of your past sexual activities?

Have you been physically protecting yourself with safe sex measures?

ANS: 3 The nurse can be proactive by using the interview process and open-ended questions such as this one, to identify risk factors in the adolescent. Once identified, the risk factors should lead to strategies for prevention. Inquiring what the client has told parents does not obtain the most information. Asking about friends activities does not address the individual and does not obtain the most information about the health behaviors of the client. Asking whether the client is having safe sex may be answered with a yes or no response and therefore does not obtain the most information. Chapter 13. Young and Middle Adults MULTIPLE CHOICE

1. A client thinks that she might be pregnant. Which first trimester physiological changes would most likely indicate this?

1 2 3 4

Amenorrhea and nausea Braxton Hicks contractions Increased urinary frequency Edematous ankles and dyspnea

ANS: 1 Amenorrhea and nausea are physiological changes that may indicate pregnancy in the first trimester. Braxton Hicks contractions are noted during the second trimester of pregnancy. Increased urinary frequency is commonly seen in the third trimester of pregnancy. Edematous ankles and dyspnea may be experienced during the third trimester of pregnancy. DIF: A REF: 183 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care; Physiological Integrity/Reduction of Risk Potential/Specific Systems Assessment 2. To determine how the client, who is a single parent of three children, will be able to cope with the current pregnancy, the nurse should ask the client:

Have you ever been married?

Where do you currently work?

Has anyone ever taught you about contraception? Who do you have for support during this pregnancy?

ANS: 4 This could be a situational crisis for a single-parent family. The nurse should assess environmental and familial factors, including support systems and coping mechanisms commonly used. Asking the client whether she has ever been married does not assess her ability to cope with the pregnancy. Asking the client where she works may help determine if there are any environmental factors that may place her pregnancy at risk, but it does not assess her ability to cope with the pregnancy. This would not be the most opportune time to discuss contraception with the client and may convey a message of disapproval. Nor does asking the client about contraception assess her ability to cope with the pregnancy. DIF: B REF: 181 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Stress Management 3. The nurse is performing a physical examination on a 40-year-old adult client. The nurse will most likely find that the client of this age is experiencing which one of the following physiological changes related to normal aging?

Decreased hearing acuity

2 3

Decreased sense of smell Decreased strength of abdominal muscles

Decreased function of the various cranial nerves

ANS: 3 A physiological change related to normal aging in the middle adult would be decreased strength of abdominal muscles. The middle adult should have normal auditory structures and acuity. The middle adult should have a normal sense of smell. The middle adult should have normal functioning of the cranial nerves. DIF: A REF: 185 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Reduction of Risk Potential/ Specific Systems Assessment 4. A 49-year-old client is experiencing problems with depression. She has come to the clinic showing signs of malnutrition and fatigue. Which of the following is the best initial statement for the nurse to make in the assessment phase?

How much weight have you lost over the past month?

Have you recently been experiencing menopausal symptoms?

Depression is something to expect at your age, and with assistance you will get better. Your depression is somewhat uncommon. Can you tell me what has happened recently to cause it?

ANS: 2 Mood changes and depression are common phenomena during menopause, and this client is in the expected age range to be experiencing menopause. Asking the client about weight loss may be an indication to verify depression; however, it is not the best initial response. Depression is not something to expect, although it can occur. Depression is not uncommon during menopause. DIF: C REF: 186 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Stress Management 5. The nurse, trying to promote positive health habits regarding stress management is aware of the external influences on young and middle adult clients. With this knowledge, the nurse recognizes that an effective strategy for this age-group is:

Teaching clients to abstain from all alcohol consumption

Demonstrating how to take an accurate blood pressure measurement

Determining an effective daily exercise schedule for stress reduction

Describing the types of medications commonly used for treating depression

ANS: 3 Exercise on a routine basis can be an effective strategy to reduce the stress experienced by young and middle adults. Exercise is a positive health habit for this age-group. Clients do not have to abstain from all alcohol consumption. Teaching clients to abstain from excessive alcohol consumption is important, but it is not a proactive positive health habit to help reduce stress. Monitoring ones blood pressure may be important, but it is not a proactive positive health habit to help reduce stress. Teaching clients about types of medication used for treating depression does not help the client develop positive health habits for reducing stress. DIF: A REF: 182 OBJ: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Lifestyle Choices 6. Individuals at the young adult point in their life are generally expected to, according to developmental patterns:

Continue physical growth

2 3

Experience severe illnesses Ignore physical symptoms

Seek frequent medical care

ANS: 3 Young adults generally are quite active, experience severe illnesses less commonly than older age-groups, tend to ignore physical symptoms, and often postpone seeking health care. Young adults generally do not continue their physical growth. Young adults experience severe illnesses less commonly than older age-groups. Young adults often postpone seeking health care. DIF: A REF: 178 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development 7. A nurse is preparing an education program on safety for a young adult group. Based on the major cause of mortality and morbidity for this age-group, the nurse should focus on:

Birth control

2 3

Automobile safety Occupational hazards

Prevention of heart disease

ANS: 2 Violence is the greatest cause of mortality and morbidity in the young adult population. Deaths and injury from motor vehicle accidents are significant among this age-group. Unplanned pregnancies may be a source of stress but is not the major cause of mortality and morbidity in the young adult population. Exposure to work-related hazards or agents may cause diseases and cancer, but it is not the major cause of mortality and morbidity in this age-group. Developing healthy habits to prevent heart disease later in life is important, but heart disease is not the leading cause of mortality and morbidity for the young adult. DIF: A REF: 181 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development/Lifestyle Choices 8. A nurse is working in the health office at a local college where most of the students are young adults. Being aware of the major concerns for this age-group, the nurse includes assessment of these clients:

1 2

Current marital history status Lifestyle and leisure activities

Experience with chronic disease

History of childhood accidents

ANS: 2 The young adult client may benefit from a personal lifestyle assessment to help identify habits that increase the risk for cardiac, malignant, pulmonary, renal, or other chronic diseases. Assessing a clients marital status does not offer much information about the clients health or risk for future illnesses. Assessing a clients experience with chronic disease is less appropriate for this age-group. Assessing the clients history of childhood accidents does not offer much information about the clients current health or risk for future illnesses. DIF: A REF: 179 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development/Lifestyle Choices 9. As an individual enters middle adulthood health problems generally become more prevalent. The middle adult may be influenced by chronic illness that results in:

Decreased health care tasks

Reinforcement of family roles

Changed sexual behavior habits

Improvement of family relationships

ANS: 3

A few examples of the problems experienced by clients who develop debilitating chronic illness during adulthood include role reversal, changes in sexual behavior, and alterations in self-image. Chronic illness would result in increased health care tasks. Family roles are often changed with chronic illness, not reinforced. Strained family relationships may result from chronic illness. DIF: A REF: 186 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development 10. The nurse is performing a physical examination on a 58-year-old adult client. The nurse will most likely find that the client of this age is experiencing which one of the following physiological changes related to normal aging?

1 2

Palpable thyroid lobes Decreased skin turgor

Reduced pupillary reaction

Increased range of joint motion

ANS: 2 There is a slow, progressive decrease in skin turgor in the middle adult. The thyroid lobes should not be palpable in the middle adult. Pupillary reaction to light and accommodation should not change in the middle adult. A normal change in the middle adult is a decreased range of joint motion. DIF: A REF: 221 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development 11. The nurse is alert to stressors that may have an influence on the young adult client. One example of a common stressor for this age-group is:

Occupational pursuits

Health-related matters

Coping with cognitive changes

Caring for the older adult parent

ANS: 1 A common stressor for the young adult is job stress. Health-related matters are not common stressors for the young adult. Coping with cognitive changes is not a common stressor for the young adult. Caring for older adult parents is more often seen with the middle adult, not the young adult. DIF: A REF: 182-183 OBJ: Knowledge TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development; Psychosocial Integrity/Stress Management 12. A client who works in a dry cleaning establishment comes to the clinic for a regular checkup. Based on this information, the nurse assesses the client for:

Asbestosis

Dermatitis

Tendonitis

Raynauds phenomenon

ANS: 2 Persons who work in dry cleaning establishments are exposed to solvents that may cause dermatitis or liver disease. Asbestosis is more likely to be found as an occupational hazard for automobile workers and insulators. Tendonitis may result from repetitive wrist motion as seen in office computer workers. Raynauds phenomenon may result from vibration as seen with jackhammer operators. DIF: C REF: 182 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Reduction of Risk Potential/ Specific Systems Assessment 13. The nurse is completing a physical exam for a 45-year-old client who has come to the family practice office. In evaluating the observations made during the examination, the nurse recognizes that an expected finding for a client in this age-group is:

Hepatomegaly

Visual acuity below 20/50

An oral temperature of 39 C

Increased amount of skin turgor

ANS: 2 The visual acuity tested by the Snellen chart should be less than 20/50. Hepatomegaly is not an expected finding and would be considered abnormal. Oral temperature should be 36.1 to 37.6 C. The expected finding would be a slow, progressive decrease in skin turgor. DIF: A REF: 221 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Reduction of Risk Potential/ Specific Systems Assessment 14. When discussing the stressors felt by a single mother in her 30s, the nurse recognizes that the greatest financial impact on this family is caused by:

The ever-rising cost of living in the United States

2 3 4

The realization that a female earns 25% less than her male coworker Court-ordered child support is often times inadequate. Daycare expenses are a strain on a single wage earner family

ANS: 2 According to the AFL-CIO (2004) workers union, women in the United States are paid 76 cents for every dollar men receive for comparable work. This fact has an all-encompassing effect on the single-parent household. The cost of living is rising; it is not unique to the single mother. While court-ordered support often is inadequate, it does not have the impact that earning power has on the family income. While daycare expenses can be a strain, does not have the impact that earning power has on the family income. DIF: C REF: 178 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Dynamics 15. Because young adults are less likely to experience serious illness, which of the following nursing interventions is most effective in determining risk for illness in this age-group?

Health screenings

Personal lifestyle assessment

Full body systems assessment

Cardiopulmonary focal assessment

ANS: 2 A personal lifestyle assessment (see Chapter 6) helps nurses and clients identify habits that increase the risk for cardiac, malignant, pulmonary, renal, or other chronic diseases. Health screening helps detect the presence of disease processes. Full body systems assessment would determine deviation from normal but not necessarily identify risk for illness. Cardiopulmonary focal assessment would determine deviation from normal but not necessarily identify risk for illness. DIF: B REF: 178 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/High Risk for Injury; Physiological Integrity/Specific System Assessment 16. Research has shown that certain postpartum factors negatively affect a womans general health status after pregnancy. Which of the following women has the greatest risk factor for poor postpartum health?

A mother with complaints of fatigue, loss of appetite, and insomnia

A practicing attorney who has reluctantly taken a 3-month maternity leave

A stay-at-home mom who gave birth 2 months ago and whose husband recently lost his job A mother of a 3-week-old and a 2-year-old whose military husband is currently deployed overseas

ANS: 4 Postpartum stress and depression have significant effects on postpartum womens health. In addition, a lack of social support can affect womens health adversely. This woman is the most likely mother to be experiencing depression and economic stressors as well as a lack of support. While fatigue, loss of appetite, and insomnia may be reflective of depression, there are no indications of the other high-risk factors. While this woman may be experiencing anxiety over being away from her career for 3 months, there is no indication of the other risk factors. While this mother may well be at risk for depression and possible financial stressors, there is no indication of a lack of support. DIF: C REF: 180 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems 17. The nurse is preparing to discuss postpartum depression as a part of discharge teaching with the parents of a newborn. Which of the following nursing actions would be most therapeutic regarding early detection of this postpartum condition?

Helping the couple understand the importance of social interaction with other adults

Providing the couple with a video that tells the story of a new mothers experience with depression

Encouraging the couple to attend parenting classes designed to minimize the stressors of parenting an infant

Having a discussion with the father in which he identifies the signs and symptoms of postpartum depression

ANS: 4 Educating both new mothers and their families regarding the signs and symptoms of postpartum stress and depression will facilitate early detection and treatment of the condition. While preventing social isolation is important to the prevention of generalized depression, it has little impact on detecting the signs and symptoms of the condition. While the video may be informative it is not the most therapeutic option because it lacks interaction between the nurse and the clients. While Option 3 is appropriate in regard to minimizing the risk of developing

depression stemming from postpartum stressors, it does not directly impact the identification of the signs and symptoms of the condition. DIF: C REF: 180 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Stress Management/Crisis Intervention 18. Which of the following young adults is at greatest risk for experiencing death or injury?

An 18-year-old with a father who is an alcoholic

2 3

A 30-year-old who is a professional rodeo rider A 20-year-old living in an urban housing project

A 26-year-old riding a motorcycle across the country

ANS: 3 Violence is the greatest cause of mortality and morbidity in the young adult population. Factors that predispose individuals to violence, injury, or death include poverty, family breakdown, child abuse and neglect, repeated exposure to violence, and ready access to guns. This option represents an individual who most likely is both poor and exposed to an environment of repeated violent acts. While Option 1 represents a potential for physical and mental abuse, it does not present the level of potential violence existing in Option 3. While Option 2 represents a potential for physical injury and possible death, it does not present the level of potential violence existing in Option 3. While Option 4 represents a potential for physical injury and possible death, it does not present the level of potential violence existing in Option 3. DIF: C REF: 181 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/High Risk for Injury 19. The most serious risk for death for a young adult living in rural poverty is:

Suicide

Homicide

Poor health maintenance practices

Family history of chronic illnesses

ANS: 1 A young adult is more likely to die of self-inflicted injury when living at or below the poverty level when no other risk factors (i.e., a violent environment, drug abuse, etc.) are present. In 2002 the death rate (per 100,000 population) for 25- to 34-year-olds in the United States caused by homicide was 11.2; the death rate caused by accidents was 31.5; and the death rate caused by suicide was 12.6 (U.S. Department of Health and Human Services [USDHHS]). DIF: C REF: 13 OBJ: Analysis TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Psychosocial Integrity/Stress Management/Crisis Intervention 20. During a routine physical assessment a 27-year-old client acknowledges the suspension of his drivers license because of an arrest for driving under the influence of alcohol. This admission should prompt the nurse to discuss which of the following in detail with the client?

Use of illegal drugs

2 3

History of depression Unprotected sexual experiences

Tendency toward violent behavior

ANS: 1 Reports of arrests because of driving while intoxicated, wife or child abuse, or disorderly conduct are reasons for you to investigate the possibility of drug abuse more carefully. A history of depression is not necessarily a risk factor for illegal drug abuse. Unprotected sex is not necessarily a risk factor for illegal drug abuse. A tendency toward violent behavior is not necessarily a risk factor for illegal abuse. DIF: C REF: 181 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/High Risk Behaviors; Psychosocial Integrity/Chemical Dependency 21. In preparing to discuss safe sex practices with a 20-year-old, it is most important that the nurse shares with the client that in addition to physical symptoms of genital pain and discharge, sexually transmitted diseases:

Can lead to chronic illness and infertility

Are particularly common in young adults

Respond well to treatment when detected early

May be effectively controlled through the use of condoms

ANS: 2 Sexually transmitted diseases (STDs) remain a major public health problem for sexually active persons, with almost half of all new infections occurring in men and women younger than 24 years of age (USDHHS, CDC, 2004). While Option 1 is true, it is vitally important that the nurse first share the high probability of contracting a STD to a sexually active young adult who practices unprotected sex. While some STDs respond well to early treatment, some, such as genital herpes and human immunodeficiency virus (HIV), can only be managed because no cure is currently available. While Option 4 may be true, it is vitally important that the nurse first share the high probability of contracting a STD in a sexually active young adult who practices unprotected sex. DIF: C REF: 181 OBJ: Analysis

TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/High Risk Behaviors 22. Which of the following lifestyle choices poses the greatest risk for chronic illness to the young adult?

1 2 3 4

Alcohol and tobacco use Ignoring seat belt and helmet laws Unprotected sex with multiple partners Poor nutrition and a lack of structured exercise

ANS: 1 Lifestyle choices of young adults (e.g., use of tobacco or alcohol) put them at risk for chronic illnesses or disabilities during their middle or older adult years. While ignoring seat belt and helmet laws represents a risk factor for injury or death it is not directly related to chronic illness. While unprotected or multiple-partner sex option does represent a risk factor for chronic disease in the form of STDs, the greater risk comes from alcohol and tobacco use. While poor nutrition and lack of exercise do represent risk factors for chronic disease such as heart disease and obesity, the greater risk comes from alcohol and tobacco use. DIF: C REF: 181 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/High Risk Behaviors 23. Which of the following client responses shows the best understanding regarding the management of risk factors for chronic illness among young adults?

Unprotected sex is just plain dangerous.

Everyone riding in my car wears a seatbelt.

Im a vegetarian, but I eat nonanimal protein. Ive never smoked and I drink only occasionally.

ANS: 4 Tobacco use and the abuse of alcohol put young adults at high risk for chronic illnesses in middle and older adult years. While Option 1 shows an understanding of the risk factor for chronic disease in the form of STDs, the greater risk comes from alcohol and tobacco use. While Option 2 shows an understanding of the risk factor for injury and death caused by vehicular accidents, it is not directly related to chronic illness. DIF: C REF: 181 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/High Risk Behaviors 24. Which of the following lifestyle choices poses the greatest risk for chronic illness to the young adult?

Alcohol and tobacco use

Ignoring seat belt and helmet laws

Unprotected sex with multiple partners Poor nutrition and a lack of structured exercise

ANS: 1 Lifestyle choices of young adults (e.g., use of tobacco or alcohol) put them at risk for chronic illnesses or disabilities during their middle or older adult years. DIF: C REF: 180-181 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/High Risk Behaviors 25. Which of the following client responses shows the best understanding regarding the management of risk factors for chronic illness among young adults?

Unprotected sex is just plain dangerous.

Everyone riding in my car wears a seat belt.

Im a vegetarian, but I eat non-animal protein.

Ive never smoked, and I drink only occasionally.

ANS: 4 Tobacco use and the abuse of alcohol put young adults at high risk for chronic illnesses in their middle and older adult years. DIF: C REF: 180-181 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/High Risk Behaviors 26. Which of the following client responses shows the best understanding regarding the management of risk factors for acquiring a sexually transmitted disease (STD) among young adults?

1 2

I may want to have children someday, so I need to be careful. Even though there are treatments for STDs, I dont take chances.

There is certainly enough literature out there on the use of condoms.

Having unprotected sex with someone my age is very risky business.

ANS: 4 Sexually transmitted diseases (STDs) remain a major public health problem for sexually active persons, with almost half of all new infections occurring in men and women younger than 24 years of age (USDHHS, CDC, 2004).

While it is true that some STDs can result in infertility, this option doesnt show the greatest understanding since it focuses on only one outcome. While some STDs respond well to early treatment, some STDs, such as genital herpes and human immunodeficiency virus (HIV), can only be managed since a cure is not currently available. DIF: C REF: 181 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: : Health Promotion and Maintenance/High Risk Behaviors 27. Which of the following statements made by a 27-year-old client shows the greatest need for further nursing assessment regarding the potential use of illegal drugs?

1 2 3 4

Whether you wear a helmet or not should be the choice of the motorcyclist. I fractured my hand 3 years ago when I got so mad I hit a wall in my dorm room. I like to drink a bit too much, and I lost my license once for drinking and driving. My father suffered from depression when he lost his job, and he still takes medication for it.

ANS: 3 Reports of arrests because of driving while intoxicated, wife or child abuse, or disorderly conduct are reasons for you to investigate the possibility of drug abuse more carefully. A tendency toward high-risk behavior such as extreme sports or not using safety equipment is not necessarily a risk factor for illegal drug use. A tendency toward violent behavior is not necessarily a risk factor for illegal drug abuse. A family history of depression is not necessarily a risk factor for illegal drug abuse. DIF: C REF: 181 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/High Risk Behaviors 28. Which of the following statements made by the parents of a newborn best reflects an understanding regarding the diagnosis of postpartum depression?

I helped my sister when she was depressed after the birth of her second child.

I have a wonderfully supportive family who will be there if I start feeling depressed.

Weve read over the literature, and Ill be able to recognize any signs of depression in my wife.

Most new moms get a little depressed, but we will be sure to pay attention to any real indications of a problem.

ANS: 3 Having someone in close contact with the new mom available to assess her for possible signs of postpartum depression shows both an understanding of the condition as well as a desire to manage it if it occurs. DIF: C REF: 180 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/ Family Systems; Psychosocial Integrity/Stress Management/Crisis Intervention 29. Which of the following questions asked by the nurse best assesses for the signs of pregnancy most likely observed in the second trimester?

Have you had any problems climbing steps?

2 3

Have you noticed any cramping in your abdomen? Have you experienced any nausea in the morning?

Have you had any problems with shoes that dont seem to fit?

ANS: 2 Braxton-Hicks contractions are noted during the second trimester of pregnancy. Edematous ankles and dyspnea may be experienced during the third trimester of pregnancy. Amenorrhea and nausea are physiological changes that may indicate pregnancy in the first trimester. Edematous ankles and dyspnea may be experienced during the third trimester of pregnancy. DIF: C REF: 183 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/ Ante/Intra/Postpartum and Newborn Care; Physiological Integrity/ Reduction of Risk Potential/Specific Systems Assessment 30. Which of the following client statements would be the best evidence that this young adult has adopted a positive strategy to promote his own personal emotional health?

I drink alcohol only on special occasions and then moderately.

I run at least three times a week; it seems to help me stay relaxed.

I watch for the signs of depression since my mother experienced it.

I know stress can affect my blood pressure, so I have it taken regularly.

ANS: 2 Exercise on a routine basis can be an effective strategy to reduce the stress experienced by young and middle adults. Exercise is a positive emotional health habit for this age group. Drinking alcohol in moderation is certainly a positive health habit, but it does not have the strongest impact on emotional health of the available options. DIF: C REF: 181 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Health Promotion and Maintenance/Lifestyle Choices; Psychosocial Integrity/Coping Mechanisms 31. Which of the following client statements, made by a young adult regarding health promotion habits, reflects a need for further client education by the nurse?

1 2

I go to the gym and work out 3 times a week with friends. My dad has high cholesterol, so I have mine checked yearly.

Diabetes runs in my family, so I watch my carbohydrate intake.

I drink alcohol only on weekends, when it doesnt interfere with work.

ANS: 4 The correct answer reflects a poor understanding of alcohol abuse. The primary criterion for healthy alcohol consumption is not drinking only when it will not affect work. Further education regarding responsible alcohol consumption and alcoholism is appropriate. The other options reflect a good understanding of health promotion habits. DIF: C REF: 181 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Health Promotion and Maintenance/Lifestyle Choices; Psychosocial Integrity/Coping Mechanisms 32. Which of the following nursing assessment questions is best directed toward determining the presence of a normal physiological change experienced by a middle-aged client?

Any problems with your teeth or gums?

Any family history of thyroid problems?

Do you have a skin-moisturizing routine? Are you having a problem with driving at night?

ANS: 3 There is a slow, progressive decrease in skin turgor in the middle-aged adult. Dental problems are not a normal physiological change seen in the middle-aged adult. Thyroid problems are not a normal physiological change seen in the middle-aged adult. Night blindness is not a normal physiological change seen in the middle-aged adult.

DIF: C REF: 185 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development 33. Which of the following nursing assessment questions is best directed toward determining the presence of an occupational hazard-related condition specific for a client working in a dry cleaning establishment?

Do you have any problems with rashes or itching?

2 3

How long have you worked in the dry cleaning business? Do you treat the minor burns you experience?

Do you drive the company van to make deliveries?

ANS: 1 Persons who work in dry cleaning establishments are exposed to solvents that may cause dermatitis or liver disease. While asking about the length of time employed is an appropriate assessment question, it is not directed toward identifying a response to any specific risk factor. While burns may be a risk factor for those working in the dry cleaning industry, the risk is not as specific as assessing for contact dermatitis. While automobile accident-related injuries may be a risk factor in this case, the risk is not as specific as assessing for contact dermatitis. DIF: C REF: 182 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/ Reduction of Risk Potential/ Specific Systems Assessment 34. Which of the following nursing assessment questions is best directed toward determining the presence of career stressors in a young adult?

What do you do to relieve stress for yourself?

What is the most stressful part of your daily job?

Career-wise, where would you like to be in 2 years? Do you miss much work as a result of injuries or illness?

ANS: 2 The correct option is an open-ended question that encourages the client to identify and discuss work-related stressors, which are a major source of stress for this age group. DIF: C REF: 182-183 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development; Psychosocial Integrity/Stress Management

35. Which of the following statements concerning health promotion habits made by a young adult best reflects an understanding regarding the primary cause of death and injury among that age group?

Eating a healthy, low-fat diet is very important to me.

AIDS is nothing to mess with, so I always practice safe sex. Regardless of what my friends say, I always wear a seat belt.

3 4

I enjoy mountain biking, but I always wear the right protection gear.

ANS: 3 Deaths and injury from motor vehicle accidents are significant among this age group. Developing healthy habits to prevent heart disease later in life is important, but heart disease is not the leading cause of mortality and morbidity for the young adult. Sexually transmitted diseases are a risk factor for this age group, but they do not represent the greatest risk for death and injury. An injury related to occupation and recreation is a risk factor, but it is not the major cause of mortality and morbidity in this age group. Chapter 14. Older Adults MULTIPLE CHOICE 1. A nurse is performing a physical examination on an older-adult client in an assisted living facility. On completion of the examination, the nurse compares the results to findings expected for individuals in this age-group. An expected finding for this client is:

Increased tactile responsiveness

Increased sensitivity to visual glare

Increased hearing acuity for higher tones

Increased thoracic expansion during ventilation

ANS: 2 A common physiological change in the older-adult client is an increased sensitivity to glare. Increased tactile responsiveness would not be an expected finding in the older-adult client. An expected physiological change in the older adult-client is a loss of hearing acuity for highfrequency tones (presbycusis). The older adult has decreased thoracic expansion during ventilation because of musculoskeletal changes. DIF: A REF: 198 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; Physiological Integrity/System Specific Assessment

2. A 70-year-old client asks the nurse to explain her hypertension as she is to have her blood pressure checked each shift. An appropriate response by the nurse as to why older clients often experience hypertension is because of:

Myocardial muscle damage

2 3

Reduction in physical activity Ingestion of foods high in sodium

Accumulation of plaque on arterial walls

ANS: 4 Although hypertension is not a normal physiological change of aging, older adults often experience hypertension because of vascular changes and accumulation of plaque on arterial walls, both of which reduce contractility. Vascular changes include thickening of vessel walls, narrowing of vessel lumen, and loss of vessel elasticity. Myocardial damage is not the reason for older adults commonly experiencing hypertension. Hypertension is not caused by a reduction in physical activity. Older adults with hypertension should be counseled on limiting fat and salt in their diet. However, ingestion of processed foods high in salt is not the reason why older clients often experience hypertension. DIF: A REF: 199 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Alteration in Body Systems 3. In reviewing changes in the older adult, the nurse recognizes that which of the following statements related to cognitive functioning in the older client is true?

Delirium is usually easily distinguished from irreversible dementia.

Therapeutic drug intoxication is a common cause of senile dementia. Reversible systemic disorders are often implicated as a cause of delirium.

3 4

Cognitive deterioration is an inevitable outcome of the human aging process.

ANS: 3 Delirium is a potentially reversible cognitive impairment that is often due to a physiological cause such as an electrolyte imbalance, cerebral anoxia, hypoglycemia, medications, tumors, cerebrovascular infection, or hemorrhage. Delirium is not always easily distinguishable from irreversible dementia. Because of the close resemblance between delirium and dementia, the

presence of delirium must be ruled out whenever dementia is suspected. The cause of senile dementia (e.g., Alzheimers disease) is not known. Medications and drug effects can cause delirium. Dementia is not an inevitable outcome of aging. DIF: A REF: 202 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; Physiological Adaptation/Alteration in Body Systems 4. A client has been recently diagnosed with Alzheimers disease. When teaching the family about the prognosis, the nurse must explain that:

Diet and exercise can slow the process considerably

Few clients live more than 3 years after the diagnosis

Many individuals can be cured if the diagnosis is made early

It usually progresses gradually with a deterioration of function

ANS: 4 Alzheimers disease usually progresses gradually with a deterioration in function. Medications, not diet and exercise, can slow the process of Alzheimers disease considerably. Clients may live years after the diagnosis of Alzheimers disease. There is no cure for Alzheimers disease but medications can be given to slow the progression of symptoms. DIF: A REF: 202 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Adaptation/Alteration in Body Systems 5. Which of the following statements accurately reflects data that the nurse should use in planning care to meet the needs of the older adult?

50% of older adults have two chronic health problems.

Cancer is the most common cause of death among older adults. Nutritional needs for both younger and older adults are essentially the same.

3 4

Adults older than 65 comprise the greatest users of prescription medications.

ANS: 4 This is a true statement. Approximately two thirds of older adults use prescription and nonprescription drugs with one third of all prescriptions being written for older adults.

Approximately 90% of adults older than 65 have at least one chronic health condition. Approximately 70% of older adults have multiple chronic conditions with arthritis, hypertension, heart disease, vision impairment, and diabetes mellitus being the most common in noninstitutionalized older adults. Heart disease is the leading cause of death in older adults. Nutritional needs of older adults are affected by their levels of activity and by clinical conditions. DIF: A REF: 209 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; Physiological Adaptation/Alteration in Body Systems 6. The nurse is aware that the majority of older adults:

Live alone

2 3

Live in institutional settings Are unable to care for themselves

Are actively involved in their community

ANS: 4 The majority of adults are indeed active within their community. The majority of older adults live with a spouse or have other living arrangements such as living with a family member. Most older adults live in noninstitutional settings. Most older adults are able to care for themselves. DIF: A REF: 193 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process 7. The nurse works with elderly clients in a wellness screening clinic on a weekly basis. Which of the following statements made by the nurse is the most therapeutic regarding their mobility?

Your shoulder pain is normal for your age.

Continue to exercise your joints regularly to your tolerance level.

Why dont you begin walking 3 to 4 miles a day, and well evaluate how you feel next week. Dont worry about taking that combination of medications since your doctor has prescribed them.

ANS: 2 Clients in the older adult age group should be advised to exercise their joints regularly to their level of tolerance. Shoulder pain is not a normal finding in the older adult. It may indicate a

condition such as arthritis. Exercise programs should begin conservatively and progress slowly. Periodic and thorough review of all medications being used is important to restrict the number of medications used to the fewest necessary. Concurrent use of medications increases the risk for adverse reactions. DIF: A REF: 207-208 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; Physiological Adaptation/Alteration in Body Systems 8. A long-term care facility sponsors a discussion group on the administration of medications. The participants have a number of questions concerning their medications. The nurse responds most appropriately by saying:

Dont worry about the medications name if you can identify it by its color and shape.

Unless you have severe side affects, dont worry about the minor changes in the way you feel.

Feel free to ask your physician why you are receiving the medications that are prescribed for you.

Remember that the hepatic system is primarily responsible for the pharmacotherapeutics of your medications.

ANS: 3 The nurse should encourage the older adult to question the physician and/or pharmacist about all prescribed drugs and over-the-counter drugs. The older adult should be taught the names of all drugs being taken, when and how to take them, and the desirable and undesirable effects of the drugs. The nurse should teach the client how to avoid adverse side effects and to report them to their care provider if they occur. If the client is disturbed by minor side effects, it could be an indication of beginning drug toxicity. Another possibility is that the client may become noncompliant with their medication because they dislike how the side effects make them feel. The hepatic system is not the only system responsible for the pharmacotherapeutics of medication. Older adults are at risk for adverse reactions because of age-related changes in the absorption, distribution, metabolism, and excretion of drugs. Changes in the GI system may affect absorption, distribution may be affected by changes in body composition and by reduced serum albumin levels, and changes in kidney functioning may impair excretion. DIF: A REF: 209 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; Pharmacological Therapies

9. Which of the following behaviors shows the greatest risk to an older adult as they attempt to minimize the effects of the aging process?

1 2 3 4

Increased cosmetic use Refusing to share their actual ages Spending less time with age-related peers Refusing assistance with certain activities

ANS: 4 Some older adults may deny functional declines associated with aging and refuse to ask for assistance with tasks that place their safety at great risk. Some older adults find it difficult to accept themselves as aging and attempt to conceal physical evidence of aging with cosmetics. Older adults who find it difficult to accept themselves as aging may understate their age when asked. Spending more time with other older adults is indicative of the older adults acceptance of personal aging. Those who find it difficult to accept themselves as aging may avoid activities designed to benefit older adults, such as senior citizens centers and senior health promotion activities. DIF: C REF: 195 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process 10. In performing a physical assessment for an older adult, the nurse anticipates finding which of the following normal physiological changes of aging?

Increased perspiration

Increased airway resistance

Increased salivary secretions Increased pitch discrimination

ANS: 2 Normal physiological changes of aging include increased airway resistance in the older adult. The older adult would be expected to have decreased perspiration and drier skin as they experience glandular atrophy (oil, moisture, sweat glands) in the integumentary system. The older adult would be expected to have a decrease in saliva. A normal physiological change of the older adult related to hearing is a loss of acuity for high-frequency tones (presbycusis). DIF: A REF: 199 OBJ: Knowledge TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; Physiological Adaptation/Alteration in Body Systems 11. There are factors that influence the musculoskeletal system associated with aging. The nurse recognizes that with age:

Men have the greatest incidence of osteoporosis

Muscle fibers increase in size and become tighter

Weight-bearing exercise reduces the loss of bone mass

Muscle strength does not diminish as much as muscle mass

ANS: 3 Older adults who exercise regularly do not lose as much bone and muscle mass or muscle tone as those who are inactive. Postmenopausal women have a greater problem with osteoporosis than older men. Muscle fibers are reduced in size with aging. Muscle strength diminishes in proportion to the decline in muscle mass. DIF: A REF: 207-208 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; Physiological Adaptation/Alteration in Body Systems 12. The nurse, preparing to discharge an 81-year-old client from the hospital, recognizes that the majority of older adults:

Require institutional care

Have no social or family support

Are unable to afford any medical treatment Are capable of taking charge of their own lives

ANS: 4 The majority of older adults are interested in their health and are capable of taking charge of their lives. Most older adults do not require institutional care. The majority of older adults have social or family support. Most older adults live with a spouse or have other living arrangements, such as living with a family member. Most older adults receive Social Security benefits and are able to afford medical treatment. DIF: A REF: 93 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process

13. To assist older adults to meet their needs for sexuality, the nurse should recognize that the greatest impact on the sexuality of older adults is:

1 2 3 4

Therapeutic medications may alter sexual function Sexual interest declines and then fades completely with age Physiological changes do not adversely influence sexual activity Prevention of sexually transmitted diseases is no longer an issue

ANS: 1 Many older adults use prescription medications that depress sexual activity, such as antihypertensives, antidepressants, sedatives, or hypnotics. Some drugs increase libido in older adults. For example, phenothiazines increase sexual desire in women, and levodopa has a similar effect in men. It is a common misconception that older adults are not interested in sex. The older adults libido does not decrease, although frequency of sexual activity may decline. Physiological changes may have an adverse influence on sexual activity. The older man may experience decreased firmness in his erection, a decreased need for ejaculation with orgasm, or a longer recovery period between episodes of intercourse. The older woman may experience vaginal dryness. Information about the prevention of sexually transmitted diseases should be included when appropriate. DIF: A REF: 203-204 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; Physiological Adaptation/Alteration in Body Systems 14. The nurse is presenting an information session on nutritional guidelines at a senior living center. Incorporated into the discussion are the recommendations for nutritional intake for individuals of this age-group, which include a reduction in:

Fiber

Protein

Vitamin A

Refined sugars

ANS: 4 Good nutrition for older adults includes a limited intake of refined sugars. Fiber should not be reduced as it has benefits of aiding bowel elimination and lowering cholesterol. Protein should not be reduced. Protein intake may be lower than recommended if older adults have reduced

financial resources or limited access to grocery stores. Difficulty chewing meat may also limit protein intake. Vitamin A does not need to be reduced in the older adult. Vitamin intake may be less than recommended if shopping for fresh fruits and vegetables is difficult. DIF: A REF: 207 OBJ: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; Physiological Adaptation/Alteration in Body Systems 15. The nurse is presenting an information session on nutritional guidelines at a senior living center. Which of the following foods meets the recommended nutritional guidelines for older adults?

Grilled chicken

2 3

Hamburger and french fries Hot dog with dill pickle relish

Baked potato with cheese and bacon bits

ANS: 1 Grilled chicken would be a good source of protein that is also low in fat. A hamburger and french fries are high in fat content and calories, making them a less desirable food choice. A hot dog with pickle relish is high in fat and sodium. Good nutrition for the older adult includes a limited intake of fat and salt. A baked potato with cheese and bacon bits is higher in calories and fat. A plain baked potato would be a healthier food choice. DIF: A REF: 207 OBJ: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; Physiological Adaptation/Alteration in Body Systems 16. In the assessment of older-adult clients, it is often difficult to discriminate between delirium and dementia. Delirium is characterized by:

A slow progression

Lasting months to years

A normal state of alertness

Occurrences at twilight or darkness

ANS: 4 Delirium is characterized by short, diurnal fluctuations in symptoms and is worse at night, in darkness, and on awakening. Delirium has an abrupt onset. Dementia has a slow progression.

Delirium lasts hours to less than 1 month, seldom longer. Dementia may last months to years. Delirium is characterized by fluctuating alertness; the client may be lethargic or hypervigilant. Alertness is generally normal with dementia. DIF: A REF: 202 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; Physiological Adaptation/Alteration in Body Systems 17. Which of the following nursing questions is best directed towards the assessment of a normal finding regarding physiological changes in an older-adult client?

Any difficulty driving at night?

Are you experiencing any loss of libido?

Do you see yourself as becoming forgetful

Have you had your cholesterol tested lately?

ANS: 1 A common physiological change in the older-adult client is an increased sensitivity to glare, which makes night driving difficult. Decreased sexual drive is not a normal physiological change of aging. Memory loss is not a normal physiological change of aging. Hyperlipidemia is not a normal physiological change of aging, nor should it be monitored only by the older adult. DIF: C REF: 198 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health promotion and Maintenance/Aging Process; Physiological Integrity/System Specific Assessment 18. Which of the following responses by an older-adult client is most reflective of a need for further education by the nurse regarding the physiological changes associated with the olderadult?

I call a cab if I want to go out after dark.

I cant help worrying about becoming forgetful.

I have my eyes checked regularly. Cant afford to fall.

I really enjoy eating good vanilla ice cream, but I have cut way down.

ANS: 2 Although some forgetfulness is accepted, memory loss is not a normal physiological change of aging. This expressed fear requires further education by the nurse so as to help eliminate the

clients concerns. A common physiological change in the older-adult client is an increased sensitivity to glare, which makes night driving difficult. A common physiological change in the older-adult client is an alteration in visual acuity, which would require regular vision check-ups. Hyperlipidemia is a concern regarding cardiac health and should be considered by the older adult. DIF: C REF: 201 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Health promotion and Maintenance/Aging Process; Physiological Integrity/System Specific Assessment 19. Which of the following statements made by a family member of a client recently diagnosed with Alzheimers disease is most reflective of an understanding of this disease process?

Dad has always been a fighter; hell fight this too. He wont give up.

We have an appointment with his care provider to see about medication therapy.

Good thing we found out about this early so steps can be taken to keep it from getting worse.

It usually progresses gradually so we are hoping it will be a while before his memory is gone.

ANS: 2 Medications can slow the process of Alzheimers disease considerably when prescribed appropriately. There is no cure for Alzheimers disease. This option suggests that the family member still clings to the hope that there is a cure. Alzheimers disease usually progresses gradually with a deterioration in function, but medications can be given to slow the progression of symptoms, not halt them. Although Alzheimers disease usually progresses gradually with a deterioration in function with some clients living years after the diagnosis of Alzheimers disease, this option does not reflect the best understanding because no mention of management is made. DIF: C REF: 202 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Physiological Adaptation/Alteration in Body Systems; Psychosocial Integrity/Sensory Perception Alterations 20. The nurse is planning client education for an older adult being prepared for discharge home after hospitalization for a cardiac problem. Which nursing action addresses the most commonly determined need for this age-group?

Suggest that he purchase an emergency in-home alert system.

Arrange for the client to receive meals delivered to his home daily.

Encourage the client to use a compartmentalized pill storage container for his daily medications. Provide a written document describing the medications the client is currently prescribed.

ANS: 3 Approximately two thirds of older adults use prescription and nonprescription drugs with one third of all prescriptions being written for older adults. A system that allows the client to sort his medication for daily dosage would help minimize the risk of overdosing as well as missing ordered medications. While this option addresses the risk of injury in the home, it does not address the greatest need experienced by this age-groupthe risk of overmedication or undermedication of prescribed drugs. While this option does address the clients nutritional needs, it does not address the greatest need experienced by this age-groupthe risk of over- or undermedication of prescribed drugs. Although this option does address the clients need to monitor the medications he is prescribed, it does not address the greatest need experienced by this agegroupthe risk of overmedication or undermedication of prescribed drugs on a daily basis. DIF: C REF: 209 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; Safe, Effective Care Environment/Safety Promotion/Safe Home Environment 21. An assisted living facility has provided its clients with an educational program on safe administration of prescribed medications. Which statement made by an older-adult client reflects the best understanding of safe self-administration of medications?

I dont seem to have problems with side effects, but Ill let my doctor know if something happens.

Im lucky since my daughter is really good about keeping up with my medications.

Ill be sure to read the inserts and ask the pharmacist if I dont understand something.

It shouldnt be too hard to keep it straight since I dont have any really serious health issues.

ANS: 3

This option reflects an understanding of the importance to understand the various aspects of the medication and its effects on the client. The older adult should be encouraged to question the physician and/or pharmacist about all prescribed drugs and over-the-counter drugs. Although this option reflects an understanding of potential risk for side effects, it is not the best option because it focuses on only one aspect of self-medication. This option appears to have the client delegating responsibility to the daughter. This option appears to have the client minimizing the importance of informed self-administration. DIF: C REF: 209 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; Pharmacological Therapies 22. Which of the following client statements regarding self-medication administration by an older-adult client requires follow-up teaching by the nurse?

I take all the pills ordered once a day at bedtime, so Im less likely to forget them.

I have one pill that needs cut in half. I am going to ask the pharmacist to do that for me.

The pharmacist said to keep my pills away from the sunlight, so I put them inside the kitchen cabinet.

My daughter comes over each morning and puts my pills into a container that sorts them by the time they are due.

ANS: 1 There may be a concern regarding drug interactions if all the medications are taken at the same time. The nurse should have a discussion with the client to determine if this practice is appropriate. This option shows the clients willingness to deal with this issue effectively and safely. This option shows an appropriate intervention for keeping the pills out of sunlight. This option shows an appropriate intervention for dealing with multiple medication schedules. DIF: C REF: 209 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; Safe and Effective Care Environment/Safety Promotion/Safe Home Environment 23. Which of the following statements made by an older-adult client poses the greatest concern for the nurse conducting an assessment regarding the clients adjustment to the aging process?

I use to enjoy dancing and jogging so much, but now I have arthritis in my knees so that its hard to even walk.

Ive given my grandchildren money for college so they can live a better life than I had.

Growing old certainly presents all sorts of challenges. I wish I knew then what I know now. As I age Ive found its harder to do the things I love doing, but I guess it will all be over soon enough.

ANS: 4 This option should give the nurse concern over the clients possible depression because there are indications of possible suicide. This option does reflect regret over the inability to do the things previously enjoyed and the presence of a painful condition, but it does not present the seriousness of other available options. This option does reflect regret regarding life situations, but it does not present the seriousness of other available options. This option does reflect regret over the perceived changes, but it does not present the seriousness of other available options. DIF: C REF: 209-210 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; Psychosocial Integrity/Coping Mechanisms 24. Which of the following statements made by a 75-year-old client shows the best understanding of how the aging process affects the musculoskeletal system?

I drink milk and eat cheese to get my calcium. I walk 1 mile everyday to strengthen my bones.

I wear sensible shoes so I wont sprain an ankle.

At my age I might never fully recover from a hip fracture.

ANS: 2 Older adults who exercise regularly do not lose as much bone and muscle mass or muscle tone as those who are inactive. Walking regularly shows that this client has an understanding of and the disciple to work on health promotion habits for a healthy musculoskeletal system. While this option shows an understanding regarding osteoporosis and the need for calcium, it is not the best option because it focuses on only one aspect of musculoskeletal health. This option focuses only on safety measures, and so it is not the best option. While this option shows an understanding regarding the seriousness of a hip fracture for someone of older age, it is not the best option because it focuses on only one aspect of musculoskeletal health. DIF: C REF: 208 OBJ: Analysis TOP: Nursing Process: Evaluation

MSC: Process/Health Promotion Programs; Physiological Adaptation/Alteration in Body Systems 25. Which statement made by an older adult would reflect the best understanding of the nutritional requirements of individuals at this developmental stage?

An apple a day is my motto; always has been.

I eat everything, but just a little a bit of things like sweets.

Fiber is more important than ever to my digestive system.

I dont need the fat so Ive taken to drinking protein shakes.

ANS: 2 Good nutrition for older adults includes a balanced diet with limited intake of refined sugars. This is not the best option because it focuses on only one aspect of nutrition. This option is not the best choice because it focuses on only one aspect of nutrition. This is not the best option because it focuses on only one aspect of nutrition. DIF: C REF: 207 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process/Health Promotion Programs 26. Which statement made by an older adult would reflect the best understanding of the nutritional guidelines for this age-group?

I can prepare grilled chicken at least 10 different, delicious ways.

When I entertain, I serve healthy foods like veggies and lowfat dip.

I know I need to eat nutritiously, and I have certainly been doing better. I take seriously the suggestions my health team gives me on healthy eating.

ANS: 2 This option shows an understanding of healthy eating as well as a commitment to incorporating this knowledge into everyday living. While this is a good option, it is not as encompassing regarding knowledge and commitment as other options. This option leaves some doubt as to how committed the client really is to nutritional eating. While this is a good option, it is not as encompassing regarding knowledge and commitment as other options.

DIF: C REF: 207 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process/Health Promotion Programs 27. Which of the following statements made by an older adult regarding sexuality would be of greatest concern for the nurse?

Will this new medication affect my libido?

What can I do to help with vaginal dryness?

I really miss the intimacy my husband and I shared.

Its so nice not to have to worry about an unwanted pregnancy.

ANS: 4 This option infers that the client is sexually active and not using protection because there is no longer a possibility of conception. Information about the prevention of sexually transmitted diseases should be included when appropriate because there is a growing number of older adults contracting STDs. Many older adults use prescription medications that depress sexual activity, such as antihypertensives, antidepressants, sedatives, or hypnotics. This question requires further education but the statement does not arouse concern regarding the clients safe sex practices. Physiological changes may have an adverse influence on sexual activity. The older woman may experience vaginal dryness. This question requires further education, but the statement does not arouse concern regarding the clients safe sex practices. It is a common misconception that older adults are not interested in sex. This statement would require further discussion to assess the degree of distress the situation is causing the client, but the statement does not arouse concern regarding the clients safe sex practices. DIF: C REF: 203-204 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; Physiological Adaptation/Alteration in Body Systems 28. Of the following options, which is the greatest barrier to providing quality health care to the older-adult client?

Poor client compliance resulting from generalized diminished capacity

Inadequate health insurance coverage for the group as a whole

Insufficient research to provide a basis for effective geriatric health care

Preconceived assumptions regarding the lifestyles and attitudes of this group

ANS: 4 Despite ongoing research in the field of gerontology, myths and stereotypes about older adults persist. These include false ideas about the physical and psychosocial characteristics and lifestyles of older adults. However, when health care providers hold negative stereotypes about aging, those stereotypes negatively affect the quality of the care. While there may be poor compliance related to diminished physical and cognitive capacity, it is not the primary barrier to effective care of this developmental group. While there are numbers of the older-adult population who are underinsured, it is not the primary barrier to effective care of this developmental group. A lack of research regarding the unique needs of this age-group is not the primary barrier to providing effective care. DIF: C REF: 93 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; Physiological Adaptation/Alteration in Body Systems 29. The nurse is preparing an educational program for members of the local senior center. Which of the following topics would present the greatest learning challenge for this developmental group?

Exercising arthritic joints

2 3

Tips for living with GERD Importance of the human touch

Principles of heart-healthy eating

ANS: 3 Of the available topics, Importance of the human touch is possibly the most abstract in nature. Older adults are lifelong learners, but concrete rather than abstract material appears to be a better choice for the learning style of most older adults. This option is concrete in nature and so a better choice for the learning style of most older adults. This option is concrete in nature and so a better choice for the learning style of most older adults. This option is concrete in nature and so a better choice for the learning style of most older adults. DIF: C REF: 210 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process/Health Promotion Programs

30. When presenting information to the older adult, the client will be most likely to engage with the nurse in the learning process if:

1 2 3 4

Client feedback is encouraged and valued Physical disabilities are accommodated for The topic or information is valued by the learner New knowledge is connected to knowledge already processed

ANS: 3 The older adult learner will be more interested and willing to participate actively in the learning if they have been given the opportunity to determine the values of the information to them personally. DIF: C REF: 193 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; 31. Of the following client statements made by an older adult client which best reflects an understanding the educational materials on nutrition presented by the nurse?

Ill keep this literature and read it again later.

I love rye bread. Its good to know its high in fiber.

Nutrition and cooking has always been passions of mine.

Now I can see the connection between food and my health.

ANS: 2 The correct option shows the client making a connection between a type of food, its nutritional value, and its impact on personal health DIF: C REF: 193 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; Physiological Adaptation/Alteration in Body Systems 32. The nurse defines ageism most accurately as:

The undervaluing of individuals based on their age.

Perception of a persons worth based on productivity

Biases directed towards individuals considered aged

Discrimination based on an individuals increasing age

ANS: 4 The correct option best describes ageism since it identifies discrimination towards a person based solely on the persons age. Devaluing is one aspect of ageism but this option failed to identify discrimination as the goal. While perception of a persons worth is a criteria used to judge, it is not the most complete description of the term. Bias and discrimination are the outcomes of ageism. DIF: C REF: 207 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process 33. Which of the following statements made by a nurse best reflects an understanding of the negative impact of ageism regarding client care?

If I dont value the older client, I will never be able to provide the care they are entitled too.

Everyone, regardless of age or position, always deserves effective, appropriate nursing care.

As a society we lose so much valuable wisdom and knowledge when we devalue our older members.

If older clients do not feel valued, they are less likely to seek the health care they need and deserve.

ANS: 1 According to experts in the field of gerontology, unopposed ageism has the potential to undermine the self-confidence of older adults, limit their access to care, and distort caregivers understanding of the uniqueness of each older adult. Health care providers must be free of such an unethical attitude so that client care will never be compromised. This is a truism that is not specific to ageism Chapter 15. Critical Thinking in Nursing Practice MULTIPLE CHOICE 1. Which of the following best reflects the philosophy of critical thinking as taught by a nurse educator to a nursing student?

Think about several interventions that you could use with this client.

Dont draw subjective inferences about your clientbe more objective.

Please think harderthere is a single solution for which I am looking.

Trust your feelingsdont be concerned about trying to find a rationale to support your decision.

ANS: 1 The nurse educator is asking the student to synthesize critical thinking skills by encouraging the student to examine alternatives to meet the clients unique needs within the context of the nursing process. Drawing inferences is a specific critical thinking competency used in diagnostic reasoning. The educator who tells the student not to draw inferences is not allowing the student to practice competencies necessary for specific critical thinking in clinical situations. The critical thinker will look beyond a single solution to a problem. Intuition develops as ones clinical experience increases. The nursing student should examine rationales in order to make good decisions. DIF: C REF: 216 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 2. The second component of critical thinking in the critical thinking model is:

Experience

2 3

Competencies Specific knowledge

Diagnostic reasoning

ANS: 1 Experience is the second component of critical thinking in the critical thinking model. The third component of the critical thinking model is competencies. Specific knowledge base is the first component of the critical thinking model. Diagnostic reasoning is a specific critical thinking competency in clinical situations. DIF: A REF: 222 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 3. The nurse enters the room of a client who has a history of heart disease. On looking at the client, the nurse feels that something is not right with the client and proceeds to take the vital signs. This is the nurse acting on:

Intuition

Reflection

Knowledge Scientific methodology

ANS: 1 Intuition is an inner sensing that something is so, as in this example. Reflection is the process of purposefully thinking back or recalling a situation to discover its purpose or meaning. Knowledge of the nurse includes information and theory from the basic sciences, humanities, behavioral sciences, and nursing. Scientific methodology is an approach to seeking the truth or verifying that a set of facts agrees with reality. DIF: A OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 4. The nurse manager has developed a staff protocol for peer evaluation. The nurses on her surgical unit are nervous about using her instrument. If the nurse manager continues to implement the new strategy, which of the following critical thinking attitudes is she portraying?

Humility

Risk-taking

Accountability

Independent thinking

ANS: 2 This is an example of the critical thinking attitude of risk-taking. A critical thinker is willing to take risks in trying different approaches to solving problems. Humility is a critical thinking attitude in which a person admits what they do not know and tries to acquire the knowledge needed to make proper decisions. To be accountable means to be answerable for the outcomes of your actions. To think independently, one questions others ways of interpreting knowledge and looks for rational and logical answers to problems. DIF: A REF: 224 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 5. The nurse is working with a client who has recently had a colostomy and is having difficulty using the provided supplies. The nurse works with the client to see which alternative supplies are easier for the client to use. This is an example of the critical thinking strategy of:

Inference

Management

Problem-solving Diagnostic reasoning

ANS: 3 This is an example of the critical thinking strategy of problem-solving. The nurse gathers information from the client and combines that information with what the nurse already knows about ostomy care to find a solution. Effective problem-solving involves the examination of alternatives. Inference is the process of drawing conclusions. Management is not a critical thinking strategy. Diagnostic reasoning is a process of determining a clients health status after the nurse assigns meaning to the behaviors, physical signs, and symptoms presented by the client. DIF: A REF: 219 OBJ: Comprehension TOP: Nursing Process: Assessment/Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 6. Which of the following is an example of a nurses statement that reflects using the scientific method in the nursing process?

I believe that this client is getting depressed.

The client doesnt look right to me; I think something is wrong.

The clients husband told me that she is feeling very uncomfortable.

The client reports more pain than yesterday and her blood pressure is elevated.

ANS: 4 Reporting more pain than yesterday and elevated blood pressure reflects using the scientific method in the nursing process. The nurse identified a problem of pain, hypothesized that it was greater than the day before, and collected data to evaluate its reality. Believing the client is depressed or thinking something is wrong reflect intuition. Speaking with the husband reflects information gathering, which may be used in diagnostic reasoning. DIF: A REF: 218 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 7. The nurse decides to administer tablets of Tylenol instead of the intramuscular Demerol she has previously been providing her orthopedic client. Which step of the nursing process does this address?

Assessment

2 3

Nursing diagnosis Planning

Implementation

ANS: 4 Taking appropriate action demonstrates the implementation step of the nursing process. Assessment involves the gathering of data. When formulating a nursing diagnosis, the nurse critically examines and analyzes the data, and identifies the clients response to a problem. The nurse may then determine priorities. Planning involves establishing goals and expected outcomes of care. DIF: A REF: 221 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 8. The nurse has a multiple client assignment on the surgical unit. On beginning the shift, the nurse needs to determine which postoperative client should be seen first. Of the following, the nurse should go to see the client who:

Has a documented blood pressure of 90/50

Was medicated for back pain 10 minutes ago

Has an order to be out of bed and ambulated

Requires instructions for wound care before discharge

ANS: 1 The nurse prioritizes actions and determines to see this client first because of a lower than normal blood pressure for a postoperative patient. This nurse is using scientifically and practicebased criteria for making clinical judgment. This is an example of following standards. The nurse uses criteria such as the clinical condition of the client, Maslows hierarchy of needs, and risks involved in treatment delays to determine which clients have the greatest priority for care. In answers 2 through 4, the client is not reported to be having any problems and therefore is not the priority. DIF: C REF: 221 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordination/Setting Priorities 9. There are a variety of levels of critical thinking. An example of critical thinking at the complex level is:

Giving medication at the time ordered

2 3

Following a procedure for catheterization step-by-step Reviewing all clients medical records thoroughly

Discussing various alternative pain management techniques

ANS: 4 Discussing alternative pain management techniques is an example of critical thinking at the complex level. The nurse analyzes and examines alternatives more independently. Giving medication at the time ordered is an example of the basic level of critical thinking. Following a procedure step-by-step is an example of the basic level of critical thinking. Reviewing the clients medical records thoroughly is an example of gathering data and may be used in evaluation of a clients care. DIF: C REF: 218 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 10. The nurse is deciding on the type of dressing to use for a client. Which step of the decisionmaking process is being used when the nurse observes the absorbency of different dressing brands?

Defining the problem

Making final decisions

Testing possible options

Considering consequences

ANS: 3 The nurse who observes the absorbency of different brands of dressing is demonstrating testing of possible options. This is not an example of defining the problem. The nurse has not yet made a final decision. The nurse is not examining pros and cons, and therefore is not considering consequences. DIF: A REF: 219 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 11. Which one of the following examples demonstrates the critical thinking attitude of responsibility and authority?

Reporting client difficulties

Offering an alternative approach

Looking for a different treatment option Sharing ideas about nursing interventions

ANS: 1 Reporting client difficulties demonstrates the critical thinking attitude of responsibility and authority. Asking for help if uncertain and following standards of practice also demonstrate the critical thinking attitudes of responsibility and authority. Offering an alternative approach would demonstrate the critical thinking attitude of risk-taking. Looking for a different treatment option demonstrates the critical thinking attitude of creativity. Sharing ideas about nursing interventions demonstrates the critical thinking attitude of thinking independently. DIF: A REF: 223 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 12. Use of the intellectual standard of critical thinking implies that the nurse:

Questions the physicians order

Recognizes conflicts of interest

Listens to both sides of the story

Approaches assessment logically

ANS: 4 Use of the intellectual standard of critical thinking implies that the nurse approaches assessment logically and consistently. Questioning the physicians order is an example of the critical thinking attitude of risk-taking. Recognizing conflicts of interest demonstrates the critical thinking attitude of integrity. Listening to both sides of the story demonstrates the critical thinking attitude of fairness. DIF: A REF: 225 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 13. A client requires urinary catheterization but has difficulty keeping her legs in the usual position needed for this procedure. The nurse has worked for many years and adapts the procedure to allow the client to lie on her side. This action is based on the critical thinking element of:

Curiosity

Experience

Perseverance

Scientific knowledge

ANS: 2 Having worked for many years and being able to adapt a procedure to meet the clients needs is an example of the second component of the critical thinking modelexperience. Curiosity is a critical thinking attitude where the nurse asks why, and continues to learn more about the client to make appropriate clinical judgments. Perseverance is a critical thinking attitude where the nurse does not readily accept the easy answer but does look further to find necessary information and appropriate solutions. Scientific knowledge is knowledge acquired from the study of science. It may be acquired through education, such as coursework, or by reading nursing literature to remain current in nursing science. DIF: A REF: 222 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 14. Which of the following statements made by a nursing student concerning the use of critical thinking and client care requires follow-up by the nursing instructor?

I feel its good practice to always have alternative interventions in mind.

I trust my feelings about a clients needs since I work hard at knowing my client. I always try to keep an open mind about what interventions my client will require.

3 4

I will wait until my assessment is completed before determining the clients needs.

ANS: 2 Intuition develops as ones clinical experience increases. The nursing instructor should instruct the student to examine rationales in order to make good decisions regarding client needs. The instructor would encourage the student to examine alternatives to meet the clients unique needs, so this statement would not require follow-up. Basing client care on identified client needs is the appropriate use of critical thinking, and so would not require follow-up. Basing client care on client needs identified by thorough nursing assessments is the appropriate use of critical thinking, and so would not require follow-up. DIF: C OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment

15. Which of the following is the best example of a nurses use of reflection?

The nurse places a client experiencing respiratory difficulties in a high-Fowlers position.

The nurse calls the provider when a client reports feeling chilled and achy while having an oral temperature of 100.2 F.

While caring for a client with a history of asthma, the nurse assesses the clients pulse oximetry reading when he doesnt sound right.

A nurse tells a client; When you refused to go to physical therapy earlier today I believe you were upset about something else besides the appointment time.

ANS: 4 Reflection is the process of purposefully thinking back or recalling a situation to discover its purpose or meaning. Knowledge of the nurse includes information and theory from the basic sciences, humanities, behavioral sciences, and nursing. Scientific methodology is an approach to seeking the truth or verifying that a set of facts agrees with reality. Intuition is an inner sensing that something is so, as in this example. DIF: C REF: 226 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 16. Which of the following nursing situations best reflects accountability?

The nurse takes the oncology nursing certification examination.

The nurse files an incident report regarding a medication error.

The nurse assesses the client for the possible cause of his pain.

The nurse tells the client, I dont know but I will find out for you.

ANS: 2 To be accountable means to be answerable for the outcomes of your actions. Answer 2 is an example of the critical thinking attitude of risk-taking. A critical thinker is willing to take risks in trying different approaches to solving problems. To think independently, one questions others ways of interpreting knowledge and looks for rational and logical answers to problems. Humility

is a critical thinking attitude where a person admits what they do not know and tries to acquire the knowledge needed to make proper decisions. DIF: C REF: 224 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 17. Which of the following nursing actions is the best example of problem solving?

Requesting the IV team to start an antibiotic drip on a client with a history of being a difficult stick

Offering to call the kitchen to provide an alternate breakfast for a client who does not like cooked cereal Trying several difficult wound dressings to determine which one the client can apply the most effectively

3 4

Calling for another pain medication order when the current drug results in the client experiencing nausea

ANS: 3 This is an example of the critical thinking strategy of problem solving. The nurse gathers information by using several different products and then uses this information to determine which will work best for the client. Effective problem solving involves the examination of alternatives. While requesting the IV team solves a problem, there is little critical thinking needed because it would be understood that the IV team would be called under these circumstances. Although calling the kitchen solves a problem, there is little critical thinking needed because it would be understood that the kitchen would be called under these circumstances. Calling for another pain medication order solves a problem, but there is little critical thinking needed because it would be understood that the provider would be called for a new drug order under these circumstances. DIF: C REF: 219 OBJ: Analysis TOP: Nursing Process: Assessment/Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 18. Which of the following clients should be prioritized with the most urgent need for a nursing assessment?

A new admission admitted for swelling in the right ankle and knee

A second day postoperative client who received pain medication 30 minutes ago

A client who the nursing assistant found crying in the bathroom

A client ready for discharge who requires a final assessment and documentation

ANS: 3 This client has an acute need that requires the nurses attention. The facility has a policy regarding the amount of time available in which to complete such an assessment and this client is in no acute distress, so the assessment does not have priority. While a pain assessment is required to evaluate the effectiveness of pain medication, it does not the have the priority of the other presented options. This client has no acute problems and so the assessment does not have the priority of some of the other options. DIF: C REF: 221 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 19. Which of the following nursing interventions is the best example of the implementation step of the nursing process?

Determining that the clients ankle edema is worse after he ambulates

Asking the client to rate his ankle pain after receiving oral pain medication

Arranging for the client to receive pain medication 30 minutes before his ordered ambulation

Crushing the clients pain medication to facilitate easier swallowing and thus minimize the risk of choking

ANS: 4 Taking appropriate action demonstrates the implementation step of the nursing process. Assessment involves the gathering of data. Assessment involves the gathering of data. Planning involves establishing goals and expected outcomes of care. DIF: C REF: 221 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 20. Which of the following nursing actions best reflects the consequence stage of the decisionmaking process?

Being physically present when a client is given the results of a tissue biopsy

Witnessing the client sign consent for surgery forms before cardiac surgery The client is informed of the various treatments available for his condition.

3 4

The nurse explains to the client the risks of leaving the hospital against medical advice.

ANS: 4 The nurse is presenting the possible outcomes, and therefore is presenting consequences. Being physically present is not an example of defining the problem. Witnessing the client sign consent is an example of a final decision. In Answer 3 the client is being given various options. DIF: C REF: 219 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 21. The concept of nursing responsibility is best reflected in which of the following nursing actions?

Providing accurate and timely documentation regarding an incident resulting in a client fall

Suggesting that a client might prefer taking a particular medication at bedtime instead of in the morning

Posting a note on the unit Kardex how to best apply a dressing to a skin wound on a particular client Referring to the institutions policy manual when unsure of how to handle a clients complaint regarding a social services consult

ANS: 4 Asking for help if uncertain and following standards of practice best demonstrate the critical thinking attitudes of responsibility because failure to do so could result in client injury. Reporting client difficulties demonstrates the critical thinking attitude of responsibility but is not the best option of those available because it would not result in client injury/harm. Offering an alternative approach would best demonstrate the critical thinking attitude of risk-taking. Sharing ideas about nursing interventions best demonstrates the critical thinking attitude of thinking independently.

DIF: C REF: 224 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 22. Which of the following situations is the best example of a nurse using intellectual standards as a critical thinking tool?

1 2 3 4

Performing a head-to-toe assessment on a new admission Placing a client experiencing shortness of breath on oxygen Arbitrating a complaint between roommates over the television Notifying a provider of a clients allergy to an ordered medication

ANS: 2 Use of the intellectual standard of critical thinking implies that the nurse approaches nursing care logically, consistently, and appropriately. This option reflects the use of such standards in a situation that addresses client distress. While performing a head-to-toe assessment is an example of intellectual standards, it is not the best example because it does not involve a clients immediate distress. Listening to both sides of the story demonstrates the critical thinking attitude of fairness. Notifying a provider of a clients allergy is an example of nursing responsibility. DIF: C REF: 225 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 23. The nurse is best demonstrating perseverance by:

Having a perfect attendance record

Completing a lengthy course on current chemotherapies

Repeatedly irrigating the nasogastric tube until it is patent

Sitting with a client until she is ready to discuss why she is crying

ANS: 4 Perseverance is a critical thinking attitude in which the nurse does not readily accept the easy answer but does look further to find necessary information and appropriate solutions. While perfect attendance shows a nurses willingness to complete the work responsibilities regardless of barriers, it is a better representation of responsibility. While completing a course on current chemotherapies shows the nurses willingness to pursue knowledge, it is more representative of

the acquiring of scientific knowledge to remain current in nursing science. While repeatedly irrigating the nasogastric tube shows a willingness to repeat a procedure as often as is appropriate, it is a better representation of possessing knowledge of the procedure. DIF: C REF: 224 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 24. With regards to client care, the most likely reason that a veteran nurse tends to be a more skillful critical thinker than a new graduate nurse is because:

The veteran nurse has a varied history of client care experiences

Critical thinking improves with experience, longevity, and interest Todays short hospital stays minimize the opportunity to develop critical thinking skills

3 4

New graduates often lack the self-confidence to take the risks often required of critical decision making

ANS: 2 Critical thinking is not a simple step-by-step, linear process that you learn overnight. It is a process acquired only through experience, commitment, and an active curiosity toward learning. While experience is a factor in the development of critical thinking skills, it is not the only factor. While having extended periods of time with clients has a positive effect on the development of critical thinking, it is not the primary or sole factor. While lack of self-confidence may have a negative effect on the development of critical thinking skills, it is not the primary or sole factor. DIF: C REF: 216 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 25. The primary factor that distinguishes a professional nurses care from care provided by ancillary nursing staff is:

Critical thinking

Years of education

Professional licensure Complexity of the task

4 ANS: 1

Clinical decision making separates professional nurses from technical personnel. While advanced education is a distinction, the primary factor regarding client care is the professional nurse is responsible for actions that require critical thinking decision making. Although licensure is a distinction, the primary factor regarding client care is the professional nurse is responsible for actions that require critical thinking decision making. 4. While complexity is a distinction, the primary factor regarding client care is that the professional nurse is responsible for actions that require critical thinking decision making. DIF: C REF: 216 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 26. A clinical nursing instructor asks the nursing students to describe a critical thinker. Which of the following represents the best response?

1 2

A person with the educational background to solve problems. A person who finds the problem and does what is best to fix it.

Its someone who uses the scientific method to solve problems.

Someone who uses a system to work through and solve a problem.

ANS: 2 A critical thinker considers what is important in a situation, imagines and explores alternatives, considers ethical principles, and then makes informed decisions. Educational background may have an impact on critical thinking but it is not the primary or sole factor to consider. Although the scientific method is often used in critical thinking it is neither the only method nor the sole factor to consider. While an orderly method is used in critical thinking, it is not the only factor to consider. DIF: C REF: 216 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 27. Which of the following statements made by a new graduate nurse regarding a clients care needs requires follow-up by the mentor?

No one really enjoys being hospitalized.

Every client is offered a back rub at bedtime.

All post surgery clients are reluctant to ambulate.

I always spend extra time with new clients to help them relax.

ANS: 3 Because no two clients respond exactly alike to similar health problems, you always have to observe each client closely in order to make critically sound decisions regarding that clients needs. Answer 1 does not require follow-up because even if it is not true, it does not have an impact on the nurses perception of the clients care needs. Answer 2 does not require follow-up because it is a nursing action that should be offered to all clients at bedtime. Answer 4 does not require follow-up because it is a nursing action that should be offered to all clients. DIF: C REF: 216 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 28. A nurse is caring for an immobile client with a large pressure ulcer on her left ankle. Which of the following statements by the nurse best reflects critical thinking regarding client care?

Im sure that friction and pressure have caused this problem.

Please be sure that her ankles are well padded when you place her in bed.

Do you have any suggestions on how we can minimize the pressure to her ankles? It was an ineffective turning schedule that allowed this to happen so now we will reposition every hour.

ANS: 3 Nurses who apply critical thinking in their work focus on options for solving problems and making decisions, rather than quickly and carelessly forming quick solutions. Asking for staff input regarding interventions shows critical thinking. While Answer 1 may be true, it is knowledge or experience, not critical thinking, that brought about this conclusion. Although Answer 2 may represent an appropriate intervention, it is knowledge or experience, not critical thinking, that brought about this conclusion. While Answer 4 may be true and an example of an appropriate intervention, it is knowledge or experience, not critical thinking, that brought about this conclusion. DIF: C REF: 217 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 29. A nurse is caring for a 35-year-old client who is 12 hours post mastectomy. The care assistant reports that the client is crying. Which of the following responses by the nurse best reflects the use of analysis regarding this clients care needs?

That surgery is painful. Ill get her pain medication ready.

She was sleeping when I checked 15 minutes ago. Ill go back in right now.

Ill be responsible for her PM care so I can spend some uninterrupted time with her. A mastectomy is a blow to a womans self image. Ill notify her provider that she is depressed.

ANS: 2 Analysis requires being opened-minded as you look at information about a client. Do not make careless assumptions. Do the data reveal what you believe is true, or are there other options? Although pain may be the cause of this clients tears, there are other possible reasons, so making an assumption is not appropriate. Although Answer 3 shows the nurses intention to analyze the clients needs, the delay is not appropriate. While the client may be experiencing some depression, there are other possible reasons for the tears and so the nurse should not assume. DIF: C REF: 217 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 30. Which of the following statements made by a nurse regarding personal reflection related to client care requires follow-up by the units nurse manager?

Mary and I were comparing foot wound dressing techniques.

Ive been caring for orthopedic clients for 10 years and I think Ive seen it all.

I cant believe that my client isnt improving after 2 weeks of physical therapy.

I always wean my orthopedic surgery clients onto oral pain medication on postoperative day 4.

ANS: 4 Reflect on your experiences. Identify the ways you can improve your own performance. This option presents a rigid attitude concerning client pain needs. Answer 1 needs follow-up because it shows a willingness to explore others opinions. Answer 2 requires no follow-up because it does not reflect an inflexible attitude toward client care need. Answer 3 requires no follow-up because it does not reflect an inflexible attitude toward client care needs. DIF: C REF: 217 OBJ: Analysis TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment MULTIPLE RESPONSE 1. The scope of a clients health problem is a result of which of the following factors? (Select all that apply.)

Religious beliefs

Life experiences

Lifestyle choices

4 5

Work environment Family relationships

Educational background

ANS: 2, 3, 4, 5 Each clients problems are unique and a product of many factors, including the clients physical health, lifestyle, culture, relationship with family and friends, living environment, and experiences. Chapter 16. Nursing Assessment MULTIPLE CHOICE 1. A client interview consists of three phases. The nurse recognizes that those phases are:

1 2 3 4

Orientation, working, termination Introduction, controlling, selection Introduction, assessment, conclusion Orientation, documentation, database

ANS: 4 The three phases of an interview are orientation, working, and termination. DIF: A REF: 236 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 2. During the admission history, the client states that he has trouble breathing at night. In obtaining data for a problem-oriented database, the nurse should first question the client about:

The onset and duration of his present breathing problem

His personal smoking, alcohol use, and exercise practices

Any extended family members who have diagnosed heart disease

Changes in other body systems that the client perceives as problematic

ANS: 1 A clients database originates with the clients perception of a symptom or health problem. If an illness is present, the nurse gathers essential and relevant data about the nature and onset of symptoms. The problem-seeking technique takes the information provided in the clients story to more fully describe and identify the clients specific problems. Habits and lifestyle patterns such as smoking, alcohol use, and exercise may be assessed in an admission history. However, it is not the first question the nurse should ask when obtaining data for a problem-oriented database after the client reports having a health problem. Information regarding family history, such as members who had heart disease, may be obtained in an admission history. However, if a client reports a problem, the nurse should first follow-up with questions relevant to the nature and onset of symptoms. The nurse may inquire about changes in other body systems during an admission history; however, if the client reports a problem, the nurse should first follow-up using a problem-oriented approach. This would include asking specific questions about the clients health problem, such as the nature and onset of symptoms. DIF: A REF: 237 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 3. The nurse begins the assessment of a client that has come to the emergency department experiencing chest pain by asking the client about:

1 2

A family history of heart problems Medications currently being taken at home

Questions or concerns about hospitalization

The onset, severity, and duration of the chest pain

ANS: 4 If a client comes to the emergency department with chest pain, the nurse should first ask the client about the onset, severity, and duration of the chest pain. In an emergency situation, the clients current health problem becomes the priority assessment. Initially, the nurse should not ask questions regarding family history. Gathering data about the problem currently affecting the client has greater priority. Asking the client about medications taken at home is appropriate, but not at this time. The priority is to assess the symptoms the client is experiencing. Asking the client about concerns regarding hospitalization is not the priority.

DIF: A REF: 241 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 4. A nurse seeks to organize the data obtained from the client in a logical manner. The organizational method that identifies relationships between factors and symptoms in the database is known as:

Clustering data

2 3

Validating data Peer reviewing

Problem statement

ANS: 1 Clustering data means the nurse organizes the information obtained into meaningful clusters. A cluster is a set of signs or symptoms grouped together in a logical order. When clustering data, the nurse identifies relationships between factors and symptoms. Validating data means to compare the data obtained with another source to ensure its accuracy. Peer review is the evaluation of the quality of the work effort of an individual by his or her peers. After validating data and clustering data, the nurse may formulate a problem statement, usually in the form of a nursing diagnosis. DIF: A REF: 234 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 5. The client recently became febrile and stated he felt hot. The nurse takes the clients temperature and finds it to be 38.2 C. In addition, the pulse rate is 88 beats per minute, and his blood pressure is 168/80 mm Hg. Which of the following is an example of subjective data?

Pulse rate of 88 beats per minute

Blood pressure of 168/80 mm Hg

The statement regarding his feeling hot

The supported fact that he became febrile

ANS: 3 Subjective data are clients perceptions about their health problems. The statement by the client regarding his feeling hot is an example of subjective data. A pulse rate of 88 beats per minute is an example of objective data. Objective data are observations or measurements made by the data collector. A blood pressure of 168/80 mm Hg is something that can be measured, and therefore is

an example of objective data. Becoming febrile can be determined by measurement, and therefore is an example of objective data. DIF: A REF: 234 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 6. The nurse decides to interview the client using the open-ended question technique. Which of the following statements reflects this type of questioning?

1 2

Is your pain worse or better than it was an hour ago? Do you believe that your nausea is from the new antibiotic?

What do you think has been causing your current depression?

What have you done to alleviate the side effects from your medications?

ANS: 3 An open-ended question prompts the client to describe a situation in more than one or two words. This option demonstrates the open-ended question technique. This question limits the clients answers to one or two words. It is an example of a closed-ended question. The question in this option limits the clients answer to one or two words such as yes or no. It is an example of a closed-ended question. This option only requires a few words to form an answer. It does not use the open-ended question technique. DIF: A REF: 239 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 7. The nurse is gathering a nursing health history on the client. The client tells the nurse that he just lost his job. Job loss best fits into which of the following categories?

Family history

Psychosocial history

Biographical history

Environmental history

ANS: 2 The psychosocial history reveals the clients support system, if there are any recent losses or stressful events, and how the individual copes with such stressors. The loss of a job would fit the psychosocial history category. Family history is used to obtain data about immediate and blood relatives to determine whether the client is at risk for illnesses of a genetic or familial nature. It

also provides information about the family itself. The biographical history provides factual demographic data about the client. The environmental history provides data about the clients home and working environments. DIF: A REF: 241 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 8. The nurse is going to perform the admission history for a newly admitted client on the medical unit. The optimum time for completion of the history is planned for:

Coordination with the physicians visit

2 3

The time when the clients family are visiting Immediately before the clients scheduled MRI testing

After the client has become comfortably oriented to the room

ANS: 4 Completion of the admission history is scheduled for a time when interruptions by other staff or visiting family members are minimal. The nurse should create an environment where the client feels comfortable. Conducting the admission history after the clients orientation to the room and completion of lunch would be optimum because the client will not be distracted by hunger, and the interview will less likely be interrupted. The admission history should be scheduled for a time when interruptions by other staff are minimal. During the physicians visit would not be an optimum time. The nurse should provide an environment private enough to allow the client to be comfortable when providing personal information. Inclusion of family members should be left up to the client to decide. Information obtained should remain confidential. Immediately before a clients testing would not be an optimum time for obtaining a nursing history. The client may feel more anxious about the upcoming test, impeding communication, and there may not be sufficient time allowed to gather all of the information. DIF: A REF: 236 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 9. The nurse has completed an assessment and found that the client has an activity and exercise abnormality. This type of wording indicates that which of the following organizing formats has been used?

Review of systems

2 3

Nursing health history Gordons functional health patterns

Biographical information database

ANS: 3 Utilizing Gordons functional health patterns format, the nurse organizes information and makes an assessment identifying functional patterns (client strengths) and dysfunctional patterns (such as an activity and exercise abnormality). The review of systems is a systematic method for collecting data on all body systems. The nurse asks the client about the normal functioning of each body system and any noted changes. A nursing health history is broader and includes information about the clients current level of wellness, a review of body systems, family and health history, sociocultural history, spiritual health, and mental and emotional reactions to illness. A biographical information database provides factual demographic data about the client, such as age, address, occupation, marital status, etc. DIF: A REF: 233 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 10. After visiting with the client, the nurse documents the assessment data. Both objective and subjective information has been obtained during the assessment. Which of the following is classified as objective data?

Pain in the left leg

Elevated blood pressure

Fear of impending surgery

Discomfort upon breathing

ANS: 2 Objective data are observations or measurements made by the data collector, such as a blood pressure reading. Subjective data are clients perceptions about their health problems, such as pain. Fear of surgery would be subjective data because it is the clients perception and not something the data collector can measure. Subjective data are clients perceptions about their health problems, such as discomfort during breathing. A respiratory rate would be an example of objective data. DIF: A REF: 234 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance

11. The primary source of information when completing an assessment of a client that is alert and oriented as he is admitted to the medical center for diagnostic testing is the:

1 2 3 4

Client Physician Family member Experienced unit nurse

ANS: 1 A client is usually the best source of information. The client who is oriented and answers questions appropriately can provide the most accurate information about health care needs, lifestyle patterns, present and past illnesses, perception of symptoms, and changes in activities of daily living. The physician may have knowledge of the clients medical problem, but the client is the primary source of information for completing an assessment. Family members can be interviewed as primary sources of information about infants or children or critically ill, mentally handicapped, disoriented, or unconscious clients. Usually, however, they are secondary sources of information and can confirm findings provided by the client. The client in this situation is capable of being the primary source of information. An experienced nurse on the unit may offer insight into a clients health care needs and care, but is not the primary source of information when completing a client assessment. DIF: A REF: 234 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 12. The process of data collection should begin with the nurse performing a:

Physical exam

Client interview

Review of medical records Discussion with other health team members

ANS: 2 The first step in establishing the database is to collect subjective information by interviewing the client. The physical examination follows the client interview so that data can be verified. A review of medical records is not the first step the nurse should take in the process of data collection. The medical record is a valuable tool for checking the consistency and congruency of personal observations made during the client interview. Discussion with other health team members may provide additional information and be used to relay information, but is not the first step in the process of data collection.

DIF: A REF: 236 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 13. During an interview, the nurse needs to obtain specific information about the signs and symptoms of the clients health problem. To obtain these data most efficiently, the nurse should use:

Channeling

2 3

Open-ended questions Closed-ended questions

Problem-seeking responses

ANS: 3 Using closed-ended questions helps the nurse to acquire specific information about health problems such as symptoms, precipitating factors, or relief measures in an efficient manner. Channeling is where the nurse uses active listening techniques, such as all right, go on, or uhhuh, to indicate the nurse has heard what the client said and encourage the client to elaborate further. Using open-ended questions prompts the client to describe a situation in more than one or two words. Because it allows the client the opportunity to tell their story and reveal what is important to them, it is not the most efficient method of obtaining specific information regarding a clients signs and symptoms of a health problem. In problem-seeking technique, the nurse takes the information provided in the clients story to more fully describe and identify the clients specific problems. Using closed-ended questions would be the most efficient method for obtaining specific information about the signs and symptoms of a clients health problem. DIF: A REF: 239 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 14. The nurse is conducting an interview with the client and wants to clarify information that the client has shared. Which response by the nurse is an example of the clarifying technique of communication?

I understand how you must feel.

This medication is used to lower your blood pressure.

You appear anxious. Youre wringing your hands constantly.

Could you give me an example of how you handle stressors?

ANS: 4

In this option, the nurse is seeking further clarification of information by asking the client to provide an example. Clarification helps the nurse to gain accurate understanding of a clients situation. This is not an example of clarifying information. This response provides information. The nurse is not using the clarifying technique of communication. In this option the nurse describes his or her observations. It does not seek clarification. DIF: A REF: 239 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 15. When clustering data according to functional health patterns, the nurse determines that the client is only able to ambulate short distances without becoming fatigued and requires rest periods during morning care. The health pattern that requires intervention is identified by the nurse as:

1 2

Respiratory Activity and exercise

Sleep and rest pattern

Self-care deficit: activities of daily living

ANS: 2 Using the functional health pattern format, the nurse clusters data that pertain to a functional health category. Fatigue upon ambulating short distances and requiring frequent periods of rest are examples of data belonging to the category of activity and exercise. Respiratory would be found in a systems approach of health assessment, not a functional health pattern assessment. The functional health pattern category of sleep and rest would focus more on the number of hours of sleep the client obtains, use of sleep aids, and any difficulties associated with sleep. Self-care deficit: activities of daily living would include such aspects as bathing, feeding, and dressing self. The symptoms described would be clustered more accurately under the functional health pattern category of activity and exercise. DIF: A REF: 233 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 16. After visiting with the client, the nurse documents the assessment data. Both objective and subjective information have been obtained during the assessment. Which of the following is classified as subjective data?

Client appears sleepy

No physical distress noted

Abdomen soft and non-tender

States feels anxious and tense

ANS: 4 Subjective data are clients perceptions about their health problems. Feeling anxious and tense is information that only the client can provide. Objective data are observations or measurements made by the data collector. In this example, the data collector is making the observation that the client appears sleepy. No physical distress noted is an example of objective data because it is an observation made by the data collector. Abdomen soft and non-tender is an example of objective data because it is an observation made by the data collector, not a clients perception. DIF: A REF: 234 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 17. An ER nurse is interviewing a client who complains of abdominal pain. Which of the following questions asked by the nurse has priority at this time?

Can you describe your pain?

Have you had this problem before?

What have you done to ease the pain? When did your abdominal pain begin?

ANS: 4 If a client presents to the emergency department with pain, the nurse should first ask the client about the onset, severity, and duration of the pain. In an emergency situation, the clients current health problem becomes the priority assessment. Gathering data about the problem currently affecting the client has greater priority, but a description of the pain does not have priority over onset. Asking the client about medical history is appropriate but not at this time. The priority is to assess the symptoms the client is experiencing. Gathering data about the problem currently affecting the client has greater priority, but attempted self-treatment does not have priority over onset. DIF: C REF: 236-237 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 18. Which subjective assessment data are most supportive of a clients diagnosis of anxiety?

Diaphoretic and cool skin

An apical pulse rate of 120 beats per minute

Reports needing to leave now

Claims something is terribly wrong

ANS: 4 Subjective data are clients perceptions about their health problems. The statement by the client regarding his sense of impending doom is the best example of subjective data regarding his anxiety because it is his own verbalization of the problem. Cool, damp skin is an example of objective data. Objective data are observations or measurements made by the data collector. A pulse rate is an example of objective data. Objective data are observations or measurements made by the data collector. While a client statement regarding the need to leave the hospital is subjective in nature, it is not as strong an indicator of anxiety as is the verbalization of impending doom. DIF: C REF: 241 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 19. Which of the following questions asked by the nurse during the assessment process is best directed towards gathering information regarding the clients depression?

Have you ever felt this depressed before?

What do you believe is the cause of your depression?

What makes you feel that you are experiencing depression? What can we do to make you comfortable while you are here?

ANS: 2 This option is an open-ended question that encourages the client to express his insight regarding his condition. This option is a closed-ended question requiring only a yes or no response and so provides minimal information regarding the clients condition. While this is an open-ended question, it is not the best option because it is not directed towards assessment of the clients current complaint. While this is an open-ended question, it is not the best option because it is directed at the clients comfort, not towards assessing his current complaint. DIF: C REF: 234 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 20. Which of the following statements best reflects the nurses correct understanding of the importance of selecting the optimum time for interviewing a client newly admitted to the unit?

Im going to do the clients history before his family leaves so they can help with the admission history questions.

You are scheduled for some x-rays, so Id like to complete this admission history interview before you have to leave.

I have some questions to ask you regarding your admission history. Ill be back once you are settled in and comfortable. Please let me know when the blood lab is finished with the new client so I can complete his admission history interview.

ANS: 3 Completion of the admission history is scheduled for a time when interruptions by other staff or visiting family members are minimal. The nurse should create an environment where the client feels comfortable and the clients orientation to the room is completed. While this may be appropriate if the client requires help with answering the questions, it is not the best option because family and visitors can be distracting and may represent a confidentiality problem. While the history must be taken within a specific time period, rushing to complete it before the client goes to radiology is not appropriate. The interview requires the clients attention and cooperation. Attempting to complete it immediately after a treatment or other intervention would not be the best choice of time. DIF: C REF: 239 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 21. The nurse is conducting an admissions history interview with a client who has a history of gastroesophageal reflux disease (GERD). Which of the following questions shows the best example of relevant questioning by the nurse?

How long have you been dealing with GERD? Are you currently taking any medications for your GERD?

Do you follow a particular diet to help manage your GERD?

Do you have any other gastrointestinal problems besides GERD?

ANS: 4 The nurse should ask relevant questions and collect relevant history and physical assessment data related to the clients presenting health care needs in order to produce the most inclusive, effective nursing care plan. The questions How long have you been dealing with GERD? and Are you currently taking any medications for your GERD? as well as Do you follow a particular diet to help manage your GERD? are directed towards the GERD itself and not towards conditions that might be related to the presence of GERD.

DIF: C REF: 236 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 22. A new graduate nurse missed cues regarding the clients emotional state at the time of admission. The most therapeutic response to the nurse by her mentor is:

1 2 3 4

That is why we perform assessments at least daily; so we can catch missed cues. Everyone has missed cues; dont be too hard on yourself and just keep trying. You will be less likely to miss client cues as you acquire more experience with assessments. The positive side to making this mistake is that you wont miss those cues again in another client.

ANS: 3 It is possible to miss important cues when you conduct an initial overview. However, always try to interpret cues from the client to know how in-depth to make your assessment. Remember, thinking is human and imperfect. You will acquire appropriate thinking processes in the conduct of assessment, but expect to make mistakes in missing important cues. While this may be true, it is not the most therapeutic option because it does not address the issue personally for the new graduate. While this is true, it is not the most therapeutic option because it does not offer a reason for the omission. While this may be true, it is not the most therapeutic option because it does not address the issue personally for the new graduate. DIF: C REF: 240-241 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 23. The nurse is performing a problem-focused assessment when the client reports pain in his left shoulder. Which of the following nursing questions has priority when determining the nature of the pain?

What makes the pain worse?

When did you first notice the pain?

What do you do to lessen the pain? Can you rate your pain using the pain scale that weve discussed?

ANS: 4 Once you complete the assessment, you thoroughly analyze the extent and nature of the clients problem so you are able to later develop a care plan. Identifying the degree of pain the client is experiencing has priority over the other options. While this option is an appropriate pain assessment question, it is more directed towards identifying contributing factors than the characteristics (nature) of the pain. While this option is an appropriate pain assessment question regarding the nature of the pain, it does not have priority over the degree of pain because that represents an issue that requires immediate intervention. While this option is an appropriate pain assessment question, it is more directed towards identifying effective self-treatment rather than the characteristics (nature) of the pain. DIF: C REF: 236 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 24. When following up on a clients report of hip pain during an admission assessment, the most nursing conclusive observation would be:

1 2

The client tearing when being ambulated to the chair A report from the ancillary staff that the client is reporting pain

The client observed grimacing when positioning self in the bed

Overhearing the client discuss hip pain with family on the phone

ANS: 3 This option where the client was observed grimacing describes nonverbal actions that are associated with pain when the client is unaware of being observed and so represents the most conclusive follow-up evidence of pain. The options where the client is tearing when ambulated to the chair, the ancillary staffs report of the clients pain as well as overhearing the client discuss hip pain may well be an observation of pain, but they are not the most conclusive of the options because the client is aware of being observed. DIF: C REF: 240 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 25. When obtaining subjective assessment data, the nurse recognizes which of the following client scenarios as being the most likely to produce accurate, credible information?

A 50-year-old in the ED reporting chest pain

A 70-year-old admitted with fever of unknown origin

A 81-year-old receiving follow-up treatment for a hip replacement

A 22-year-old being treated at a clinic for a sexually transmitted disease

ANS: 3 This option where the 81-year-old is receiving follow-up treatment for a hip replacement presents a client who is not necessarily experiencing pain, embarrassment, guilt, or any other emotion/factor that would inhibit the free communication of subjective symptom data. The 50year-old client is experiencing pain; this is likely to inhibit the communication process. The 70year-old client is febrile; this could interfere with the communication process, especially for an older adult because it may cause confusion and the 22-year-old client may be experiencing guilt and/or embarrassment; both may interfere with the communication process. DIF: C REF: 234 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 26. A nurse is observed conducting an assessment interview for a newly admitted client. Which of the following would require immediate follow-up by the nurses mentor?

Conducting the interview with the clients boyfriend present

Stopping the interview to answer a page from the nursing station Frequently checking the time while waiting for the client to answer

3 4

Heard asking the client, Am I correct; youve rated your pain a 9 out of 10?

ANS: 3 Clients are less likely to fully reveal the nature of their health care problems when nurses show little interest, appear rushed, or are easily distracted by activities around them. As long as the nurse had the clients permission, this would not require follow-up. While interrupting an assessment is not recommended, a page is an example of an acceptable exception and so this would not require follow-up. If the nurse were confirming the information, it would not require follow-up. If the mentor felt the nurse was questioning the validity of clients pain rating, a follow-up would be appropriate because a clients pain rating should not be questioned. DIF: C dm 234 OBJ: Analysis TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment 27. Which of the following assessment data provided by a clients family will have the greatest impact on the clients care while hospitalized?

1 2

Mom falls asleep fastest with the television on. Dad starts off the day with hot coffee; it regulates his bowels.

My wifes sister died 4 months ago, and she is still grieving over her loss.

My husband doesnt like to let people know his arthritis is bothering him.

ANS: 4 Family and friends can make important observations about the clients health status, changes, and needs that can affect the way care is delivered. Being aware of the clients reluctance to discuss his pain will impact the frequency and way his pain is assessed. While this information will affect the way the staff prepares the client for sleep, it does not have priority over pain assessment. While this information will allow the staff to meet the clients morning coffee need, it does not have priority over pain assessment. While this information will affect the way the staff address the clients emotional needs, it does not have priority over pain assessment. DIF: C dm 237 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 28. What is the most appropriate method for the nurse to communicate a clients wishes to the nurses on the next shift?

Document the request in the nursing notes.

Include the clients request in the shift report.

Place instructions regarding the clients wishes above the clients bed.

Verbally inform the unit clerk of the clients request.

ANS: 2 In the acute care setting, the change-of-shift report is the way for nurses from one shift to communicate information to nurses on the next shift Documenting the request in the nursing notes is not appropriate for inclusion in the nursing notes because it does not reflect information regarding the clients condition, response to treatment, or current health status. Placing the instructions regarding the clients wishes above the bed is not appropriate because there is no guarantee that staff will see the posting, but more importantly there are confidentiality issues

being ignored. While verbally informing the unit clerk of the clients request may result in the clients wishes being respected, it is not the most effective option. DIF: C dm 234-235 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 29. While discussing a clients medication history, the client tells the nurse that she thinks she is allergic to a particular type of medication. Which of the following nursing actions has priority in this situation?

1 2

Note the allergy on the clients Kardex. Inform the provider of the clients possible allergy.

Review the clients medical record for confirmation of the allergy.

Tell the client to have all medications identified before taking them.

ANS: 3 The medical record is a valuable tool for checking the consistency and similarities of personal observations. Information such as a history of allergic reactions would be found in the medical record. Noting the allergy on the clients Kardex would be appropriate only after the allergy is confirmed; although if there was true concern, a notation of a possible allergy should be noted on the medication record. Informing the provider of the clients possible allergy would be appropriate after the medical record was reviewed and no mention of the allergy was confirmed or denied. While telling the client to have all medications identified before taking them is a safety measure appropriate for all clients, it is not the priority in this situation. DIF: C dm 235 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 30. The nurse realizes that in order to share information from a clients medical record with another facility, the client must provide written consent. The primary reason for this requirement is to:

Facilitate the exchange of information between appropriate parties

Minimize the opportunity for this information to be assessed inappropriately

Ensure the clients right to have his medical information regarded as personal and confidential

Guarantee that the information will be shared with only those requiring it for client care purposes

ANS: 3 Educational, military, and employment records may contain significant health care information. You need written permission from the client or guardian to access or transfer the records. Any information you obtain is confidential, and you treat it as part of the clients legal medical record. This process recognizes the clients right to confidentiality. The other three options, facilitating the exchange of information, ensuring the clients rights to have his medical information regarded as personal and confidential as well as guaranteeing the sharing of information will be only when required for client care purposes are outcomes of the process but not the primary reason for the consent. DIF: C dm 235-236 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 31. The nurse recognizes that a clients hearing deficits impact the development of the nurseclient relationship. Which of the following has the greatest impact on minimizing this obstacle?

Speaking slowly, clearly, and in a normal tone

Using various forms of nonverbal communication Relying heavily on touch to convey caring and interest

3 4

Involving family in discussions concerning meeting clients needs

ANS: 2 When a client has limited hearing or visual deficits, it becomes more important for a nurse to use nonverbal communication when establishing nurse-client relationships. Speaking slowly, clearly and in a normal tone may make verbal communication more effective, but it will not have the greatest positive impact of the offered options. Relying heavily on touch is only one form of nonverbal communication that can positively impact the development of the relationship. While involving family in discussions may help in the identification of client needs, it does not necessarily have positive impact on developing a healthy nurse-client relationship. DIF: C dm 236 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment

32. Which of the following questions will provide the nurse with the best understanding of a terminally ill clients spiritual needs?

1 2 3 4

Do you have a religious preference? Have you given thought to your spiritual needs? Is there a particular clergy you would like to visit with? Are there any spiritual needs you have that I may help with?

ANS: 4 In asking if there are any spiritual needs that the client might need help with, you collect information about life goals, values, and religious practices; part of a clients spirituality. This option provides the client with an opportunity to discuss his needs if indeed he has any while reaffirming the nurses wish to meet his needs. Asking simply is a client has a religious preference is a closed-ended question and provides little encouragement to discuss spiritual needs. While asking if the client has given thought to their spiritual needs provides an opportunity to discuss any client needs, it does not allow for the nurse to be of help with attending to these needs. Inquiring about a particular clergy is a closed-ended question and provides little encouragement to discuss spiritual needs. DIF: C dm 237 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment MULTIPLE RESPONSE 1. Which of the following statements made by the nurse should be included in the orientation phase of a nursing interview? (Select all that apply.)

Youre answers will be kept confidential.

My name is Susan Smith and Im a registered nurse.

We are here to make your hospitalization as pleasant as possible.

I need to ask you some questions that will help with planning your care.

Only those directly involved in your care will have access to this information. If there is anything you need or help you require simply use your call bell and someone will be right in.

ANS: 1, 2, 4, 5 The orientation phase begins with you introducing yourself and your position and explaining the purpose of the interview. Explain to clients why you are collecting data (e.g., for a nursing history or for a focused assessment) and assure them that any information obtained will remain confidential and will be used only by health care professionals. The statements We are here to make your hospitalization as pleasant as possible and I need to ask you some questions that will help with planning your care are more appropriate for the termination phase. DIF: C dm 241 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 2. The nurse has determined that the assessment data have resulted in a strong inference that the client is suffering from depression. Which of the following client responses to nursing questions best supports the possibility of depression? (Select all that apply.)

My work environment would depress anyone.

It seems like almost anything can make me cry. Being here away from my family makes me sad.

3 4 5 6

I just cant seem to get excited about anything anymore. The family always thought that my father was depressed. I like winter because I can just cover up on the couch and sleep.

ANS: 4, 5 I just cant seem to get excited about anything anymore and The family always thought that my father was depressed. Remember to always have supporting cues before you make an inference. These options relate a broad lack of interest in life and a family history of depression. While mentioning My work environment would depress anyone as a depressing situation, this option does not infer personal depression. While mentioning It seems like almost anything can make me cry as a potential sign of depression, this option is not a strong inference because crying can be a result of other emotions. While mentioning Being here away from my family makes me sad notes sadness, this option describes a normal reaction to being separated from loved ones. While mentioning I like winter because I can just cover up on the couch and sleep shows withdrawal behaviors, this option is not a strong inference because winter often evokes stay-at-home tendencies in people. DIF: C dm 241 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment

3. The goal of the orientation phase of a nursing interview is to: (select all that apply)

1 2

Initiate the nurse-client relationship Begin identifying the clients needs

Earn the trust and confidence of the client

Assume the decision role for the client

Welcome the client to the nursing unit

Gather the clients demographic information

ANS: 1, 2, 3 Initiating the nurse-client relationship, beginning to identify the clients needs and earning the clients trust and confidence. During the orientation phase you establish trust and confidence with a client. One important goal for the initial interview is to make the foundation for understanding the clients primary needs. Another is to begin a relationship that allows the client to become an active partner in decisions about care. As the orientation phase proceeds, the client should begin to feel more comfortable speaking with you so the necessary information can be obtained. Assuming the decision role isnt correct as the client should be involved in all care decisions; assuming this role is not appropriate. While welcoming the client to the nursing unit is an expected outcome of the orientation phase of the interview process, it is not a goal. While gathering the clients demographic information is an expected outcome of the orientation phase of the interview process, it is not a goal. Chapter 17. Nursing Diagnosis MULTIPLE CHOICE 1. The nurse uses nursing diagnoses after completion of the client assessment, because they:

Are required for accreditation purposes

Identify the domain and focus of nursing

Assist the nurse to distinguish medical from nursing problems

Make all client problems become more quickly and easily resolved

ANS: 2 After completing the client assessment, the nurse develops nursing diagnoses based on the data obtained. Nursing diagnoses distinguish the nurses role from that of the physician, and nursing diagnoses help nurses to focus on the role of nursing in client care. Although most state nurse practice acts include nursing diagnosis as part of the domain of nursing practice, nursing diagnoses are not required for accreditation purposes. Medical problems are identified with medical diagnostic statements to treat a disease condition. Nursing diagnoses describe the clients

actual or potential response to a health problem that the nurse is licensed and competent to treat. Nursing diagnoses distinguish the nurses role from that of the physician. Nursing diagnoses may facilitate communication among health professionals, but they do not necessarily allow all client problems to become more quickly and easily resolved. DIF: A dm 248 OBJ: Knowledge TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 2. A 53-year-old client is seen at the clinic for a yearly physical examination. In evaluating the clients weight, the nurse also considers the age and height. This is an example of:

Defining the client problem

Recognizing gaps in data assessment

Comparing data with normal health patterns

Drawing conclusions about the clients response

ANS: 3 The nurse uses scientific knowledge and experience to analyze and interpret data collected about the client. This includes comparing the data with norms. The nurse is comparing data to determine if there is a problem. A problem has not yet been identified. The nurse is not recognizing gaps in data assessment. An example of a gap in data assessment would be if the clients weight had not been measured. The nurse has not drawn a conclusion about the clients response. The nurse must first compare the data with normal health problems to be able to arrive at a conclusion. DIF: A dm 249 OBJ: Comprehension TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 3. Of the following statements, which one is an example of an appropriately written nursing diagnosis?

Acute pain related to left mastectomy

Impaired gas exchange related to altered blood gases

Deficient knowledge related to need for cardiac catheterization Need for high protein diet related to alteration in client nutrition

ANS: 3

This nursing diagnosis is written correctly. It defines a problem and its etiology. In this case the problem is the clients response to a diagnostic test. A medical diagnosis should not be recorded as the etiology because nursing interventions cannot change the medical diagnosis. It would be appropriate to state acute pain related to impaired skin integrity secondary to mastectomy incision. This nursing diagnosis is written incorrectly because it uses supportive data of the problem as the etiology. This nursing diagnosis does not identify the problem and etiology. It identifies the clients goal rather than the problem. It could be reworded as imbalanced nutrition: less than body requirements related to inadequate protein intake. DIF: A dm 252 OBJ: Comprehension TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 4. Of the following statements, which one is an example of an appropriately written nursing diagnosis?

1 2

Risk for change in body image related to cancer Cardiac output decreased related to motor vehicle accident

Ineffective airway clearance related to increased secretions

Potential for injury related to improper teaching in the use of crutches

ANS: 3 Ineffective airway clearance related to increased secretions is written appropriately. It identifies a problem using a NANDA International diagnostic statement and connects it to its etiology. Risk for change in body image related to cancer is written incorrectly. It uses a medical diagnosis for the etiology. Cardiac output decreased related to motor vehicle accident is written incorrectly. The etiology is not treatable. Potential for injury related to improper teaching in the use of crutches is written incorrectly. It identifies the nurses problem, not the clients. DIF: A dm 250 OBJ: Comprehension TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 5. The nurse has diagnosed the clients problem as altered elimination. From the database the nurse identifies all the following as appropriate etiologies for this diagnosis except:

Poor fiber intake

Limited fluid intake

Total hip replacement Lower abdominal discomfort

ANS: 3 Total hip replacement because the medical diagnosis requires medical interventions, it is legally inadvisable to use it in the nursing diagnosis. Rather, the nurse should identify the clients response, such as decreased mobility. The nurse should be able to provide nursing interventions that will treat the etiology. Poor fiber intake would be an appropriate etiology for the problem of altered elimination. Limited fluid intake would be an appropriate etiology for the nursing diagnosis of altered elimination. Lower abdominal discomfort is an appropriate etiology for the nursing diagnosis of altered elimination. DIF: A dm 248 OBJ: Comprehension TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 6. The nurse is concerned that atelectasis may develop as a postoperative complication. Which of the following is an appropriate diagnostic label for this problem, should it occur?

Impaired gas exchange

2 3

Decreased cardiac output Ineffective airway clearance

Impaired spontaneous ventilation

ANS: 1 A potential etiology for impaired gas exchange may be atelectasis. Atelectasis would not support the diagnostic label for decreased cardiac output. Atelectasis would not be an etiology for ineffective airway clearance. Increased tenacious sputum production would be a possible etiology for ineffective airway clearance. Impaired spontaneous ventilation would not be an appropriate diagnostic label for atelectasis. DIF: A dm 252 OBJ: Comprehension TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 7. The nurse recognizes that which one of the following statements is true with regard to the formulation of nursing diagnoses?

The diagnosis should identify a cause and effect relationship.

The diagnosis must remain constant during the clients hospitalization. The etiology of the diagnosis must be within the scope of the health care teams practice.

The diagnosis should include the problem and the related contributing conditions.

ANS: 4 The diagnosis should include the problem and the related contributing conditions is a true statement. Related factors are causative or other contributing conditions that have influenced the clients actual or potential response to the health problem and can be changed by nursing interventions. The nursing diagnosis does not identify a cause and effect relationship; rather, it indicates that the etiology contributes to or is associated with the clients problem. The nursing diagnosis does not have to remain constant during the clients hospitalization. It should change according to changes in the patient. The etiology or cause of the nursing diagnosis must be within the domain of nursing practice and a condition that responds to nursing interventions, not those of the entire health care team. DIF: A dm 253 OBJ: Comprehension TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 8. A diagnostic error can influence the application of the nursing care plan. A likely source for a nursing diagnosis error is if the nurse:

Validates the assessment information in the data base

Uses the NANDA International list of diagnoses as a primary source

Formulates a diagnosis too closely resembling a medical diagnosis Distinguishes the nursing focus instead of other health care disciplines

ANS: 3 A nursing diagnosis should identify the clients response, not the medical diagnosis. Because the medical diagnosis requires medical interventions, it is legally inadvisable to include it in the nursing diagnosis. A nurse should validate assessment data for accuracy and understanding. Using the NANDA International list of diagnoses as a source helps to ensure accuracy. One purpose the nursing diagnosis serves is to distinguish the nurses role from that of the physician. Another purpose is to help nurses focus on the role of nursing in client care. Nursing diagnoses promote understanding between nurses regarding clients health problems. DIF: A dm 248 OBJ: Knowledge TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance

9. Identify the defining characteristics in the following nursing diagnosis: Altered speech related to recent neurological disturbance, as evidenced by inability to speak in complete sentences.

1 2 3 4

Altered speech As evidenced by Recent neurological disturbances Inability to speak in complete sentences

ANS: 4 Defining characteristics are assessment findings that support the nursing diagnosis. In this example, the inability to speak in complete sentences supports the nursing diagnosis of altered speech. Altered speech is the diagnostic label identifying the problem. As evidenced by is a connecting statement for the problem and the defining characteristics. Recent neurological disturbances is the etiology. DIF: A dm 252 OBJ: Comprehension TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 10. The primary purpose of a nursing diagnosis, according to the nurses, is to:

Support the medical plan of care

Provide a standardized approach for all clients

Recognize the clients response to an illness or situation Offer the nurses subjective view of the clients behaviors

ANS: 3 The primary purpose of a nursing diagnosis is to recognize the clients response to an illness or situation. The nurse can then use the nursing diagnosis to select appropriate nursing interventions to achieve positive client outcomes. A nursing diagnosis is based on the client, not on the medical plan of care. Although nursing diagnoses may facilitate communication, it does not mean they provide a standardized approach for all clients. Nursing diagnoses are individualized to meet the clients needs. The primary purpose of nursing diagnoses is not to offer the nurses subjective view of the clients behaviors. Nursing diagnoses are based on subjective and objective client data and should not include the nurses personal beliefs and values. DIF: A dm 248 OBJ: Knowledge TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 11. Which one of the following is an appropriate etiology for a nursing diagnosis?

Myocardial infarction

2 3

Cardiac catheterization Abnormal blood gas levels

Increased airway secretions

ANS: 4 Increased airway secretions is a condition that responds to nursing interventions and therefore would be an appropriate etiology for a nursing diagnosis. Myocardial infarction would not be an appropriate etiology for a nursing diagnosis because it is a medical diagnosis. Nursing interventions will not alter the medical diagnosis of myocardial infarction. Cardiac catheterization is a diagnostic procedure and would not be an appropriate etiology for a nursing diagnosis. Rather, the clients response to the procedure would be the area of nursing concern. Abnormal blood gas levels would not be an appropriate etiology for a nursing diagnosis because it is not a causative factor, but rather it is a defining characteristic of a problem. DIF: A REF: 253-254 OBJ: Comprehension TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 12. Which of the following is an appropriate etiology for a nursing diagnosis?

Incisional pain

Poor hygienic practices

Need to offer bedpan frequently

Inadequate prescription of medication

ANS: 1 Incisional pain is an appropriate etiology for a nursing diagnosis. It is a condition that identifies the cause of a clients response to a health problem, and a condition that a nurse can treat or manage. Poor hygiene practices would not be an appropriate etiology for a nursing diagnosis because it insinuates a nurses prejudicial judgment. Need to offer bedpan frequently is not an appropriate etiology because it identifies a nursing intervention, not an etiology. Inadequate prescription of medication by the physician is not an appropriate etiology because it identifies the nurses problem, not the clients problem. The nursing diagnosis should center attention on client needs. DIF: A dm 253-254 OBJ: Comprehension TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance

13. Of the following statements, which one is an example of an appropriately written nursing diagnosis?

1 2 3 4

Diarrhea related to food intolerance Alteration in comfort related to pain Risk for impaired skin integrity related to poor hygiene habits Potential complications related to insufficient vascular access

ANS: 1 Diarrhea related to food intolerance is a correctly written nursing diagnosis. It consists of a problem related to an etiology, and it is a condition that nursing interventions can treat or manage. Alteration in comfort related to pain is not written correctly because it is a circular statement. It would be appropriate to state ineffective breathing pattern related to incisional pain. Risk for impaired skin integrity related to poor hygiene habits is not written correctly because it uses a nurses prejudicial judgment. It would be more appropriate and professional to state risk for impaired skin integrity related to knowledge about perineal care. Potential complications related to insufficient vascular access is not written appropriately because it identifies a nursing problem, not a clients problem. It would be appropriate to state risk for infection related to presence of invasive lines. DIF: A dm 252 OBJ: Comprehension TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 14. Of the following statements, which one is an example of an appropriately written nursing diagnosis?

Anxiety related to cardiac monitor

Pain related to difficulty ambulating

Chronic pain related to insufficient use of medication Bedpan required frequently as a result of altered elimination pattern

ANS: 3 Chronic pain related to insufficient use of medication is an example of an appropriately written nursing diagnosis. It consists of a diagnostic label and the associated etiology. Nursing interventions can be directed at treating or managing the behavior of insufficient medication use. Anxiety related to cardiac monitor is written incorrectly because it identifies the equipment rather than the clients response to the equipment. It would be appropriate to state deficient knowledge regarding the need for cardiac monitoring. Pain related to difficulty ambulating is not

written correctly. What could be a defining characteristic is used as an etiology. This nursing diagnosis could be rewritten more appropriately as impaired mobility related to pain as evidenced by difficulty ambulating. Or it could be an inaccurate diagnostic label and could be rewritten as anxiety related to difficulty in ambulating. Bedpan required frequently as a result of altered elimination pattern is written incorrectly because it identifies a nursing intervention, not the clients problem. It could be reworded as diarrhea related to food intolerance. DIF: A dm 252 OBJ: Comprehension TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 15. Based on the following information, what would the nurse identify as the most appropriate nursing diagnosis? The client has abnormal breath sounds, dyspnea, an intermittent cough, and variable respiratory rate.

Risk for injury

2 3

Excess fluid volume Ineffective airway clearance

Impaired spontaneous ventilation

ANS: 3 The defining characteristics of abnormal breath sounds, dyspnea, an intermittent cough, and variable respiratory rate cue the nurse to the nursing diagnosis of ineffective airway clearance. Risk for injury does not support the diagnostic label of risk for injury. Excess fluid volume does not support the diagnostic label of excess fluid volume. There would be other defining characteristics such as edema, weight gain, and an elevated blood pressure. Impaired spontaneous ventilation does not most accurately describe impaired spontaneous ventilation. Other characteristics, such as apnea, would better support the diagnostic label of impaired spontaneous ventilation. DIF: A dm 252 OBJ: Comprehension TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 16. Which one of the following is a NANDA International nursing diagnosis label?

Frequent urination

Coughing and dyspnea

Risk for impaired parenting Abnormal hygienic care practices

ANS: 3 Frequent urination is a symptom, not a NANDA International nursing diagnosis label. Coughing and dyspnea are symptoms, not a NANDA International nursing diagnosis label. Risk for impaired parenting is a NANDA International nursing diagnosis label. Abnormal hygienic care practices is not a NANDA International nursing diagnosis label. It incorrectly implies a nurses prejudicial judgment. DIF: A dm 251 OBJ: Knowledge TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 17. When asked to define Nursing Diagnosis the nurses best response is:

1 2

It is the second step in the Nursing Process. It is the process of defining a clients problems.

It correlates a clients problem with a condition a nurse is competent to treat.

It focuses care a licensed nurse can provide with the identified needs of a client.

ANS: 3 It correlates a clients problem with a condition a nurse is competent to treat is a statement that describes the clients actual or potential response to a health problem that the nurse is licensed and competent to treat. Although It is the second step in the Nursing Process is true, it does not define the term. Although It is the process of defining a clients problems is true, is does not address the nursing aspect of the term. Although It focuses care a licensed nurse can provide with the identified needs of a client is true, the focus is not primarily on care. DIF: C dm 248 OBJ: Analysis TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 18. The nurses initial responsibility in the management of a clients collaborative problem is to:

Monitor for changes

Advocate for the client

Implement interventions

Evaluate client outcomes

ANS: 1

Nurses initially monitor to detect the onset of changes in a clients status. Although advocating for the client is a nursing role, it is not reserved exclusively to collaborative problems. Implement interventions is not the initial responsibility. Evaluate client outcomes is not the initial responsibility. DIF: C dm 248 OBJ: Comprehension TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 19. The nurse has identified deficient knowledge regarding surgery for a client who is scheduled for an outpatient procedure. Which of the following instructional topics will best minimize the clients anxiety regarding the procedure?

1 2

Assure the client that preoperative sedation will be administered. Discuss the pre- and postprocedure care that will be provided.

Provide a detailed explanation of why the procedure is necessary.

Guarantee that family will be regularly updated during the procedure.

ANS: 2 A nursing diagnosis focuses on a clients actual or potential response to a health problem rather than on the physiological event, complications, or disease. In the case of the diagnosis deficient knowledge regarding surgery, the nurse will best minimize anxiety by providing information regarding pre- and postoperative routines so as to facilitate the client in formulating realistic expectations. Although the other options are appropriate, they are limited in scope and do not have as much impact on anxiety. DIF: C dm 249 OBJ: Analysis TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 20. The nursing diagnosis of acute pain falls under which of the following comfort domain classifications?

Social comfort

Physical comfort

Interpersonal comfort Environmental comfort

ANS: 2 There are only three classifications for the comfort domain. Acute pain is a physiological response and so is classified as a physical comfort problem. Impaired verbal communication is considered a social comfort issue, while at risk for poisoning would be considered an environmental comfort issue. DIF: A dm 251 OBJ: Comprehension TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 21. When asked to define the purpose of diagnostic reasoning, the best nursing response is:

Diagnostic reasoning is the foundation of the second step of the nursing process; Nursing Diagnosis.

The diagnostic reasoning process flows from the assessment process and includes decision-making steps.

Diagnostic reasoning includes data clustering, identifying client needs and formulating the diagnosis or problem.

Diagnostic reasoning involves using the assessment collected on a specific client to logically arrive at an appropriate nursing diagnosis.

ANS: 4 Diagnostic reasoning is a process of using the assessment data gathered about a client to logically explain a clinical judgment, in this case a nursing diagnosis. The remaining options do not describe purpose but rather identify outcomes of diagnostic reasoning. DIF: C dm 253 OBJ: Analysis TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 22. A nursing student expresses some confusion about identifying the appropriate nursing diagnosis for a specific client. Which of the following responses by the clinical instructor is most instructional?

After defining the clients symptomatology, eliminate those nursing diagnoses that are not supported by the database.

Assess your client and then select the nursing diagnosis that has the greatest number of observable defining characteristics.

After assessing the client, compare their symptoms carefully to the defining characteristic of the nursing diagnosis in order to support or eliminate it as applicable.

With experience you will become skilled at identifying the defining characteristics of a nursing diagnosis in your client. Until that time use a nursing diagnosis book to help in the selection process.

ANS: 3 After assessing the client, always examine the defining characteristics in your database carefully to support or eliminate a nursing diagnosis. Although the other options are correct, they do not provide as concise an explanation as after assessing the client, compare their symptoms carefully to the defining characteristic of the nursing diagnosis in order to support or eliminate it as applicable. DIF: C dm 252 OBJ: Analysis TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 23. A client newly diagnosed with type 2 diabetes mellitus asks the nurse to explain, what the diagnosis means. Which of the following rationales best supports the nurses determination that the client has knowledge deficit rather than a readiness for enhanced knowledge?

The client initiated the question.

2 3

This is a new diagnosis for the client. The client identified a lack of understanding.

Type 2 diabetes mellitus is a complicated disease process.

ANS: 2 Although all the options are accurate, this is a new diagnosis for the client best reflects the need for knowledge because the client had no previous experience with the condition and so had a true knowledge deficit. DIF: C dm 252 OBJ: Analysis TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 24. Which of the following responses best reflects an understanding of the purpose of the related to phrase attached to the diagnostic label deficient knowledge regarding postoperative routines?

To focus on the cause of the clients needs

To identify the etiology of the clients diagnosis

To provide for individualization of the nursing interventions To communicate the clients deficits to the nursing staff

ANS: 3 The inclusion of the related to phrase requires you to use critical thinking skills to individualize the nursing diagnosis and then select personalized nursing interventions. Although the other options are not incorrect, they do not reflect the best understanding of the purpose of the phrase, To provide for individualization of the nursing interventions is the correct answer. DIF: C dm 253 OBJ: Analysis TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 25. Which of the following assessment findings best supports the nursing diagnosis of pain in right knee joint related to degenerative process?

Paternal family history of osteoarthritis has been reported.

Client is observed grimacing when walking to bathroom.

Right knee appears edematous when compared to left knee.

Client rated the pain felt after walking at a 6 on a scale of 1 to 10.

ANS: 2 To collect complete, relevant, and correct assessment data it helps to identify assessment activities that produce specific kinds of data. When possible, the nurse should collect objective data because they are often more supportive than subjective data. Observation of the clients response to the use of the affected joint is the most supportive of the options. DIF: C dm 254 OBJ: Analysis TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 26. Which of the following statements made by a nursing student regarding the cultural characteristics of pain requires immediate follow-up by the clinical instructor?

1 2

I can tell when my Hispanic clients are in pain. Moaning is a classic sign of pain in most cultures.

All clients will tell you when they need pain medication.

Chronic pain is difficult to manage especially for the stoic individual.

ANS: 3 Nurses who are not familiar with how a particular culture or developmental group expresses pain can often miss the objective signs or assume there is a lack of pain when familiar signs are absent. Being culturally and developmentally aware and sensitive will improve your accuracy in making nursing diagnoses. All clients will tell you when they need pain medication is the correct answer. DIF: C dm 255 OBJ: Analysis TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 27. Which of the following statements best reflects the nurses understanding of the primary nursing-related purpose of a concept map?

To facilitate holistic nursing care

To provide visualization of the clients health problems

To assist in the identification of client-oriented nursing diagnoses To demonstrate the relationship between the clients various health problems

ANS: 4 Concept mapping is one way to graphically represent the connections between concepts and ideas that are related to a central subject (e.g., the clients health problems). Although the other options are correct, they do not provide the best understanding of the purpose of concept mapping in nursing practice as well as to demonstrate the relationship between the clients various health problems. DIF: C dm 255 OBJ: Analysis TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 28. Which of the following statements made by the nurse reflects the best understanding of the usefulness of a concept map to client care?

Concept maps help me see the whole client, not just individual health problems.

Concept maps can be easily edited to reflect a clients ever changing health needs.

I need help organizing my assessment data and concept mapping is really good for that. I like concept mapping because it helps me focus on how the disease processes affect the client.

ANS: 1 The advantage of a concept map is its central focus on the client rather than the clients disease or health alteration, thus concept maps help me see the whole client, not just individual health problems is the correct answer. DIF: C dm 255 OBJ: Analysis TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 29. A client expresses concern over a scheduled intravenous pyelogram by stating, I dont know what to expect. Which of the following nursing diagnoses is most appropriate for this client need?

Anxiety related to scheduled diagnostic testing

Knowledge deficit regarding need for diagnostic testing

Knowledge deficit related to need for intravenous pyelogram

Anxiety related to lack of knowledge concerning intravenous pyelogram

ANS: 4 Identify the problem caused by the treatment or diagnostic study rather than the treatment or study itself. The client need, identified by the statement, is not related to the necessity for the test but concern over a lack of knowledge about what to expect before, during, and after the test. The remaining options fail to identify a client need. DIF: C dm 255 OBJ: Analysis TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 30. Which of the following assessment findings best supports the nursing diagnosis of Pain in right knee joint related to degenerative process?

Paternal family history of osteoarthritis reported

Client observed grimacing when walking to bathroom.

Right knee appears edematous when compared to left knee Client rated the pain felt after walking at a 6 on a scale of 1-10

ANS: 2 To collect complete, relevant, and correct assessment data it helps to identify assessment activities that produce specific kinds of data. When possible, the nurse should collect objective data, because it is often more supportive than subjective data. Observation of the clients response to the use of the affected joint is the most supportive of the options. DIF: C dm 254 OBJ: Analysis TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 31. Which of the following statements best reflects the nurses understanding of the primary nursing related purpose of a concept map?

To facilitate holistic nursing care

To provide visualization of the clients health problems

Assist in the identification of client-oriented nursing diagnoses

Demonstrate the relationship between the clients various health problems

ANS: 4 Concept mapping is one way to graphically represent the connections between concepts and ideas that are related to a central subject (e.g., the clients health problems). While the other options are correct they do not provide the best understanding of the purpose of concept mapping in nursing practice. DIF: C dm 255 OBJ: Analysis TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 32. Which of the following statements made by the nurse reflects the best understanding of the usefulness of a concept mapping to client care?

Concept maps help me see the whole client, not just individual health problems

Concept maps can be easily edited to reflect a clients everchanging health needs.

I need help organizing my assessment data and concept mapping is really good for that.

I like concept mapping because it helps me focus on how the disease processes affect the client

ANS: 1 The advantage of a concept map is its central focus on the client rather than the clients disease or health alteration. DIF: C dm 255 OBJ: Analysis TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance MULTIPLE RESPONSE 1. Research has shown that which of the following nursing skills is best strengthened through the use of concept mapping? (Select all that apply.)

Client teaching related to health and wellness topics

Evaluation of client outcomes in regards to nursing care Identification of patterns in the clients health assessment data

3 4

Recognition of relationships among the clients various health issues

Planning specialized nursing interventions to meet a clients health needs

Facilitating assessment data collection through observation and communication

ANS: 2, 3, 4, 5 Concept mapping significantly improved students abilities to see patterns and relationships as well as to organize, plan, and evaluate nursing care. Client teaching and assessment collecting are not markedly affected by concept mapping. Chapter 18. Planning Nursing Care MULTIPLE CHOICE 1. The nurse is working with a client who is being prepared for a diagnostic test this afternoon. The client tells the nurse that she wants to have her hair shampooed. Which of the following is the most appropriate label with regard to prioritizing her request?

Low priority

An unmet need

Intermediate priority A safety and security need

ANS: 1 The clients request would be of low priority because it is not directly related to a specific illness or prognosis. An unmet need is not the most appropriate label for the clients request. The clients request is not an intermediate priority. An intermediate priority is one that involves the nonemergent, nonlife-threatening needs of the client. The clients request is not a safety and security need; the outcome does not threaten her well-being. DIF: A dm 262 OBJ: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 2. Assuming that all of the following are realistic, a long-term goal for a client that is a tailor by trade and has been admitted for eye surgery should include:

Returning to sewing Preventing ocular infection

Administering eye drops on time in the hospital

Performing independent hygienic care in the hospital

ANS: 1 Long-term goals focus on prevention, rehabilitation, discharge, and health education. An appropriate long-term goal for this client would be for rehabilitation and the clients return to occupation, in this case sewing. Preventing ocular infection is a short-term goal. A short-term goal is expected to be achieved within a short time, usually in less than 1 week. In 1 weeks time, the clients risk for infection should be greatly reduced. Administering eye drops on time in the hospital is a short-term goal. Long-term goals are usually designed for problem resolution after discharge, especially from an acute care setting. Performing independent hygienic care in the hospital is a short-term goal. Long-term goals are usually made for problem resolution after discharge, especially from an acute care setting. DIF: A dm 265 OBJ: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 3. The nurse writes the following goal for a client who is hypertensive: Client will maintain a blood pressure within acceptable limits. Which of the following would be the most appropriate outcome criterion?

Client will request pain medication as needed.

Client will experience no headache or dizziness. Client will identify at least two things that cause stress.

3 4

Client will have a 7 AM blood pressure reading less than 140/90.

ANS: 4 Client will have a 7 AM blood pressure reading less than 140/90 would be the most appropriate outcome criterion. It is client-centered, singular, observable, measurable, time-limited, and realistic. Client will request pain medication as needed does not allow the nurse to be able to determine if change has taken place. It would be more measurable to state the client will rate pain below 4 on a scale of 0 to 10 by 24 hours. Client will experience no headache or dizziness is not time-limited. Client will identify at least two things that cause stress is not time-limited or singular. DIF: A dm 266 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 4. Nursing interventions may be categorized based upon the degree of nursing autonomy. Which of the following nursing interventions is considered as physician- or prescriber-initiated?

Teaching a client to administer his or her insulin injection

Assisting a new mother with learning the art of breast-feeding

Notifying the nutritionist of a clients specific dietary preferences Administering a cleansing enema in preparation for radiological testing

ANS: 4 Preparing a client for a diagnostic test is an example of a physician-initiated intervention. Teaching a client to administer his or her insulin injection is an example of a nurse-initiated intervention. Assisting a new mother with breast-feeding is an example of a nurse-initiated intervention. Notifying a nutritionist of a clients dietary preferences is a collaborative intervention. DIF: A dm 268 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance

5. Nursing interventions should be documented according to specific criteria in order that they may be clearly understood by other members of the nursing team. The intervention statement Nurse will apply warm, wet soaks to the patients leg while awake lacks which of the following components?

Method

Quantity

Frequency

Performing staff

ANS: 3 The intervention statement does not include how frequently the warm soaks should be applied. The method is applying warm, wet soaks to the patients leg while awake. The quantity is warm, wet soaks. The qualification of the person who will perform the action is the designation of the nurse. DIF: A dm 273 OBJ: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 6. In order that they are clear and easily understood by other members of the health care team, the nurse recognizes that client goals or outcomes should be documented according to specific criterion. Of the following, the outcome statement that best meets the established criteria is:

Client will describe activity restrictions.

Client will verbalize understanding of treatments.

Client will be ambulated in hallway 3 times each day.

Clients respiratory rate will remain within 20 to 24 breaths per minute by 9/24.

ANS: 4 Clients respiratory rate will remain within 20 to 24 breaths per minute by 9/24 is a correctly written outcome statement. It is client-centered, singular, observable, measurable, time-limited, and realistic. Client will describe activity restrictions is not time-limited. Client will verbalize understanding of treatments is not observable or time-limited. The client will state the purpose of the breathing treatments by 4/10 would be more appropriate. Client will be ambulated in hallway 3 times each day is not client-centered. A correct outcome statement would be Client will ambulate in the hall 3 times a day. DIF: A dm 267 OBJ: Comprehension

TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 7. The client is receiving postural drainage from physical therapy and intermittent breathing treatments from respiratory therapy. Which type of care plan would be the ideal method to document interventions for this client?

Nursing Kardex

2 3

Computerized care plan Critical pathway

Standardized care plan

ANS: 3 Critical pathways allow staff from all disciplines to develop integrated care plans for a projected length of stay or number of visits for clients with a specific case type. The nursing Kardex is a card-filing system that allows quick reference to the particular needs of the client for certain aspects of nursing care. A computerized care plan is a standardized care plan on the computer. A standardized care plan is a prewritten plan created for a specific nursing diagnosis or clinical problem. The nurse individualizes the care plan for the clients needs. DIF: A dm 274 OBJ: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 8. The nurse is involved in requesting a management consultation for personnel-related issues. Which of the following is true regarding the consultation process in which the nurse is involved?

The problem area should be totally delegated to the consultant.

Consultation is often used when the exact problem remains unclear.

The problem area is identified by any member of the health care team. Feelings about the problem should be described to the consultant by the nurse.

ANS: 2 Consultation is appropriate when the nurse has identified a problem that cannot be solved using personal knowledge, skills, and resources, or when the exact problem remains unclear. A consultant objectively entering a situation can more clearly assess and identify the exact nature of the problem. The whole problem is not turned over to the consultant. The consultant is not there to take over the problem but is there to assist the nurse in resolving it. The person

requesting the consult usually identifies the problem area. The nurse should not bias the consultant with subjective and emotional conclusions about the client and problem. DIF: A dm 276 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 9. In completing an assessment on an assigned client, the nurse obtains important information for planning nursing care. Which of the following client needs should take priority?

1 2 3 4

Difficulty breathing Financial problems A nutritional deficit An impending divorce

ANS: 1 Difficulty breathing would be the highest priority client need. In general, priorities that protect clients basic needs of safety, adequate oxygenation, and comfort are considered high priority. Financial problems are a low-priority client need. Financial problems are not directly related to a specific illness or prognosis but may affect the clients future well-being. A nutritional deficit is an intermediate priority client need. It involves a nonlife-threatening need of the client. An impending divorce is a low-priority client need. It is a need that is not directly related to a specific illness or prognosis but may affect the clients future well-being. DIF: C dm 262 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 10. The nurse recognizes that client goals or outcomes should be documented according to specific criterion in order that they are clear and easily understood by other members of the health care team. Of the following, the outcome statement that best meets the established criteria is the following:

Vital signs will return to within normal levels for a middle aged adult.

Nursing assistant will ambulate the client in the hallway 3 times each day.

Lungs will be clear to auscultation and respiratory rate will be 20/minute. Output will be at least 100 mL/hour of clear yellow urine within 24 hours.

ANS: 4 Output will be at least 100 mL/hour of clear yellow urine within 24 hours. is client-centered, singular, observable, measurable, time-limited, and realistic. Vital signs will return to within normal levels for a middle aged adult. is not measurable (i.e., guidelines for normal are not stated), and it is not time-limited (e.g., by when?). Nursing assistant will ambulate the client in the hallway 3 times each day. is not client-centered. Lungs will be clear to auscultation and respiratory rate will be 20/minute. is not singular and it is not time-limited. DIF: C dm 267 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 11. In goal setting, the nurse is aware that the factor that is associated with available client resources and motivation is:

1 2 3 4

Realistic Observable Measurable Client-centered

ANS: 1 The nurse sets realistic goals that can be achieved. This increases the clients motivation. The nurse also takes available resources into consideration in order to set realistic goals. Being observable means the nurse must be able to determine through observation if change has taken place. Being measurable means the goal is written so the nurse has a standard against which to measure the clients response to nursing care. Being client-centered means the goal should reflect the clients behavior and responses expected as a result of nursing interventions. DIF: A dm 267 OBJ: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 12. Nursing interventions may be categorized based upon the degree of nursing autonomy. An example of a nurse-initiated intervention is:

Providing client teaching

Administering medication

Ordering a liver CAT scan

Referring a client to physical therapy

ANS: 1 Health teaching is an example of a nurse-initiated intervention. Administering medication is a physician-initiated intervention. Ordering a CAT scan is a physician-initiated intervention. Referring a client to physical therapy is a collaborative intervention. DIF: A dm 267-268 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 13. Nursing interventions may be categorized based upon the degree of nursing autonomy. Which of the following nursing interventions is considered as physician- or prescriber-initiated?

Taking vital signs

Providing support to a family

Changing a dressing 2 times each day

Measuring intake and output each shift

ANS: 3 Changing a dressing is a physician- or prescriber-initiated intervention. Taking vital signs is a nurse-initiated intervention. Providing support to a family is a nurse-initiated intervention. Measuring intake and output is a nurse-initiated intervention. DIF: A dm 268 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 14. Which one of the following interventions selected by the nurse is classified as Level 2, Domain 2 (Physiological: complex)?

Maintaining regular bowel elimination

Promoting the health of the entire family

Managing severely restricted body movement Restoring tissue integrity to areas damaged by friction

ANS: 4 Interventions to maintain or restore tissue integrity are classified as Level 2, Domain 2 (Physiological: Complex). Maintaining regular bowel elimination is classified as Level 2, Domain 1 (Physiological: Basic). Promoting the health of the family is classified as Level 2, Domain 5 (Family). Managing restricted body movement is classified as Level 2, Domain 1 (Physiological: Basic).

DIF: A dm 270 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 15. In documentation of nursing care plans, critical pathways differ from traditional nursing care plans in their:

Client outcomes

2 3

Client assessment Nursing interventions

Multidisciplinary approach

ANS: 4 Critical pathways are multidisciplinary. They allow staff from all disciplines, such as medicine, nursing, pharmacy, and social work, to develop integrated care plans for a projected length of stay or number of visits for clients with a specific case type. Client outcomes are included in both critical pathways and traditional nursing care plans. Client assessment is necessary for developing and evaluating critical pathways and traditional nursing care plans. Nursing interventions are included in critical pathways and in the traditional nursing care plan. DIF: A dm 274 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 16. Nursing interventions should be documented according to specific criteria in order that they may be clearly understood by other members of the nursing team. The most appropriate of the following intervention statements is:

Offer fluids to the client q2h

Observe the clients respirations

Change the clients dressing daily Irrigate the nasogastric tube q2h with 30 ml normal saline

ANS: 4 Irrigate the nasogastric tube q2h with 30 ml normal saline is the most appropriate intervention statement. It includes the action, frequency, quantity, and method. Offer fluids to the client q2h lacks the component of quantity. Observe the clients respirations fails to indicate the frequency or method. Also, what is the reason for observation of the clients respirations? Change the clients dressing daily omits the method. DIF: C dm 267 OBJ: Analysis

TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 17. Nursing interventions should be documented according to specific criteria in order that they may be clearly understood by other members of the nursing team. The most appropriate of the following intervention statements is the following:

Take vital signs.

2 3

Refer client to a therapist. Turn client as needed while in bed.

Apply two 4 4 dry gauze dressing pads tid.

ANS: 4 Apply two 4 4 dry gauze dressing pads tid. is the most appropriate. It identifies the action, frequency, quantity, and method. Take vital signs. fails to indicate the frequency and fails to completely indicate nursing actions (e.g., what parameters are used to notify the physician). Refer client to a therapist. fails to completely indicate nursing interventions (e.g., what type of therapist). Turn client as needed while in bed. fails to state an accurate frequency or precisely indicate the nursing actions. DIF: A dm 267 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 18. Care plans created by nursing students usually differ from those that are completed by nurses working on client units. An aspect of the plan that is usually included in the students care plan but not in the clients record is:

Client outcomes

Nursing diagnoses

Scientific rationales Nursing interventions

ANS: 3 An aspect of a nursing care plan that is usually included in the students care plan, but not in the clients record, is scientific rationales. Client outcomes are included in both student care plans and the clients record. Nursing diagnoses are included in both student care plans and the clients record. Nursing interventions are a component of both student care plans and a nursing care plan in the clients record. DIF: A dm 271 OBJ: Knowledge

TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 19. The purpose and distinction of a concept map, which a nurse may use when implementing a plan of care, are for:

1 2

Multidisciplinary communication Quality assurance in the health care facility

Provision of a standardized format for client problems

Identification of the relationship of client problems and interventions

ANS: 4 A concept map is a diagram of client problems and interventions that shows their relationship to one another. Multidisciplinary communication is enhanced with the use of critical pathways, not concept maps. The use of a concept map promotes critical thinking and helps nurses to organize complex client data, process complex relationships, and achieve a holistic view of the clients situation. The purpose is not quality assurance in the health care facility. Standardized or computerized care plans provide a standardized format for client problems, not the concept map. A concept map is highly individualized. DIF: A dm 274 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 20. A client is newly diagnosed with diabetes mellitus. The nurse identifies a nursing diagnosis of knowledge deficient related to new diagnosis and treatment needs. The most appropriate outcome statement based upon the established criteria is the following:

Client will perform glucose measurements often.

Client will appear less anxious regarding diagnosis.

Urinary output will reach normal young adult levels. Client will independently perform subcutaneous insulin injection by 8/31.

ANS: 4 Client will independently perform subcutaneous insulin injection by 8/31. is the most appropriate outcome statement. It addresses the nursing diagnosis by identifying a singular outcome the client can realistically achieve, is observable, and provides a time frame. Client will perform glucose measurements often. does not specify a time frame. Client will appear less anxious regarding diagnosis. is not an appropriate outcome statement. There is no specific behavior

observable for will appear. Urinary output will reach normal young adult levels. is not an appropriate outcome statement. It does not provide a standard against which to measure the clients response to nursing care, and therefore is not measurable. It is also not time-limited. DIF: A REF: 267 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 21. Which of the following is the best example of an intermediate prioritized client need for a client diagnosed with risk of injury related to poor skin integrity?

Applying adequate clothing to ensure the clients warmth

Providing sufficient quantities of an aloe-based skin lotion

Helping the client select her favorite foods from the menu form

Dressing the clients feet in non-skid soled slippers when ambulating

ANS: 2 An intermediate priority is one that involves the non-emergent, nonlife-threatening needs of the client. Having sufficient aloe-based lotion is required for maintaining good skin integrity but is not required for meeting a life-threatening need. Although the other options are an intermediate need, they are not the best option because they are not directly related to the clients stated nursing diagnosis. DIF: C dm 262 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 22. Which of the following would be the best example of a short-term safety goal for a client who recently experienced abdominal surgery?

The client will show no systemic or local signs of infection by time of discharge from hospital.

The client will demonstrate an understanding of the proper use of patient-controlled analgesia (PCA). The client will demonstrate effective coughing and deepbreathing techniques within 2 hours of surgery.

The client will consistently use the call bell to notify the staff of a need for assistance to the bathroom upon return to the nursing unit.

ANS: 4 Although all the options represent short-term goals, this option (consistently use the call bell to notify the staff) is directly related to client safety because it deals with fall prevention. Although this is short-term goal (by time of discharge), it is not as directly related to safety as some other options. Although this is short-term goal (time is inferred by nature of pain needs), it is not as directly related to safety as some other options. Although this is short-term goal (2 hours), it is not as directly related to safety as some other options. DIF: C dm 265 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 23. Which of the following would be the most appropriate outcome criterion for the goal, Clients pain will be managed to within an acceptable level within 30 minutes of receiving pain medication.

Client will deny presence of any pain or discomfort.

Client will rate pain at a level of 3 or less out of a possible 10.

Client will demonstrate ability to request pain medication as needed.

Client will identify two external factors that decrease presence of pain.

ANS: 2 Client will rate pain at a level of 3 or less out of a possible 10 would be the most appropriate outcome criterion because it is directly related to the management of pain levels as reflected by the pain scale. Client will deny presence of any pain or discomfort does not necessarily reflect a reasonable goal. Although client will demonstrate ability to request pain medication as needed is directed towards pain management, it does not have the primary focus that evaluating the pain management intervention has. Client will identify two external factors that decrease presence of pain is not the best option because it does not directly relate to pain management but the identification of contributing factors. DIF: C dm 266 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance

24. The nurse is caring for a newly admitted client who is scheduled for diagnostic testing in the morning. Which of the following client needs should take priority?

1 2 3 4

Inventory of clothes and other personal belongings Orientation to the nursing unit and individual room Interview regarding medications currently being taken Assessment of body systems for presurgery checklist

ANS: 2 The clients admission has no acute physical needs and so the emotional need of familiarization with the environment has priority. Inventory of clothes and other personal belongings does not reflect a priority because it does not relate directly to a physical need, and there are other emotional needs of higher priority. Interview regarding medications currently being taken does not reflect a priority because it does not relate directly to a physical need, and there are emotional needs of higher priority. Although assessment of body systems for presurgery checklist reflects a needed nursing action, it is not a priority because it does not relate directly to physical need, and there are other emotional needs of higher priority. DIF: C dm 262 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 25. Which of the following outcomes, made by a nurse planning care for a client recently fitted with a hearing aid, best reflects an understanding of short-term client education goals?

Client will properly clean the hearing aid ear piece daily with soap and water.

Client will state 3 positive effects of wearing his hearing aid at follow-up appointment.

Client will wear hearing aid while awake to help improve his ability to understand instructions. Client will demonstrate ability to change the batteries in his hearing aid before leaving clinic today.

ANS: 4 Although all the options represent short-term goals, client will demonstrate ability to change the batteries in his hearing aid before leaving clinic today is directly related to patient education because it relates to the proper care of the hearing aid. Client will properly clean the hearing aid ear piece daily with soap and water does not directly relate to client education but more to an expected client action. The goal does not include a time limit for compliance. Although client

will state 3 positive effects of wearing his hearing aid at follow-up appointment may be a shortterm goal (depends on time of next appointment), it is not as directly related to client education as it is compliance-oriented. Although client will wear hearing aid while awake to help improve his ability to understand instructions may be a short-term goal, although there is no time limit, it is not as related to client education as some other options. DIF: C dm 262-263 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 26. Which of the following statements made by a new nursing graduate best reflects an understanding of expected outcomes?

It gives the client something positive to strive towards.

They are statements of how the clients behavior should change. They are measurable criteria by which I can evaluation whether a goal has been achieved.

3 4

They provide the client with suggestions on how to achieve their long and short term goals.

ANS: 3 They are measurable criteria by which I can evaluation whether a goal has been achieved. It is necessary to use expected outcomes or measurable criteria to evaluate goal achievement. Although outcomes are directed at times toward the alteration of client behavior, They are statements of how the clients behavior should change. is not the best option provided to reflect an understanding of the term. It gives the client something positive to strive towards and They provide the client with suggestions on how to achieve their long and short term goals are incorrect as outcomes are nursing-oriented, not client-oriented. DIF: C dm 266 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 27. A nurse is caring for a client newly diagnosed with diabetes mellitus. Which of the following statements best reflects an understanding of client-centered goals?

The clients A1C levels will be 7 or below at the first testing date.

The client will experience no blood sugar readings below 60 mg/dL before first follow up visit.

The client will be visited weekly by home health nursing staff beginning 1 week after discharge.

The client will demonstrate the ability to appropriately measure blood sugar levels using a glucometer by discharge from nursing unit.

ANS: 4 A client-centered goal is a specific and measurable behavior or response that reflects a clients highest possible level of wellness and independence in function, therefore The client will demonstrate the ability to appropriately measure blood sugar levels using a glucometer by discharge from nursing unit is correct. Although The clients A1C levels will be 7 or below at the first testing date and The client will experience no blood sugar readings below 60 mg/dL before first follow up visit are appropriate, they are not the best options because they do not reflect independence in function. The client will be visited weekly by home health nursing staff beginning 1 week after discharge is not client-centered because it does not reflect a clients highest possible level of wellness and independence in function. DIF: C dm 267 OBJ: Evaluation TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 28. The expected outcome that best evaluates the presurgical goal of, Client will understand purpose of coughing and deep breathing within 4 hours of returning to room is:

Client will demonstrate proper technique for coughing and deep breathing

Client will cough and deep breathe every 1 hour while awake without staff prompting Client is capable of restating the purpose of coughing and deep breathing in own words

3 4

Clients lungs will be free of abnormal breath sounds within 1 hour of being returned to room

ANS: 2 An expected outcome is a criteria designed to evaluate the achievement of the stated goal. This option best represents evaluation of the clients understanding of the purpose of deep breathing and coughing because it shows appropriate compliance. Although demonstration evaluates the proper technique, it is not the best option to evaluate understanding of purpose. Although restatement evaluates understanding, it is not the best option to evaluate understanding of

purpose because it does not include client compliance. The clients lungs being free of abnormal breath sounds within 1 hour is more reflective of a goal than of an expected outcome. DIF: C dm 266 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 29. Which of the following statements made by the nurse best reflects an understanding of the clients role in goal setting?

1 2

He knows what he needs better than anyone else. When he sets the goals he is more likely to follow the plan.

He identifies the goals and then together we create the plan of action.

He is best suited to determine the level of effort he is capable of providing.

ANS: 4 Unless you set goals mutually and make a clear plan for action, clients will not follow the care plan. Clients alone are not always appropriately prepared to set and plan goals without professional help. Although the other answers may be true for many clients, it is not a guarantee that the client possesses all the skills and knowledge necessary to set and plan realistic goals. DIF: C dm 267 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 30. A nurse is caring for a client who experienced short-term memory loss as a result of a head injury. Which of the following statements made by the nurse regarding goal setting requires follow-up by the nurse manager?

The client will certainly need frequent reorientation to the care plan goals.

I will restate the goals Ive created for him regularly so as to win his compliance.

Im not sure that his family will be able to support him with these goals but I will discuss it with them. He seems very willing to work towards achieving his goals but his condition will certainly create barriers.

ANS: 2 If a client or significant other is not able to participate in goal development, you assume responsibility until the client is able to participate. It is vital that to the degree that the client is capable, the client be included in the decision-making process. Frequent reorientation to the care plan goals may be true and so does not require follow-up. The nurse seems pessimistic about the familys ability to play a role in the clients care plan but declares that an attempt will be made to include them; so follow-up is not an immediate priority. The client seems very willing to work towards achieving his goals may be true and so does not require follow-up because there is no indication of the nurses intention to minimize his participation. DIF: C dm 265 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 31. Which of the following goals best shows that the nurse understands the concept of a clientcentered goal?

1 2

Client will consume at least 75% of each meal served. ADLs will be completed before breakfast is served.

Pain will be managed so as to be rated at 3 or less out of 10.

Client will be transported to physical therapy by 9 AM daily.

ANS: 1 Client will consume at least 75% of each meal served is correct. Outcomes and goals reflect the clients behavior and responses expected as a result of nursing interventions. Write a goal to reflect client behavior, not to reflect your goals or interventions. The other options are nursingcentered. DIF: C dm 267 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 32. Which of the following client-centered goals best rest reflects singular focus?

Client will cough and deep breathe every hour while awake.

Client will be free of shoulder and elbow pain by discharge.

Client will adhere to a low-fat diet and lose 3 pounds in 30 days. Client will ambulate to the bathroom for the purpose of showering daily.

ANS: 4 Each goal and outcome addresses only one behavior or response. In this case the client will walk to the shower daily. Although coughing and deep breathing are usually done as a unit, they are really two separate actions. The client being free of shoulder and elbow pain by discharge relates to two different anatomical locations. Adhering to a diet and losing 3 pounds are two different actions. DIF: C dm 267 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 33. The nurse realizes that goals should be singular in focus primarily because:

The nurse will find it difficult to modify the plan of care if the goals are not met.

The client may not have the strength to accomplish multiply behavioral changes.

The client may have difficulty focusing on more than one behavioral modification at a time.

The nurse will find it difficult to identify appropriate interventions to address multiple behaviors.

ANS: 1 The nurse finding it difficult to modify the plan of care if the goals are not met is correct. Singularity allows you to decide if there is a need to modify the plan of care because only one response is considered. Although the other answers may be true, they are not the primary reason for having only one focus per goal. DIF: C dm 267 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 34. Which of the following goals concerning client anxiety is the best example of measurability?

Client will be less anxious by discharge.

Client will appear less anxious by discharge.

Client will report anxiety at less than 3 out of 5 by discharge.

Client pulse rate and blood pressure will be within normal limits by discharge.

ANS: 3 You need to be able to observe if change takes place in a clients status. Observable changes occur in physiological findings and the clients knowledge, perceptions, and behavior. You observe outcomes by directly asking clients about their condition or by using assessment skills. The client rating his anxiety is one method of observing improvement. The phrase will be less anxious is not observable. The phrase will appear less anxious is not observable. Although pulse rate and blood pressure may be affected by anxiety, there is no assurance that normal readings reflect an improvement. DIF: C dm 267 OBJ: Anxiety TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 35. Which of the following goals best reflects measurability?

1 2

Clients emotional state will be stable by time of discharge. Client will experience normal sensations in feet by discharge.

Client will report being free of shoulder pain by discharge.

Client will have acceptable range of motion in elbow by discharge.

ANS: 3 Terms describing quality, quantity, frequency, length, or weight allow you to evaluate outcomes precisely. Pain free relates to quantity as well as quality. Do not use vague qualifiers such as normal, acceptable, or stable in an expected outcome statement. Vague terms result in guesswork in determining a clients response to care. DIF: C dm 267 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 36. When developing appropriate nurse-initiated interventions for a client admitted to an acute care facility for abdominal pain, the nurse must first consider:

The institutions policies and procedures

The states defined scope of nursing practice

The clients physiological and psychological needs

The scientific rationale for the proposed nursing action

ANS: 2

Each state within the United States has developed a Nurse Practice Act that defines the legal scope of nursing practice (see Chapter 22). According to the Nurse Practice Act in a majority of states, independent nursing interventions pertain to activities of daily living, health education and promotion, and counseling. Although the other answers must be considered, they are not the first consideration. DIF: C dm 268 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 37. The nurse realizes that the primary nursing responsibility regarding a physician-initiated intervention is to:

Facilitate the intervention in a timely manner

Evaluate the clients response to the intervention

Possess the technical skills required to implement the intervention

Provide client education regarding the implementation of the intervention

ANS: 3 Each physician-initiated intervention requires specific nursing responsibilities and technical nursing knowledge. Although the other options are expectations, they are not the primary consideration. DIF: C dm 268 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 38. The primary function of a care plan is to provide:

The client with continuity of care

The staff with written client-centered nursing interventions

An established criteria for the evaluation of nursing outcomes

An organized means of exchanging information between caregivers

ANS: 1 The nursing care plan enhances the continuity of nursing care by listing specific nursing interventions needed to achieve the goals of care. Although the rest are functions, they are not the primary function.

DIF: C dm 269 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance MULTIPLE RESPONSE 1. Which of the following characteristics are considered guidelines for the writing of appropriate goals and outcomes? (Select all that apply.)

Singular

Realistic Practical

3 4 5

Observable Measurable

Meaningful

ANS: 1, 2, 4, 5 There are seven guidelines for writing goals and expected outcomes. The guidelines are clientcentered, singular, observable, measurable, time-limited, mutual, and realistic. Practical and meaningful are not recognized characteristics

Chapter 19. Implementing Nursing Care MULTIPLE CHOICE 1. The nurse is working with postoperative clients on a surgical unit. One aspect of care is manipulation of the clients environment. This involves the nurse:

1 2 3 4

Repositioning the client q2h Removing clutter from the clients room Delegating ambulation of clients to the nursing assistant Providing pain medication to the client before a dressing change

ANS: 2 Making rooms free of clutter is an example of manipulating the environment to create safe surroundings. The remaining options are examples of the organization of care and personnel. DIF: A dm 282 OBJ: Comprehension TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Safe, Effective Care Environment 2. The client is given an injection of an antibiotic. Shortly afterwards the client reports hives and itching. The nurse administers an antihistamine to counteract the effect of the antibiotic. The nurse is using which one of the following intervention methods?

Preventive measures

Assisting with ADLs

Preparing for special procedures

Compensation for adverse reactions

ANS: 4 Nursing actions that control for adverse reactions reduce or counteract the reaction, such as administering an antihistamine after an allergic reaction to a medication. Preventive measures promote health and prevent illness while assisting with ADLs and preparing for special procedures are direct care measures. DIF: A dm 283-284 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 3. The client is scheduled to receive Coumadin (an anticoagulant) at 9:00 AM. His morning laboratory results show him to have a high partial thromboplastin time (PTT). His nurse decides to withhold the Coumadin. Which step of the implementation process is she using?

Reassessing the client

Stating an expected outcome

Revising the nursing diagnosis

Modifying the nursing care plan

ANS: 4 The nurse is modifying the nursing care plan. Data have been updated to reflect the clients current status of an elevated PTT; nursing diagnoses and specific interventions are revised. In this case, the revised intervention is withholding the Coumadin. By gathering further assessment data and revising nursing interventions, the nurse is modifying the nursing care plan. DIF: A dm 282 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment

4. The nurse notes that a narcotic is to be administered per epidural cath. The nurse; however, does not know how to perform this procedure. Which aspect of the implementation process should be followed?

Seek assistance

2 3

Reassess the client Use interpersonal skills

Critical decision making

ANS: 1 If a nurse does not know how to perform a procedure, he or she should seek assistance. Information about the procedure is obtained from the literature and the agencys procedure book. All equipment necessary for the procedure is collected. Finally, another nurse who has completed the procedure correctly and safely provides assistance and guidance. Reassessing the client is a partial assessment that may focus on one dimension of the client or on one system. Interpersonal skills are used to develop a trusting relationship, express a level of caring, and communicate clearly with the client, family, and health care team. Critical decision making is used when the nurse implements the care plan using the knowledge bases necessary for care planning and then completing the planned interventions most effectively. DIF: A dm 284 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 5. The nurse recognizes the discharge needs of a client following a hip replacement. This is an example of which type of nursing skill?

Cognitive

Interactive

Psychomotor

Communication

ANS: 1 Cognitive skills involve the application of nursing knowledge. Being able to identify a clients discharge needs is a cognitive skill. Interactive skills are interpersonal skills such as developing a trusting relationship and communicating effectively. Psychomotor skills involve the integration of cognitive and motor skills such as with administering an injection. Effective communication is an interpersonal skill. The nurse communicates with the client and family when providing client teaching and emotional support. The nurse communicates with the health care team to achieve client outcomes.

DIF: A dm 284 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 6. An example of a cognitive nursing skill is:

1 2

Providing a soothing bed bath Communicating with the client and family

Giving an injection to the client per the physicians orders

Recognizing the potential complications of a blood transfusion

ANS: 4 Cognitive skills involve the application of nursing knowledge. Understanding normal and abnormal physiological and psychological responses is a cognitive skill, as in recognizing the potential complications of a blood transfusion. Providing a soothing bed bath involves both interpersonal skills and psychomotor skills. The nurse who provides a soothing bed bath is expressing a level of caring that is an interpersonal skill. The nurse who provides a soothing bed bath is also using a psychomotor skill in performing the bed bath correctly. Communicating with the client and family is an example of an interpersonal skill. Giving an injection to the client is a psychomotor skill. DIF: A dm 284 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 7. An enterostomal nurse shows a clients significant other how to assist with the supplies for the ostomy and how to manipulate the ostomy equipment. In demonstrating this technique to the clients significant other, the nurse is using what type of nursing skill?

Affective

Cognitive

Interactive Psychomotor

ANS: 4 Psychomotor skills involve the integration of cognitive and motor activities, such as in providing ostomy care. Cognitive skills involve the application of nursing knowledge. Knowing the rationale for therapeutic interventions, understanding normal and abnormal physiological and psychological responses, and being able to identify client learning and discharge needs all require cognitive skills. Interpersonal skills are used when the nurse interacts with clients, their

families, and other health care team members. Effective communication is an example of an interpersonal skill. Affective means pertaining to an emotion or mental state. DIF: A dm 284 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 8. For a client with a nursing diagnosis of impaired physical mobility related to bilateral arm casts, the nurse should select which of the following methods of nursing intervention?

1 2 3 4

Teaching Counseling Compensating for adverse reactions Assisting with activities of daily living (ADLs)

ANS: 4 A client with bilateral arm casts has a temporary need for assistance with ADLs. Counseling is a direct care method that helps the client use a problem-solving process to develop new attitudes and feelings. It does not meet the physical need for assistance with ADLs. Teaching is an implementation method used to present correct principles, procedures, and techniques of health care to clients and to inform clients about their health status. Compensating for adverse reactions means the nurse takes action to reduce or counteract the reaction, such as by administering an antihistamine when a client has an allergic reaction to a medication. Assisting with ADLs would be compensating for the clients impaired mobility. DIF: A dm 285 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 9. The plan of care offers a number of different types of nursing interventions that may be incorporated in. An example of a nurse implemented specific life-saving measure is:

Administering analgesics

Restraining a violent client

Initiating stress-reduction therapy Teaching the client how to take his/her pulse rate

ANS: 2 Restraining a violent client is an example of a life-saving measure to protect the client. The purpose of a life-saving measure is to restore physiological or psychological equilibrium. Administering analgesics is an example of physical care techniques. It is not a life-saving

measure. Initiating stress-reduction therapy is an example of a counseling technique. Teaching the client how to take his or her pulse rate is an example of the nursing intervention of teaching. The focus is for the client to obtain new knowledge or psychomotor skills. DIF: A dm 285 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 10. To provide optimum care, a nursing intervention should be based on:

An appropriate nursing diagnosis

Subjective and objective client data

Sound clinical judgment and knowledge

Identified physical and psychosocial needs of the client

ANS: 3 The assessment data direct the nurse in the formulation of a client-specific care plan grounded within clear, relevant nursing diagnoses and directed towards appropriate, attainable client outcomes. A nursing intervention is any treatment, based upon clinical judgment and knowledge that a nurse performs to enhance client outcomes. Ideally, the interventions a nurse uses are evidence-based, providing the most current, up-to-date, and effective approaches for client problems. Interventions include both direct and indirect care measures, aimed at individuals, families, and/or the community. DIF: C dm 279 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 11. Which of the following interventions is the best example of an indirect intervention directed towards client safety?

Checking on a restrained client every 15 minutes

Performing hand hygiene between client contacts

Including the diagnosis at risk for injury related to falls to a clients care plan

Turning on a night light to illuminate the path to the bathroom

ANS: 4 Indirect care interventions are treatments performed away from the client but on behalf of the client or group of clients. For example, indirect care measures include actions for managing the clients environment (e.g., safety and infection control), documentation, and interdisciplinary

collaboration. Directly impacting the light level in a clients room to minimize the risk for falls is the best example of a safety-oriented indirect care intervention. Including a nursing diagnosis regarding falls would also be an example of an indirect care intervention but it is not as actively affecting the clients safety. Checking a restrained client is a direct care intervention because it involves actual client contact, while performing hand hygiene is directed more towards infection control than safety. DIF: C dm 287 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 12. Which of the following interventions best reflects the nurses understanding of direct care interventions regarding a cognitively impaired clients need for social interaction?

Arranging for the client to attend a sing along in the dayroom

Helping the client place a long distance telephone call to his daughter

Turning the clients television on when his or her favorite program is playing

Talking about the clients favorite sports team while redressing his or her wound

ANS: 4 Direct care interventions are treatments performed through interactions with clients. Actively engaging in a conversation with the client is the best direct care intervention and so demonstrates the best understanding of the concept. Facilitating interaction does not have as much impact as being actively involved. Turning on the TV is an example of an indirect care intervention. DIF: C dm 285 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 13. The primary reason for the establishment of standing orders is to:

Provide appropriate nursing autonomy in settings where client needs can change rapidly

Facilitate adequate care when direct contact with a primary health care provider is not immediately possible

Allow nurses to provide certain routine therapies without first notifying the primary health care provider

Afford the client interventions that reflect the appropriate standard of care in the absence of a primary health care provider

ANS: 1 Licensed prescribing physicians or health care providers in charge of care at the time of implementation approve and sign standing orders. These orders are common in critical care settings and other specialized practice settings where clients needs change rapidly and require immediate attention, thus providing for nursing autonomy to assess and implement appropriate care. DIF: C dm 281 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 14. Which of the following statements best reflects the nurses understanding of the function of client reassessment?

The clients blood pressure is lower this morning than it was yesterday morning.

30 minutes after receiving his pain medication, the client evaluated his pain at 3 out of 10.

Turning the client every 2 hours has helped in the healing of the pressure ulcer on his coccyx. Since the client has been ambulating to the bedroom without difficulty, Ill walk with him to the dayroom after dinner.

ANS: 4 When reassessment results in the collection of new data that identify a new client need, the care plan is modified. Modification of a plan also occurs when a clients health care need shows improvement or is resolved. The other options reflect recognition of a change in the clients condition but do not reflect an alteration of the care plan. DIF: C dm 281-282 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 15. Which of the following statements made by a nurse practitioner best reflects an understanding of the availability of clinical practice guidelines?

Clinical guidelines are so very helpful in providing the most up-to-date nursing care.

Im sure we could get a team together and develop a pressure ulcer prevention protocol or search sites for established protocols. I am particularly impressed by the type 2 diabetic guidelines posted on the National Guidelines Clearinghouse (NGC) site.

3 4

Im told that for gerontological issues, the Gerontological Nursing Interventions Research Center (GNIRC) is the primary resource site.

ANS: 3 There are clinical practice guidelines already developed by national health groups. These guidelines are readily available to any clinician or health care institution that wishes to adopt evidence-based guidelines in the care of clients with specific health problems. The best option reflects the nurses personal experience with a published protocol. DIF: C dm 281 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 16. The fundamental goal for the development of a protocol for care of a client who has had a myocardial infarction client is to:

Implement care that has its basis in evidence-based practice

Produce care plans that are specific to the individual client needs Improve the standard of care provided to the clients cared for on that unit Provide the staff on that unit with guidelines to ensure the delivery of quality care

3 4

ANS: 3 Clinicians within a health care agency sometimes choose to review the scientific literature and their own standard of practice to develop guidelines and protocols in an effort to improve their standard of care. All the other options are potential outcomes of the implementation of a protocol.

DIF: C dm 281 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 17. Which of the following nursing actions is most likely a result of the nurses clinical experience?

Placing an immobile client on a turning schedule

Always assessing a clients IV site before hanging a new bag of fluid Requesting that the nursing assistant have vital signs recorded by 0815

3 4

Administering a pain medication 30 minutes before changing a burn dressing

ANS: 2 As a nurse gains clinical experience, he or she will be able to consider which interventions have worked previously, which have not, and why. The decision to check each IV site has become a practice standard for this nurse as a result of previous experiences with IV sites. The remaining options are either standards of care or facility/unit standards. DIF: C dm 280 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 18. Which of the following statements made by a new nursing graduate requires immediate follow-up by the nurses mentor?

Older clients with arthritis require additional time to complete to complete their own AM care.

My clients wife says he loves chocolate milk so I will order his dietary supplement in chocolate.

My client just received some bad news regarding her tests. Ill see if the chaplain can visit this evening.

Teenage diabetics seem to have a more difficult time making good food choices in order to control their blood sugars.

ANS: 3 The nurse delivers each intervention within the context of a clients unique situation. It is an assumption that a client who has received bad news would want a visit from a clergy member.

The other options represent statements relating to normal characteristics of a specific development stage, condition, or preference. DIF: C dm 279 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 19. A client reports to the nurse that the room is too hot. Which of the following nursing actions best reflects the nurses understanding of the therapeutic manipulation of the clients environment?

Bringing a portable fan into the room

Assisting the client in the removal of excess clothing

Offering to ambulate the client into the visiting lounge

Closing the blinds to minimize the sunshine through the windows

ANS: 1 Although closing the blinds may manipulate the environment, it will always minimize the ambient light in the room. Cooling the room by introducing the fan will not impact any other aspect of the environment. It may not be appropriate for the client to remove clothing and leaving the room is only a temporary solution to the problem. DIF: C dm 282 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 20. Which of the following statements made by a new graduate nurse regarding the modification of a clients care plan requires immediate follow-up by the nurses preceptor?

I will review the care plan before I do my charting.

The client prefers to bathe at night, so thats what Ill do.

I gave her a bed bath this morning, but she could really manage showering herself. The order reads clear liquids, but I hear good bowel sounds and shes really hungry.

ANS: 4 With the assessment data supporting advancement in diet, the new graduate should initiate a modification of the clients nursing care plan because this directly impacts the clients nutritional status. Although facilitating client independence is appropriate, this option does not have priority

over the option impacting nutrition. The other options do not involve modification of the care plan. DIF: C dm 282 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 21. Which of the following statements regarding utilization of personnel made by a new graduate nurse requires immediate follow-up by the nurses mentor?

My LPN is really good with dressings, so I usually delegate them to her.

I always take the time to ambulate a post op client the first time out of bed.

I always try to help my nursing assistant with the clients who require a total bed bath.

I have my nursing assistant take and document all vital signs and intake and outputs.

ANS: 4 The nurse is responsible for determining whether to perform an intervention or to delegate it to another member of the nursing team. Assessment of a client directs the decision about delegation and not the intervention alone. Vital signs are important indicators of a clients health status and the task should be delegated to ancillary personnel only when the client is in a stable condition; otherwise, the nurse should be responsible. The other options reflect responsible assignment of personnel. Chapter 20. Evaluation MULTIPLE CHOICE 1. The client smokes two packs of cigarettes per day. The nurse works with the client, and they agree that he will smoke one cigarette less each week until he is down to one pack per day. In 3 weeks, the client is smoking two and a half packs of cigarettes per day. This is an example of:

A realistic goal

A compliant client

A negative evaluation A nonmeasurable goal

ANS: 3 This is an example of a negative evaluation. During evaluation, the nurse is able to determine that the client has not met the expected outcome of decreasing smoking by one cigarette each

week but rather has increased his smoking. This is not an example of a realistic goal. It is an example of the evaluation step of the nursing process. The client is noncompliant. The goal is measurable. During evaluation, the nurse determines if expected outcomes are met in order to judge if goals have been met. DIF: A REF: 291 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 2. The nurse formulates a diagnosis of knowledge deficit related to complications of pregnancy. One outcome criterion is that the client can state five symptoms that indicate a possible problem that should be reported. The client is able to tell the nurse three symptoms. The evaluation statement would be:

Goal met; client able to state three symptoms

Goal not met; client able to list three symptoms

Goal not met; client unable to list five symptoms

Goal partially met; client able to state three symptoms

ANS: 4 The client is showing changes but does not yet meet criteria set; therefore, the goal is partially met. The clients response, being able to state three symptoms, does not meet or exceed the outcome criteria of being able to state five symptoms. The clients response, being able to list three symptoms, demonstrates some change. If the client were showing no progress, then the goal would not be met. If the client were showing no progress, then the goal would not be met. However, this clients response does indicate some change. DIF: A dm 296 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 3. The nurse begins to auscultate the clients lungs. While listening, the nurse notices fresh bloody drainage oozing from the abdominal dressing. The nurse stops auscultating and applies direct pressure to the wound site. This is an example of:

Performing a nursing assessment

Reorganizing the nursing diagnoses

Implementing nursing interventions Critically analyzing client assessment data

4 ANS: 4

The nurse who stops auscultating lung sounds to take measures to stop noticeable bleeding is analyzing data presented. This is demonstrated by the nurse setting priorities and effectively implementing the safest nursing action. The nurse is doing more than performing a nursing assessment. The nurse is taking action based on new assessment data. The nurse is not reorganizing nursing diagnoses. The nurse is implementing the priority nursing action. This is not an example of setting realistic goals and implementing nursing interventions. Applying direct pressure to a wound site to stop bleeding demonstrates critical analysis of the data and implementation of the safest nursing action. DIF: A dm 298 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 4. The client is able to ambulate without signs or symptoms of shortness of breath. Which statement by the nurse is the best example of an objective evaluation of the clients goal attainment?

Client has no pain after ambulating.

Client has no manifestations of nausea while up in hall. Client walked well and did not have any problem when up.

3 4

Client has no evidence of respiratory distress when ambulating.

ANS: 4 Client has no evidence of respiratory distress when ambulating is the best example of an objective evaluation of the clients goal attainment. It uses the same evaluative measures gathered during assessment and clearly describes objective data. Client has no pain after ambulating does not use the same evaluative measure gathered during assessment. The assessment measure concerned respiratory changes during ambulation, not pain. If the clients pain level were going to be used as an evaluative measure, it would be optimal to have the client report the pain using a pain scale to make it more measurable for comparison. Client has no manifestations of nausea while up in hall is not the best example of an objective evaluation of the clients goal attainment. It does not use the same evaluative measure gathered during assessment. The assessment measure concerned respiratory changes during ambulation, not nausea. Also, nausea is more subjective. Client walked well and did not have any problem when up is not the best example of an objective evaluation. It includes the nurses interpretation rather than documentation of objective data. DIF: A dm 294 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment

5. When modifying a care plan to meet a client whose status has changed significantly over the past few days, the nurse should:

1 2

Redevelop the entire client care plan Focus on changing the nursing diagnoses and goals

Perform a complete reassessment of all client factors

Add more nursing interventions from a standardized plan of care

ANS: 3 A complete reassessment of all client factors relating to the nursing diagnosis and etiology is necessary when modifying a plan. After reassessment the nurse will determine what components of the care plan are accurate for the situation. It may not require redoing the entire care plan. The nurse should not only focus on the nursing diagnoses and goals that have changed. Interventions may also need revising to meet new goals. Adding more nursing interventions may or may not be necessary. The nurse adjusts interventions on the basis of the clients response and previous experience with similar clients. Standards of care are used to determine whether the right interventions have been chosen or whether additional ones are required. DIF: A dm 297 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 6. Based on the following outcome criterion determined by the nurse: Client will independently complete necessary assessments prior to administration of digoxin (cardiotonic) the nurse will evaluate the clients ability to:

Assess the respiratory rate

Palpate the radial pulse

Review dietary habits Inspect color of the skin

ANS: 2 The nurse should compare the established outcome criteria with the clients behavior or response. In this case the client is expected to independently complete the necessary assessments before administration of digoxin. The client should be able to palpate the radial pulse as an assessment before administration of digoxin. The outcome criterion does not state anything about exercise. During evaluation, the nurse is to judge the degree of agreement between the outcome criteria and the clients behavior. The outcome criterion does not state anything about diet. Evaluating whether the client reviews dietary habits would not be comparable to necessary assessment

before medication administration. The outcome criterion does not state anything about the skin. The nurse, who knows that digoxin is a cardiotonic, understands that the client should be assessing the heart rate. DIF: A dm 291 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 7. The nurse has determined the following outcome for a client with a skin impairment: Erythema will be reduced in 3 days. Evaluation will specifically focus on:

Selection of appropriate wound care

2 3

Notation of the odor and color of drainage Inspection of the color and condition of the area

Measurement of the diameter of the ulceration daily

ANS: 3 Erythema is reddening of the skin; therefore, the evaluation should specifically focus on inspection of the color of the skin, as stated in the outcome criterion. Selection of appropriate wound care is an intervention, not an evaluation of a clients behavior or response. The outcome criterion does not state anything about drainage. Noting the color and amount of drainage may be a part of reassessment of the client, but is not what the nurse is evaluating according to this outcome criterion. The outcome criterion states the erythema will be reduced, not the size of the ulceration. During the evaluation step of the nursing process, the clients behavior or response should be compared to the outcome criterion and judged for degree of agreement between the two. DIF: A dm 294 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 8. The client has a nursing diagnosis of impaired gas exchange as a result of excessive secretions. An outcome for the client is that the airways will be free of secretions. A positive evaluation will focus upon the clients:

Respiratory rate

Complaint of chest pain

Lungs clear bilaterally on auscultation Ability to perform incentive spirometry

4 ANS: 3

Auscultating lung sounds is the best way to determine if airways are clear. A positive evaluation is that they are clear, as expected in the outcome statement. Respiratory rate may be an indicator of respiratory status, but it is not the best way to determine if airways are free of secretions. A complaint of chest pain would be a negative outcome, and it is not the focus for determining whether airways are free of secretions as written in the outcome statement. Having the ability to perform incentive spirometry does not determine whether the airways are clear or not. It is an intervention that may help achieve clear airways. DIF: A dm 294 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 9. A client shares with the nurse that they have, almost reached the goal of smoking only one-half pack of cigarettes a day. The best example of a nursing intervention to correct this unmet outcome is:

1 2 3 4

Discuss with the client the desire to comply with the ordered therapy Suggest that the client use another smoking cessation tool to achieve the goal Reevaluate the time frame originally decided upon for achievement of the goal Suggest that the strength of the prescribed nicotine patches be increased to 21 mg

ANS: 4 An unmet outcome reveals the client has not responded to interventions as planned. As a result, the nurse changes the plan of care by trying different therapies or changing the frequency or approach of existing therapies. The best option is one that adds to the existing therapy. The remaining options should have been explored as a part of the goal-setting process or exercised if the current therapy proves ineffective. DIF: C dm 296 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 10. The primary purpose of the nursing evaluation process is to:

Determine the effectiveness of the nursing care provided

Identify interventions that are ineffective in achieving client goals

Establish the progress the client is making towards health and wellness

Critique the nurses ability to implement appropriate nursing interventions

ANS: 1 The evaluation process determines the effectiveness of nursing care. The remaining options are all examples of evaluation but do not reflect the primary purpose of nursing evaluation. DIF: C dm 291 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 11. Which of the following statements best reflects a goal based on a clinical standard of practice?

Client will lose 10 pounds in 90 days.

Client will walk 30 feet with minimal assistance. Clients peripheral intravenous site will be free of redness.

3 4

Clients chronic pain will be managed with oral medication by discharge.

ANS: 3 Goals often are also based on standards of care or guidelines established for minimal safe practice. Prevention of acquired infection is a standard of practice; the remaining options reflect client-specific goals. DIF: C dm 293 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 12. Which of the following outcomes best reflects a nurse-sensitive client outcome?

Client will consume 75% of all meals.

Client will perform personal hygiene daily. Client will experience no falls during hospitalization.

3 4

Client will report lessened anxiety regarding surgical procedure.

ANS: 3 A nurse-sensitive client outcome is a measurable client or family state, behavior, or perception largely influenced by and sensitive to nursing interventions. The nurse is instrumental in the prevention of falls while the remaining options are dependent on the client. DIF: C dm 293 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 13. The nurse has identified a nursing diagnosis of knowledge deficit regarding the need to monitor blood glucose levels daily. Which of the following statements best reflects the clients understanding of the need for therapy?

1 2

Client agrees to test blood glucose levels 4 times a day. Client records blood glucose levels for a 3-week period.

Client is observed testing his blood glucose level before breakfast.

Client is able to demonstrate the proper technique for performing a finger stick.

ANS: 2 During the planning phase of the nursing process it is important for you to select an observable client state, behavior, or self-reported perception that will reflect goal achievement. The actual written result of regular blood glucose monitoring is the best indicator of the clients understanding of the importance of regular testing. The remaining options may show initial willingness or ability to perform the test but do not show consistent compliance. DIF: C dm 293 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 14. Which of the following nursing notes demonstrates the best evaluation of nursing interventions regarding the care provided?

Pressure ulcer located on left heel has shown improvement.

Pressure ulcer located on left heel has responded to treatment.

Pressure ulcer on left heel is no longer producing purulent drainage. Pressure ulcer on left heel has not enlarged in size within the last 24 hours.

ANS: 3 In many clinical situations it is important to collect evaluative measures over a period of time to determine if a pattern of improvement or change exists. The absence of purulent drainage indicates successful nursing interventions while the other options either fail to provide measurable data regarding the wound or indicate no improvement. DIF: C REF: 294 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 15. Which of the following statements made by a clients family is the most reliable for use in the evaluation of a clients outcome?

Mom has been eating 90% of all of her meals since shes been home.

My daughter is in much less pain now that she is going to physical therapy. My husband has been less depressed since hes been on that antidepressant pill.

3 4

Mom has been so much better since shes been able to get up and walk by herself.

ANS: 1 Input from the family and other caregivers can be used to evaluate client outcomes but it is best to use their observations of measurable actions, such as the amount eaten, than to rely on their subjective opinions of a clients reaction, such as pain, anxiety, or mood. DIF: C dm 294 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 16. A nurse is providing care for a client receiving normal saline when the IV infiltrates. Which of the following nursing actions represents the evaluation phase of the nursing process?

IV is discontinued.

Warm compress applied to IV site.

Site reinspected for presence of swelling. IV site observed as having significant swelling.

4 ANS: 3

Evaluation, the final step of the nursing process, is crucial to determine whether, after application of the nursing process, the clients condition or well-being improves. The remaining options represent the assessment and implementation phases. DIF: A dm 291 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 17. Which of the following questions, asked by a nurse, best reflects an understanding of effective evaluation?

Do you feel confident in the use of your glucometer?

Have you been following your low carbohydrate diet? Any questions regarding the tests you are scheduled for today?

3 4

May we review what we discussed earlier about your medications?

ANS: 4 In effective evaluation, the nurse compares client behavior and responses that were assessed before delivering nursing interventions with behavior and responses that occur after administering nursing care. The answer shows direct client knowledge related to the material previously discussed, while the other options reflect close-ended questions that require only a yes or no answer. DIF: C dm 291 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 18. The nurse caring for an immobile client with a pressure ulcer implements an intervention that requires repositioning the client every 2 hours. Which of the following represents the best evaluation method for this intervention?

No additional pressure ulcers are noted over a 1-week period.

Client expresses a decrease in pressure ulcer related pain within 1 week.

The clients pressure ulcer shows a decrease in size over a 1week period.

The turning schedule is initiated to reflect appropriate positioning for a 1-week period.

ANS: 3

You conduct evaluation measures to determine if you met expected outcomes, not if nursing interventions were completed. The decrease in size of the pressure ulcer best evaluates the effectiveness of this intervention while the remaining options reflect client opinion, further skin breakdown, or implementation of the intervention. DIF: C dm 291 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 19. Which of the following statements best defines quality improvement (performance improvement)?

The assessment of the delivery system responsible for the implementation of client-oriented interventions

Integration of evidence-based practice research into the delivery process used to implement client-oriented interventions

High-priority evaluation process directed towards differentiating between good and poor intervention delivery by providers

An ongoing evaluation of interventions that is used to improve the delivery of health care for the purpose of managing the clients needs

ANS: 4 Quality improvement (QI) and performance improvement (PI) are interchangeable terms that describe an approach to the continuous study and improvement of the processes of providing health care services to meet the needs of clients and others. The remaining options reflect individual facets of QI. DIF: C dm 298 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 20. The primary reason for documenting discontinued portions of the care plan when a client goal has been met is to ensure:

Effective use of both nursing time and resources

Delivery of both timely and relevant nursing care

Concrete evidence of successful outcome achievement

Minimal ineffective communication among the nursing staff

ANS: 2 Documentation of a discontinued plan ensures that other nurses will not unnecessarily continue interventions for that portion of the plan of care. Continuity of care assumes that care provided to clients is relevant and timely. The remaining options refer to the potential nursing outcomes related to poor documentation of care plan editing. DIF: C dm 297 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 21. Which of the following nursing actions should be initiated first when dealing with the following unmet client goal: Client will lose 10 pounds in 3 months?

Interview the client to identify reasons why the goal was not met.

Assess the client for possible physical reasons for failure to lose the weight.

Discuss with the client whether they were truly motivated to lose the weight.

Re-evaluate whether it was realistic for the client to lose 10 pounds in 3 months.

ANS: 1 When goals are not met, the nurse should identify the factors that interfere with goal achievement. The remaining options reflect actions to be taken after the interview to further determine how the care plan will be modified. DIF: C dm 297 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 22. When a client goal is unmet, which of the following nursing actions is most appropriate?

Reevaluation of the original client goal

Selection of new but appropriate interventions

Evaluation of the clients ability and motivation to be compliant

Repetition of the entire nursing process regarding the nursing diagnosis

ANS: 4 When there is failure to achieve a goal, no matter what the reason, repeat the entire nursing process sequence for that nursing diagnosis to discover changes the plan needs. The remaining options reflect individual elements within the nursing process. DIF: C dm 297 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment MULTIPLE RESPONSE 1. Which of the following is a recognized focus area for quality improvement (performance improvement) evaluations? (Select all that apply.)

Effective care

Delivery of care

3 4

Client satisfaction Exceeding the standard of care

Identification of missed client needs

Multidisciplinary approach to client care

ANS: 1, 2, 3, 4 Quality improvement is concerned with exceeding the standard of care, examining ways to be more efficient, improving client satisfaction, and focusing on service. Although the remaining options are pertinent, they are not major considerations of QI evaluation. Chapter 21. Managing Patient Care MULTIPLE CHOICE 1. It is necessary for the nurse manager to delegate tasks to the staff. Which of the following is a requirement of the delegation process?

Working alongside the staff to evaluate their care

2 3

Functioning from a laissez-faire style of leadership Obtaining the employees voluntary acceptance of the task

Communicating the work assignment in understandable terms

ANS: 4

When delegating, the nurse should always provide unambiguous and clear directions by describing a task, the desired outcome, and the time period within which the task should be completed. The nurse manager does not necessarily have to work alongside staff to evaluate their care. The nurse manager can often evaluate staff performance in client outcomes. A laissez-faire style of leadership is not a requirement for delegation. Tasks should be delegated to those who are capable, not necessarily to those who are willing. DIF: A dm 309 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 2. As the nurse starts to perform a procedure, a peer says, Ive done that before. Would you like me to help? The peers leadership style is described as:

1 2 3 4

Directing Coaching Democratic Laissez-faire

ANS: 2 This situational leadership style is described as coaching. The peer is willing to explain the procedure and provide the opportunity for clarification. Directing is a highly directive style of leadership where leaders provide specific instructions and close supervision. A laissez-faire style of leadership is where the leader intervenes as little as possible in the direction of others. The laissez-faire style of leadership is described as nondirective, permissive, ultraliberal. A democratic leadership style encourages group discussion and decision making. The democratic leadership style is described as participative and consultative. DIF: A OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 3. A unit manager on a busy multi-service medical nursing unit decides to take responsibility for the direct client care of one of the many new admissions. Later the manager decides she is too busy to give adequate client care. Which of the following situational leadership styles does the nurse manager need to apply?

Coaching

Supporting

Delegating Directing

ANS: 3 Delegation is transferring responsibility for the performance of an activity or task while retaining accountability for the outcome. To be more efficient in providing adequate client care, the manager needs to use delegation. Coaching would not be the situational leadership style to apply. The manager does not have time to explain decisions and provide the opportunity for clarification. Supporting would not be the situational leadership style of choice. The manager does not need to share ideas and facilitate decision making of other employees at this time. Directing is a highly directive style of leadership. The manager needs to delegate, not provide specific instructions and close supervision. DIF: A dm 309 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 4. Which of the following statements best reflects the autocratic style of leadership?

Lets discuss this case study thoroughly and decide on a plan of action as a group.

Ill try to pair you in comparable work teams, and lets evaluate the success of this approach in 2 weeks.

Everyone knows their work assignment, so lets not meet together unless we have an unexpected crisis.

Ill consider each of your requests, and then Ill give you the guidelines for establishing new acuity ratings for our clients.

ANS: 4 Ill consider each of your requests, and then Ill give you the guidelines for establishing new acuity ratings for our clients reflects the autocratic style of leadership. The leader is making the decision. Lets discuss this case study thoroughly and decide on a plan of action as a group reflects the democratic style of leadership. The leader encourages group discussion and decision making. Ill try to pair you in comparable work teams, and lets evaluate the success of this approach in 2 weeks reflects the delegating style of leadership. Responsibility and implementation are being turned over to the group, but the leader remains accountable. Everyone knows their work assignment, so lets not meet together unless we have an unexpected crisis reflects the laissez-faire style of leadership. There is much freedom, and the leader assumes a hands off approach. DIF: A OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment

5. To meet the needs of assigned clients and the responsibilities associated with the position, nurses need to be aware of time management techniques. The time management skills for the nurse include:

Meeting all of the clients needs in the early morning hours

Anticipating possible interruptions by therapists and visitors

Leaving each day unplanned to allow for adaptations in treatments

Completing client assessments and treatments individually at separate times

ANS: 2 To manage time, the nurse must anticipate when care will be interrupted for medication administration and any diagnostic testing, and the nurse should also determine the best time for planned therapies such as dressing changes, client education, and client ambulation. Meeting all the needs in the early morning hours would be unrealistic. Some activities have specific time limits in terms of addressing client needs and some activities follow scheduled routines according to hospital policy. The nurse may also have to work around other schedules, such as if the client had a test ordered for the morning. Therefore, the nurse cannot expect to meet all of the clients needs at a specified time of day. Because the nurse has a limited amount of time with clients, it is essential to remain goal-oriented and make a plan for using time wisely. Time management involves using client goals as a way to identify priorities. The nurse in reviewing the care requirements organizes his or her time so the activities of care and client goals can be achieved. A nurse should complete the activities started with one client before moving on to another. DIF: A dm 308 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 6. In anticipation of a nursing shortage, the nursing management in a facility is investigating a nursing care delivery model that involves the division of tasks, with one nurse assuming the responsibility for particular tasks. This model is called:

Total patient care

Functional nursing

Team nursing Primary nursing

4 ANS: 2

Functional nursing is task-focused, not client-focused. In this model, tasks are divided, with one nurse assuming responsibility for specific tasks. Total patient care is a model of care where an RN is responsible for all aspects of care for one or more clients. The RN may delegate aspects of care, but retains accountability for care of all assigned clients. In team nursing a registered nurse leads a team that is composed of other RNs, LPNs or LVNs, and nurse assistants or technicians. The team members provide direct client care to groups of clients, under the direction of the RN team leader. Nurse assistants are given client assignments rather than being assigned particular tasks. Primary nursing is a model of care delivery whereby an RN assumes responsibility for a caseload of clients over time. Typically the RN selects the clients for his or her caseload and cares for the same clients during their hospitalization or stay in the health care setting. DIF: A dm 303 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 7. One advantage of a decentralized management structure for nursing units over a centralized structure is that:

1 2

Communication pathways are simplified Staff are not responsible for defining their roles

Managers handle all of the difficult decision making

Each staff member is accountable for evaluating the plan of care

ANS: 4 In decentralized management, decision making is moved down to the level of staff. It requires workers to be empowered to accept greater responsibility for the quality of client care provided. This means that each staff member is accountable for evaluating the plan of care. Communication pathways are not simplified. If decentralized decision making is in place, professional staff have a voice in identifying the RN role. Each RN on the work team is responsible for knowing his or her role and how it is to be implemented on the nursing unit. In decentralized management, there is autonomy. In other words, there is freedom to decide and act. The nurse manager does not necessarily handle the difficult decisions. Those staff members who are best informed about a problem or issue make decisions on the basis of knowledge. DIF: A dm 304 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 8. Indicators in a quality improvement program that evaluates the manner in which care is delivered are:

Structure indicators

Team indicators

Process indicators Client indicators

ANS: 3 A quality indicator for evaluating the manner in which care is delivered is a process indicator. Structure indicators evaluate the structure or systems for delivering care; an example is adherence to checking if emergency carts are adequately stocked. There is no team indicator. Client indicators would actually be outcome indicators. Outcome indicators evaluate the end result of care delivered. DIF: A dm Chapter 20, 298 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 9. A threshold of 90% is identified for an outcome indicator in the quality improvement program. Which of the following situations indicates a need for further review of the quality improvement plan?

The waiting time for clinic appointments has decreased 96%.

Clients with renal dialysis expressed a 95% satisfaction with their care.

In 93% of clients, subjective expressions of postoperative pain have decreased. Wound infections are evident in 92% of clients after care of their IV access ports.

ANS: 4 Wound infections are exceeding the designated threshold, indicating a need for further review of the quality improvement plan. Waiting time for clinic appointments has decreased, meeting the threshold. Satisfaction with care meets the threshold. Expressions of pain have decreased, meeting the threshold. DIF: A dm Chapter 20, 298 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 10. In anticipation of a nursing shortage, the nursing management in a facility are investigating a nursing care delivery model that involves staff members working under the direction of a registered nurse leader. This model is called:

Team nursing

2 3

Primary nursing Functional nursing

Total patient care nursing

ANS: 1 In team nursing a registered nurse leads a team that is composed of other RNs, LPNs or LVNs, and nurse assistants or technicians. The team members provide direct client care to groups of clients, under the direction of the RN team leader. Nurse assistants are given client assignments rather than being assigned particular tasks. Primary nursing is a model of care delivery whereby an RN assumes responsibility for a caseload of clients over time. Typically the RN selects the clients for his or her caseload and cares for the same clients during their hospitalization or stay in the health care setting. Functional nursing is task-focused, not client focused. In this model, tasks are divided, with one nurse assuming responsibility for specific tasks. Total patient care is a model of care where an RN is responsible for all aspects of care for one or more clients. The RN may delegate aspects of care but retains accountability for care of all assigned clients. DIF: A dm 303 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 11. Accountability is a critical aspect of nursing care. An example of a specific decision-making process of accountability is demonstrated by:

Selecting the medication schedule for the client

Implementing discharge teaching plans that meet individual needs

Evaluating the clients outcomes following implementation of care

Promoting participation of all staff members in regular unit meetings

ANS: 3 Accountability refers to individuals being responsible for their actions. It involves follow-up and a reflective analysis of ones decisions to evaluate their effectiveness. Selecting the medication schedule for the client is an example of taking responsibility. Implementing discharge teaching plans that meet individual needs is an example of autonomy. Promoting participation of all staff members in unit meetings is an example of decentralized management and of promoting authority.

DIF: A dm 305 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 12. The student nurse is seeking to learn skills associated with priority setting. In discussing different priorities of care, an example of a second-order priority is:

The need to urinate

An obstructed airway

The side effects of a medication

Activities of daily living in the home environment

ANS: 1 Second-order priority needs are actual problems for which the client or family has requested immediate help, such as a full bladder. An obstructed airway is a first-order priority need because it is an immediate threat to a clients survival or safety. Side effects of a medication is an example of a third-order priority need. It is a relatively urgent actual or potential problem that the client or family does not recognize. Activities of daily living in the home environment is a fourth-order priority need. It is an actual or potential problem with which the client or family may need help in the future. DIF: A dm 307 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 13. The nurse on the unit is determining which activities may be delegated to assistive personnel. Assuming that the nurse assistant is competent, which one of the following activities may be safely delegated by the registered nurse?

Vital signs on a stable client

An admission history on a new client

Initial transfer of a postoperative client

Administration of medications prepared by the nurse

ANS: 1 An institutions policies and procedures and job description for assistive personnel provide specific guidelines in regard to which tasks or activities can be delegated. The nurse should match tasks to the delegates skills, such as delegating vital signs to a nurse assistant. It would not be appropriate to delegate an admission history on a new client to a nurse assistant. The RN should perform this task. Initial transfer of a postoperative client should not be delegated to a

nurse assistant, as the client would be considered unstable. The RN should perform this task. The nurse should not delegate medication administration to a nurse assistant, even if the nurse prepared it. The nurse assistant is not licensed to administer medication. DIF: A dm 309 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 14. The most important responsibility of a nurse manager is to:

Foster an environment that enables staff to provide quality nursing care

Provide leadership and role modeling for nursing and ancillary staff

Evaluate the delivery of nursing care in regard to its effect on client outcomes

Create a unit attitude of cooperative engagement directed toward positive client outcomes

ANS: 1 Perhaps the most important responsibility of the nurse executive is to establish a vision for nursing that enables managers and staff to provide quality nursing care. The remaining options are means by which the manager can affect the proper environment. DIF: C dm 302 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 15. The primary benefit of achieving Magnet status is the nursing staff is empowered to make innovative changes that:

Promote nursing autonomy

Positively affect client care outcomes

Enhance the perception of the nursing profession Strengthen the collaborative RN/MD relationship

ANS: 2 A Magnet hospital empowers the nursing team to make changes and be innovative. This culture and empowerment combine to produce a strong collaborative relationship among team members and so ultimately improves client quality outcomes. The remaining options are outcomes of the Magnet status but not the primary benefit.

DIF: C dm 302 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 16. Which of the following statements best reflects the nurses understanding of team nursing?

1 2 3 4

The team provides the client care and I provide the leadership and decision making. I will manage the complex care and delegate the remaining care to my LPN and ancillary assistants. Everyone on the team has responsibilities and is accountable to me regarding the effective execution of that care. I delegate the care of the clients to the appropriate team members and I am responsible for coordinating and directing that care.

ANS: 4 In team nursing a registered nurse (RN) leads a team that is made up of other RNs, licensed practical nurses (LPNs) or licensed vocational nurses (LVNs), and nurse assistants or technicians. The team members provide direct client care to groups of clients under the direction of the RN team leader. In this model, nurse assistants have client assignments rather than being assigned particular nursing tasks. The remaining options fail to provide an inclusive definition of team nursing. DIF: C dm 303 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 17. Which statement best reflects the major limitation of the team nursing model?

The team really needed an extra pair of hands today.

It complicates things when you have a different team each day.

Getting our two new admissions stabilized took up all of my time today.

My nursing assistants need to be in-serviced on how to do a bladder scan.

ANS: 3

One of the limitations to the model is that the team leader does not spend a large amount of time with clients. Depending on the mix of staff members, this sometimes means that clients see an RN infrequently. Risks exist if an RN is unable to make necessary client assessments and be involved in important clinical decision making. The remaining options refer to less frequent problems inherent to the team nursing model. DIF: C dm 303 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 18. Which of the following clients would most benefit from the case manager model of nursing care?

A client diagnosed with end-stage renal failure

A client who has a chronic wound on the left foot A client newly diagnosed with type 2 diabetes mellitus

3 4

A postoperative client who had a cholecystectomy (gallbladder removal)

ANS: 1 A case manager follows up with the client after discharge home. Case managers do not always provide direct care, but instead they work with and supervise the care delivered by other staff members. Case managers actively coordinate client discharge planning by identifying health care needs, determining the availability of services and resources, and assisting the client in choosing cost-efficient health care options. The client dealing with end-stage renal failure would most benefit from this model of care because the clients case is the most complex and will require extension discharge support. DIF: C dm 304 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 19. Which of the following actions is the best example of a nurse exercising nursing authority?

Assigning team responsibilities to individual team members

Evaluating a team members ability to perform a bladder scan

Readjusting a clients turning schedule to provide hourly repositioning

Determining that a client will not be ambulated based on assessment findings

ANS: 4 Authority refers to legitimate power to give commands and make final decisions specific to a given position. Canceling a clients ambulation is the best example because it shows critical thinking in determining the appropriateness of an intervention. The remaining options are better examples of nursing responsibility. DIF: C dm 305 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 20. Which of the following actions best reflects accountability for the clients care outcomes?

Reassessing a clients BP when the reported value is higher than usual

Assisting a team member in providing a client with a complete bed bath

Reevaluating a clients pain 30 minutes after administering pain medication

Asking a clients daughter to bring her fathers non-skid slippers to the hospital

ANS: 1 Accountability refers to individuals being responsible for their actions. It means that a nurse accepts the commitment to provide excellent client care and the responsibility for the outcomes of the actions in providing that care. Reassessing an abnormally high BP is the best example of nursing accountability because it shows the nurse being responsible for the accuracy of the assessment. The remaining options better reflect nursing responsibility. DIF: C dm 305 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 21. When the oncology units interdisciplinary team meets every Monday morning at 0830 to discuss the units individual clients, the group is best displaying:

Staff education

Collaborative practice

Team communication Nursing shared governance

4 ANS: 2

Collaboration of health care team members is required to help meet the complex needs of clients in health care settings. Such collaborative interaction may strengthen individual members knowledge and communication skills. Nursing shared governance is a process directed towards the standard of nursing care among a particular groups of professional nurses. DIF: C dm 306 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 22. Clinical nursing decisions are best made using:

1 2

Clinical pathways Accurate assessment data

Previous nursing knowledge

Interdisciplinary collaboration

ANS: 2 When beginning an assignment with a client, the first nursing activity involves a focused but complete assessment of the clients condition. This information enables the nurse to make an accurate clinical decision as to the clients health problems and required nursing therapies. The remaining options support the clinical decision-making process. DIF: C dm 307 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 23. A client has reported all of the following; which should be given priority by the nurse?

Pain

Hunger

Anxiety

Constipation

ANS: 1 When a client has diverse priority needs, it helps to focus on the clients basic needs; pain will exacerbate the clients anxiety and interfere with eating and thus should be attended to first. While a concern, constipation is the lowest priority problem. DIF: C dm 307 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment

24. A nurse who performs a skin assessment while bathing an immobile client would be displaying:

1 2 3 4

Efficiency Leadership Organization Effectiveness

ANS: 1 Effective use of time means doing the right things, whereas efficient use of time means doing things right. The nurse is showing efficiency by combining various nursing activitiesin other words, doing more than one thing at a time. Organization is a general term that may include efficiency, while leadership is the ability to manage people and resources. DIF: A dm 307-308 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 25. When the nurse gathers all the equipment needed for a particular procedure and arranges the clients room for proficient implementation of the procedure, the nurse is displaying:

Multitasking

Organization

Effectiveness

Professionalism

ANS: 2 The well-organized nurse approaches any planned procedures by having all of the necessary equipment available and making sure the client is prepared. It always is wise to have the work area organized and preliminary steps completed before asking co-workers for assistance. Multitasking is dealing with more than one task at a time while being effective means doing the right things correctly. Being professional means showing the characteristics of performing the expected tasks of the profession. DIF: A dm 308 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 26. The primary reason the nurse asks for help when changing a clients complicated dressing is to:

Foster efficient client-oriented interventions

Facilitate a comfortable, safe dressing change

Minimize the amount of time spent on a specific task

Engage in collaborative learning with other health care professionals

ANS: 2 A nurse should never hesitate to have staff assist, especially when there is an opportunity to make a procedure or activity more comfortable and safer for the client. While it is possible that having help with a task can be a learning experience as well as making the task more efficient and less time-consuming, it is not always the case and not the primary reason for asking for assistance. DIF: C dm 308 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 27. The nurse is prioritizing care for two postoperative abdominal surgery clients; the first is 15 hours postoperative and the second is ready for discharge. Which of the interventions should be accomplished first?

Discharge pain control First day dangling and ambulation

First day post op coughing and deep breathing

Discharge teaching regarding the dressing change

ANS: 3 The first clients goals center on restoring physiological function impaired as a result of the stress of surgery. The second clients goals center on adequate preparation to assume self-care at home. Physiological interventions, particularly those affecting breathing, should receive priority. Dangling and ambulation may be addressed after the second client is readied for discharge. DIF: C dm 307 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 28. Which of the following statements made by a nurse related to the organization of client care requires follow-up by the mentor?

I had my LPN bring the Foley catheterization supplies into the room so theyd be there when I got there.

I delegated all the stable vital signs to my nursing assistant and the treatments to the LPN.

I was taking vitals on one client, dangling a second client while I had the third expelling an enema. Organization was never a strength of mine, but I believe Im getting better at completing all my clients care.

ANS: 3 Good time management involves completing one task before starting another. If possible, complete the activities started with one client before moving on to the next. Care will then become less fragmented, and the nurse will be better able to focus on what is being done for each client. As a result, it is less likely that errors will be made. The remaining options are not reflective of poor management and so do not need follow-up. DIF: C dm 308 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment MULTIPLE RESPONSE 1. Which of the following are recognized competencies for an entry-level nurse? (Select all that apply.)

Views clients holistically

Utilizes the nursing process

Participates in life-long learning

4 5

Exhibits nursing professionalism Delegates client care appropriately

Exhibits expert nursing knowledge

ANS: 1, 2, 3, 4, 5 All provided options are recognized competencies for entry-level nurses except the ability to practice with expert nursing knowledge. This will be acquired with time and experience. DIF: C dm 302 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 2. To achieve Magnet status, the nursing staff of a hospital must exhibit: (Select all that apply.)

A client first mentality

Autonomy of personal practice

Strong involvement in life-long learning Ability to use state of the art technology

4 5 6

Strong nurse-health care provider collaboration Clinical competence through earned certifications

ANS: 1, 2, 3, 5, 6 All provided options are characteristics required of the nursing staff for recognition as a Magnet hospital except for expertise with state of the art technology. DIF: C dm 302-303 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 3. The advantages of team nursing include: (Select all that apply)

Fosters team cooperation

Allows for ancillary staff autonomy Strengthens the RN-client relationship

3 4 5

Facilitates decision making at the clinical level Encourages collaboration between team members

Provides management experience for team leaders

ANS: 1, 4, 5, 6 An advantage of team nursing is the collaborative style that encourages each member of the team to help the other members. This model has a high level of autonomy for the team leader and is an example of decision making occurring at a clinical level. Team nursing can limit the actual time the RN spends with the clients; ancillary staff are not afforded autonomy regardless of the nursing care model because their work must be supervised by the RN. Chapter 22. Ethics and Values MULTIPLE CHOICE 1. The client states that she needs to exercise regularly, watch her weight, and reduce her fat intake. This demonstrates that the client:

Values health promotion activities

Believes she will not become sick

Believes she will have a heart attack

Has unrealistic expectations for herself

ANS: 1 A value is a personal belief about the worth of a given idea, attitude, custom, or object that sets standards that influence behavior. The client is expressing her value of health promotion activities. A belief is a conviction of the truth or reality of a thing. The client does not state she believes these health promotion activities will keep her from becoming sick. A belief is a conviction of the truth of a thing. The clients statement does not indicate she believes she will have a heart attack. These are not unrealistic expectations. DIF: A dm 315 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 2. A client has actively picketed for gun control. During a robbery of his business, he was shot in the leg. As the nurse assists him with morning care, which statement would the nurse expect him to make that coincides with his values?

Firearms may have a place in our society.

2 3

Individuals should arm themselves for protection. Prosecution should be the maximum for that felon.

Protection is a necessary evil for the good guy of the world.

ANS: 3 Individual experience influences what we come to value. The client who experienced a gunshot during a robbery of his business may value gun control and verbalize a desire to have his attacker prosecuted for the violent crime. The client who has picketed for gun control and who was gunshot is unlikely to value firearms in our society. The individual who has actively picketed for gun control is unlikely to desire the use of guns. The individual would be more likely to believe that if there were gun control, there would be no need for guns. The individual who has actively picketed for gun control is unlikely to desire the use of guns. The individual would be more likely to believe that if there were gun control, there would be no need for guns. DIF: A dm 316 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 3. A secondary school teacher with advanced multiple sclerosis insists on teaching from a wheelchair and being treated the same as other colleagues. The teacher is demonstrating which of the following?

Prizing her choice

Choosing from alternatives

Considering all consequences Acting with a pattern of consistency

ANS: 1 The teacher is demonstrating prizing her choice. She cherishes her choice of being treated like everyone else despite her medical condition and publicly affirms the choice by teaching from a wheelchair and insisting she be treated the same as her colleagues. At this point, the teacher is not choosing from alternatives. She could have chosen to quit teaching, but she did not. She has already made her choice. The teacher is not demonstrating considering all consequences. She has already made her choice. At this point, the teacher is not demonstrating acting with a pattern of consistency. She is not repeating a behavior. DIF: A dm 316 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 4. The nurse recognizes that values clarification interventions are beneficial for the client when:

The client and nurse have different beliefs The client is experiencing a values conflict

The nurse is unsure of a clients personal values

The client has chosen to reject the normal values

ANS: 2 Values clarification can help clients gain an awareness of personal priorities, identify ambiguities in values, and resolve major conflicts between values and behavior. Values clarification for nurses can help nurses strengthen their ability to advocate for a client because nurses are better able to identify personal values and accurately identify the values of the client. Values clarification is not necessarily beneficial for the client when the client and nurse have different beliefs. Values clarification for the client will not necessarily help the nurse who is unsure of the clients values. Values clarification interventions for the client will help the client, not the nurse, gain awareness. The values that an individual holds reflect cultural and social influences, relationships, and personal needs. Values vary among people and develop and change over time. Therefore it may be inappropriate to state a client has rejected normal values when value systems vary among people. What is considered normal to one person may not be to another. DIF: A dm 316 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment

5. The nurse is working with the client and trying to clarify the clients values regarding his care. Which of the following statements reflects an example of the type of response a nurse should use in a values clarification situation?

Your questions were pretty blunt.

2 3

Tell me what youre thinking right now. Ive felt that way before. Id be upset, too.

You seem concerned about your tests. Let me explain them.

ANS: 2 Tell me what youre thinking right now is correct. Values clarification is a process of selfdiscovery in which the nurse should assist the client. The goal of values clarification with a client is effective nurse-client communication. As the client becomes more willing to express problems and feelings, the nurse can better establish an individualized plan of care. The character of a nurses response to a client can motivate the client to examine personal thoughts and actions. When the nurse makes a clarifying response, it should be brief and nonjudgmental. Your questions were pretty blunt is incorrect. Values clarification is a process of self-discovery in which the nurse should assist the client. The character of a nurses response to a client can motivate the client to examine personal thoughts and actions. When the nurse makes a clarifying response, it should be brief and nonjudgmental. The client is being judgmental in this response. Ive felt that way before. Id be upset, too is incorrect as well. The nurse should not influence the client with his or her own values, even if they are similar. You seem concerned about your tests. Let me explain them is also incorrect. This statement is therapeutic in that it is reflective of a clients feeling, and offers information. However, it does not encourage the client to examine their values. DIF: A dm 316 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 6. A nurses use of ethical responsibility can best be seen in which of the following nursing actions?

Delivery of competent care

Formation of interpersonal relationships

Correct application of the nursing process

Evaluation of new computerized technologies

ANS: 1

The term responsibility refers to the characteristics of reliability and dependability. In professional nursing, responsibility includes a duty to perform actions well and thoughtfully. When the nurse provides competent care, the nurse is demonstrating ethical responsibility. Formation of interpersonal relationships is not an ethical responsibility. Application of the nursing process is not an ethical responsibility. Evaluation of new computerized technologies is not an ethical responsibility. DIF: A dm 314-315 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 7. A nursing student that immediately informs her clinical instructor after she realizes that she has administered the wrong dose of medication to a patient is best described professionally as:

1 2 3 4

Confident Trustworthy Compliant Accountable

ANS: 4 Accountability refers to the ability to answer for ones own actions. The goal is the prevention of injury to the client. The student nurse who informs her instructor of an error is being accountable for her actions and has a goal to prevent injury to the client. The student nurse would not be described professionally as confident (i.e., sure of oneself). The student is not best described as trustworthy. To be trustworthy, one is worthy of trust or confidence and reliable. In this case, the student was not reliable to administer medication correctly. This student nurse is not best described professionally as compliant. The student is not acting in accordance with wishes, commands, or requirements. DIF: A dm 315 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 8. A client who is recently diagnosed with cancer is encouraged to consider sharing the information with her family so they can support her through the decisions she will need to make regarding her care. The nurse is using the principle of:

Confidentiality

Fidelity

Veracity Justice

ANS: 3 Veracity in general means accuracy or conformity to truth. The nurse is encouraging the client to be truthful with the clients family. Confidentiality means to not impart private matters. Fidelity refers to the agreement to keep promises. Justice refers to fairness. DIF: A OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 9. The correct sequence for attaining the resolution of an ethical problem is:

Examine values, evaluate, and identify the problem

Evaluate the outcomes, gather data, and consider actions

Gather facts, verbalize the problem, and consider actions

Recognize the dilemma, evaluate, and gather information

ANS: 3 The correct sequence for resolving ethical problems is recognizing the dilemma, gathering facts, examining ones own values, verbalizing the problem, considering actions, negotiating the outcome, and evaluating the action. DIF: A dm 319 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 10. A nurse is ambivalent as to the need to vigorously suction the secretions of a terminal client in a comatose state. Which of the following is an appropriate statement by the nurse in regard to processing an ethical dilemma?

I just feel like I should not suction this client.

I need to know the legalities of the living will of this client.

I cannot figure out whats right in this situation. I need to collect more data.

My spiritual beliefs mandate that I continue to provide all the interventions in my scope of practice.

ANS: 3 The first step in processing an ethical dilemma is determining whether the problem is an ethical one. The nurse who cannot figure out what is right, is stating a characteristic of an ethical dilemma, which is that the problem is perplexing. The next step is to gather as much information

as possible that is relevant to the case. I just feel like I should not suction this client is the nurse is stating the problem according to her feelings. I need to know the legalities of the living will of this client is the nurse who wants to know the legalities of the living will of a client is collecting some, but not all, data pertaining to the problem. My spiritual beliefs mandate that I continue to provide all the interventions in my scope of practice is the nurse stating her own beliefs. DIF: A dm 316-317 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 11. Which of the following statements best illustrates the deontological ethical theory?

I believe this disease was allowed by a supreme being.

He has become a stronger individual through experiencing the loss of his father.

Under no circumstances would it ever be right for a person to stop CPR efforts.

The chemotherapy did not cure this person, but it provided a better life for him.

ANS: 3 Under no circumstances would it ever be right for a person to stop CPR efforts is correct. Deontology defines actions as right or wrong based on their right-making characteristics, such as fidelity to promises, truthfulness, and justice. Deontology does not look at consequences of actions to determine rightness or wrongness. Fidelity to promises and beneficence may be principles upon which this statement is based on determining wrongness. I believe this disease was allowed by a supreme being does not reflect the deontological ethical theory. Because it reflects a relationship between disease and a supreme being, it follows the feminist ethical theory. He has become a stronger individual through experiencing the loss of his father does not best illustrate the deontological ethical theory because it is citing a consequence. It follows the utilitarian ethical theory. The chemotherapy did not cure this person, but it provided a better life for him does not best illustrate the deontological ethical theory because it is citing a consequence. It follows the utilitarian ethical theory. DIF: A dm 316-317 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 12. On admission to the hospital, a terminal cancer patient says he has a living will. This document functions to state the clients desire to:

Receive all technical assistance to prolong his life

Have his wife make the decisions regarding his care

Be allowed to die without life-prolonging techniques Have a lethal injection administered to relieve his suffering

ANS: 3 A living will is an advance directive, prepared when the individual is competent and able to make decisions, regarding that persons specific instructions about end-of-life care. Living wills allow people to specify whether they would want to be intubated, treated with pressor drugs, shocked with electricity, and fed or hydrated intravenously. A living will specifies what interventions the client does not want, so that his or her life will not be prolonged. If his wife has power of attorney she would be able to make decisions regarding the clients care. Assisted suicide, such as a lethal injection, is not a function of a living will. A living will defines a clients wishes for withholding treatment that would prolong his or her life. DIF: A dm 314 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 13. At an accident scene a nurse stopped and began to provide emergency care for the victims. Her actions are best labeled ethically as:

Triage

Beneficence

Nonmaleficence

Respect for persons

ANS: 2 Beneficence refers to taking positive actions to help others, as in providing emergency care at an accident scene. Triage is the screening and classification of casualties to make optimal use of treatment resources and to maximize the survival and welfare of clients. Nonmaleficence is the avoidance of harm or hurt. Respect for persons has to do with treating people equally despite their social standing, for example. DIF: A dm 314 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 14. The nurse is aware that an ethics committee in a health care facility serves to:

1 2

Interview all persons involved in a case Illustrate circumstances that demonstrate malpractice

Serve as a resource for specific situations that may occur

Examine similar previous instances for comparison of outcome decisions

ANS: 3 Ethics committees serve as a resource to support the processing of ethical dilemmas. Ethics committees serve several purposes: education, policy recommendation, and case consultation or review. Although an ethics committee may gather further information, ethics committees do not interview all persons involved in a case. Rather, they offer consultation or case review. Illustrating circumstances that demonstrate malpractice is not a purpose of an ethics committee. Examining similar previous instances for comparison of outcome decisions may be part of data gathering to help process an ethical dilemma or for policy recommendation, but it is not the purpose of an ethics committee. DIF: A dm 321 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 15. In the emergency department a client feels that she has been waiting longer than the other individuals due to the fact that she has no insurance. The ethical principle that is involved in this exact situation is:

Justice

2 3

Autonomy Beneficence

Nonmaleficence

ANS: 1 Justice refers to treating people fairly. Allocation of resources and access to health care involves the ethical principle of justice. The client without medical insurance should not have to wait longer to receive health care than those with insurance. Autonomy refers to a persons independence. Autonomy represents an agreement to respect anothers right to determine a course of action. Beneficence refers to taking positive actions to help others. Nonmaleficence refers to the avoidance of harm or hurt. DIF: A dm 314 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 16. Regarding the nurses use of the specific ethical principle of autonomy in a client situation, an example would be:

Learning to do a procedure safely and effectively

2 3

Returning to speak to a client at an agreed upon time Preparing the clients room for comfort and privacy

Supporting a clients right to refuse a specific type of therapy

ANS: 4 Following the ethical principle of autonomy, the nurse allows a client to make his or her own decisions regarding care and then supports that decision. Learning how to perform a procedure safely and effectively is a nurses use of ethical responsibility. Returning to speak to a client at an agreed upon time demonstrates the ethical principle of fidelity. Preparing the clients room for comfort and privacy is a nurses use of ethical responsibility. DIF: A dm 314 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 17. Which of the following statements reflects application of the specific ethical principle of confidentiality?

Im concerned that funding may affect the outpatient program.

Im going to make sure that the client understands the instructions. I cannot share that information with you about the clients condition.

3 4

I need to get more information about the clients personal health history.

ANS: 3 I cannot share that information with you about the clients condition reflects the application of the ethical principle of confidentiality. Information is not to be shared with others without specific client consent. Im concerned that funding may affect the outpatient program reflects a concern regarding allocation of resources. It is not a confidentiality issue. The nurse who makes sure a client has gained understanding is being ethically responsible. I need to get more information about the clients personal health history reflects data gathering. Information gathered is to be used for the purpose of providing competent health care. It should not be shared with others without specific consent of the client. DIF: A dm 315 OBJ: Comprehension TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment 18. The client has been diagnosed with malignant bone cancer and the treatment involves chemotherapy on an outpatient basis. While treating the cancer the client unfortunately becomes very ill, experiences significant side effects from the therapy, and has a severe reduction in the quality of life. The specific ethical principle that is in question in this situation is:

Veracity

2 3

Fidelity Justice

Nonmaleficence

ANS: 4 Nonmaleficence is the avoidance of harm or hurt. Whether the discomforts of treatment are benefiting the client or are worse than the disease itself have to be considered. The health care professional tries to balance the risks and benefits of a plan of care while striving to do the least harm possible. Veracity refers to truthfulness. This situation is not questioning truthfulness. Fidelity refers to the agreement to keep promises. This situation does not question fidelity. Justice refers to fairness. This situation is not a matter of justice. DIF: A dm 314 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 19. Which of the following statements best reflects the nurses ethical concern for nonmaleficence regarding the clients treatment plan?

The radiation therapy has not substantially decreased the clients tumor related pain.

The client expressed the idea that this treatment was definitively going to cure her cancer:

The clients family requested that she not be informed of the seriousness of her cardiac condition. The procedure is quite invasive, and there is little chance that it will improve the clients quality of life.

harm possible. The remaining options are related to veracity (truthfulness), fidelity (keeping a promise), and possibly fairness. DIF: A dm 314 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 20. Which of the following statements related to confidentiality made by a nurse requires immediate follow-up by the nurse manager?

I believe the client is eligible for both Medicare and Medicaid.

The client with pneumonia has tested positive for TB (tuberculosis).

Did you know that the client in Room 45 has a daughter who has type 1 diabetes mellitus?

I arranged for the clients information to be faxed to the assistive living facility she will be transferred to.

ANS: 3 This information is private and the nurse is violating the clients right to confidentiality because the information has no bearing on the care needs of the client. The remaining options are not reflective of an ethical breech because the exchange of that information has a direct bearing on the clients care. DIF: C dm 315 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 21. Which of the following nursing actions best reflects a nurses commitment to the ethical principle of fostering autonomy regarding an older client living in an extended care facility?

Providing options regarding the furniture arrangement of the clients room

Supporting a clients decision to adopt a DNR (do not resuscitate) status Allowing sufficient time for the client to independently accomplish morning hygiene

3 4

Consulting the client regarding personal preferences regarding treatment options

ANS: 2 Following the ethical principle of autonomy, the nurse facilitates a clients decision-making process in order to make their own decisions regarding all aspects of life, including their care, and then supports those decisions. The most important and possibly controversial decision is that of DNR status and thus shows the greatest commitment on the nurses part. DIF: C dm 314 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 22. Which of the following statements made by a terminally ill client reflects the best understanding of the purpose of a living will?

It will make sure my wishes are respected.

My family wont be burdened with making those hard decisions. I dont want strangers making those kinds of decisions for me.

3 4

I can make my wishes known while I still have the ability to express them.

ANS: 4 A living will is an advance directive, prepared when the individual is competent and able to make and communicate personal decisions, regarding specific instructions about end-of-life care. The remaining options represent motivation for implementing a living will. DIF: C dm Chapter 23, 328 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 23. The nurse is showing respect for a clients right to autonomy regarding an invasive procedure by:

Obtaining consent for the procedure

Performing the procedure appropriately

Providing client education regarding the procedure

Being frank when discussing the pros and cons of the procedure

ANS: 1

The signed consent ensures that the nurse obtained the clients permission before proceeding with the procedure. The remaining options are examples of nonmaleficence, client right to be informed, and veracity. DIF: A dm 314 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 24. The nurse holds a clients hand during a painful procedure. This action shows a positive act towards the client that is referred to as:

Veracity

2 3

Fidelity Beneficence

Nonmaleficence

ANS: 3 Beneficence refers to taking positive actions to help others. The practice of beneficence encourages the urge to do good for others. The agreement to act with beneficence also requires that the best interests of the client remain more important than self-interest. The remaining options reflect truthfulness, keeping true to a promise, and doing no harm. DIF: A dm 314 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 25. When a nurse considers the possible positive effect a treatment will have against the pain it may cause the client, the nurse is displaying:

Justice

Fidelity

Beneficence Nonmaleficence

ANS: 4 Nonmaleficence is the avoidance of harm or hurt. In health care, ethical practice involves not only the will to do good but also the equal commitment to do no harm. The remaining options refer to fairness, truthfulness, and kindness. DIF: A dm 314 OBJ: Comprehension TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment 26. When a client who is in need of a lung transplant is placed on the organ donor registry according to his current health needs, this is an example of ethical:

1 2

Justice Fidelity

Beneficence

Nonmaleficence

ANS: 1 Health care providers agree to strive for fairness in health care. Criteria set by a national multidisciplinary committee make every effort to ensure justice by ranking client organ recipients according to need. The remaining options refer to keeping a promise, kindness, and doing no harm. DIF: A dm 314 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 27. Abandoning a client would be an example of a nurses failure to professionally display:

Justice

Fidelity

Beneficence Nonmaleficence

ANS: 2 Fidelity refers to the agreement to keep promises. A commitment to fidelity supports the reluctance to abandon clients. The remaining options refer to fairness, kindness, and doing no harm. DIF: A dm 314 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 28. The nursing professional code of ethics is best defined as:

The criteria for judging nursing professionalism

A benchmark for professional nursing deeds and actions

The nursing professions expectations of its members behavior

A document that holds nurses responsible for professional behavior

ANS: 3 It is a collective statement about the groups expectations and standards of behavior. The remaining options are not accurate or complete descriptions of the nursing professional code of ethics. DIF: C dm 314 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 29. The nurse has successfully completed a distance learning class on ECG (electrocardiogram) interpretation. This is an example of the nurse exhibiting the professional principle of:

Advocacy

Responsibility

Accountability Confidentiality

ANS: 2 The word responsibility refers to a willingness to respect obligations and to follow through on promises. The nurse has a responsibility to remain competent to practice so that he or she is able to reliably follow through on responsibilities. The remaining options are reflective of other professional principles.i DIF: A dm 314-315 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 30. The nurse is explaining the rationale for seeking the familys permission to apply a physical restraint to a combative client. This is an example of the nurse exhibiting the professional principle of:

Advocacy

Responsibility

Accountability

Confidentiality

ANS: 3

Accountability refers to the ability to answer for ones own actions. Nurses should ensure that their professional actions are explainable to their clients and to their employer. The remaining options are reflective of other professional principles. DIF: A dm 315 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 31. The nurse realizes that sharing ones computer password is a violation of which of the professional nursing principles?

Advocacy

2 3

Responsibility Accountability

Confidentiality

ANS: 4 When medical records are computerized, computer security measures include special access codes for all authorized users; sharing private passwords is a breech of client confidentiality because it allows unauthorized individuals to access client information. The remaining options are reflective of other professional principles. DIF: A dm 315 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 32. The belief that all life is sacred and must be preserved regardless of the quality of that life is an example of:

Cultural bias

Personal value

Universal truth Individual preference

ANS: 2 A value is a personal belief about the worth of a given idea, attitude, custom, or object that sets standards that influence behavior. A cultural bias refers to interpreting and judging phenomena in terms particular to ones own culture while a universal truth is so overwhelmingly true that all mankind respects and acknowledges the validity of the statement. An individual preference is a personal choice.

DIF: A dm 315 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 33. The nurse realizes that an individual clients value system is most affected by:

1 2 3 4

Life experiences Economic status Spiritual beliefs Formal education

ANS: 1 Development of values begins in childhood, shaped by experiences within the family unit, especially dramatic events during the formative years. The other options may influence the value system, but not to the same extent. DIF: C dm 316 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 34. An older client is experiencing the greatest problem with the concept of autonomy when he has difficulty:

Expressing his need for pain medication

Disagreeing with his health care provider

Participating in discussions regarding his treatment Discussing his need for assistive living arrangements

ANS: 2 Older people are usually not as familiar with the concept of autonomy as people from younger generations. As a result, older adults are sometimes uncomfortable disagreeing with doctors or nurses. They view assertiveness as a violation of trust. The remaining options reflect autonomy problems but management of personal health issues is the most important issue. DIF: C dm 314 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment MULTIPLE RESPONSE 1. Which of the following elements are essential among a group working towards the successful resolution of a conflict of opinion? (Select all that apply.)

Similar value systems

Presumption of good will

Similar cultural background Client-centered decision making

4 5 6

Strict adherence to confidentiality Participation of all involved parties

ANS: 2, 4, 5, 6 The resolution of conflicting opinions works best when the following elements are part of the process: the presumption of good will on the part of all participants, strict adherence to confidentiality, client-centered decision making, and the welcome participation of families and primary caregivers. The remaining options represent group characteristics that usually minimize conflict in decision making. DIF: C dm 319 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 2. Although the American Nurses Associations (ANAs) code of ethics is reviewed and revised regularly to reflect changes in nursing practice, the basic principles that remain constant are: (Select all that apply)

Advocacy

Reliability Responsibility

3 4 5

Accountability Confidentiality

Professionalism

ANS: 1, 3, 4, 5 The American Nurses Association (ANA) established the first code of nursing ethics decades ago. The ANA reviews and revises the Code regularly to reflect changes in practice. Basic principles remain constant; however, responsibility, accountability, advocacy, and confidentiality. Although admirable, the remaining options are not considered core principles of the code. DIF: C dm 315 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment

3. The nurse knows that when making choices concerning the adoption of evidence-based practice, the literature must be reviewed regarding its: (Select all that apply)

1 2 3

Content Relevance

Reliability Ethical soundness

Economic feasibility

Transcultural versatility

ANS: 1, 2, 3, 4 Nurses make choices regarding evidence-based practice proposals based on content, relevance, reliability, and the ethical implications to their practice. The remaining options are not typically considered when evaluating the global usefulness of research findings. Chapter 23. Legal Implications in Nursing Practice MULTIPLE CHOICE 1. Which source of law best addresses a situation where nurse accidentally administers an incorrect dosage of morphine sulfate to the client?

1 2 3 4

Civil law Criminal law Common law Administrative law

ANS: 1 Civil laws protect the rights of individual persons within our society and encourage fair and equitable treatment among people. Generally, violations of civil laws cause harm to an individual or property and damages involve payment of money. Administering an incorrect dosage of morphine sulfate would fall under civil law because it could cause harm to an individual. Criminal laws prevent harm to society and provide punishment for crimes (often imprisonment). Common law is created by judicial decisions made in courts when individual legal cases are decided (i.e., informed consent). Administrative law is created by administrative bodies, such as state boards of nursing when they pass rules and regulations (i.e., the duty to report unethical nursing conduct) DIF: A dm 326 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment

2. What standard of care applies to the student nurses conduct when providing care normally performed by a registered nurse (RN)?

1 2 3 4

The same standard of care as an RN A standard of care of an unlicensed person No special standard of care because her faculty member is responsible for her conduct A standard similar to but not the same as the staff nurse with whom she is assigned to work

ANS: 1 Student nurses are expected to perform as professional nurses (i.e., as an RN would in providing safe client care). Students are not working in the same capacity as an unlicensed person, and therefore are not compared to the standard of an unlicensed person. No special standard of care because her faculty member is responsible for her conduct is not a true statement. Staff nurses may serve as preceptors, but that does not excuse the student from performing at the level of an RN. If a client is harmed as a direct result of a nursing students actions or lack of action, the liability for the incorrect action is generally shared by the student, instructor, hospital or health care facility, and university or educational institution. DIF: A dm 333 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 3. Which of the following is the most important factor in a nurse deciding whether or not to carry malpractice insurance?

The nurses knowledge level of Good Samaritan laws

The amount of malpractice insurance provided by the nurses employer

The time frames and individual liability of the employers malpractice coverage The evaluation of whether the nurse works in a critical area of nursing where clients have higher morbidity and mortality rates

ANS: 3 It would be important to know the time frames of the employers malpractice coverage. In other words, is the nurse only covered during the times he or she is working within the institution? It

would be important to know the individual liability. For example, if sued, what financial responsibility would the nurse have? The nurse should be aware of Good Samaritan laws, but this would not be sufficient coverage for most nursing practice. Therefore it is not the most importance factor in determining whether to purchase private malpractice insurance. The amount of malpractice insurance provided by the employer is not the most important factor in deciding whether to carry private insurance. Generally, the employers malpractice insurance coverage is much greater than private insurance coverage. The area of nursing in which the nurse is employed is not the most important factor in deciding whether or not to carry malpractice insurance. Lawsuits can occur anywhere. DIF: A dm 334-335 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 4. An unconscious client with a head injury needs surgery to live. His wife only speaks French, and the health care providers are having a difficult time explaining his condition. Which of the following is the most correct answer regarding this situation?

An institutional review board needs to be contacted to give their emergency advice on the situation.

The health care team should continue with the surgery after providing information in the best manner possible.

A friend of the family could act as an interpreter, but the explanation could not provide details of the clients accident, because of confidentiality laws. Two licensed health care personnel should witness and sign the preoperative consent indicating they heard an explanation of the procedure given in English.

ANS: 2 In emergency situations, if it is impossible to obtain consent from the client or an authorized person, the procedure required to benefit the client or save a life may be undertaken without liability for failure to obtain consent. In such cases, the law assumes that the client would wish to be treated. In an emergency, it is not necessary to contact the institutional review board. In doing so, it would take up valuable time. A family member or acquaintance that is able to speak a clients language should not be used to interpret health information. An official interpreter must be available to explain the terms of consent (except in an emergency situation). Telephone consents usually require two witnesses. This is not the case in this situation. DIF: A dm 333 OBJ: Comprehension TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Safe, Effective Care Environment 5. A physician asks a family nurse practitioner to prescribe a medication that the nurse practitioner knows is incompatible with the current medication regimen. If the nurse practitioner follows the physicians desire, which of the following is the most correct answer?

Good Samaritan laws will protect the nurse.

The nurse practitioner will be liable for the action.

This type of situation is why nurse practitioners should have malpractice insurance.

If the nurse practitioner has developed a good relationship with the client, there will probably not be a problem.

ANS: 2 A nurse carrying out an inaccurate or inappropriate order may be legally responsible for any harm suffered by the client. Good Samaritan laws will not protect the nurse in this situation. Good Samaritan laws are for providing care at the scene of an accident. The nurse should refuse to administer the medication when he or she knows it is wrong. Having malpractice insurance is not the answer, as it does not protect the client from harm. The nurse practitioner should refuse administering the medication. Developing a good relationship with the client is important, but will not protect the nurse from legal liability for providing incompetent care. DIF: A dm 327 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 6. A registered nurse interprets a scribbled medication order by the attending physician as 25 mg. The nurse administers 25 mg of the medication to a client, and then discovers that the dose was incorrectly interpreted and should have been 15 mg. Who would ultimately be responsible for the error?

Attending physician

Assisting resident

Pharmacist

Nurse

ANS: 4 A nurse carrying out an inaccurate or inappropriate order may be legally responsible for any harm suffered by the client. The nurse should clarify the order with the physician if unable to read the order. The attending physician could be included in a lawsuit, but it would be the nurse who is ultimately responsible for the error. The assisting resident would not be ultimately

responsible for the error. The assisting resident did not carry out an inaccurate order. The pharmacist could be included in a lawsuit, but it would be the nurse who is ultimately responsible for the error because the nurse was the individual who carried out an inaccurate order. DIF: A dm 327 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 7. A nurse is being asked to move from the eye unit to a general surgery floor where she in inexperienced in this specialty due to an influenza epidemic among the nursing staff. She is aware of her inexperience. The nurses initial recourse is to:

Fill out a report noting her dissatisfaction

Ask to work with another general surgery nurse Notify the State Board of Nursing of the problem

3 4

Politely refuse to move, take a leave-of-absence day, and go home

ANS: 2 Nurses who float should inform the supervisor of any lack of experience in caring for the type of clients on the nursing unit. They should also request and be given orientation to the unit. Asking to work with another general surgery nurse would be an appropriate action. A nurse can make a written protest to nursing administrators, but it should not be the nurses initial recourse. Notifying the state board of nursing should not be the nurses initial recourse. The nurse should first notify the supervisor and request appropriate orientation and training. If problems continue, the nurse should attempt the usual chain of command within the institution before contacting the state board of nursing. A nurse who refuses to accept an assignment may be considered insubordinate, and clients will not benefit from having less staff available. DIF: A dm 335-336 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 8. There are issues concerning death and dying may influence nursing practice which the nurse recognizes. Concerning the legalities of death and dying issues, which of the following is true?

Passive euthanasia is illegal in all states.

Assisted suicide is a constitutional right.

Organ donation must be attempted if it will save the recipients life.

Feedings may be refused by competent individuals who are unable to self-feed.

ANS: 4 Competent clients have the right to refuse treatment. This includes life-saving hydration and nutrition. This is not a true statement. Furthermore, physician-assisted suicide is legal in the state of Oregon. In 1997 the Supreme Court ruled that there is no fundamental constitutional right to assisted suicide. Organ donation does not have to be attempted to save a recipients life. DIF: A dm 330 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 9. The Joint Commission (TJC) sets standards of care, in which an institution is required to have:

Limits of professional liability

Educational standards for nurses

A delineated scope of practice for health professionals Written nursing policies and procedures for client care

ANS: 4 The TJC requires that accredited hospitals have written nursing policies and procedures. Standards of care help define the limits of professional liability. The TJC does not require an institution to have limits of professional liability. Nurse practice acts establish educational requirements for nurses. Nurse practice acts define the scope of nursing practice. The rules and regulations enacted by the state board of nursing define the practice of nursing more specifically. The American Nurses Association has developed standards for nursing practice that delineate the scope, function, and role of the nurse and establish clinical practice standards. DIF: A dm 326 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 10. In the event that a nursing license is revoked, which of the following is correct?

The hearings are usually held in court.

Due process rights are waived by the nurse.

Appeals may be made regarding the decisions.

The federal government becomes involved in the procedures.

ANS: 3

Because a license is viewed as a property right, due process must be followed before a license can be suspended or revoked. Due process means that nurses must be notified of the charges brought against them, and that the nurses have an opportunity to defend against the charges in a hearing. Hearings for suspension or revocation of a license do not occur in court but are usually conducted by a hearing panel of professionals. Due process must be followed. They do not have to be waived by the nurse. Some states, not the federal government, provide administrative and judicial review of such cases after nurses have exhausted all other forms of appeal. DIF: A dm 330 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 11. Which one of the following actions is an example of an unintentional tort?

1 2 3 4

Restraining a client who refuses care Taking photos of a clients surgical wounds Leaving the side rails down and the client falls and is injured Talking about a clients history of sexually transmitted diseases

ANS: 3 An unintentional tort is an unintended wrongful act against another person that produces injury or harm. An example of an unintentional tort would be leaving the side rails down and the client falls and is injured. Restraining a client who refuses care would be an example of assault and battery. Taking photos of a clients surgical wounds without the clients permission is an example of invasion of privacy. Talking about a clients history of sexually transmitted diseases would fall under the category of invasion of privacy. Personal information should be kept confidential. DIF: A dm 332 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 12. Which one of the following individuals may legally give informed consent?

A 16-year-old for her newborn child

A sedated 42-year-old preoperative client

The friend of an 84-year-old married client

A 56-year-old who does not understand the proposed treatment plan

ANS: 1

An emancipated minor, one who is below the age of 18 but who is a parent, can legally give informed consent for the care of her newborn. An emancipated minor can also be someone below the age of 18 who is legally married. A person who has been sedated cannot legally give informed consent. Consent should be obtained before a sedative is administered. If the 84-yearold client were unable to give consent, then the clients wife would be the person legally authorized to do so on the clients behalf. In order for a friend to be legally able to give consent, he or she would have to possess power of attorney or legal guardianship of the client. If a client does not understand the proposed treatment plan, the nurse must notify the physician or nursing supervisor and must make certain that clients are informed before signing the consent. DIF: A dm 332-333 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 13. When a nurse signs as a witness on an informed consent form, she is indicating that the client:

1 2

Fully understands the procedure Agrees with the procedure to be done

Has voluntarily signed the consent form

Has authorized the physician to continue with the treatment

ANS: 3 The nurses signature witnessing the consent means that the client voluntarily gave consent, that the clients signature is authentic, and that the client appears to be competent to give consent. It is the physicians responsibility to make sure the client fully understands the procedure. If the nurse suspects the client does not understand, the nurse should notify the physician. The nurses signature does not indicate that the client agrees with the procedure, but that the client has voluntarily given consent and is competent to do so. Clients also have the right to refuse treatment, which is also signed and witnessed. The nurses signature does not verify that the client has authorized the physician to continue with treatment. It only verifies that the consent was given voluntarily, the client is competent to give consent, and the signature is authentic. DIF: A dm 332 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 14. A nurse who is working with clients who have DNR (do not resuscitate) orders knows that these orders:

Are legally required for terminally ill clients

May be written by the physician without client consent if resuscitation is futile Are maintained throughout the clients stay in either an acute care or a long-term care facility

3 4

Follow nationally consistent standards for implementation of client interventions

ANS: 2 If the client is unable, and there is no surrogate available to give consent, the DNR order can be written but only if the physician is reasonably medically certain that the resuscitation would be futile. A DNR order is not legally required for terminally ill patients.. DNR orders are not necessarily maintained throughout the clients stay because a clients condition may warrant a change in DNR status. The attending physician must review the DNR orders every 3 days for hospitalized clients or every 60 days for clients in residential health facilities. There is no nationally consistent standard for DNR implementation. States have their own statutes regarding DNR orders. DIF: A dm 328-329 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 15. The nurse understands the implications of the Patient Self-Determination Act. This legislation requires that:

Clients designate a power of attorney

DNR orders for clients meet standard criteria

Organ donation is required upon death, if possible

Information be provided to the client regarding rights for refusal of care

ANS: 4 The Patient Self-Determination Act requires health care institutions to provide written information to clients concerning the clients rights under state law to make decisions, including the right to refuse treatment and formulate advance directives. The Patient Self-Determination Act does not require clients to designate a power of attorney. The Patient Self-Determination Act does not require that DNR orders meet standard criteria. The Patient Self-Determination Act does not require organ donation upon death. It is the clients decision whether he or she wants to participate in organ donation.

DIF: A dm 328 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 16. The newly enacted Health Insurance Portability and Accountability Act (HIPAA) of 2003 requires:

Insurance coverage for all clients

Policies on how to report communicable diseases

Limits on information and damages awarded in court cases

Safeguards to protect written and verbal information about clients

ANS: 4 The Health Insurance Portability and Accountability Act (HIPAA) requires all hospitals and health agencies to have specific policies and procedures in place to ensure that there are reasonable safeguards to protect written and verbal communications about clients. HIPAA does not require insurance coverage for all clients. It limits the extent to which health plans may impose preexisting condition limitations and prohibits discrimination in health plans against individual participants and beneficiaries based on health status. HIPAA does not require policies on how to report communicable diseases. It does require safeguards to protect written and verbal information about clients. HIPAA does not require limits on information and damages awarded in court cases. DIF: A dm 329 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 17. A client is told by his nurse that he has to take the medications, including an injection. The client refuses the medications, but continues to have them administered by the nurse. This action is an example of the intentional tort of:

Assault

Battery

Malpractice Invasion of privacy

ANS: 2 Battery is any intentional touching without consent. An example of battery is a nurse who gives a medication after the client has refused. Assault is any intentional threat to bring about harmful or

offensive contact. No actual contact is necessary. Malpractice is negligence committed by a professional such as a nurse or physician. This case is not an example of malpractice. Invasion of privacy is where the client has unwanted intrusion into his or her private affairs. This case is not an example of invasion of privacy. DIF: A dm 331 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 18. A nurse who is working with a client who has been diagnosed with AIDS reveals the clients name and diagnosis with a co-worker on the way downstairs in an elevator. Unknowingly, a friend of the client that happens to be sharing the elevator and hears the entire story. The nurse who shared the information may be held liable for:

Slander

Assault

Malpractice

Invasion of privacy

ANS: 1 A nurse can be held liable for slander if he or she shares private client information that can be overheard by others. Assault is any intentional threat to bring about harmful or offensive contact. No actual contact is necessary. The nurse in this situation has not committed assault. Malpractice is negligence committed by a professional such as a nurse or physician. Nursing malpractice results when care falls below the standard of care. This case is not an example of malpractice. Invasion of privacy occurs when the client has unwanted intrusion into his or her private affairs. This case is not an example of invasion of privacy. This instance falls under the category of defamation of character. DIF: A dm 331 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 19. A nurse stealing narcotics from an acute care nursing unit is guilty of a:

Civil offense

Criminal offense

Common law offense Administrative law offense

4 ANS: 2

Criminal laws prevent harm to society and provide punishment for crimes (often imprisonment). A felony is a crime of a serious nature that has a penalty of imprisonment for greater than 1 year or even death. A misdemeanor is a less serious crime that has a penalty of a fine or imprisonment for less than 1 year. An example of criminal conduct for nurses is misuse of a controlled substance. Civil laws protect the rights of individual persons within our society and encourage fair and equitable treatment among people. Common law is created by judicial decisions made in courts when individual legal cases are decided (i.e., informed consent). Administrative law is created by administrative bodies, such as state boards of nursing, when they pass rules and regulations. DIF: A dm 326 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 20. The case of a nurse accused of unethical nursing conduct will be heard by the state board of nursing. This is an example of:

1 2

Civil law Criminal law

Common law

Administrative law

ANS: 4 Administrative law is created by administrative bodies, such as state boards of nursing when they pass rules and regulations such as unethical nursing conduct. Civil laws protect the rights of individual persons within our society and encourage fair and equitable treatment among people. Criminal laws prevent harm to society and provide punishment for crimes (often imprisonment). Common law is created by judicial decisions made in courts when individual legal cases are decided. DIF: A dm 330 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 21. Which of the following statements made by a nursing student regarding responsibility for provided care requires immediate follow-up by the nursing instructor?

Im not held to the same standards as a licensed RN.

I am required to provide the safest, appropriate care I am capable of.

My clinical instructor is ultimately responsible for the care I provide.

No one expects nursing students to provide care on the level as an experienced RN.

ANS: 3 Student nurses are expected to perform as professional nurses, that is, as an RN would in providing safe, appropriate client care. The clinical instructor is responsible for proper instruction, supervision, and guidance but the student is responsible for their own acts. The remaining options do reflect misconceptions, but the issue of responsibility has priority. DIF: C dm 333 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 22. The nurse is having difficulty reading the prescribed dosage on a handwritten order for a pain medication. The most appropriate action to ensure the clients safety and to minimize legal issues is for the nurse to:

Ask another RN to confirm the order

Request the pharmacist to interpret the order

Call the health care provider to clarify the order

Consult a current drug book to determine the normal dosage range

ANS: 3 A nurse carrying out an inaccurate or inappropriate order may be legally responsible for any harm suffered by the client. The nurse should clarify the order with the prescriber if unable to read the order. Although asking others to interpret the order may appear prudent, it is ultimately the nurses responsibility if a medication error is made. Although the drug book may provide a normal range it does not aid in determining definitively what the order intended. DIF: A dm 336 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 23. The legal basis for a nurse to provide emergency treatment without consent to a client incapable of informed consent is:

Such care is clearly a nursing responsibility

To fail to provide such care is nursing negligence

It is presumed that the client would want the emergency treatment

Health care providers have an obligation to provide emergency treatment

ANS: 3 In emergency situations, if it is impossible to obtain consent from the client or an authorized person, the law assumes that the client would wish to be treated. Providing appropriate nursing care is a nursing responsibility, and failure to do so is negligence. DIF: C dm 332 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 24. An experienced pediatric nurse is reassigned to an adult oncology floor because of staffing issues and immediately recognizes a lack of experience in this specialty. Which of the following nursing actions shows a lack of professionalism?

Politely declining the assignment

Filling out a report noting her dissatisfaction

Asking to work with another oncology nurse Notifying the state board of nursing of the problem

ANS: 1 A nurse who refuses to accept an assignment may be considered insubordinate, and clients will not benefit from having less staff available. This is an unprofessional attempt to resolve the problem. Asking to work with another oncology nurse, sending a written protest, and notifying the state nursing board would be appropriates action, and so are not examples of unprofessional behavior. DIF: C dm 335 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 25. Although a nurse may not agree, the nurse recognizes that a terminally ill client has the legal right to:

Seek passive euthanasia in some states

Sign an organ donor pledge statement

Refuse DNR (do not resuscitate) status Refuse treatment in the form of food and water

4 ANS: 4

Competent clients have the right to refuse treatment. This includes life-saving hydration and nutrition. Physician-assisted suicide is legal in the state of Oregon, and it is legally a clients decision to declare a DNR status or to sign an organ donor card. DIF: A dm 328 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 26. Which of the following statements best reflects a nurses understanding of the proper critical thinking process regarding the need for personal malpractice insurance?

The states Good Samaritan laws protect me outside of the hospital.

I work in a very low risk area of nursing, so I dont really have a need. The hospital carries its own malpractice insurance, so I dont need extra.

3 4

Lawsuits can occur years after the event, so I carry my own liability insurance.

ANS: 4 The employing institutions insurance only covers nurses while they are working within the scope of their employment. Because nurses are professionals and it is often difficult to separate their private lives from their professional skills, nurses need to consider purchasing individual professional liability insurance, even if the employing institution has coverage. It would be important to know the time frames of the employers malpractice coverage. The nurse may be only covered during the times he or she is working within the institution. Good Samaritan laws have a narrow scope and would not cover many nursing activities. Although it is true that some areas of nursing have a higher potential for liability claims, all areas have risk. The hospitals insurance may not cover all potential expenses and may not be applicable in all liability situations. DIF: C dm 334-335 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 27. Which of the following statements made by a nurse puts the nurse at risk for assault of the client?

You will be sorry if you dont agree to take this medication.

You cant refuse this medication if you really want to feel better.

Ill be so disappointed in you if you dont take your medication.

Ill tell your son you arent cooperating if you dont take your medication.

ANS: 1 Assault is any intentional threat to bring about harmful or offensive contact. No actual contact is necessary. Threatening to tell a family member may be a breech of confidentiality; the remaining options are examples of unnecessary pressuring of the client. This case is not an example of invasion of privacy. DIF: C dm 331 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 28. Which of the following statements made by a nurse shows the best understanding regarding the requirements of the Health Insurance Portability and Accountability Act (HIPAA) of 2003?

Im always careful to close the door when taping or listening to the units shift report.

The nursing assistants know to hand me the vital signs sheet and not just put it on the medication cart. I called the radiology department to tell them I would be faxing the client information they requested.

3 4

The clients niece called to see how she slept last night, but I told her I couldnt share that with her over the phone.

ANS: 3 The Health Insurance Portability and Accountability Act (HIPAA) requires all hospitals and health care agencies to have specific policies and procedures in place to ensure that there are reasonable safeguards to protect written and verbal communications about clients. By notifying the receiver of an impending client-oriented fax, the nurse has taken a reasonable measures to ensure it is seen by only the appropriate individuals. Although the remaining options deal with safeguards, the potential for a breech in client confidentiality is not as great in those scenarios. DIF: C dm 331 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 29. Which of the following statements made by a nurse reflects the best understanding of the legal safeguards of a DNR (do not resuscitate) order?

All family members need to agree before a DNR order can be written.

All terminally ill clients are ultimately required to be declared a DNR status. The DNR order on the terminally ill client in Room 45 needs reviewed today.

3 4

If the clients family cant be located, the physician will write the DNR order.

ANS: 3 DNR orders are not necessarily maintained throughout the clients stay because a clients condition may warrant a change in DNR status. To ensure client safety, the attending physician must review the DNR orders every 3 days for hospitalized clients or every 60 days for clients in residential health facilities. If there is no living will or durable power of attorney appointed, members of the family will be consulted regarding a DNR order. Although not all family members need to agree, an order will usually not be written if some family members express strong opposition to the status change. If no family can be located, the attending physician has the legal right to write the order. There is no legal requirement for a terminally ill client to be required to assume DNR status. DIF: C dm 328-329 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 30. Which of the following statements made by a nurse reflects a lack of understanding regarding a DNR (do not resuscitate) order?

All family members need to agree before a DNR order can be written.

All terminally ill clients are ultimately required to be declared a DNR status. The DNR order on the terminally ill client in Room 45 needs reviewed today.

3 4

ANS: 1

If the clients family cant be located the physician will write the DNR order.

If there is no living will or durable power of attorney appointed, members of the family will be consulted regarding a DNR order. Although not all family members need to agree, an order will usually not be written if some family members express strong opposition to the status change. DNR orders are not necessarily maintained throughout the clients stay because a clients condition may warrant a change in DNR status. To ensure client safety, the attending physician must review the DNR orders every 3 days for hospitalized clients or every 60 days for clients in residential health facilities. If no family can be located, the attending physician has the legal right to write the order. There is no legal requirement for a terminally ill client to be required to assume DNR status. DIF: C dm 328-329 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 31. Which of the following statements made by a nurse shows a lack of understanding regarding the Uniform Anatomical Gift Act?

A client must be 21 to give consent to be an organ donor.

All clients admitted to the hospital are asked about becoming an organ donor. We have a form here on the unit that must be signed to show a clients informed consent to be an organ donor.

3 4

In our state, you can check the back of a clients drivers license to verify whether they are an organ donor.

ANS: 1 An individual who is at least 18 years of age has the right to make an organ donation (defined as a donation of all or part of a human body to take effect upon or after death). Donors need to make the gift in writing with their signature. In many states, adults sign the back of their drivers license, indicating consent to organ donation. In most states, required request laws mandate that at the time of admission to a hospital, a qualified health care provider has to ask each client older than 18 whether he or she is an organ or tissue donor. DIF: C dm 329 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 32. The nurse is heard stating to another staff member that, the client in Room 54 is such a whiner; you would think she was dying. This nurse is liable of:

Libel

Slander

Malpractice

Invasion of privacy

ANS: 2 Defamation of character is the publication of false statements either verbally or in writing that result in damage to a persons reputation. Slander occurs when one verbalizes the false statement. Libel is the written defamation of character, whereas invasion of privacy occurs when the client has unwanted intrusion into his or her private affairs. Malpractice is negligence committed by a professional such as a nurse or physician. Nursing malpractice results when care falls below the standard of care. DIF: A dm 332 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 33. Which of the following nursing statements reflects the best understanding of the importance of appropriate nursing documentation regarding risk management?

If the client isnt compliant, Im sure to put that in my notes.

Im always careful to document any changes in the clients condition.

My notes are the proof that I provided the client with effective, appropriate care.

When there is a lawsuit, the nursing notes are the first thing the attorney looks at.

ANS: 3 The nurses documentation is often the evidence of care received by a client and serves as proof that the nurse acted reasonably and safely. The remaining options are not incorrect but do not identify the primary importance to the nurse. DIF: C dm 336 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 34. Which of the following statements reflects a nurses need for further instructions regarding an incident report?

I hope this incident report will help determine a way to help prevent falls.

Risk management will want to review the incident report on the clients fall.

I put the incident report on the clients fall in his chart as soon as I was finished. I need to review the guidelines before I fill out this incident report regarding the clients fall.

ANS: 3 The report is confidential and separate from the medical record. The remaining options reflect an understanding about incident reports. DIF: C 336 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 35. Regarding hours worked and frequency of errors, recent research has shown that nurses working more than 12.5 hours per shift and more than a 40-hour week are:

1 2

Reporting more physical illnesses than those working only 40 hours per week Three times more likely to commit an error in nursing judgment related to client care

Experiencing more physical injuries than those working only 40 hours per week

Experiencing signs of emotional burn out more frequently than those working only 40 hours per week

ANS: 2 Results showed that nurses who worked shifts lasting 12.5 hours or more had a three times greater likelihood of making an error. Overtime increased the odds of making at least one error regardless of length of original shift scheduled. The remaining options are not supported by research data. DIF: C REF: 335 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 36. While working as a nursing assistant, a nursing student is asked to reinsert a Foley catheter by the RN. Which of the following reflects the most appropriate initial student response to the request?

Notify the nursing supervisor of the inappropriate request.

2 3

Tell the RN that she can only perform as a nursing assistant. Agree to perform the task but with the supervision of the RN.

Jointly read the nursing assistant job description with the RN.

ANS: 2 When students work as nursing assistants or nurses aides, they should not perform tasks that do not appear in a job description for a nurses aide or assistant. The remaining options do not appropriately address the immediate situation. DIF: C REF: 333-334 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment MULTIPLE RESPONSE 1. Which of the following statements is true regarding the implications of the nurses signature as a witness for a clients consent? (Select all that apply.)

Client signed voluntarily.

The signature is authentic.

Client appears to be competent.

Client appears knowledgeable about the procedure.

The nurse has discussed the possible risks of the procedure.

The nurse has discussed possible post procedure nursing care.

ANS: 1, 2, 3, 4 The nurses signature witnessing the consent means that the client voluntarily gave consent, that the clients signature is authentic, and that the client appears to be competent to give consent. When nurses provide consent forms for clients to sign, nurses must ask the clients if they understand the procedure for which they are giving consent. If clients deny understanding or you suspect they do not understand, notify the physician or nursing supervisor. Nursing care post procedure should be discussed but is not inferred by a nurses signature as a witness. Discussing possible risk factors is the physicians responsibility. DIF: C REF: 332-333 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment

2. When documenting notification of the primary health care provider concerning a client whose condition is deteriorating, the nurse must be sure to include which of the following? (Select all that apply.)

Clients wife at bedside.

2 3

Client rating pain at 3 out of 10 at 0920. Client asking to have wife called to come to hospital.

Dr. Smith notified of clients pain rating of 8 out of 10 at 0900.

Client administered 2 mg morphine sulfate IV every 5 minutes for two doses.

Client ordered morphine sulfate 2 mg IV every 5 minutes until pain relief is achieved.

ANS: 2, 4, 5, 6 The nurse must be certain to document that the physician was notified and his or her response, nursing action in follow-up of orders, and the clients response. The remaining options are not relevant to the proper documentation of the situation. Chapter 24. Communication MULTIPLE CHOICE 1. The client tells the nurse that he understands most of the information but still has questions concerning the medication after the nurse has provided the client with information regarding the treatment plan for the diagnosis the. This response is an example of:

1 2 3 4

Referent Receiver Channel Feedback

ANS: 4 This response is an example of feedback. Feedback is the message returned by the receiver. The referent motivates one person to communicate with another, such as a time schedule. This is not an example of a referent. The receiver is the person who receives and decodes the message. This question is not asking about the receiver, but rather the response. Channels are means of conveying and receiving messages through visual, auditory, and tactile senses. This response is not an example of a channel. DIF: A REF: 343 OBJ: Comprehension TOP: Nursing Process: Implementation/Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment 2. The nurse is in the process of conducting an admission interview with the client. At one point in the discussion, the client has provided information that the nurse would like to clarify. The nurse employs the technique of clarification as indicated by the response:

Im not sure that I understand what you mean by that statement.

The ECG records information about your hearts electrical activity.

Lets look at the problem you have had with your medication when you were home.

Whats your biggest concern related to your hospitalization at the moment?

ANS: 1 Im not sure that I understand what you mean by that statement is correct. Clarifying is when the nurse checks whether understanding is accurate by restating an unclear message to clarify the senders meaning, or by asking the other person to restate the message, explain further, or give an example of what the person means. This response indicates the nurse wants to clarify what the client is saying so he or she can have an accurate understanding of what the client means. The ECG records information about your hearts electrical activity is an example of providing information, not clarification. Lets look at the problem you have had with your medication when you were home is an example of focusing, not clarification. Whats your biggest concern related to your hospitalization at the moment is an example of sharing empathy. DIF: A REF: 354 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 3. The faculty member is reviewing a process recording with the student nurse. The student has been working with a client who has had an amputation of the lower left leg and is emotionally fragile. The student receives positive feedback from the faculty member for the following response made to the client:

Why are you so upset today?

Im sure that everything will be all right.

You shouldnt cry. The wound will heal soon.

It must be very difficult to have this happen to you.

ANS: 4

It must be very difficult to have this happen to you is an example of using the therapeutic communication technique of sharing empathy. Why are you so upset today? is an example of a nontherapeutic communication technique of asking for explanations. Im sure that everything will be all right is an example of a nontherapeutic communication technique of giving false reassurance. You shouldnt cry. The wound will heal soon is an example of a nontherapeutic communication technique of giving disapproval. DIF: A REF: 353 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 4. When reaching over the side rails to take a clients blood pressure, he draws back. To promote effective communication, the nurse should first:

Tell the client that the blood pressure can be taken at a later time

Rotate the nurses who are assigned to take the clients blood pressure

Continue to perform the blood pressure assessment quickly and quietly

Apologize for startling the client and explain the need for touching the client

ANS: 4 Nurses often have to enter a clients personal space to provide care. The nurse should convey confidence, gentleness, and respect for privacy. This response demonstrates respect and provides information so the client can understand the need for personal contact. Telling the client that the blood pressure can be taken at a later time does not promote effective communication. Rotating the nurses who are assigned to take the clients blood pressure impedes the nurses ability to form a therapeutic, helping relationship. Continuing to perform the procedure quickly and quietly may send a negative nonverbal message. It also does not promote effective communication. DIF: A REF: 343 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 5. Communication involves both active listening and body language working together. The nurse actively listens to the client and:

Sits facing the client

Keeps the arms and legs crossed

Leans back in the chair away from the client

Avoids eye contact as much as is physically possible

ANS: 1 Active listening means to be attentive to what the client is saying both verbally and nonverbally. A nonverbal skill to facilitate attentive listening is to sit facing the client. This posture gives the message that the nurse is there to listen and is interested in what the client is saying. For active listening, the arms and legs should be uncrossed. This posture suggests that the nurse is open to what the client says. For active listening, the nurse should lean toward the client. This posture conveys that the nurse is involved and interested in the interaction. For active listening, the nurse should establish and maintain intermittent eye contact. This conveys the nurses involvement in and willingness to listen to what the client is saying. DIF: A REF: 344 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 6. During the assessment phase of the nursing process, the nurse may uncover data that help to identify communication problems. An example of this information is:

Extreme dyspnea or shortness of breath

2 3

Urinary frequency and pain Chronic stomach pain

Lack of appetite

ANS: 1 An extremely breathless person must use oxygen to breathe rather than speak. Urinary frequency may interrupt conversation but is not a communication problem. Chronic stomach pain would not be a communication problem. The patient with chronic pain is, to some degree, used to the pain. A lack of appetite is not a communication problem. DIF: A REF: 349 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 7. When a nurse tells an advanced nurse practitioner that her client is slipping a little in reference to hemodynamic pressures, The nurse is using:

Brevity

Relevance

Pacing and control.

Connotative meaning

ANS: 4 The connotative meaning is the shade or interpretation of a words meaning influenced by the thoughts, feelings, or ideas people have about the word. Slipping a little in reference to hemodynamic pressures is an example of using connotative meaning. Brevity means that communication is simple, brief, and direct. This is not an example of using brevity. Relevance means the message is relevant or important to the situation at hand. This is not an example of using relevance. Pacing and control mean speaking slowly enough to enunciate clearly and not changing subjects rapidly. This is not an example of using pacing and control. DIF: A REF: 344 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 8. A client is admitted for a CAT scan (diagnostic test) of the cranium. As the nurse explains this diagnostic test, the client moves away from the nurse. This is an example of what influencing factor in communication?

Gender

Environment

Space and territoriality Sociocultural background

ANS: 3 Territoriality is the need to gain, maintain, and defend ones right to space. The client who moves away from the nurse during a conversation is demonstrating the influence of space and territoriality on communication. This not an example of gender influencing communication. This is not an example of environment influencing communication. Noise, temperature extremes, distractions, and lack of privacy are examples of environmental factors that may influence communication. Although people do maintain varying distances between each other depending on their culture, this is not an example of sociocultural background influencing communication, as cultural orientation is not mentioned in this situation. DIF: A REF: 345 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 9. The nurse will often display empathy in communication with clients. Of the following responses by the nurse, which one best conveys empathy?

Good morning. How did you sleep last night?

I can understand your concern about learning to inject yourself.

Do you mean you would like to talk to the new family nurse practitioner? Can you describe to me what the pain in your abdomen feels like right now?

ANS: 2 I can understand your concern about learning to inject yourself is correct. Empathy is the ability to understand and accept another persons reality, to accurately perceive feelings, and to communicate this understanding to others. Good morning. How did you sleep last night? is asking a question. It does not convey empathy. Do you mean you would like to talk to the new family nurse practitioner? is asking a question to clarify the clients meaning. It does not convey empathy. Can you describe to me what the pain in your abdomen feels like right now? is asking a relevant question that may focus on a particular topic. It is not an example of empathy. DIF: A REF: 353 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 10. In working with a client who is newly diagnosed with diabetes mellitus, the nurse provides feedback to the client on her progress in learning the treatment regimen. Of the following, the nurse demonstrates the use of therapeutic communication by stating:

I believe that you have come a long way in learning how to manage your care.

It didnt look like you were ever going to be able to get the injection technique.

Check your blood sugar unless you really want to come back to the hospital again.

You dont appear to have any real interest in managing your daily dietary intake.

ANS: 1 In stating, I believe that you have come a long way in learning how to manage your care the nurse is demonstrating the use of therapeutic communication by sharing hope. The nurse is pointing out that personal growth can come from illness experiences. It didnt look like you were ever going to be able to get the injection technique is a negative statement. The nurse should not state observations that might embarrass or anger the client. Check your blood sugar unless you

really want to come back to the hospital again does not demonstrate the use of therapeutic communication. It implies disapproval and is an aggressive, threatening type of response. You dont appear to have any real interest in managing your daily dietary intake is not a therapeutic statement. It is negative and aggressive in nature. If it is a true observation, it is one the nurse should not state as it could anger the client. DIF: A REF: 353 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 11. Ive never told anyone this information about my son, is an example of a parent:

Identifying problems

Building trust

Clarifying roles

Revealing

ANS: 2 This response is an example of trust. Trusting another person involves risk and vulnerability, but it also fosters open, therapeutic communication and enhances the expression of feelings, thoughts, and needs. This statement is not an example of revealing. Although the parent may have provided information that was never before revealed, in this statement the parent is indicating there is trust between himself or herself and the nurse practitioner. This statement is not clarifying roles of the nurse and client. This statement is not an example of identifying problems and goals. DIF: A REF: 348 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 12. Discussing the clients follow-up dietary needs immediately after the surgery when the client is experiencing discomfort is an error in:

Pacing

Intonation

Timing and relevance Denotative meaning

ANS: 3 Discussing follow-up dietary needs immediately after surgery when the client is experiencing discomfort is an error in timing and relevance. The client is less likely to be able to pay attention

and comprehend instruction when in pain, and immediately after surgery, discussing follow-up dietary needs would seem irrelevant. Pacing has to do with the speed of conversation. This is not an example of an error in pacing. Intonation is the tone of voice used. This is not an example of an error in intonation. Denotative meaning is when a single word can have several meanings. This is not an example of an error in denotative meaning. DIF: A REF: 3744 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 13. The nurse is aware of the clients zones of personal space when planning interactions. The zone of personal space and touch that extends the greatest amount from an individual is the:

Social zone

2 3

Personal zone Consent zone

Vulnerable zone

ANS: 1 The social zone extends the greatest amount from an individual in personal space and touch. It is a distance of 4 to 12 feet. Permission is not needed for touch in the social zone. The personal zone is 18 inches to 4 feet. The consent zone of touch requires permission. The vulnerable zone is in the consent zone of touch. Because the vulnerable zone implies special care is needed, permission is required. DIF: A REF: 348 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 14. Throughout the nursing process communication is used. During the evaluation phase, communication is specifically used by the nurse to:

Delegate activities to other staff members

Validate the clients health and wellness needs

Acquire both verbal and nonverbal client feedback

Document expected outcomes and planned interventions

ANS: 3 The nurse and client determine whether the plan of care has been successful by evaluating the client communication outcomes established during planning. This process involves acquiring verbal and nonverbal feedback. Delegation is not the purpose of communication in the evaluation

phase of the nursing process. Delegation is more likely to be used in the implementation phase of the nursing process. Validation of the clients needs is not why the nurse specifically uses communication in the evaluation phase of the nursing process. Validation of the clients needs is often determined when data are gathered during the assessment phase of the nursing process. Documenting expected outcomes and planned interventions is part of the planning phase of the nursing process, not the evaluation phase. DIF: A REF: 344 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 15. There are a number of variables that may influence the clients communication with the health care team. Which of the following is an example of an interpersonal variable?

1 2 3 4

Postoperative discomfort An extremely warm room A talkative roommate A loud television

ANS: 1 Interpersonal variables are factors within both the sender and receiver that influence communication. An example of an interpersonal variable is postoperative discomfort. An extremely warm room is an example of an environmental variable that may affect communication. A talkative roommate is an example of an environmental variable that may affect communication because of the lack of privacy and distraction. Noise, such as a loud television, is an example of an environmental variable that may affect communication. DIF: A REF: 343-344 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 16. A helping relationship is being established between nurse and client. In addressing the client, the nurse should:

Use the clients first name

Touch the client right away to establish contact

Sit far enough away from the clients personal space

Always knock and pause before entering the clients room

ANS: 4

Common courtesy is part of professional communication. To practice courtesy, the nurse says hello and goodbye, knocks on doors before entering, and uses self-introduction. Knocking on doors is important in addressing the client. Because using last names is respectful in most cultures, nurses usually use the clients last name in the initial interaction, and then use the first name if the client requests it. Touching the client right away would not be an appropriate action in establishing a helping relationship. It would more likely be interpreted as invading the clients personal space. Sitting far enough away from the client is important in that the nurse should not enter the clients personal space when establishing a helping relationship. However, leaning toward the client conveys that the nurse is involved and interested in the client. Knocking on the door before entering the clients room would be the first step in addressing the client properly. DIF: A REF: 348 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 17. In using communication skills with clients, the nurse evaluates which response as being the most therapeutic?

1 2

Why dont you stick to the special diet? I noticed that you didnt eat lunch. Is something wrong?

I think you need to find another physician thats better than this one.

We cant continue talking about your problems; its time for your bath.

ANS: 2 The nurse who is sharing an observation, I noticed that you didnt eat lunch. Is something wrong? is using the most therapeutic response. Sharing observations often helps the client communicate without the need for extensive questioning, focusing, or clarification. Why dont you stick to the special diet? is an example of a nontherapeutic response. It is asking for an explanation. Why questions can cause resentment, insecurity, and mistrust. I think you need to find another physician thats better than this one. is not a therapeutic response. It is giving a personal opinion. Changing the subject, We cant continue talking about your problems; its time for your bath, is not therapeutic. DIF: A REF: 352 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 18. When dealing with toddlers or preschoolers what communication technique may be used most effectively?

Using analogies to explain health-related ideas

Allowing manipulation of equipment to be used

Moving quickly and minimizing contact to avoid distress

Focusing on what other children on the unit may have been doing

ANS: 2 Allowing toddlers and preschoolers to touch and examine objects that will come in contact with them is an effective communication technique. Toddlers and preschoolers are unable to understand analogies. Sudden movements can be frightening. Children often prefer to make the first move in interpersonal contacts. Focusing on what other children have done is not an effective communication technique for toddlers or preschoolers. Communication should be focused on the child. DIF: A REF: 350 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 19. When working with a client with aphasia, the nurse may attempt to enhance communication by:

Using visual cues Speaking loudly

Using open-ended questions

Communicating through a speech therapist

ANS: 1 The nurse may enhance communication for a client with aphasia by using visual cues (e.g., words, pictures, and objects) when possible. The nurse should not shout or speak too loudly to enhance communication with a person who has aphasia. The nurse should ask simple questions that require yes or no answers to enhance communication with the client who has aphasia. Using a speech therapist is not the primary way to enhance communication with a client who has aphasia. The nurse can use communication techniques to facilitate communication and to develop a helping relationship with the client. The speech therapist may help the client to learn new ways or to relearn how to communicate. DIF: A REF: 357 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 20. Which of the following statements best reflects the clients positive feedback to the nurses question, Do you understand how to check your blood sugar?

Nodding affirmatively

2 3

I test it 4 times a day. Yes, I understand how to do it.

Demonstrating a fingerstick to the nurse

ANS: 4 Feedback is the message the receiver returns. It indicates whether the receiver understood the meaning of the senders message. Demonstrating the technique is the best way to show the nurse an understanding of the process. The other options either nonverbally or verbally indicate understanding; they are not as conclusive as showing understanding. DIF: C REF: 343 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 21. Which of the following nursing statements is the best example of the communication tool of clarification?

Please say that again.

I dont think I understand.

What did you mean by that?

Can you give me an example?

ANS: 4 To check whether understanding is accurate, ask the other person to rephrase it, explain further, or give an example of what the person means. By asking for an example, the nurse is best able to determine the meaning of the clients statement. The other options either simply ask the client to repeat the statement or state that the nurse needs further information. DIF: C REF: 354 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 22. Which of the following is the single most negative factor affecting a nurses credibility?

Deficient technical skills

Unethical or illegal behavior

Lack of caring and empathy

Poor nurse-client communication

ANS: 4 Breakdown in communication is a top contributor to errors in the workplace and threatens professional credibility. The remaining options affect credibility but not to the extent that poor communication does. DIF: C REF: 340 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 23. The best communicator is the nurse who:

1 2 3 4

Thinks critically Is a good listener Is comfortable talking Empathizes with the client

ANS: 1 Nurses who develop good critical thinking skills make the best communicators. The remaining options identify components of good communication. DIF: C REF: 340-341 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 24. Which of the following statements shows the best attempt by a nurse to overcome personal biases?

So how does that make you feel?

Most people really like Dr. Jones.

I know how that must frighten you.

How much did the medication help your pain?

ANS: 1 People often assume that others think, feel, act, react, and behave as they would in similar circumstances. They tend to distort or ignore information that goes against their expectations, preconceptions, or stereotypes. This statement clearly shows the nurse attempting to assist the client in expressing his or her personal feelings. The remaining options all make a presumption about the clients feelings or attitudes. DIF: C REF: 341 OBJ: Analysis

TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 25. A close, effective nurse-client relationship impacts interpersonal communication most by facilitating:

1 2 3 4

Client education regarding health-related issues The accurate interpretation of shared information A free exchange of information between client and nurse The clients expression of physical and emotional needs

ANS: 2 The more the sender and receiver have in common and the closer the relationship, the more likely they will accurately perceive one anothers meaning and respond accordingly. The remaining options are outcomes of an effective nurse-client relationship but they do not impact communication as directly. DIF: C REF: 340 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 26. Mentally reviewing the steps of a complicated nursing procedure before entering the clients room is an example of:

Nonverbal communication

Interpersonal communication

Intrapersonal communication

Transpersonal communication

ANS: 2 A type of intrapersonal communication, self-instructions, provides a mental rehearsal for difficult tasks or situations so individuals are able to deal with them more effectively. Interpersonal communication is one-to-one interaction between the nurse and another person that often occurs face to face while transpersonal communication is interaction that occurs within a persons spiritual domain. Nonverbal communication includes all five senses and everything that does not involve the spoken or written word. DIF: A REF: 342 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment

27. The nurse can best detect that a client needs clarification of the information provided on a special diet by:

1 2 3 4

Asking the client frequently if they have any questions Assessing the clients nonverbal cues that suggest confusion Providing the client with written supportive materials on the diet Requesting that the client rephrase the information in his or her own words

ANS: 2 You determine the need for clarification by watching the listener for nonverbal cues that suggest confusion or misunderstanding. The remaining options are means of reinforcing or evaluating the listeners understanding of the information. DIF: C REF: 354 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 28. The nurse observes a client with head bowed and hands folded seemingly in prayer. The nurse recognizes this as an example of:

Nonverbal communication

Interpersonal communication

Intrapersonal communication

Transpersonal communication

ANS: 4 Transpersonal communication is interaction that occurs within a persons spiritual domain. Many persons use prayer, meditation, guided reflection, religious rituals, or other means to communicate with their higher power. Intrapersonal communication, self-talk or self-instruction provides a mental rehearsal for difficult tasks or situations so individuals are able to deal with them more effectively. Interpersonal communication is one-to-one interaction between the nurse and another person that often occurs face to face while nonverbal communication includes all five senses and everything that does not involve the spoken or written word. DIF: A REF: 342 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment

29. The nurse is discussing discharge instructions with a client who was recently diagnosed with type 1 diabetes mellitus and is now taking insulin. The nurse recognizes this as an example of:

1 2 3 4

Nonverbal communication Interpersonal communication Intrapersonal communication Transpersonal communication

ANS: 2 Interpersonal communication is one-to-one interaction between the nurse and another person that often occurs face to face. Transpersonal communication is interaction that occurs within a persons spiritual domain whileintrapersonal communication, self-talk or self-instruction provides a mental rehearsal for difficult tasks or situations so individuals are able to deal with them more effectively. Nonverbal communication includes all five senses and everything that does not involve the spoken or written word. DIF: A REF: 342 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 30. A nurse provides a brief but concise orientation to the use of the rooms telephone and television to a newly admitted older client experiencing abdominal pain. The clients daughter later reports that her father attempted to call her but was never shown how to use the telephone. The most likely cause for the clients apparent lack of knowledge retention is:

Admission to the hospital has caused mild confusion that is not atypical in older clients

The pain was distracting him from focusing on the information when it was provided

He is experiencing forgetfulness regarding newly introduced nonessential information The nurse did not take adequate time to explain the use of either the telephone or the television

ANS: 2 Timing is critical in communication. Even though a message is clear, poor timing prevents it from being effective. Do not begin routine teaching when a client is in severe pain or emotional distress. Although the other options may affect client retention of information, the scenario did not provide reason to believe that any of the options rather than poor timing was the primary factor.

DIF: C REF: 344 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 31. An older client who appears confused after discussing his new diagnosis of Parkinsons disease shares with the nurse that, I didnt understand much of what you said. The nurse determines that the most likely cause of the clients failure to understand is that:

The conversation included unfamiliar medical terminology

The client is in denial concerning the diagnosis of Parkinsons disease The nurses choice of timing for the client education was poor

3 4

The etiology of the condition is too complicated for this client to understand

ANS: 1 Medical jargon (technical terminology used by health care providers) sounds like a foreign language to clients unfamiliar with the health care setting. Limiting use of medical jargon to conversations with other health team members will improve communication. The remaining options may have contributed to the problem, but the more common problem deals with inappropriate use of jargon. DIF: C REF: 344 OBJ: Analysis TOP: Nursing Process: Planning/Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 32. The nurse shares with a client diagnosed with bipolar disorder who is in the manic phase that, The CNA will be in 20 minutes to complete your ADLs. This nurse-initiated communication will likely result in client confusion or noncompliance because:

The timing of the conversation was poorly chosen

The client was not actively involved in the decision-making process

The conversation relied on terms familiar only to health care providers The nurse assumed that the client would accept the nursing assistants help

ANS: 3

Medical jargon (technical terminology used by health care providers) sounds like a foreign language to clients unfamiliar with the health care setting. Limiting use of medical jargon to conversations with other health team members will improve communication. The remaining options may contribute to client confusion and/or noncompliance, but the heavy reliance on unfamiliar terms is the most likely primary cause in this situation. DIF: C REF: 344 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 33. The nurse sits on a chair alongside a clients bed to discuss the postoperative nursing care the client will receive. The therapeutic outcome of sitting beside the client is that:

1 2

The nurse-client relationship will be strengthened The client will feel less threatened by the nurses presence

The nurse can appear more relaxed during the conversation

The nurse and client will be equal participants in the conversation

ANS: 1 Looking down on a person establishes authority, whereas interacting at the same eye level indicates equality in the relationship. While the remaining options may be correct in some situations, the primary benefit of the nurse sitting is to convey to the client that both are equal contributors to the conversation. DIF: C REF: 345 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 34. The nurse enters a clients room and finds her crying softly. The most therapeutic statement the nurse can make at this time is to ask:

Are you alright?

Why are you crying?

What can I do to help you? Is being hospitalized upsetting you?

ANS: 2 Sounds have several interpretations: crying may communicate happiness, sadness, or anger. The nurse needs to validate such nonverbal messages with the client to interpret them accurately. Although the other options may elicit information regarding the clients tears, they make

assumptions or attempt to provide generalized comfort without first establishing the cause of the tears. DIF: C REF: 345 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 35. Supporting a client by holding onto her elbow while accompanying her as she ambulates around the nursing unit is considered social touching and so would typically:

Be considered nonthreatening by the client

Not require the clients permission

Be viewed as therapeutic by the nurse

Not be needed unless the client was ataxic

ANS: 2 A persons hands, arms, shoulders, and back are considered social zones and typically do not cause a client emotional discomfort if touched, and so permission to do so is not generally required. Nurses frequently move into clients personal space because of the nature of caregiving. You need to convey confidence, gentleness, and respect for privacy, especially when your actions require intimate contact or involve a clients vulnerable zone. The remaining options do not necessarily deal with a clients social touching zone. DIF: C REF: 353-354 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 36. When meeting for the first time, the home health nurse smiles warmly and shakes the clients hand. The nurse-client relationship is in the:

Working phase

Orientation phase

Termination phase Preinteraction phase

ANS: 2 When the nurse and client meet and get to know one another, they are engaged in the orientation phase of the nurse-client relationship. The remaining options are phases that occur either before or after the orientation phase. DIF: C REF: 346 OBJ: Analysis

TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 37. The nurse recognizes that a clients sense of personal control is most therapeutically impacted when:

1 2 3 4

The client attends a self-help/support group The nurse encourages the client to make menu selections The client views a video on the use of a personal glucose monitor The nurse provides instructions on a patient-controlled analgesic (PCA) pump

ANS: 4 Personal control over the situation contributes to emotional comfort. Pain control is a very basic need, and by providing the client with the power to control that pain, the need has been therapeutic. The remaining options contribute to personal control but not on the same elemental level as pain control. DIF: C REF: 348 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 38. Which of the following statements made by a nurse best reflects an understanding of the therapeutic value of perceived client control?

The client was very interested in the information about support groups.

The client fell right to sleep when I told her the procedure was canceled. Research has shown that clients are less stressed when told what to expect.

3 4

I always include the client in on any decisions regarding their nursing care.

ANS: 3 Research has shown that personal control over a situation contributes to emotional comfort. By informing the client of expectations, the clients personal sense of control is increased and emotional stress should then be decreased. The remaining options show an understanding of emotional comfort but do not express an understanding of the origin of that comfort.

DIF: C REF: 348 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 39. Which of the following statements made by a nurse most reflects a poor understanding of trustworthiness regarding nurse-client communication in response to a clients report that, I dont like the night shift nurse?

How can I meet your needs and expectations on dayshift?

2 3

Tell me more about why you dislike the night shift nurse. Can you give me an example of why you are dissatisfied?

The nurse on night shift has your well being in mind always.

ANS: 2 To foster trust, the nurse communicates warmth and demonstrates consistency, reliability, honesty, competence, and respect. Sharing personal information or gossiping about others sends the message you cannot be trusted and damages interpersonal relationships. The nurse appears to be gossiping by the way the client is encouraged to discuss what the night shift nurse is doing. The remaining options show varying degrees of addressing the clients statement. DIF: C REF: 348 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 40. Which of the following statements made by a nurse most reflects the best understanding of the effect assertiveness has on interpersonal communication?

Can anyone help; Im feeling overwhelmed today?

I think we need to tell the doctors to write more legibly.

I will need some help with that complicated dressing change.

You will need to do the admission assessments today because Im so busy.

ANS: 3 Assertiveness conveys a sense of self-assurance while also communicating respect for the other person. Assertive responses often contain I messages, such as I want, I need, I think, or I feel, but in a fashion that is not demeaning or demanding. The remaining options are not the best examples because some lack an explanation of the nurses actual needs while others are not respectfully stated.

DIF: C REF: 348 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 41. The nurse identifies the nursing diagnosis risk for injury for a client who is unable to verbally communicate effectively. The primary risk for injury occurs because the client:

1 2

Lacks the ability to tell the staff what he or she needs Cannot notify the staff when he or she has fallen

Is not able to effectively use the call bell to communicate

Displays impatience when needs are not met effectively

ANS: 1 The client who cannot communicate effectively will often have difficulty expressing needs and responding appropriately to the environment. A client who is unable to speak is at risk for injury unless the nurse identifies an alternate communication method. The remaining options relate to potential outcomes of ineffective verbal communication but not to the risk for injury. DIF: C REF: 351 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 42. Which of the following statements made by a nurse reflects a need for further instruction regarding communicating with the older adult client?

Children and the elderly have the same communication barriers.

If I tell him why he needs to know something, hell usually listen.

Hearing deficits can certainly make communication a challenge.

I always try to have family around when I talk with an elderly client.

ANS: 1 Even though some older adults have communication barriers, you need to communicate with them on an adult level and avoid patronizing or speaking in a condescending manner. Older adults do not necessarily have the same barriers as children. The remaining options reflect interventions and/or statements that are not inappropriate and so do not require further instructions.

DIF: C REF: 356-357 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment MULTIPLE RESPONSE 1. Which of the following critical thinking attitudes contributes to an effective nurse-client relationship? (Select all that apply.)

Fairness

Guarded

Curiosity

4 5

Creativity Perseverance

Self-confidence

ANS: 1, 3, 4, 5, 6 Curiosity motivates the nurse to communicate and know more about a person. Perseverance and creativity are also attitudes conducive to communication because they motivate the nurse to communicate and identify innovative solutions. A self-confident attitude is important because the nurse who conveys confidence and comfort while communicating more readily establishes an interpersonal, helping-trust relationship. Risk-taking rather than a guarded attitude is important because colleagues sometimes question the suggested nursing interventions. At the same time, an attitude of fairness goes a long way in the ability to listen to both sides of any discussion. DIF: C REF: 340-341 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 2. The nurse realizes that the cancer support group for breast cancer clients will be most effective if the group: (Select all that apply.)

Is not too large

Is similar in age

Members feel valued

4 5

Communicates freely Shares a common culture

Meets in a comfortable place

ANS: 1, 3, 4, 6

Small groups are more effective when they are a workable size and have an appropriate meeting place, suitable seating arrangements, and cohesiveness and commitment among group members. Group participants need to feel accepted, feel able to communicate openly and honestly, and actively listen to others in the group. Similarity in age and similarity in culture are not necessary criteria for a successful group interaction. DIF: C REF: 342 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 3. The nurse is preparing a community outreach program on stress management. The nurse realizes that speaking in public requires some specific adaptations regarding: (Select all that apply.)

Makeup

Clothing attire

Vocal inflection

4 5

Voice projection Physical gesturing

Making eye contact

ANS: 3, 4, 5, 6 Public communication requires special adaptations in eye contact, gestures, voice inflection, and use of media materials to communicate messages effectively. Makeup and clothing need to be appropriate but do not require specific adaptations. DIF: C REF: 342 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 4. Which of the following are reasons for communication during the assessment phase of the nursing process? (Select all that apply.)

1 2 3

Providing information to the client Obtaining information from the client

Establishment of the nurse-client relationship Identification of the clients physical health needs

Mutual goal setting regarding client health needs

Identification of clients emotional health

ANS: 1, 2, 4, 5, 6 The reasons for communication include information exchange, goal achievement, problem resolution, and expression of feelings. The initiation of the nurse-client relationship is not considered a facet of assessment communication. Chapter 25. Patient Education MULTIPLE CHOICE 1. The client has been informed that he can be discharged once he can irrigate his colostomy independently. The client requests the nurse to observe his irrigation technique. Which of the following learning motives is the client displaying?

Physical need

Social activity

Task mastery

Evaluation stance

ANS: 3 Task mastery motives are based on needs such as achievement and competence. The client who must demonstrate irrigating his colostomy independently in order to be discharged is displaying the learning motive of task mastery. A physical motive may be seen in the client who desires to return to a level of physical normalcy. A social motive is the need for connection, social approval, or self-esteem. An evaluation stance would be determining whether the outcomes of the teaching-leaning process met the clients goal. Evaluation is not a learning motive. DIF: A REF: 366-367 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 2. An industrial nurse is planning to give an informative talk on hypertension to employees in honor of heart month. He plans to teach individuals how to take their blood pressure measurements. Which information is important for him to ask the planning committee before this presentation?

Ages of all employees involved

Names of employees who are married

Number of employees with high blood pressure Type of room available and number of participants

4 ANS: 4

The number of persons being taught, the need for privacy, the room temperature, the room lighting, noise, the room ventilation, and the room furniture are important factors when choosing the setting. The ideal setting helps the client focus on the learning task. Knowing the specific ages of all the people involved is not as important as providing an environment conducive to learning. It is not necessary to know the names of employees who are married to teach individuals how to take their blood pressure. Whether an employee has high blood pressure should not be as important to the teacher as providing an environment conducive to learning. Having high blood pressure may be a motivating factor for employees to learn how to take their blood pressure, because of its personal relevance. DIF: A REF: 369 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 3. The nurse established the following objective for the client who was unable to void: The clients intake will be at least 1000 mL between 7 AM and 3:30 PM. Feedback showing success is indicated by the client:

1 2 3 4

Voiding at least 1000 mL during the shift Verbalizing abdominal comfort without pressure Having adequate fluid intake and urinary output Drinking 240 mL of fluid five or six times during the shift

ANS: 4 The nurse evaluates success by observing the clients performance of each expected behavior. Feedback indicating success in this situation is the client drinking 240 mL of fluid five or six times during the shift. This would be a fluid intake of 1200-1440 mL, meeting the objective of at least 1000 mL during the designated time period. Voiding at least 1000 mL is not the objective. The objective is to have the client drink at least 1000 mL. Verbalizing abdominal comfort without pressure is not an evaluation of the objective regarding specific fluid intake. Having adequate intake and output is not accurate feedback indicating success. The term adequate is not quantified. DIF: A REF: 381 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 4. There are a variety of teaching methodologies fro a nurse to choose from to use with clients. For a toddler, the nurse should use:

Role-playing

Problem-solving

Independent learning

Simple explanations and pictures

ANS: 4 Effective teaching methodologies for the toddler include simple explanations and picture books that describe a story of children in a hospital or clinic. Role-playing is an appropriate teaching methodology for the preschooler. Problem-solving is an appropriate teaching methodology for the adolescent. Independent learning is best used as a teaching methodology for the young or middle adult. DIF: A REF: 368 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 5. The nurse has important information to share with a parent who has brought his child to the emergency department. The nurse discovers that the parent, who appears very anxious, has just learned his son will require surgery. The most effective teaching approach in this situation is:

Telling

2 3

Trusting Participating

Group teaching

ANS: 1 The telling approach is useful when limited information must be taught. If a client is highly anxious but it is vital for information to be given, telling can be effective. The entrusting approach provides the client the opportunity to manage self-care. The nurse observes the clients progress and remains available to assist without introducing more new information. This would not be the most effective teaching approach in this situation. Participating involves the nurse and client setting objectives and becoming involved in the learning process together. This would not be the most effective teaching approach in this emergency situation. Group teaching would not be the most effective teaching approach in this situation. A person who is anxious would benefit more from individual instruction. DIF: A REF: 376 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 6. A client, after being taught of the clinical manifestations of inflammation to enable early detection of a complication of a surgical wound states, I will look at the wound four times a day and tell my surgeon if it looks red or swollen. Her statement is an example of:

Attitudes

2 3

Application Analysis

Evaluation

ANS: 2 Application involves using abstract, newly learned ideas in a concrete situation. The client who is taught the clinical manifestations of inflammation and who will assess for signs such as redness or edema is using newly learned information in a concrete manner. Attitude has to do with affective learning. The client is not expressing an attitude, but is applying new knowledge in a concrete way. Analysis involves breaking down information into organized parts. The client is not demonstrating analysis. Evaluation is a judgment of the worth of a body of information for a given purpose. The client is not expressing judgment. DIF: A REF: 365 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 7. The client continues to ask questions about a surgical wound. The client states, I think I would like help the first time I look at my wound. This is an example of:

Adaptation

Perception

Organizing Guided response

ANS: 4 A guided response is the performance of an act under the guidance of an instructor. The client who is seeking help is demonstrating a guided response. Adaptation occurs when a person is able to change a motor response when unexpected problems arise. The client is not exhibiting adaptation. Perception is being aware of objects or qualities through the use of sense organs. This situation is not an example of perception. Organizing is developing a value system by identifying and organizing values and resolving conflicts. This situation is not an example of organizing. DIF: C REF: 449 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 8. There are many factors are assessed before teaching the client to learn insulin injection sites, but the most important factor for the nurse to assess first is the:

Previous knowledge level of the client

2 3

Willingness of the client to want to learn the injection sites Financial resources available to the client for the equipment

Intelligence and developmental level of the individual client

ANS: 2 If a person does not want to learn, it is unlikely that learning will occur. Motivation is the first factor the nurse should assess before teaching. To determine learning needs, the nurse should assess the clients previous knowledge level. However, this would not be the most important factor for the nurse to assess first. Assessing the financial resources available to the client for obtaining equipment is important; however, it is not the most important factor for the nurse to assess first. Assessing the clients physical and cognitive ability to learn is important. However, it is not the most important factor for the nurse to assess first. DIF: A REF: 364 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 9. The nurse is demonstrating to the client how to put on anti-embolitic stockings. In the middle of the lesson the client asks, Why have my feet been swelling? The nurse stops and responds to the client. Which of the following is the teaching principle that the nurse should follow?

Timing

Setting priorities

Building on existing knowledge

Organizing the teaching materials

ANS: 1 The nurse who stops a demonstration of applying anti-embolitic stockings to answer a clients question is following the teaching principle of timing. If the client has a question, it is important to answer the question immediately, so the client may return his or her focus to the task being taught. Setting priorities is important to conserve the time and energy of the client and nurse. The nurse who stops to answer a question is not setting priorities. A client learns best on the basis of preexisting cognitive abilities and knowledge. This situation is not an example of building on existing knowledge. Organizing teaching materials means the nurse considers the order of information to present. This is not an example of organizing teaching materials. DIF: A REF: 375 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment

10. Clients give various responses to teaching sessions. For the nurse, an example of an evaluation of a psychomotor skill is:

1 2 3 4

Client states side effects of a medication Client responds appropriately to eye contact Client independently plans an exercise program Client demonstrates the proper use of a walking cane

ANS: 4 Determining whether the client is able to demonstrate a newly learned skill is an example of an evaluation of a psychomotor skill. Psychomotor learning involves acquiring skills that require the integration of mental and muscular activity, such as walking with a cane. Having the client state side effects of a medication is an example of an evaluation of cognitive learning. Determining whether a client responds appropriately to eye contact is an example of evaluation of affective learning. The client who planned an exercise program is demonstrating cognitive learning. DIF: A REF: 366 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 11. Different topics are presented in the information sessions that are held in the outpatient clinic. In planning for a session on health maintenance/illness prevention, the nurse should select a topic on:

Use of assistive devices, such as canes

Self-help devices for post-CVA clients

Stress management techniques for working parents Environmental alterations for clients in wheelchairs

ANS: 3 Stress management techniques for working parents is an appropriate topic for health maintenance/illness prevention. Use of assistive devices, such as canes, is not a health maintenance/illness prevention topic. It is a coping with impaired function topic. Self-help devices for post-CVA clients is not a health maintenance/illness prevention topic. It is a coping with impaired function topic. Environmental alterations for clients in wheelchairs is not a health maintenance/illness prevention topic. It is a coping with impaired function topic. DIF: A REF: 362 OBJ: Comprehension TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe, Effective Care Environment 12. The nurse is evaluating the responses of clients to teaching sessions. An example of an evaluation of a clients attainment of a cognitive skill is:

Client explains that the medication should be taken with meals

Client looks at the surgical incision without requiring prompting Client uses crutches appropriately to move both up and down stairs

3 4

Client independently capable of dressing self after eating breakfast

ANS: 1 The client who is able to explain that the medication should be taken with meals is demonstrating attainment of a cognitive skill. The client who is able to look at the surgical incision without prompting is demonstrating attainment of affective learning. The client who uses crutches appropriately is demonstrating attainment of a psychomotor skill. The client who dresses self after breakfast is most likely demonstrating attainment of psychomotor learning. DIF: A REF: 365 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 13. The nurse evaluates which of the following statements as an indication that the client is not ready to learn at this time?

I need to understand more about the reason for the colostomy.

I will find out more about that when the support group meets.

Theres no sense in showing me that now. Im too sick right now. Please be sure to tell me if I am completing all the steps correctly.

ANS: 3 Readiness to learn is related to the stage of grieving. This response by the client is demonstrating anger. The client is unwilling to learn at this time. The client has not yet reached the acceptance state of grieving in which learning can occur. This statement indicates the client is ready to learn and desires to find out more to gain understanding. This statement indicates the client is willing to learn. The client who requests feedback is expressing readiness to learn.

DIF: A REF: 362 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 14. In planning to teach an older adult client, the nurse should incorporate which teaching method or principle into the plan?

Keep teaching sessions short.

Teach in the early morning or late evening.

Put as much as possible into each teaching session.

Focus on teaching a family member or caregiver instead.

ANS: 1 Keeping teaching sessions short is an appropriate method when teaching an older adult client. The older adult should be taught when the client is alert and rested, not early morning or late evening. The teaching session should not be filled with numerous topics. The older adult client is capable of learning and should be the focus. A family member or caregiver may be included in teaching, but the older adult client should not be excluded. DIF: A REF: 376 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 15. The nurse has completed an assessment on the client and identified the following nursing diagnoses. Which one of the following nursing diagnoses indicates a need to postpone teaching that was planned?

Activity intolerance related to pain

Ineffective management of treatment regimen

Noncompliance with prescribed exercise plan Knowledge deficit regarding impending surgery

ANS: 1 Pain, fatigue, or anxiety can interfere with the ability to pay attention and participate. The nursing diagnosis of activity intolerance related to pain indicates a need to postpone teaching. Teaching may be delayed until the nursing diagnosis is resolved or the health problem is controlled. Ineffective management of treatment regimen does not indicate a need to postpone teaching. Ineffective management of treatment regimen reinforces the need for teaching. Noncompliance with prescribed exercise plan does not indicate a need to postpone teaching. The client who is noncompliant may require further teaching. Knowledge deficit regarding

impending surgery does not indicate a need to postpone teaching. A knowledge deficit reinforces the need for teaching. DIF: A REF: 366 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 16. There are a variety of teaching methodologies that may be utilized to meet the clients needs. Which teaching method is best applied to a cognitive learning need?

1 2 3 4

Modeling of behavior Discussion of feelings Computer-assisted instruction Demonstration of a procedure

ANS: 3 An independent project such as computer-assisted instruction is an appropriate teaching method for cognitive learning. Modeling of behavior is an appropriate teaching method for psychomotor learning. Discussion of feelings is an appropriate teaching method for affective learning. Demonstration is an appropriate teaching method for psychomotor learning. DIF: A REF: 365 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 17. For a functionally illiterate client, the nurse particularly focuses on:

Using intricate analogies and examples

Avoiding lengthy return demonstrations

Incorporating familiar nonmedical terminology Providing longer learning sessions with the client

ANS: 3 When teaching a functionally illiterate client, the nurse should use simple terminology, avoiding medical jargon. The nurse should incorporate familiar terminology to enhance the clients understanding. The nurse should use simple analogies and real life examples. The nurse should ask for return demonstrations as this provides the opportunity to clarify instructions and time to review procedures. Although teaching sessions may be kept short, they should be scheduled at more frequent intervals. DIF: A REF: 378-379 OBJ: Comprehension

TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 18. In preparing a teaching plan for adult clients in a cancer support group, the nurse incorporates evidence-based information. The nurse recognizes that evidence obtained about adult learners has identified that this group prefers:

Computer-assisted instruction

2 3

Traditional classroom settings Long sessions with plenty of technical information

Interesting personal communication techniques

ANS: 4 Adults have a wide variety of personal and life experiences to employ. Therefore adult learning is enhanced when they are encouraged to use these experiences to solve problems. Evidencebased information indicates that adult clients prefer interactive, personal communication with nurses or physicians. Evidence-based information indicates computer-assisted learning is not a preferred method of instruction by many adult learners. As clients become more comfortable with computers, this preference may change. Evidence-based information indicates that not all clients are comfortable in class settings or in support groups. Other educational opportunities should be available. Adult learners prefer short teaching sessions without a great deal of technical information. DIF: A REF: 369 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 19. While teaching the client about management of his heart disease, a nurse might use a strategy that is implemented to promote learning in the affective domain such as:

Asking the client what he believes he needs to know about the diagnosis

Providing brochures both on current exercises and on nutrition guidelines Encouraging the client to personally discuss his feelings about his health status

3 4

ANS: 3

Having the client return-demonstrate self-measurement of his own blood pressure

An intervention to promote learning in the affective domain would be encouraging the client to discuss his feelings about his health status. Asking the client what he believes he needs to know about the diagnosis would be an intervention to promote learning in the cognitive domain. Providing brochures on current exercises and nutrition guidelines would be an intervention to promote learning in the cognitive domain. Having the client return-demonstrate selfmeasurement of his blood pressure would be an intervention to promote learning in the psychomotor domain. DIF: A REF: 365 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 20. The nurse is preparing to present a teaching session on skin protection for a group of older adults at a senior center. A principle that has been found to be most effective in teaching older adults is:

1 2 3 4

Moving the group along at a predetermined pace Providing information in longer teaching sessions Speaking very slowly and in a louder tone of voice Beginning and ending each session with important information

ANS: 4 The nurse should begin and end each teaching session with important information because clients are more likely to remember information that is taught early in the teaching session, and key points can be summarized at the end. Repetition also reinforces learning. The group should not be moved along at a predetermined pace. Clients may have questions that would go unanswered if there were a predetermined pace. Or, sometimes teaching sessions have to be stopped after the nurse observes a clients loss of concentration such as nonverbal cues of poor eye contact or slumped posture. Shorter (approximately 20 minutes), frequent sessions are more easily tolerated and retain the clients interest in the material. The nurse should face the client and speak in a low tone of voice for the older adult with a hearing problem. DIF: A REF: 380-381 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 21. The nurse is preparing the discharge teaching materials on newly prescribed drugs to a client diagnosed to be in the early stage of Alzheimers disease. The nurse best deals with the clients cognitive deficits by:

Providing written material to supplement the discussion

Arranging for family to be present during the discussion

Presenting the material in two short but focused sessions

Requiring the client to restate the information in her own words

ANS: 2 The clients family needs to understand and accept many changes in the patients physical and/or cognitive capabilities. The familys ability to provide support results in part from education, which begins as soon as the nurse identifies the clients needs and the family displays a willingness to help. The remaining options may support retention of material but not as effectively as including family in the educational sharing. DIF: C REF: 381 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 22. The nurse recognizes that the clients teaching plan is most directly driven by:

1 2

The clients identified learning needs The complexity of the clients health needs

The clients readiness and motivation to learn

The presence of cultural or physical barriers

ANS: 1 Teaching is most effective when it responds to the learners needs. While assessing and diagnosing a clients health care problems, the nurse identifies the need for education that in turn generates the teaching plan. The remaining options reflect factors that will affect both the teaching plan and the clients learning. DIF: C REF: 363 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 23. The nurse recognizes that the primary goal of a clients teaching plan is to:

Facilitate a knowledge-based client decision-making process

Provide information that brings about informed client consent

Enhance the clients sense of personal control regarding his or her health care

Therapeutically affect the clients health, wellness, and independence

ANS: 4 Creating a well-designed, comprehensive teaching plan that fits a clients unique learning needs ultimately helps clients make informed decisions about their care and results in clients becoming healthier and more independent. The remaining options affect the primary goal by enhancing decision making, providing for informed consent, and bringing about a sense of personal control. DIF: C REF: 363 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 24. Which of the following teaching topics is an example of health maintenance and promotion and illness prevention?

Glucose monitoring at home

Living with rheumatoid arthritis

Stress managements impact on depression

What to expect after hip replacement surgery

ANS: 1 Promoting healthy behavior through education allows clients to assume more responsibility for their health. Greater knowledge results in better health maintenance habits. When clients become more health conscious, they are more likely to seek early diagnosis of health problems. The remaining options address restoration of health and coping with impaired functioning, whereas stress management is a topic that relates to the promotion of health and the prevention of illness. DIF: A REF: 362-363 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 25. Which of the following teaching topics is an example of restoration of health?

Glucose monitoring at home

Living with rheumatoid arthritis

Stress managements impact on depression What to expect after hip replacement surgery

ANS: 4 Injured or ill clients need information and skills to help them regain or maintain their levels of health. The remaining options address health maintenance and promotion and illness prevention

and coping with impaired functioning while what to expect after hip replacement surgery is a topic that relates to the restoration of health and function. DIF: A REF: 363 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 26. Which of the following actions is the primary nursing responsibility regarding client education?

1 2

Providing accurate, current, relevant information Answering the clients questions regarding health-related issues

Assessing the individual clients readiness and motivation to learn

Identifying areas where clients are in need of educational information

ANS: 1 Nurses have an ethical responsibility to teach their clients (Redman, 2005, 2007). The information needs to be accurate, complete, and relevant to the clients needs. The remaining options are factors that affect learning and so require the nurses attention but are not as primary as providing information that is accurate, current, and relevant to the clients needs. DIF: C REF: 363 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 27. When a client newly diagnosed with type 2 diabetes mellitus assumes responsibility for checking her blood glucose level four times a day, this is an example of:

Cognitive learning

Affective learning

Impaired learning Psychomotor learning

ANS: 4 Psychomotor learning involves acquiring skills that require the integration of mental and muscular activity. The remaining options are involved with expression of feelings and acceptance of attitudes, opinions, or values or the acquisition of knowledge. Impaired learning involves alteration to the normal learning process that requires alterations in methods and techniques.

DIF: A REF: 366 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 28. When a client newly diagnosed with type 2 diabetes mellitus selects a lunch menu that correlates with the number of carbohydrates he is allowed for that meal, this is an example of:

Cognitive learning

2 3

Affective learning Impaired learning

Psychomotor learning

ANS: 1 Cognitive learning includes all intellectual behaviors and requires thinking. The remaining options are involved with expression of feelings and acceptance of attitudes, opinions, or values or acquiring skills that require the integration of mental and muscular activity. Impairing learning involves alteration to the normal learning process that requires alterations in methods and techniques. DIF: A REF: 365 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 29. Which of the following statement best reflects the nurses appropriate attention to a clients need for self-efficacy?

What can I do to help you lose the weight?

Are you really ready to start a regular exercise regimen?

After you watch me demonstrate this inhaler, you will have no problems using it at all.

Come on; with all the self-help products out there, you will be able to stop smoking.

ANS: 3 Self-efficacy refers to a persons perceived ability to successfully complete a task. When people believe that they are able to execute a particular behavior, they are more likely to actually perform the behavior consistently and correctly. Although the other options are related to behavioral change to achieve a goal, they do not support the client by both encouragement and providing the skills necessary to be successful. DIF: C REF: 367 OBJ: Analysis

TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 30. A client has been recently told that the primary cancer has metastasized, and the cancer is considered terminal. When the nurse offers to discuss palliative care options, the client replies, Im going to have the reports reevaluated by another doctor; I feel fine and I think a mistake has been made. The nurse recognizes this response as:

Anger

Disbelief

Bargaining

Acceptance

ANS: 2 In this example, the client avoids discussion of the illness, choosing to believe a mistake has been made. The remaining options are other stages of the grieving process. DIF: A REF: 368 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 31. A client has been recently told that the primary cancer has metastasized and the cancer is considered terminal. When the nurse offers to discuss palliative care options the client replies, I cant understand why you all want to upset me by bringing the topic up. Now please just leave me alone. The nurse recognizes this response as:

Anger

Disbelief

Bargaining Acceptance

ANS: 1 In this example, the client blames others and complains. The client often directs anger toward the nurse or others. The remaining options are other stages of the grieving process. Chapter 26. Informatics and Documentation MULTIPLE CHOICE 1. The nurse is preparing the information that will be provided to the staff on the next shift. Which of the following should the nurse include in the inter-shift report to nursing colleagues?

Audit of client care procedures

The clients diagnostic-related group

All routine care procedures required by the client

Instructions given to the client in a teaching plan

ANS: 4 A change-of-shift report should include instructions given in a teaching plan and the clients response. This should not include detailed content unless staff members ask for clarification. The nurse should relay to staff significant changes in the way therapies are given, but should not describe basic steps of a procedure. The clients diagnosis-related group is not essential background information to be shared in an inter-shift report. The nurse should not review all routine care procedures or tasks. DIF: A REF: 399 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 2. An incident report is to be completed because the client climbed over the side rails and fell to the floor. The correct reporting of an incident involves which of the following?

1 2

The witnessing nurse completes the report. Details of the incident are subjectively described.

An explanation of the possible cause for the incident is entered.

A notation is included in the medical record that an incident report was prepared.

ANS: 1 The nurse who witnessed the incident is the one who completes the report. Details of the incident should be objectively described. An explanation of the possible cause is not included. The sequence of events is described objectively. A notation is not included in the medical record that an incident report was written. DIF: A REF: 403 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 3. Which is the most appropriate notation for a use to use according to the guidelines that should be followed when documenting client care?

1230Clients vital signs taken.

0700Client drank adequate amount of fluids.

0900Demerol given for lower abdominal pain.

0830Increased IV fluid rate to 100 mL/hr according to protocol.

ANS: 4 Information within a recorded entry needs to be complete, containing appropriate and essential information. This notation (0830) provides the time and action taken by the nurse including the reason for doing so. This entry (1230) does not indicate what the vital signs were. This entry (0700) does not provide the specific amount the client drank. Stating adequate is subjective, not objective. This notation (0900) does not have the client describe his or her pain or rate it according to a pain scale for comparison later. It also does not indicate whether the clients pain was in the lower left or lower right quadrant, or both. DIF: A REF: 389 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 4. The nurse makes a late entry in a clients record. Which of the following is the best example of how to document this type of situation?

2:45 PMASA gr X given for temperature of 38.1 C.

8:30 AMClient received Percodan (1 tablet) PO an hour before going to radiology. 12:15 PMI gave the client morphine 10 mg IM at 11:10 AM but did not document it then.

3 4

8:30 PMAbdominal dressing change at 7:30 PM. No s/s of infection, and wound edges approximating well.

ANS: 1 This is the best example of a late entry. The time (2:45 PM) is indicated along with the action and an objective observation. This notation (8:30 AM) is not complete. It does not indicate why the Percodan was given. What was the clients level of pain? Where was the pain located? The nurse does not need to document about herself; only the client. In this option (12:15 PM), the nurse does not indicate why the morphine was given (clients level of pain? location of pain?). This entry (8:30 PM) is not complete. It does not state the size of the wound, type of dressing used, or the clients tolerance of the procedure. DIF: A REF: 389 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment

5. The following statement: Upon exertion, the client is wheezing and experiencing some dyspnea, is an example of:

1 2 3 4

The P of PIE FOCUS documentation The R in DAR documentation The S in SOAP documentation

ANS: 1 These data are examples of the P of PIE because they describe the problem. FOCUS charting does not concentrate on only problems. It is structured according to a clients concerns. The R in DAR documentation is the response of the client. This situation describes the clients problem, not the clients response. The S in SOAP documentation represents subjective data (verbalizations of the client). DIF: A REF: 391 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 6. To locate the recording of a nurses description of the teaching provided to the client on performance of self-medication administration, one would look in a(n):

Kardex

Incident report

Nursing history form

Discharge summary form

ANS: 4 A nurses description of the teaching provided to the client on performance of self-medication administration is recorded in the discharge summary form. A Kardex is a written form that contains basic client information. A Kardex contains an activity and treatment section and a nursing care plan section that organizes information for quick reference as nurses give changeof-shift report. It does not include a description of teaching that was provided to the client. An incident report is any event that is not consistent with the routine operation of a health care unit or routine care of a client (e.g., a client falls). A nursing history form guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems. It provides baseline data about the client. DIF: A REF: 397-398 OBJ: Comprehension TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment 7. The nurse has made an error and is documenting such on the clients record and notes. The action that the nurse should take is to:

1 2

Draw a straight line through the error and initial it. Erase the error and write over the material in the same spot.

Use a dark color marker to cover the error and continue immediately after that point.

Footnote the error at the bottom of the page.

ANS: 1 If a nurse has made an error in documentation, the nurse should draw a single line through the error, write the word error above it, and sign his or her name or initials. Then record the note correctly. The nurse should not erase, apply correction fluid, or scratch out errors made while recording because charting becomes illegible. Also, entries should only be made in ink so they cannot be erased. Using a dark color marker to cover the error is not correct. It may appear as if the nurse was attempting to hide something or deface the record. Footnotes are not used in nursing documentation. DIF: A REF: 388-389 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 8. The new staff nurse is having her documentation evaluated by the charge nurse. On review of her charting, the charge nurse notes that there is evidence of appropriate documentation when the new staff nurse:

Uses a pencil to make the entries

Uses correction fluid to correct written errors

Identifies an error made by the attending physician Dates and signs all of the entries made in the record

ANS: 4 Each entry should begin with the time and end with the signature and title of the person recording the entry. All entries should be recorded legibly and in black ink because pencil can be erased. The nurse should never erase entries, never use correction fluid, or never use a pencil. The use of correction fluid could make the charting become illegible and it may appear as if the nurse were attempting to hide something or to deface the record. If the physician made an error, the nurse should not document it in the clients chart. It should be documented in an incident report.

DIF: A REF: 389 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 9. What is the correct response for the licensed practical nurse that answers the phone to respond within the following scenario? The physician calls to leave orders late at night for one of his clients.

Let me get the Registered Nurse on the phone.

I am unable to take the order at this time. Please call in the morning. Please repeat the order for me so I can make sure it is written correctly.

3 4

Let me have your phone number and I will have the supervisor call you back.

ANS: 1 A telephone order involves a physician stating a prescribed therapy over the phone to a registered nurse. Saying that an order is unable to be taken and to call back in the morning is not an appropriate response and not in the clients best interest. It is best to repeat any prescribed orders back to the physician, who can then verify if it is correct or clarify the order. This is not the appropriate response. A registered nurse needs to take the verbal order, but it does not have to be the nursing supervisor. DIF: A REF: 402 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 10. The client developed a slight hematoma on his left forearm. The nurse labels the problem as an infiltrated intravenous (IV) line. The nurse elevates the forearm. The client states, My arm feels better. What is documented as the R in FOCUS charting?

Infiltrated IV line

My arm feels better

Elevation of left forearm Slight hematoma on left forearm

ANS: 2 The R in FOCUS charting is the clients response. In this case, the nurse would document, My arm feels better. Infiltrated IV line would be documented as D referring to data in FOCUS

charting. Elevation of left forearm is the A in FOCUS charting. It describes the action or nursing intervention. Slight hematoma on left forearm is the D referring to data in FOCUS charting. DIF: A REF: 391 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 11. Which of the following is evaluated as a legally appropriate notation?

Dr. Green made an error in the amount of medication to administer. Verbalized sharp, stabbing pain along the left side of chest. Nurse Williams spoke with the client about the surgery.

Client upset about the physical therapy.

ANS: 2 Entries should be concise, factual, and accurate. Verbalized sharp, stabbing pain along the left side of chest is an example of an objective description of a clients behavior. The nurse should not document physician made error. Instead, the nurse could chart that Dr. Green was called to clarify order for medication administration. The nurse should chart only for himself or herself. In this case, nurse Williams should write the charting entry. Only objective descriptions of the clients behavior should be recorded. For example: Client states, I dont want physical therapy! I want to go home! DIF: A REF: 388-389 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 12. To avoid legal risks and possible lack of confidentiality associated with computerized documentation, many programs currently have:

Periodic changes in staff passwords

Thumbprint identification restrictions

All nursing staff uses the same access code Only centralized medical records use the client data

ANS: 1 A good system of computerized documentation requires periodic changes in personal passwords to prevent unauthorized persons form tampering with records. Many programs do not have thumbprint identification restrictions. All nurses do not use the same access code. Each nurse should have his or her own password. Only centralized medical records using the client data is

not a true statement. Authorized health care providers from any department can access and use the data. DIF: A REF: 406 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 13. Which of the following nursing statements reflects the best understanding of the role of documentation and the Medicare reimbursement policy?

1 2

Medicare reviews client charts to determine care given. Good charting results in good Medicare reimbursement.

Our nursing salaries are paid for by the Medicare reimbursement funds.

The hospital is reimbursed for the nursing care documented in the client chart.

ANS: 4 Under the prospective payment system, Medicare reimburses hospitals a set dollar amount for each diagnosis-related group (DRG). Everything that is done for a client must be documented in the medical record for the health care institution to recover its costs. DIF: C REF: 387 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 14. The professional nurse realizes there is both a legal and an ethical obligation to keep client information obtained through examination, observation, conversation, or treatment:

Secured

Accessible

Confidential

Documented

ANS: 3 Nurses are legally and ethically obligated to keep information about clients confidential. Nurses may not discuss a clients examination, observation, conversation, or treatment with other clients or staff not involved in the clients care. The other options are primarily directed towards written records and are not ethically oriented. DIF: A REF: 385 OBJ: Comprehension

TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 15. Which of the following nursing statements regarding the release of a clients medical record to another institution requires immediate follow-up by the nurses manager?

Im pretty sure this will require the clients permission.

Are you sure of the exact policy? Do you know what I should do?

The client agreed to the consultation, so Ill have the chart sent over. I think the client will need to give a verbal consent before it can be sent.

ANS: 3 Each institution has policies to control the manner for sharing records. In most situations, clients are required to give written permission for release of medical information. The other options have the nurse asking for help or expressing doubt about the proper protocol for the release of the records; these would be appropriate statements and the manager should provide the correct information. DIF: C REF: 385 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 16. Regarding access to client records, the nursing faculty informs the nursing students to be prepared to:

Show the unit staff proper student identification

Sign a confidentiality agreement when on the unit to preplan

Review the medical record only in the presence of unit staff Obtain permission from the client to access his or her medical record

ANS: 1 When nurses and other health care professionals have a legitimate reason to use records for data gathering, research, or continuing education, they obtain appropriate authorization according to agency policy. Nursing students and faculty may be required to present identification indicating access to the record is authorized. The remaining options are not required if the student is properly identified and shows need to access the material.

DIF: C REF: 385 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 17. Which of the following nursing actions is most directly aimed at affording a client confidential treatment of his or her medical information while minimizing delay in accessing needed medical and nursing care?

Notifying the client of the institutions privacy policy

Denying nonessential personal access to the clients medical records

Acquiring the clients verbal consent to share his or her medical record with essential personnel

Requiring that the client sign the Health Insurance Portability and Accountability Act (HIPAA) form

ANS: 1 Under new regulations, Health Insurance Portability and Accountability Act (HIPAA), in order to eliminate barriers that could delay access to care, required only that health care providers notify clients of their privacy policy and make a reasonable effort to get written acknowledgment of this notification. DIF: A REF: 385 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 18. When another health care professional is asked to assess a client for the purpose of suggesting treatment to the primary health care provider, this is called a:

Referral

Consultation

Transfer report Multidisciplinary meeting

ANS: 1 Referrals are the request for services by another care provider usually for the purpose of determining appropriate client care. Consultations are a form of discussion whereby one professional caregiver actually gives formal advice about the care of a client to another caregiver. The remaining options are methods of exchanging general information regarding a client. DIF: A REF: 386 OBJ: Comprehension

TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 19. Which of the following nursing notations shows the best understanding regarding the need to document only objective client assessment data?

1 2 3 4

Client was angry because breakfast was not to her liking. Client is depressed; was observed crying while alone in room. Client expressed pain as an 8 out of 10, was diaphoretic, guarding her abdomen and clenching her fists. Client was verbally abusive to staff when approached concerning clients continued attempts to smoke in the bathroom.

ANS: 3 Do not write personal opinions. Document observable, measurable client-oriented data only. The remaining options either make assumptions regarding observed client behavior or fail to objectively describe the noted client behavior. DIF: C REF: 388-389 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 20. Which of the following nursing notations shows the greatest need for instruction regarding the need to document only objective client assessment data?

Client was angry because breakfast was not to her liking.

Client is depressed; was observed crying while alone in room.

Client expressed pain as an 8 out of 10, was diaphoretic, guarding her abdomen and clenching her fists.

Client was verbally abusive to staff when approached concerning clients continued attempts to smoke in the bathroom.

ANS: 2 Do not write personal opinions. Document observable, measurable client-oriented data only. Recording that the client is depressed based on the observation of tears is not objective and so is not acceptable. While one option does report only observable, measurable behavior, the remaining options, while noting observed client behavior, do fail to objectively describe the noted client behavior.

DIF: C REF: 388-389 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 21. Which of the following statements made by a nurse most reflects a need for additional instruction on areas of client care requiring nursing documentation?

1 2 3

The fact that the client refused the prescribed antidepressant medication was noted in his chart. I provided a detailed description of the dressing change in the clients chart in order to show it was done as prescribed. The clients wife told me he often develops a rash when he comes into contact with scented soaps, so I noted that in his chart. I had a long conversation with the client concerning his fears about his upcoming surgery and I mentioned his concerns in my nursing note.

ANS: 2 Common charting mistakes that can result in malpractice include the following: (1) failing to record pertinent health or drug information; (2) failing to record nursing actions; (3) failing to record that medications have been given; (4) failing to record drug reactions or changes in clients condition; (5) writing illegible or incomplete records; and (6) failing to document a discontinued medication. Detailed descriptions of procedures are not included in the nursing notes. DIF: C REF: 388 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 22. The nursing faculty recognizes the correct way to instruct the nursing students to acknowledge their charting in a clients medical record is:

James Thicket, NS, WVU

J. Jones, NS, Montclair Shores College

N.H, SN, Bellfield City Community College Linda Mozden, SN, Fairmont State University

4 ANS: 4

A nursing student enters full name, student nurse abbreviation (e.g., SN or NS), and educational institution, such as David Jones, SN (student nurse), CMTC (Central Maine Technical College). DIF: A REF: 389 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 23. The nurse realizes that the incorrect spelling of terms in the medical record most importantly:

Shows a lack of competency

2 3

Displays little attention to detail Contributes to serious treatment errors

Negatively affects the accuracy of the documentation

ANS: 3 Spelling errors can result in serious treatment errors; for example, the names of certain medications such as digitoxin and digoxin or morphine and Numorphan are similar. Misspelling such terms can result in medication errors that may cause serious harm to a client. The other options are correct but do not have the seriousness of client care errors. DIF: C REF: 389 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 24. Related to Problem Oriented Medical Record (POMR) documentation, which of the following statements made by a nurse reflects the greatest need for additional instruction on the proper management of a resolved client problem?

His surgery corrected the mobility problem, so I drew a line through it and dated it.

The clients problem list has several resolved problems on it; should I take them off? The client no longer has anxiety issues so I highlighted that problem on his problem list.

3 4

He doesnt experience any dizziness now that we have his medication regulated, so Ive erased that from his problem list.

DIF: A REF: 390-391 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 25. Which of the following is an example of a problem statement used in the ProblemIntervention-Evaluation documentation method?

Risk for injury related to falling due to dizziness

Client fell while walking to bathroom unassisted

Client continues to report periods of dizziness upon sitting up

Educated to the purpose of dangling on the bedside before standing

ANS: 1 The problem is reflected by a nursing diagnosis while the interventions are related to nursing actions directed toward minimizing or eliminating the problem. The evaluation is the clients objective or subjective response to the nursing intervention. DIF: A REF: 391 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 26. Which of the following is an example of an intervention used in the Problem-InterventionEvaluation documentation method?

Risk for injury related to falling due to dizziness

Client fell while walking to bathroom unassisted

Client continues to report periods of dizziness upon sitting up

Educated to the purpose of dangling on the bedside before standing

ANS: 4 The problem is reflected by a nursing diagnosis while the interventions are related to nursing actions directed toward minimizing or eliminating the problem. The evaluation is the clients objective or subjective response to the nursing intervention. DIF: A REF: 391 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment

27. Related to Problem Oriented Medical Record (POMR) documentation, which of the following statements made by a nurse reflects the greatest need for additional instruction on the proper management of a resolved client problem?

His surgery corrected the mobility problem, so I draw a line through it and dated it.

The clients problem list has several resolved problems on it; should I take them off? The client no longer has anxiety issues so I highlighted that problem on his problem list.

3 4

He doesnt experience any dizziness now that we have his medication regulated, so Ive erased that from his problem list.

ANS: 4 New problems are added as they are identified. When a problem has been resolved, record the date and highlight it or draw a line through the problem and its number. Erasure is not an acceptable method of showing that a problem has been resolved. DIF: A REF: 387 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 28. Which of the following is an example of a problem statement used in the ProblemIntervention-Evaluation documentation method?

Risk for injury related to falling due to dizziness

Client fell while walking to bathroom unassisted

Client continues to report periods of dizziness upon sitting up Educated to the purpose of dangling on the bedside before standing

ANS: 1 The problem is reflected by a nursing diagnosis while the interventions are related to nursing actions directed toward minimizing or eliminating the problem. The evaluation is the clients objective or subjective response to the nursing intervention. DIF: A REF: 385 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment

29. Which of the following is an example of an intervention used in the Problem-InterventionEvaluation documentation method?

1 2

Risk for injury related to falling due to dizziness Client fell while walking to bathroom unassisted

Client continues to report periods of dizziness on sitting up

Educated to the purpose of dangling on the bedside before standing

ANS: 4 The problem is reflected by a nursing diagnosis while the interventions are related to nursing actions directed toward minimizing or eliminating the problem. The evaluation is the clients objective or subjective response to the nursing intervention. DIF: A REF: 390 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment MULTIPLE RESPONSE 1. Nursing documentation should fulfill which of the following criteria? (Select all that apply.)

Accurate

Inclusive

Well organized Show continuity of care

4 5 6

Record nursing opinion Identify client outcomes

ANS: 1, 2, 3, 4, 6 Nursing documentation must be accurate, comprehensive, and flexible enough to retrieve critical data, maintain continuity of care, track client outcomes, and reflect current standards of nursing practice. Nursing documentation should include nursing observations, not nursing opinions. DIF: C REF: 390-391 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 2. The nurse realizes that effective nursing documentation encourages: (Select all that apply.)

Safe nursing practice

Continuity of client care

Positive client outcomes Efficient time management

4 5 6

Cost-conscious nursing care Effective nurse-client relationships

ANS: 1, 2, 4 Effective documentation ensures continuity of care, saves time, and minimizes the risk of errors. While important, the remaining options are not criteria for effective nursing documentation. DIF: C REF: 391 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 3. Problem Oriented Medical Record (POMR) method of documentation includes which of the following sections? (Select all that apply.)

Database

Care plan Evaluations

3 4 5

Problem list Interventions

Progress notes

ANS: 1, 2, 4, 6 The POMR has the following major sections: database, problem list, care plan, and progress notes. Interventions and evaluations are documentation sections related to PIE (Problem, Interventions, and Evaluation) charting. Chapter 27. Patient Safety and Quality MULTIPLE CHOICE 1. The nurse has investigated safety hazards and recognizes that which one of the following statements is accurate regarding safety needs?

Bacterial contamination of foods is uncontrollable.

Fire is the greatest cause of unintentional death.

Carbon dioxide levels should be monitored in home settings.

Temperature extremes seldom affect the safety of clients in acute care facilities.

ANS: 3 Annual inspections of heating systems, chimneys, and appliances should be done in private homes. Carbon monoxide detectors are available but should not be used as a replacement for proper use and maintenance of fuel-burning appliances. Bacterial contamination of foods is controllable. The FDA is a federal agency responsible for the enforcement of federal regulations regarding the manufacture, processing, and distribution of foods, drugs, and cosmetics to protect consumers against the sale of impure or dangerous substances. Motor vehicle accidents are the leading cause of unintentional death, not fire. Temperature extremes can affect the safety of clients in acute care facilities, especially the elderly. PTS: 1 DIF: A REF: 812 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 2. An ambulatory client is admitted to the extended care facility with a diagnosis of Alzheimers disease. In using a falls assessment tool, the nurse knows that the greatest indicator of risk is:

Confusion

Impaired judgment

Sensory deficits History of falls

ANS: 4 According to the falls assessment tool, the greatest indicator of risk is a history of falls. According to the falls assessment tool, the second leading risk factor for falls is confusion. According to the falls assessment tool, impaired judgment is the fourth leading risk factor for falls. According to the falls assessment tool, sensory deficit is the fifth leading risk factor for falls. PTS: 1 DIF: A REF: 817 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 3. An inservice program is being offered in the hospital on bioterrorism and the response of the health care agency. During the program, the mitigation phase is described. The nurse is informed that this phase includes:

Determination of hazard vulnerability and the impact of the emergency situation

2 3

Steps taken to manage the effects of the event and an inventory of available resources Steps taken by staff to triage victims

Restoration of essential services

ANS: 1 The mitigation phase consists of the assessment process to determine hazard vulnerability for the hospitals service area. This includes an identification of the kinds of emergency situations that are most likely to occur and their probable impact. During the preparedness phase, steps are taken to manage the effects of the event, and an inventory of available resources is taken. During the response phase, steps are taken by staff to triage victims. During the recovery phase, steps are taken to restore essential services. PTS: 1 DIF: A REF: 821 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 4. An inservice program is being offered in the hospital on bioterrorism and the response of the health care agency. An important aspect of the program is the recognition of the signs and symptoms of bacterial and viral infections. A practice drill is held and the nurse recognizes that the clients admitted with possible anthrax will demonstrate:

Abdominal cramping, diarrhea, drooping eyelids, jaw clench, and difficulty swallowing

Flulike symptoms, gastrointestinal distress, and papular lesions

Fever, cough, chest pain, and hemoptysis

Vesicular skin lesions on the face and extremities

ANS: 2 Clinical features of anthrax include flulike symptoms, gastrointestinal distress, and papular lesions. Abdominal cramping, diarrhea, drooping eyelids, jaw clench, and difficulty swallowing are clinical features of botulism. Fever, cough, chest pain, and hemoptysis are characteristic of plague. Vesicular skin lesions on the face and extremities are seen with smallpox. PTS: 1 DIF: A REF: 821 OBJ: Comprehension

TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 5. A 1-year-old child is scheduled to receive an IV line. The most appropriate type of restraint to use for this client to prevent removal of the IV line would be a(n):

Wrist restraint

2 3

Jacket restraint Elbow restraint

Mummy restraint

ANS: 4 A mummy restraint is used short-term for a small child or infant for examination or treatment involving the head and neck. This would be the most appropriate type of restraint to use for a 1year-old child who is going to receive an IV line. The wrist restraint maintains immobility of an extremity to prevent the client from removing a therapeutic device, such as an IV tube. It would not be the best choice for starting an IV on a 1-year-old child. The jacket restraint is often used to prevent a client from getting up and falling. It is not the best choice for starting an IV line. An elbow restraint is commonly used with infants and children to prevent elbow flexion, such as after an IV line is in place. PTS: 1 DIF: A REF: 832 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 6. A 79-year-old resident in a long-term care facility is known to wander at night and has fallen in the past. Which of the following is the most appropriate nursing intervention?

An abdominal restraint should be placed on the client during sleeping hours.

The client should be checked frequently during the night.

A radio should be left playing at the bedside to assist in reality orientation. The client should be placed in a room that is away from the activity of the nurses station.

ANS: 2

Alternatives to restraints should be attempted first. (A physicians order is required for restraints to be applied.) The most appropriate intervention is to check on the client frequently. Alternatives to restraints should be attempted first before an abdominal restraint while sleeping. A radio may help orientate a client to reality. However, the most appropriate intervention for the client who wanders is to check on the client frequently. Clients who wander should be assigned to rooms near the nurses station and checked on frequently. PTS: 1 DIF: C REF: 832 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 7. The workmen cause an electrical fire when installing a new piece of equipment in the intensive care unit. A client is on a ventilator in the next room. The first action the nurse should take is to:

Pull the fire alarm

Attempt to extinguish the fire

Call the physician to obtain orders to take the client off the ventilator Use an Ambu-bag and remove the client from the area

ANS: 4 If there is a fire, and the client is on life support, the nurse should maintain the clients respiratory status manually with an Ambu-bag and move the client away from the fire. The first action of the nurse is not to pull the fire alarm. The workmen could do that. The workman can attempt to extinguish the fire. The nurse should attend to the client who is closest to the fire in the next room. The nurse should not call the doctor to obtain orders to take the client off the ventilator because this will take valuable time. The client needs to be moved away from the fire, and the source of oxygen needs to be discontinued, as it is combustible. The client will need to be manually resuscitated with an Ambu-bag. PTS: 1 DIF: C REF: 839 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 8. In a nursing home an elderly client drops his burning cigarette in a trash can and starts a fire. The most appropriate type of fire extinguisher for the nurse to use is the:

Type A

Type B

Type C

Type D

ANS: 1 Type A fire extinguishers are used for ordinary combustibles such as wood, cloth, paper, and plastic. A trash can fire would require a type A fire extinguisher. Type B fire extinguishers are used for flammable liquids such as gasoline, grease, paint, and anesthetic gas. Type C fire extinguishers are used for electrical equipment. There is no type D fire extinguisher. PTS: 1 DIF: A REF: 840 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 9. A visiting nurse completes an assessment of the ambulatory client in the home and determines the nursing diagnosis of risk for injury related to decreased vision. Based on this assessment, the client will benefit the most from:

Installing fluorescent lighting throughout the house

Becoming oriented to the position of the furniture and stairways

Maintaining complete bed rest in a hospital bed with side rails

Applying physical restraints

ANS: 2 Orienting the client to the position of furniture in the room and stairways is the best intervention to help prevent falls for the client with decreased vision. Attempts should be made to reduce glare. Light bulbs that are 60 watts or less may be increased to 75 watts to help improve visibility. The best intervention to prevent falls is to first orient the client to the surroundings. Maintaining complete bed rest is not the best option. Complete bed rest can cause other health problems resulting from a lack of mobility. The client should not be restrained for poor vision. Attempts should be made to help compensate for the decreased vision in order to prevent falls. PTS: 1 DIF: C REF: 819 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 10. Which one of the following statements by the parent of a child indicates that further teaching by the nurse is required?

Now that my child is 2 years old, I can let her sit in the front seat of the car with me.

2 3

I make sure that my child wears a helmet when he rides his bicycle. I have spoken to my child about safe sex practices.

My child is taking swimming classes at the community center.

ANS: 1 This statement indicates that further teaching is required. Children weighing less than 80 pounds or who are under 8 years of age should always be in an age/weight-appropriate car seat that has been installed according to manufacturers directions. In cars with a passenger air bag, children under 12 should be in the back seat. Answer 2 is an appropriate safety measure to reduce injuries from falling off a bike or being hit by a car. Answer 3 is an important safety measure because many adolescents begin sexual relationships. Answer 4 is an appropriate safety measure that may someday save a childs life. PTS: 1 DIF: C REF: 827 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 11. The nurse assesses that the client may need a restraint and recognizes that:

An order for a restraint may be implemented indefinitely until it is no longer required by the client

Restraints may be ordered on an as-needed basis

No order or consent is necessary for restraints in long-term care facilities

Restraints are to be periodically removed to have the client reevaluated

ANS: 4 Restraints must be periodically removed, and the nurse must assess the client to determine if the restraints continue to be needed. Answer 1 is not a true statement. A physicians order for restraints must have a limited time frame. If the orders are renewed, it should be done so within a specified time frame according to the agencys policy. Restraints are not to be ordered prn (as needed). The use of restraints must be part of the clients medical treatment. An order or consent is necessary for restraints in long-term care facilities.

PTS: 1 DIF: A REF: 831 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 12. On entering the clients room, the nurse sees a fire burning in the trash can next to the bed. The nurse removes the client and calls in the fire. The next action of the nurse is to:

Extinguish the fire

Remove all of the other clients from the unit

Close all the doors of client rooms

Move the trash can into the bathroom

ANS: 3 The next action the nurse should take is to confine the fire by closing doors and windows and turning off oxygen and electrical equipment. The nurse should extinguish the fire using an extinguisher after closing the doors of the client rooms. After activating the alarm, the nurse should close all the doors, not remove all of the other clients from the unit. Answer 4 would not be an appropriate action because the nurse could get burned in attempting to move the trash can. PTS: 1 DIF: A REF: 839 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 13. A mother of a young child enters the kitchen and finds the child on the floor. There is a bottle of cleanser next to the child and particles of the substance around the childs mouth. The parents first action should be to:

Call the Poison Control unit

Provide ipecac syrup

Check the childs airway and breathing

Remove the particles of cleanser from the mouth

ANS: 3 The first action is to assess for airway patency, breathing, and circulation. After checking the childs airway, breathing, and circulation, the parent should remove any particles of cleanser from the mouth. The parent should identify the type and amount of substance ingested and then call the Poison Control unit. The parent should only administer ipecac syrup if instructed to induce vomiting by the Poison Control unit. Administering ipecac is not the parents first action.

Removing the particles of cleanser is not the parents first action. The parent may do so after assessing the childs airway, breathing, and circulation. PTS: 1 DIF: C REF: 840 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 14. Which of the following nursing assessment data are most reflective of hypothermia?

Cyanotic lips, fingers, and toes

2 3

Rectal temperature of 35 C (95 F) Bradycardia of 56 beats per minute

Exposure to outdoor temperatures of <32 F

ANS: 2 Hypothermia occurs when the core body temperature is 35 C (95 F) or below. While the remaining options are not incorrect, they may be due to other factors. PTS: 1 DIF: A REF: 812 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 15. Which of the following clients who is experiencing the heat of mid-August is at greatest risk for heatstroke or heat exhaustion?

A 65-year-old diagnosed with COPD A 35-year-old novice marathon runner

A 15-year-old playing in an outdoor tennis tournament

A 9-month-old whose bedroom is cooled with a mechanical fan

ANS: 1 Exposure to extreme heat raises the core body temperature, resulting in heatstroke or heat exhaustion. Chronically ill clients, older adults, and infants are at greatest risk for injury from extreme heat. These clients need to avoid extremely hot, humid environments. While the remaining options reflect a risk, it is not as high as the answer. PTS: 1 DIF: C REF: 812 OBJ: Analysis TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 16. The nurse should recognize which of the following clients as being at greatest risk for an unintentional death?

A 58-year-old who skis regularly

A 44-year-old alcoholic who lives alone

A 72-year-old identified as at high risk for falls

A 34-year-old diagnosed with chronic depression

ANS: 3 Among older adults 65 years and older, falls are the leading cause of unintentional death. While the remaining options reflect clients at risk, the probability is not as great. PTS: 1 DIF: C REF: 813 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 17. Which of the following nursing interventions has the greatest likelihood of minimizing the risk of injury for a client who frequently gets out of bed at night to go into the bathroom?

Limiting fluid intake after 6 PM

Illuminating the pathway to the bathroom

Toileting the client whenever awake at night

Checking on the client at least hourly during the night

ANS: 2 While checking on the client frequently is not incorrect, night-lights in dark halls, bathrooms, and the rooms of children and older adults help maintain safety by reducing the risk of falls. The remaining options are more directed at controlling urinary output than preventing injury. PTS: 1 DIF: C REF: 813 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 18. When discussing the prevention of fire-related injuries and deaths, the nurse should place the greatest emphasis on the:

Prevention role smoke detectors play

Dangers of careless smoking habits

Supervision of children around open flames Importance of readily accessible fire extinguishers

ANS: 2 The leading cause of fire-related death is careless smoking. While the other options reflect risk, they are not as highly prioritized as the answer. PTS: 1 DIF: C REF: 813 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 19. The nurse recognizes that the leading cause of death for the otherwise healthy 1-year-old is:

Physical abuse

Accidental injury

Contagious diseases

Stranger abduction

ANS: 2 Injuries are the leading cause of death in children older than 1 year of age and cause more deaths and disabilities than do all diseases combined. PTS: 1 DIF: A REF: 814 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 20. The nurse is preparing a safety-related program for a group of parents of 5- to 14-yearolds. Which of the following topics is most likely to positively impact the leading cause of injury forthis age-group?

Keeping them safe while they play sports

2 3

Bicycle riding with safety in mind Safety first when around water

Dont let fire hurt your child

ANS: 2

Children 5 to 14 years of age account for nearly one third of bicyclists killed in traffic accidents. While the remaining options deal with risk factors, the priority relates to bicycle-oriented accidents. PTS: 1 DIF: C REF: 815 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 21. The nurse recognizes which of the following clients is at greatest risk for an accidental death?

A 60-year-old who is a weekend alcoholic

A 40-year-old who is a professional mountain climber A 35-year-old who commutes 35 miles to work each morning

3 4

A 50-year-old who recently lost his job because of a workrelated injury

ANS: 4 The adult experiencing a high level of stress is more likely to have an accident or illness such as headaches, gastrointestinal (GI) disorders, and infections. While the remaining options identify risks, they are not a high as that of the stressed adult. PTS: 1 DIF: C REF: 815 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 22. A client who is experiencing a generalized clonic-tonic seizure is at greatest risk for injury caused by:

The physical collapse that occurs at the onset of the seizure

Muscle strains that result from the severe muscle jerking during the seizure

The tongue laceration that occurs from jaw clenching during the seizure Aspiration resulting from the temporary loss of consciousness after the seizure

ANS: 1 During a fall, or as a result of muscle jerking, musculoskeletal injuries can occur. The fall is the most problematic since is occurs in the vast majority of the seizure events.

PTS: 1 DIF: C REF: 817 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 23. Which of the following clients is at greatest risk for injury related to medical diagnoses and conditions?

A history of asthma and alcohol abuse

2 3

A history of heart failure and urinary urgency A history of hypertension and wearing corrective lenses

A history of chronic bronchitis and impaired hearing

ANS: 2 This client is likely using diuretics that increase the frequency of voiding and result in the client having to use toilet facilities more often. Falls often occur with clients who have to get out of bed quickly because of urinary urgency. PTS: 1 DIF: C REF: 817 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 24. The nurse is conducting an admission interview and assessment on a cognitively impaired, uncooperative client for the risk for injury. Which of the following options will most likely provide the information to confirm the diagnosis?

Base the degree of risk on observable data at the time of the clients current hospital admission.

Closely monitor the clients behavior and habits until risk for injury can be reasonably determined.

Make certain critically sound assumptions are based on the clients developmental stage and current cognitive stasis. Interview the clients family, friends, and/or caregivers regarding prehospitalization risk factors.

ANS: 4 In many cases family members are important resources in assessing a clients fall risk. Families often are able to report on the clients level of confusion and ability to ambulate.

PTS: 1 DIF: C REF: 818 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 25. A nurse working in an acute care facilitys emergency department should recognize which of the following client reports as being most suspicious of a terrorist attack?

Four deaths resulting from a privately owned airplane crashing into a four-story building

Numerous reports of respiratory distress among older adults who attended an outdoor musical event

15 cases of nausea and vomiting reported over a 2-day period when 4 cases would be within normal for the facility

10 children, all who attended a child-oriented arts and crafts fair, presenting with rashes on their hands and faces

ANS: 3 An unusual increase in the number of people seeking care, especially with fever, respiratory, or gastrointestinal complaints, is a classic indicator of such an event. While the other options present possible indicators, there are other possible reasons for the incidents. PTS: 1 DIF: C REF: 820 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 26. The nurse is discussing safety issues with the mother of three children. Which of the following statements has the greatest possibility for decreasing the potential for injury among the children?

Where do you see a need for safety improvements in your home?

Keep all toxic liquids capped and stored out of reach of the children.

Installing safety gates at the top and bottom of each set of stairs will help minimize falls. Take great care to keep the children away from kitchen appliances and tools that can hurt them.

ANS: 1 Clients generally expect to be safe in their homes and health care settings. However, there are times when a clients view of what is safe does not agree with that of the nurse. For this reason, any assessment needs to include the clients understanding of his or her perception of risk factors. The remaining options are directed toward specific safety issues. PTS: 1 DIF: C REF: 824 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 27. The nurse recognizes that the greatest benefit of engaging the mother of two small children into a discussion about child-proofing her home is that:

1 2 3 4

The home will be safe for the immediate time being If an accident occurs, it will likely be minor in nature She is likely to monitor the house for safety issues in the future She will serve as a role model regarding safety issues for her children

ANS: 3 The client who is an active participant in reducing threats to safety becomes more alert to potential hazards. PTS: 1 DIF: C REF: 824 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 28. The nurse and a mother of two small children are discussing child safety issues. Which of the following nursing interventions has the greatest potential for using collaboration to help ensure the childrens safety?

Arranging to teach the children how to react in the case of a fire in the home

Teaching the children to telephone 911 if there is ever an emergency in the home

Helping the mother identify an emergency person for the children to telephone in the case of an emergency

Helping the mother create a list of emergency telephone numbers to be posted next to the homes telephone

ANS: 4 Clients need to learn how to identify and select resources within their community that enhance safety (e.g., neighborhood block homes, local police departments, and neighbors willing to check on a clients well-being).The remaining options deal with individual aspects of a complete plan. PTS: 1 DIF: C REF: 824 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 29. When preparing a safety workshop for early teens (13 to 15 years old), the nurse recognizes that which of the following active strategy topics has the greatest potential for decreasing injuries in this population by affecting lifestyle changes?

Avoiding the nicotine habit

2 3

Keeping immunizations up to date Eating a well-balanced, low-fat diet

Wearing a seat belt when riding in an automobile

ANS: 4 To promote an individuals health, it is necessary for the individual to be in a safe environment and to practice a lifestyle that minimizes risk of injury. Active strategies are those in which the individual is actively involved through changes in lifestyle (e.g., wearing seat belts or installing outdoor lighting) and participation in wellness programs. Accidents involving automobiles account for the most substantial number of injuries and deaths among this population from among the options provided. PTS: 1 DIF: C REF: 824 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 30. The nurse is discussing measures to minimize the risk of injury from an automobile accident with an 83-year-old adult client who lives alone and claims to drive only to church, the doctors office, and for groceries. Which of the following suggestions has the greatest potential for affecting this clients safety?

Take public transportation whenever it is available.

Plan errands around church or doctors appointments.

Plan driving for short trips and only during the daylight hours.

Arrange for family or friends to drive you whenever it is possible.

ANS: 3 The nurse educates clients regarding safe driving tips (e.g., driving shorter distances or only in daylight, using side and rearview mirrors carefully, and looking behind them toward their blind spot before changing lanes). The other options, while not incorrect, may not be realistic or appealing to an independent client. PTS: 1 DIF: C REF: 824 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 31. Which of the following assessment findings is most critical in a client who is currently being restrained with mechanical wrist restraints?

Angry, loud crying

2 3

Urinary incontinence Reddened areas on wrists

Hands are cool to the touch

ANS: 4 While the use of any restraint may be associated with serious complications, including pressure ulcers, constipation, pneumonia, urinary and fecal incontinence, and urinary retention, the most serious are contractures, nerve damage, and circulatory impairment. The coolness of the clients hands indicates poor circulation and can result in permanent damage. PTS: 1 DIF: C REF: 837 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 32. The nurse is discussing a newly ordered diuretic with an older adult client who is homebound. Which of the following suggestions has the greatest potential for minimizing the clients risk for injury related to urinary urgency or incontinence?

Consider decreasing fluid intake after 6 PM.

Illuminate the path to the bathroom at night. Encourage the client to urinate immediately before bed.

Encourage the client to take the medication early in the morning.

ANS: 4 Nocturia and incontinence are more frequent in older adults. Give diuretics in the morning. While the other options may have value, they do not have an impact on the situation as directly as the administration of the medication. PTS: 1 DIF: C REF: 813 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 33. A nurse caring for an elderly client who has had surgery and is in the hospital knows that the client is at high risk for developing a nosocomial infection. One of the most important things that the nurse can do to prevent this client from obtaining a nosocomial infection is to:

Practice appropriate hand hygiene

Request prophylactic antibiotics for the client Place the client in isolation

3 4

Encourage the client to turn, cough and deep breath every 2 hours

ANS: 2 Antibiotics should be used appropriately to prevent resistant organisms. The best way to prevent nosocomial infections is to perform hand hygiene before and after each client encounter and after contact with contaminated objects. Isolation will not in itself prevent a nosocomial infection. Answer 4 will help prevent atelectasis, but not necessarily a nosocomial infection. PTS: 1 DIF: B REF: 829 OBJ: Application TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection Control 34. The nurse caring for an elderly client in the hospital notes on assessment that the client has a scald burn on her foot. On questioning the client, the nurse learns that the client scalded her foot when adding hot water from the tap to her bath while she was in the tub. The nurse should do which of the following?

Report the incident as suspected elder abuse.

Suggest that the temperature of the hot water heater be lowered.

Instruct the client that she should not be taking tub baths to prevent this from happening again. Discuss the incident with social services so that arrangements can be made for the client to go to a nursing home on discharge from the hospital.

ANS: 2 Hot water from the tap should not have the potential to scald, because it is a safety hazard. The client had a plausible explanation for the incident without other signs to indicate abuse. There is no reason that the client should not be able to continue to take tub baths if the water temperature is within a safe range. The client has no other indications that she is in any danger of caring for herself; thus Answer 4 is not appropriate. PTS: 1 DIF: A REF: 824 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection Control 35. A nurse in the emergency department (ED) of a community hospital notes that an unusually high number of clients have presented in the ED with flulike symptoms, abdominal pain, nausea, vomiting, bloody diarrhea, hematemesis and itching of the hands, forearms, and head. The nurse is concerned with bioterrorism, reports this to the supervisor, and suspects an outbreak of:

Botulism

Anthrax

Plague

Smallpox

ANS: 2 The symptoms of the clients all point to an endemic outbreak of anthrax. PTS: 1 DIF: A REF: 816 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection Control 36. When discussing the new mothers pending discharge from the hospital, the nurse determines that additional client teaching needs to take place because of which of the following comments?

My husband has installed the new car seat in the middle of the backseat of our car.

I cant wait to put my baby in her new crib with the ensemble that my mom made sheets, blankets, and bumper to match. I need to place my baby on her back to sleep, right?

3 4

I have checked all my babys toys to make sure that they dont contain lead paint.

ANS: 2 Newborns should not be placed in cribs with loose comforters, bumper pads, etc. The middle of the back seat is the safest place to put the infant car seat. Babies should not be placed on their stomachs with their mouth and nose in close proximity to the mattress, which is associated with sudden death syndrome. Lead paint on infant toys can lead to brain damage. PTS: 1 DIF: A REF: 829 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 37. A confused client on a ventilator was restrained to prevent him from pulling out his endotracheal tube. Which of the following could be a possible alternative measure that the nurse could use to avoid the use of the restraints?

Orient the client to the environment and explain the need for the endotracheal tube.

Provide a trained sitter to continuously supervise the client.

Camouflage the endotracheal tube with stockinette dressing.

Promote relaxation techniques.

ANS: 2 A trained sitter can prevent the client from pulling out the endotracheal tube. The client is confused and does not understand. The endotracheal tube cannot be camouflaged effectivelythe client feels it more than sees it. Because the client is confused, it may be very difficult to communicate relaxation techniques so that the client has an understanding. PTS: 1 DIF: C REF: 821 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection Control

38. A confused client needs to have restraints to prevent him from pulling out his Foley catheter. Which of the following can the nurse delegate to the nursing assistive personnel?

1 2 3 4

Applying restraints Obtaining a physicians order to restrain the client Document the events that led to restraining the client Evaluating the effectiveness of the restraints

ANS: 1 Although the nursing assistive personnel can apply the restraints under the nurses direction, they cannot document, evaluate, or take physicians orders. PTS: 1 DIF: A REF: 826 OBJ: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection Control 39. A nurse finds that an electrical cord has shorted out in a clients room, causing a fire. The nurse should do which of the following actions first?

Activate the alarm.

Confine the fire by closing the clients door.

Remove the client from the room.

Extinguish the fire.

ANS: 3 The mnemonic RACE should be used to help remember to rescue or remove all clients in immediate danger, activate the alarm, confine the fire, and extinguish the fire PTS: 1 DIF: A REF: 832 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection Control 40. Which of the following statements indicates that the client is at risk for an electrical shock at home?

1 2

I had to cut off the third prong on the electrical plug so that it would fit in the extension cord. My bread got stuck in my toaster this morning, and I unplugged it before trying to remove it.

I always read the owners manual when I purchase a new electrical appliance.

I always make sure that I am standing in a dry area before operating electrical equipment.

ANS: 2 The third prong is used to ground the piece of equipment. Improperly grounded equipment can cause electrical injury. PTS: 1 DIF: B REF: 834 OBJ: Application TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection Control 41. The nurse is caring for a client with a history of epileptic seizures. The nursing assistive personnel notifies the nurse that the client is having a seizure. The first thing that the nurse should do when arriving in the room is to:

Raise the bed side rails

2 3

Put the bed in the lowest position Position the client safely

Provide privacy

ANS: 3 Although Answers 1, 2 and 3 are all important safety interventions, the priority is to safely position the client. It is important to provide privacy, but safety interventions are a priority. PTS: 1 DIF: B REF: 840 OBJ: Application TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection Control 42. A client with a history of epilepsy arrives in the emergency department experiencing status epilepticus. The nurse should never do which of the following?

Document sequence of events, including any adverse outcomes.

Prepare to initiate IV access. Access oxygen and suctioning equipment.

Open clients mouth by placing fingers on jaw and inserting thumb on bottom teeth to place oral airway between seizures.

ANS: 4 Nurses should never put their fingers in or close to a clients mouth who is or has been experiencing seizure activity, to prevent being bitten in the event that the client should experience more seizure activity. The nurse is responsible for all of these measures in Answers 1, 2, and 3 to provide for the safety of the client, as well as document the sequence of events including any unexpected outcomes. PTS: 1 DIF: B REF: 842 OBJ: Application TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection Control MULTIPLE RESPONSE 1. The nurse caring for clients in an acute care facility recognizes that attending to the safety of each client is most likely to result in: (Select all that apply.)

Freedom from illness

2 3

A shorter hospital stay Attention to the basic human needs

A well-founded sense of well-being

Preservation of the optimal functioning level

Minimal exposure to bacterial cross-contamination

ANS: 2, 3, 4, 5, 6 Safety in health care settings reduces the incidence of illness and injury, prevents extended length of treatment and/or hospitalization, improves or maintains a clients functional status, and increases the clients sense of well-being. A safe environment gives protection to the staff as well, allowing them to function at an optimal level. A safe environment includes meeting basic needs, reducing physical hazards, reducing the transmission of pathogens, maintaining sanitation, and controlling pollution. While a reduction of illness is an expectation, there is no assurance of the freedom from illness. PTS: 1 DIF: A REF: 843 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control

2. The nurse recognizes that children living in older housing that may contain lead-based paints may exhibit which of the following signs and symptoms? (Select all that apply.)

1 2 3

Vomiting Anorexia

Headaches Bloody urine

Thoracic rash

Swollen joints

ANS: 1, 2, 3 Signs and symptoms of lead poisoning typically include impaired hearing, vomiting, headaches, appetite loss, and learning and behavioral problems. The remaining options are not typically seen with this condition. Chapter 28. Infection Prevention and Control MULTIPLE CHOICE 1. The client has a 6-inch laceration on his right forearm. The arm develops an infection. Which of the following is a sign of an acute inflammatory process?

1 2 3 4

A blanching of the skin A decrease in temperature at the site A decrease in the number of white blood cells A release of histamine trhat adds to the pain response

ANS: 4 A sign of an acute inflammatory process is pain. The swelling of inflamed tissues increases pressure on nerve endings, causing pain. Chemical substances such as histamine also stimulate nerve endings, adding to the pain response. The skin is not blanched; but rather, with the increase in local blood flow; it is reddened. The symptom of localized warmth results from a greater volume of blood at the inflammatory site. The cellular response of acute inflammation involves WBCs arriving at the site. There is an increase in WBCs, rather than a decrease. DIF: A REF: 646 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safety and Infection Control 2. A female client has been undergoing diagnostic testing since admission to the medical unit in the hospital. The results of blood testing are sent back to the unit. Upon reviewing the results, the nurse will report which of the following findings to the physician, which is abnormal?

Erythrocyte sedimentation rate (ESR) 35 mm/hr

2 3

White blood cell (WBC) count 8000/mm3 Neutrophils 65%

Iron 75 g/100 mL

ANS: 1 The normal erythrocyte sedimentation rate for women is 20 mm/hr. The clients ESR is 35 mm/hr, indicating the presence of the inflammatory process. The normal WBC count is 5000-10,000/ mm3. The client is within normal limits at 8000/mm3. The normal neutrophil count is 55-70%. The client is within normal limits at 65%. The normal iron level is 60-90 g/100 mL. The client is within normal limits at 75 g/100 mL. DIF: A REF: 646 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safety and Infection Control 3. The nurse is observing the new staff member work with the client. Of the following activities, which one has the greatest possibility of contributing to a nosocomial infection and requires correction?

Washing hands before applying a dressing

Taping a plastic bag to the bed rail for tissue disposal

Placing a Foley catheter bag on the bed when transferring a client

Using alcohol to cleanse the skin before starting an intravenous line

ANS: 3 The staff member who places the Foley catheter bag on the bed when transferring the client is placing the client at risk for a nosocomial infection because urine in the catheter or drainage tube may reenter the bladder (reflux). Washing hands before applying a dressing is a correct action to help prevent a nosocomial infection. Taping a plastic bag to the bed rail for tissue disposal is a correct action to aid the client in proper disposal of secretions. Using alcohol to cleanse the skin before starting an intravenous line is a correct action to prevent a nosocomial infection of the bloodstream. DIF: A REF: 648 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safety and Infection Control

4. Droplet precautions will be instituted for the client admitted to the infectious disease unit with:

1 2

Streptococcal pharyngitis Herpes simplex

Pertussis

Measles

ANS: 1 Droplet precautions are instituted when droplets are larger than 5 micrometers, such as in the case of streptococcal pharyngitis. Contact precautions are instituted for herpes simplex. Airborne precautions are instituted with pulmonary TB. Airborne precautions are instituted with measles. DIF: A REF: 662 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safety and Infection Control 5. In a small rural hospital they work with a wide variety of clients. Of this afternoon clients admitted, the nurse acknowledges the client with the highest susceptibility to infection is the individual with:

Burns

Diabetes

Pulmonary emphysema Peripheral vascular disease

ANS: 1 Burn clients have a very high susceptibility to infection because of the damage to skin surfaces. This would be the individual with the highest risk for infection. Victims of chronic diseases such as diabetes mellitus and multiple sclerosis are susceptible to infection because of general debilitation and nutritional impairment. Diseases that impair body system defenses, such as emphysema and bronchitis (which impair ciliary action and thicken mucus), increase susceptibility to infection. Diseases that impair body system defenses, such as peripheral vascular disease (which reduces blood flow to injured tissues), increase susceptibility to infection. DIF: C REF: 668-669 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safety and Infection Control

6. A nurse must display understanding of the mental implications of a client on isolation precautions when planning care to control the risk of:

1 2 3 4

Denial Aggression Regression Isolation

ANS: 4 A sense of loneliness may develop because normal social relationships become disrupted. The nurse should plan care to control the risk of the client feeling isolated. Denial is not a risk related to isolation. Aggression is not a risk for the client on isolation precautions. Regression is not a risk related to isolation. DIF: A REF: 661 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safety and Infection Control 7. Surgical aseptic techniques are employed by a nurse when:

Inserting an intravenous catheter

Placing soiled linen in moisture-resistant bags

Disposing of syringes in puncture-proof containers Washing hands before changing a dressing

ANS: 1 Surgical asepsis should be used during procedures that require intentional perforation of the clients skin, such as with the insertion of IV catheters. The nurse is employing medical aseptic technique when placing soiled linen in moisture-resistant bags. The nurse is employing medical aseptic technique when disposing of syringes in puncture-proof containers. The nurse is employing medical aseptic technique when washing hands before changing a dressing. DIF: A REF: 669 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safety and Infection Control 8. A nurse is changing the dressing and accidentally drops the packing onto the clients abdomen. The client has a large, deep abdominal incision that is packed with sterile half-inch packing and covered with a dry 4 4 gauze. The nurse should:

Add alcohol to the packing and insert it into the incision

Throw the packing away, and prepare a new one

Pick up the packing with sterile forceps, and gently place it into the incision Rinse the packing with sterile water, and put the packing into the incision with sterile gloves

ANS: 2 A sterile object (the packing) remains sterile only when touched by another sterile object. The clients abdomen is not sterile; therefore, the nurse should throw the packing away and prepare a new one. The nurse should not add alcohol to the packing and insert it into the incision. The packing is considered contaminated as it touched a nonsterile surface and should be discarded. The nurse should not rinse the packing with sterile water and put the packing into the incision as it is considered contaminated. It touched a nonsterile surface. The nurse should throw the packing away and prepare a new one. DIF: A REF: 669 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safety and Infection Control 9. A client has a viral infection. Which of the following is typical of the illness stage of the course of her infection?

There are no longer any acute symptoms.

An oral temperature reveals a febrile state.

The client was first exposed to the infection 2 days ago but has no symptoms.

The client feels sick but is able to continue her normal activities.

ANS: 2 During the illness stage the client manifests signs and symptoms specific to the type of infection. The client with a viral infection would likely exhibit a fever. There are no longer any acute symptoms during the convalescent period. An example of a client in the incubation period is when the client was first exposed to the infection 2 days ago, but has no symptoms. The client who feels sick but is able to continue normal activities is in the prodromal stage of a course of infection. DIF: A REF: 646 OBJ: Comprehension TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safety and Infection Control 10. The nurse recognizes that special care must be taken in the handling of which of the following to prevent the transmission of hepatitis A?

1 2

Blood Feces

Saliva

Vaginal secretions

ANS: 2 To prevent the transmission of hepatitis A, the nurse needs to take special care when handling feces. Hepatitis B and C may be found in blood. Hepatitis A is not found in saliva. Hepatitis A is not found in vaginal secretions. DIF: A REF: 643 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safety and Infection Control 11. The parent of a preschool child asks the nurse how chickenpox (varicella zoster) is transmitted. The nurse identifies that the virus is:

Carried by a vector organism

Carried though the air in droplets after sneezing or coughing

Transmitted through person-to-person contact Acquired through contact with contaminated objects

ANS: 2 Varicella zoster virus (chickenpox) is transmitted by droplets carried through the air after sneezing or coughing. Varicella zoster virus (chickenpox) is not transmitted by a vector. Person-to-person contact is not responsible for varicella zoster virus (chickenpox) transmission. The transmission of varicella zoster virus (chickenpox) does not occur by contact with contaminated objects. DIF: A REF: 643 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safety and Infection Control 12. While working with clients in the postoperative period, the nurse is very alert to the results of laboratory tests. Which one of the following results is indicative of an infectious process?

Iron 80 g/100 mL

Neutrophils 65%

White blood cells (WBC) 18,000/mm3 Erythrocyte sedimentation rate (ESR) 15 mm/hr

ANS: 3 An elevated WBC count is indicative of an acute infection. The normal WBC count is 5000 to 10,000/mm3. The normal neutrophil count is 55%-70%. The client is within normal limits at 65%. The normal iron level is 60-90 g/100 mL. The client is within normal limits at 80 g/100 mL. The normal erythrocyte sedimentation rate (ESR) is up to 15 mm/hr for men and up to 20 mm/hr for women. The client is within normal limits at 15 mm/hr. DIF: A REF: 651 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safety and Infection Control 13. Which of the following is an example of a nursing intervention that is implemented to reduce a reservoir of infection for a client?

Covering the mouth and nose when sneezing Wearing disposable gloves

Isolating clients articles

Changing soiled dressings

ANS: 4 To control or eliminate reservoir sites for infection, the nurse eliminates or controls sources of body fluids, drainage, or solutions that might harbor microorganisms. The nurse also carefully discards articles that become contaminated with infectious material such as in changing soiled dressings. Covering the mouth and nose when sneezing is an intervention to control a portal of exit. Wearing disposable gloves helps protect the susceptible host. Isolating clients articles is an intervention to control transmission. DIF: A REF: 643 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safety and Infection Control 14. In preventing and controlling the transmission of infections, the single most important technique is:

Hand hygiene

The use of disposable gloves

The use of isolation precautions

Sterilization of equipment

ANS: 1 The most important and most basic technique in preventing and controlling transmission of infections is hand hygiene. Use of disposable gloves may help reduce the transmission of infections, but is not the single most important technique to prevent and control the transmission of infections. The use of isolation precautions is not the single most important technique to prevent and control the transmission of infections. Sterilization of equipment is not the single most important technique to prevent and control the transmission of infections. DIF: A REF: 655 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safety and Infection Control 15. A client with active tuberculosis is admitted to the medical center. The nurse recognizes that admission of this client to the unit will require the implementation by the staff of:

1 2

Airborne precautions Droplet precautions

Contact precautions

Reverse isolation

ANS: 1 A client with active tuberculosis requires airborne precautions. A client with active tuberculosis does not require droplet precautions, as the droplet nuclei of tuberculosis are smaller than 5 micrometers. Contact precautions are not necessary for the client with active tuberculosis. Reverse isolation is not required for the client with active tuberculosis DIF: A REF: 645 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safety and Infection Control 16. The nurse recognizes the appropriate procedures for sterile asepsis. Of the following, which action is consistent with sterile asepsis?

Clean forceps may be used to move items on the sterile field.

Sterile fields may be prepared well in advance of the procedures.

The first small amount of sterile solution should be poured and discarded .

Wrapped sterile packages should be opened starting with the flap closest to the nurse.

ANS: 3 Before pouring the solution into the container, the nurse pours a small amount (1 to 2 mL) into a disposable cap or plastic-lined waste receptacle. The discarded solution cleans the lip of the bottle. This action is consistent with sterile asepsis. Sterile forceps should be used to move items on a sterile field when using sterile asepsis. Sterile fields should not be prepared well in advance of a sterile procedure. A sterile object or field becomes contaminated by prolonged exposure to air. Wrapped sterile packages should be opened starting with the flap farthest away from the nurse (i.e., the top flap). DIF: A REF: 674 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safety and Infection Control 17. Older adult clients may react differently to infectious processes and a nurse suspects that her older adult client may be experiencing hypostatic pneumonia. The nurse must be alert to atypical signs and symptoms, such as:

1 2

Hypotension Confusion

Erythema

Chills

ANS: 2 An infection in older adults may not present with typical signs and symptoms. Atypical symptoms such as confusion, incontinence, or agitation may be the only symptoms of an infectious illness. An unexplained increased heart rate, confusion, or generalized fatigue may be the only symptoms of pneumonia in the older adult. Hypotension is not one of the atypical symptoms of an older adult experiencing infection. It may be a symptom of a systemic infection related to an elevation in body temperature (regardless of age). Erythema is a typical symptom of a localized infection. Chills are a typical symptom of a systemic infection. DIF: A REF: 649-650 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safety and Infection Control

18. What is the correct order for a nursing assistant for putting on the protective equipment when caring for a client in isolation?

1 2 3 4

Wash her hands, apply the mask and eyewear, put on the gown, and then apply gloves Apply the mask and eyewear, put on the gown, wash her hands, and then apply gloves Wash her hands, put on the gown, apply the mask and eyewear, and then apply the gloves Put on the gown, apply the mask and eyewear, wash her hands, and then apply gloves

ANS: 1 The correct sequence for putting on protective equipment is to perform hand hygiene, apply the mask and eyewear, apply gown, and then apply gloves. Apply the mask and eyewear, put on the gown, wash her hands, and then apply gloves; wash her hands, put on the gown, apply the mask and eyewear, and then apply the gloves; put on the gown, apply the mask and eyewear, wash her hands, and then apply gloves are not the correct sequences for putting on protective equipment. DIF: A REF: 664 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safety and Infection Control 19. A client has requires a mid-abdominal surgical incision which necessitates a sterile dressing. An appropriate intervention for the nurse to implement in maintaining sterile asepsis is to:

Put sterile gloves on before opening sterile packages

Discard packages that may have been in contact with the area below waist level

Place the cap of the sterile solution well within the sterile field

Place sterile items on the very edge of the sterile drape

ANS: 2 A sterile object held below a persons waist is considered contaminated. To maintain sterile asepsis, packages that may have been in contact with the area below waist level should be discarded. Sterile gloves are not put on before opening sterile packages as the outside of the packages is not sterile. The nurse uses hand hygiene and opens sterile packages, being careful to keep the inner contents sterile. After a cap or lid is removed, it is held in the hand or placed sterile side (inside) up on a clean surface. A bottle cap or lid should never rest on a sterile

surface, even though the inside of the cap is sterile. The edges of a sterile field are considered to be contaminated. Sterile items should be placed in the middle of the sterile field to maintain sterile asepsis. DIF: A REF: 669 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safety and Infection Control 20. The nurse is preparing to assist with a sterile procedure in the surgical suite. An appropriate technique that the nurse includes in the surgical scrub is to:

Keep the hands below the elbows throughout the scrub

2 3

Use a brush on the palms and dorsal surface of the hands Maintain the scrub for at least 2 to 5 minutes

Wash well around all jewelry

ANS: 3 A surgical scrub should be maintained for at least 2 to 5 minutes. To avoid contamination during a surgical hand scrub, the nurse holds the hands above the elbows. Several studies suggest that neither a brush nor a sponge is necessary to reduce bacterial counts on the hands, especially when an alcohol-based product is used. For maximum elimination of bacteria, all jewelry should be removed. DIF: A REF: 675 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safety and Infection Control 21. An appropriate isolation procedure for the nurse to implement when working with a client who is found to have methicillin-resistant Staphylococcus aureus (MRSA) is to:

Leave all linen in the clients room

Place specimen containers in plastic bags for transport

Wipe the stethoscope off before removing it from the room

Remove the mask and goggles first when leaving the clients room

ANS: 2 Specimen containers should be placed in plastic bags for transport with a label on the outside of the bag. Linen should be placed in an impervious linen bag and may be removed from the clients room. Bags should be tied securely at the top with a knot. For the person infected with MRSA,

equipment remains in the room. After discharge or with the discontinuation of isolation, client care equipment is properly cleaned and reprocessed, and single-use items are discarded. Gloves should be removed first when leaving the clients room. DIF: A REF: 667 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safety and Infection Control 22. A client is found to have a bacterial infection of Escherichia coli. The nurse, recognizing the effects of this bacterium, anticipates that the client will demonstrate:

Diarrhea

2 3

Coughing Cold sores around the mouth

Discharge from the eyes

ANS: 1 Escherichia coli causes gastroenteritis and urinary tract infections. The client with E. coli infection is likely to demonstrate diarrhea. E. coli is found in the colon, not the respiratory tract. Cold sores are seen with herpes simplex virus (type 1), not with E. coli. Discharge from the eyes is not seen with E. coli infection. It may be seen with Neisseria gonorrhoeae. DIF: A REF: 643 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safety and Infection Control 23. Which of the following clients is at greatest risk for acquiring an infection?

A 56-year-old with a urinary catheter 2 days after prostatectomy

A 27-year-old diagnosed with human immunodeficiency virus (HIV) A 43-year-old who is 3 days post appendectomy and is currently afebrile

3 4

A 16-year-old with a compound fractured femur as a result of a bike accident

ANS: 4 Clients are at risk for acquiring infections because of lower resistance to infectious microorganisms, increased exposure to numbers and types of disease-causing microorganisms,

and invasive procedures. The exposure to earth-bound microorganisms makes the compound fracture client at the greatest risk since that risk is uncontrollable. DIF: C REF: 644 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safety and Infection Control 24. A nurse is caring for a client who has colonized methicillin-resistant Staphylococcus aureus (MRSA). Which of the following statements reflects the best understanding of the clients condition?

This client has the bacteria present but it hasnt become infected.

This makes the clients MRSA very infectious and so a danger to others.

Just be sure to follow standard precautions and there wont be a problem.

The client needs to be watched closely for a conversion to active MRSA.

ANS: 1 If a microorganism is present or invades a host, grows, and/or multiplies but does not cause infection, this is referred to as colonization. DIF: C REF: 643 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safety and Infection Control 25. The greatest drawback to the routine use of antibacterial hand soaps and gels is that they:

Are expensive

Irritate the skin

Kill resident flora Encourage resistant bacteria

ANS: 2 Antibacterial products kill resident flora and that can lead to the development of infection. The remaining options may be true but they are not the primary negative outcome of the regular use of antibacterial hand cleansing products. DIF: C REF: 646 OBJ: Analysis

TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safety and Infection Control 26. The nurse knows that Staphylococcus aureus found normally on the skin of a client who has had surgery poses a particular risk for that client developing:

1 2 3 4

A cold sore Gastroenteritis A wound infection A urinary tract infection

ANS: 3 Staphylococcus aureus found normally on/in skin, hair, anterior nares, and the mouth can result in wound infections, pneumonia, food poisoning, and cellulitis. Streptococcus (-hemolytic group B) organisms may result in urinary tract infections or gastroenteritis while herpes simplex is viral in nature. DIF: A REF: 669 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safety and Infection Control 27. What is the most appropriate answer to the clients question, Whats the difference between antibacterial and antimicrobial hand soaps?

There is no real difference; use the less expensive.

Antibacterial soaps are more effective at preventing infections.

Antimicrobial soap is better since it wont kill the good bacteria on the skin.

Any soap will do; its the technique for proper hand washing that is the key.

ANS: 3 The use of antimicrobial hand hygiene products is recommended because they remove transient organisms but leave resident flora intact. There is a difference in the products and it is true that the effectiveness of hand hygiene is dependent on proper technique, but the clients question is best answered by the information provided in option 3. DIF: C REF: 646 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safety and Infection Control

28. A presurgical client asks the nurse why it seems so easy to get an infection in the wound after surgery. The nurses most appropriate response to this question is:

1 2 3

The contaminated dressing acts as a breeding ground for microorganisms that then infect the wound. The bodys immune system is weakened by the surgery and cant fight off the infection as effectively. While infections occur, there are many very effective antibiotics available to help minimize the risk of that happening. The surgical wound provides the microorganisms on the surrounding skin a path to enter deep into the bodys tissues.

ANS: 4 Resident skin microorganisms are not virulent. However, they can cause serious infection when surgery or other invasive procedures allow them to enter deep tissues. While the other options are not incorrect, they do not answer the clients question as effectively. DIF: C REF: 643 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safety and Infection Control 29. The nurse obtains a new, dry nebulizer when preparing to give an elderly asthmatic client a nebulizer treatment because the risk of infection is increased because:

The clients age increases the risk factor for potential infection

The clients immune system is compromised as a result of asthma There is a potential presence of Pseudomonas organisms in the reservoir

3 4

There is a chance for microorganisms to enter the body via the respiratory system

ANS: 3 Pseudomonas organisms survive and multiply in nebulizer reservoirs used in the care of clients with respiratory problems. While the remaining options are correct, they are not the primary reason for getting a new, dry nebulizer. DIF: C REF: 643 OBJ: Analysis

TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safety and Infection Control 30. A client is told that he is a carrier of the hepatitis B virus. When asked to explain this situation in more detail, the nurses best response is:

1 2 3 4

You need to be careful not to pass the virus to other people. You arent sick, but you do have the virus within your body. Be tested often so as to monitor whether the virus becomes active. While you show no signs of the illness, you can pass the virus to others.

ANS: 4 Carriers are persons who show no symptoms of illness but who have pathogens on or in their bodies that are transferred to others. While the other options are not incorrect, they do not address the clients questions as directly as does the answer. DIF: C REF: 643 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safety and Infection Control 31. The nurse can best minimize the risk for infection when initiating an intravenous site by:

Proper vein site selection

Effective topical skin preparation

Appropriate site dressing Gloving for the procedure

ANS: 2 When a needle pierces a clients skin regardless of the location, organisms enter the body if proper skin prepping was not performed. The remaining options have an effect on infection control but not to the degree that skin prepping does. DIF: C REF: 644-645 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safety and Infection Control 32. A client enters a neighborhood walk-in clinic reporting the symptoms of a head cold. When the health care provider does not prescribe an antibiotic, the client asks the nurse to explain why not. The nurses most appropriate response is:

Antibiotics arent usually necessary for colds, and they are really very expensive if you dont have insurance.

You know what they say; a cold will go away with medication in 2 weeks; without medication in 14 days. Your health care provider believes in treating the symptoms since there are so many different strains of the common cold.

3 4

Common colds dont usually require an antibiotic, and taking one results in making it harder to treat infections when they do occur.

ANS: 4 Organisms with resistance to key antibiotics are becoming more common in acute care settings. This is associated with the frequent and sometimes inappropriate use of antibiotics. While the remaining options are not incorrect, they may seem insensitive or incomplete in answering the clients question. DIF: C REF: 646 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safety and Infection Control 33. The nurse is caring for a postoperative client with a localized sinus infection. The most appropriate means by which the nurse can minimize the risk of this client developing a systemic infection is to:

Adhere strictly to standard precaution techniques

Dispense prescribed anti-infective medication as ordered

Monitor the client regularly for exacerbation of the sinus infection

Review lab work daily to determine the presence of increased white cell count

ANS: 1 If an infection is localized (e.g., a wound infection), use of standard precautions and personal protective equipment (PPE) will block the spread of infection to other sites, thus preventing an infection that affects the entire body instead of just a single organ or part (systemic). While the other options are not incorrect, they are not as directed at minimizing the risk of infection as is the answer.

DIF: C REF: 645 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safety and Infection Control 34. The nurse and a client are discussing the clients tendency to develop numerous colds during the winter months. The clients health history reveals that he is a 1 pack a day smoker. Which of the following nursing statements is most appropriate regarding the possible relationship between the clients cigarette smoking and the frequency of winter colds?

Smoking decreases your bodys immune system, and so you cant fight off the colds as effectively.

If you stopped smoking you would have fewer colds and just generally feel better all year around. The nicotine in the cigarettes has an effect on your blood vessels, decreasing the circulation of antibodies that would attack the cold viruses.

Smoking damages the little hairs in your nose and airways so they cant trap the airborne cold viruses and keep them from entering your body.

ANS: 4 Cilia lining the upper airway trap inhaled microbes and sweep them outward in mucus to be expectorated or swallowed. Smoking appears to paralyze these tiny hairs, and so they are not able to function effectively. Consequently, microbes including the cold viruses are able to enter into the respiratory tract. The other options present unproven theories, generalized statements, or less thorough explanations of the relationship between smoking and respiratory illnesses. DIF: C REF: 647 OBJ: Analysis TOP: Nursing Process: Implantation MSC: NCLEX test plan designation: Safety and Infection Control 35. Which of the following clients is at greatest risk for acquiring a health careassociated (nosocomial) infection?

A 32-year-old hospitalized for 2 days for migraine headaches

A client with type 1 diabetes who has been experiencing hypoglycemia

A trauma victim taken directly from the ED to surgery and then to the postsurgical unit

A pregnant 24-year-old diagnosed with both sinusitis and otitis media and prescribed an oral antibiotic

ANS: 3 The number of health care employees having direct contact with a client, the type and number of invasive procedures, the therapy received, and the length of hospitalization influence the risk of infection. The other options do not have the potential for infection as does the client who has been treated in various locations within the health care facility. DIF: C REF: 648 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safety and Infection Control 36. A client is admitted for treatment of various poorly healing, infected leg ulcers. The nurse recognizes that the clients nutritional history is of primary importance since:

Nutrition is vital to the clients overall health status

The clients food intake will likely be decreased as a result of the illness

Wound healing and infection prevention are negatively impacted by poor nutrition The clients habits regarding food intake are directly related to this hospitalization

ANS: 3 A reduction in protein, carbohydrates, and fats as a result of illness, inadequate diet, or debility increases a clients susceptibility to infection and delays wound healing. While the other options are not incorrect, they are not as directly related to the cause of the clients poorly healing, infected wounds. DIF: C REF: 650 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safety and Infection Control 37. A client admitted for an abdominal hysterectomy reports that she has been under a lot of stress since the death of her mother and wonders how that will affect her surgery and recovery. Which of the following nursing statements reflects the most therapeutic response to the clients question?

Being under stress isnt going to help your recovery; you need to relax and focus on yourself and getting well.

Your mothers death must be very stressful for you but she would want you to concentrate on getting healthy.

Stress does have a negative effect on the bodys ability to heal; is there anything I can do to help you minimize the stress you feel? Your health care provider can prescribe you some medication to help you cope with the stress; would you like me to mention it?

ANS: 3 Increased stress elevates cortisone levels, causing decreased resistance to infection and the ability to heal. While the other options may not be incorrect, they do not have the degree of therapeutic value as does the answer since it explains the effects of stress and also offers support. DIF: C REF: 650 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safety and Infection Control 38. A client admitted for an abdominal hysterectomy reports that she has been under a lot of stress since the death of her mother and wonders how that will affect her surgery and recovery. Which of the following nursing interventions reflects the most therapeutic understanding of the relationship stress has on the body and its ability to recover from surgery?

Suggest a demonstration of relaxation techniques

Arrange for the hospital chaplain to visit the client

Offer to call and get an order for an antianxiety medication

Share a personal antidote concerning a similarly stressful situation

ANS: 1 Increased stress elevates cortisone levels, causing decreased resistance to infection and the ability to heal. Reinforcement of relaxation techniques would be the most therapeutic response because it would provide the client with a long-term, self-initiated coping mechanism. It would not be appropriate to arrange for a clergy visit without first discussing it with the client. Sharing a similar personal situation would have little therapeutic value, and such a personal nurseoriented conversation should be avoided. While facilitating antianxiety medication may not be incorrect, it is premature at this time. DIF: C REF: 650 OBJ: Analysis

TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safety and Infection Control 39. The nurse is providing care for a client who postoperatively has developed an infected incisional wound and is depressed and anorexic. Which of the following nursing interventions has priority?

Sterile wound care

2 3

Frequent small meals Administration of antidepressant medication

Educating the client regarding wound care at home

ANS: 1 The priority of administering therapies to promote wound healing overrides the goal of educating the client to assume self-care therapies at home. While the other options reflect appropriate interventions for this client, none has priority over wound care. DIF: C REF: 652 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safety and Infection Control 40. The nurse is educating a client diagnosed with type 2 diabetes, who is susceptible to foot wounds, on how to minimize the risk for infection related to poor wound healing by not being a susceptible host. The most appropriate suggestion would be to:

Inspect feet and legs daily for skin breakdown

See a podiatrist regularly for appropriate foot care

Keep blood sugar levels within normal range to maximize the ability to heal

Eat well-balanced meals in order to provide the nutrients necessary for healing

ANS: 4 Good infection control begins with prevention. Review with clients and their families preventive measures to strengthen their defenses. In the case of a diabetic client, keeping blood sugar levels within normal limits maximizes the clients ability to both heal and fight infection. While the other options are not incorrect, they are more directed towards healing than prevention. DIF: C REF: 652 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safety and Infection Control

MULTIPLE RESPONSE 1. For infectious organisms to grow and multiply enough to cause illness, they need an environment that has appropriate amounts of: (Select all that apply.)

1 2

Food Space

Water

Oxygen

Warmth

Darkness

ANS: 1, 3, 4, 5, 6 To thrive, organisms require a proper environment, including appropriate food, oxygen, water, temperature, pH, and light. Space does not generally affect microorganism growth. DIF: C REF: 643-644 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safety and Infection Control 2. Which of the following are considered portals of exit in the chain of infection? (Select all that apply.)

A bleeding cut

A hardy sneeze

A kiss on the lips

4 5

A urinary catheter A scraped knuckle

A friendly handshake

ANS: 1, 2, 3, 4, 5 After microorganisms find a site to grow and multiply, they must find a portal of exit if they are to enter another host and cause disease. Portals of exit include sites such as blood, skin/mucous membranes, respiratory tract, genitourinary tract, gastrointestinal tract, and transplacental (mother to fetus). Unless the skin of the hands was broken (not intact), this contact would not be considered a portal of exit. DIF: C REF: 644 OBJ: Analysis TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safety and Infection Control 3. Which of the following assessment data indicate the presence of a local inflammatory process? (Select all that apply.)

1 2

Client reports being cold Left elbow warm to the touch

Elevated white blood cell (WBC) count

Pitting edema of +2 around the right ankle

Client reports knee pain of 5 on a scale of 1 to10

Client observed grimacing while raising shoulder to brush hair

ANS: 2, 4, 5, 6 Signs of localized inflammation include swelling, redness, heat, pain or tenderness, and loss of function in the affected body part. When inflammation becomes systemic, other signs and symptoms develop, including fever, leukocytosis, malaise, anorexia, nausea, vomiting, lymph node enlargement, or organ failure. Chapter 29. Vital Signs MULTIPLE CHOICE 1. A client has developed pneumonia, and his temperature has increased to 37.7 C. The client is shivering and feels uncomfortable. The nurse should:

1 2 3 4

Apply hot packs to the axilla and groin Wrap the clients four extremities Restrict oral fluid consumption Apply a hypothermia mattress

ANS: 3 Wrapping the clients extremities has been recommended to reduce the incidence and intensity of shivering. Hot packs should not be applied to the clients axilla and groin. Fluids should not be restricted, but increased to replace fluids lost as a result of the fever. Hypothermia blankets may be used to reduce fever, but if the client is already shivering, a hypothermia blanket is not used, as further stimulation of shivering should be avoided. DIF: A REF: 506 OBJ: Comprehension TOP: Nursing Process: Application MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

2. The client comes to the emergency department after having been in the sun for an extended period of time. The nurse also determines that the client is taking a diuretic. Heatstroke is suspected and the nurse observes for:

Diaphoresis

2 3

Confusion Temperature of 36 C

Decreased heart rate

ANS: 2 Confusion is a symptom of heatstroke, along with delirium, nausea, muscle cramps, visual disturbances, and even incontinence. The most important sign of heatstroke is hot, dry skin, not diaphoresis. Victims of heatstroke do not sweat because of severe electrolyte loss and hypothalamic malfunction. A normal temperature is 36 to 38 C. With heatstroke the clients body temperature may reach as high as 45C. The heart rate is increased with heatstroke, not decreased. DIF: A REF: 507 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 3. A construction worker is seen in the emergency department with low blood pressure, normal pulse rate, diaphoresis, and weakness. These are clinical signs of:

Heatstroke

Heat cramp

Hypothermia

Heat exhaustion

ANS: 4 The client is exhibiting signs of heat exhaustion (e.g., symptoms of fluid volume deficit). If the client were experiencing heatstroke, the client would have an increased pulse rate and would not be sweating. Muscle cramps are related to heatstroke. The client is not exhibiting signs consistent with heatstroke. The client is not exhibiting signs of hypothermia such as shivering, loss of memory, or cyanosis. DIF: A REF: 508 OBJ: Comprehension TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 4. A 6-year-old boy has just eaten a grape popsicle and the nurse is ready to take vital signs. An appropriate action would be to:

Take the rectal temperature

2 3

Take the oral temperature as planned Have the child rinse out the mouth with warm water

Wait 20 minutes before assessing the oral temperature

ANS: 4 The nurse should wait 20 to 30 minutes before measuring the oral temperature. The nurse should wait, rather than measuring the childs temperature rectally, as this is not an emergency situation. Taking the oral temperature at this time would result in an inaccurate reading. Rinsing the mouth with warm water may also provide an inaccurate reading of the childs actual body temperature. The nurse should wait 20 minutes and measure the childs oral temperature. DIF: A REF: 510 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 5. The client is seen in the emergency center for heat exhaustion as a result of exposure. The nurse anticipates that treatment will include:

Replacement of fluid and electrolytes

Initiation of oral antibiotic therapy

Application of hypothermia wraps

Alcohol sponge baths

ANS: 1 The treatment of heat exhaustion includes transporting the client to a cooler environment and restoring fluid and electrolyte balance. Antibiotic therapy is not warranted. Hypothermia wraps are not used to treat heat exhaustion. Alcohol baths are not recommended. DIF: A REF: 508 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 6. The appropriate site for taking the pulse of a 2-year-old is:

Radial

Apical

Femoral Pedal

ANS: 2 The brachial or apical pulse is the best site for assessing an infants or young childs pulse because other peripheral pulses are deep and difficult to palpate accurately. The radial pulse is not the best site for assessing a 2-year-olds pulse. The femoral pulse is not the best site for assessing a 2year-olds pulse. The pedal pulse is not the best site for assessing a 2-year-olds pulse. DIF: A REF: 521 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 7. The client appears to be breathing faster than before. The nurse should:

1 2

Ask the client if he has felt stressful Have the client lay down on the bed

Count the clients rate of respirations

Palpate the clients own radial pulse

ANS: 3 The first action the nurse should take is to assess the clients respiratory rate. The nurse can then determine if it is within normal limits and will be able to compare it to the previous measurement to determine if the client is breathing faster than before. Stress may increase an individuals respiratory rate. The nurse should first make the objective measurement of the clients rate. Having the client lay down may decrease a clients respiratory rate, but the nurse should first assess the client before implementing any nursing measures. The nurse should count the respiratory rate. Based on these findings the nurse may or may not need to take the clients pulse. Assessing the pulse will not verify if the client is breathing faster. DIF: A REF: 529 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 8. A nurse administers pain medication for a client complaining of pain. The nurse first assesses vital signs and finds them to be as follows: blood pressure, 134/92 mm Hg; pulse, 90 beats per minute; respirations, 26 breaths per minute. The nurses most appropriate action is to:

Give the medication

Ask if the client is anxious

Check the clients dressing for bleeding Recheck the clients vital signs in 30 minutes

ANS: 1 The clients vital signs are consistent with the client being in pain. It would be safe and appropriate for the nurse to give the pain medication. Asking if the client is anxious is not the most appropriate action. The client is not demonstrating signs of shock (e.g., decreased blood pressure, increased pulse). The most appropriate action is for the nurse to administer pain medication. Rechecking would not be the most appropriate action. The nurse should medicate the client for pain. DIF: C REF: 529 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 9. The client has bilateral casts on the upper extremities, so the nurse will be measuring the blood pressure in the leg. The nurse expects the diastolic pressure to be:

10 to 40 mm Hg higher than in the brachial artery

2 3

20 to 30 mm Hg lower than in the brachial artery 40 to 50 mm Hg higher than in the brachial artery

Essentially the same as that in the brachial artery

ANS: 4 When measuring the blood pressure in the legs, systolic pressure is usually higher by 10 to 40 mm Hg than that in the brachial artery, but the diastolic pressure is the same. The systolic pressure, not the diastolic pressure, is 10 to 40 mm Hg higher than that in the brachial artery. Measurements of 20 to 30 mm Hg lower and 40 to 50 mm Hg higher are not true statements. DIF: A REF: 546 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 10. An 84-year-old client with diabetes is admitted for insulin regulation. Which of the following blood pressure, pulse, and respiration measurements, respectively, is considered to be within the expected limits for a client of this age?

BP = 138/88 mm Hg, P = 68 beats/min, R = 16 breaths/min

BP = 104/52 mm Hg, P = 68 beats/min, R = 30 breaths/min

BP = 108/80 mm Hg, P = 112 beats/min, R = 15 breaths/min

BP = 132/74 mm Hg, P = 90 beats/min, R = 24 breaths/min

ANS: 1

These measurements are within the expected limits for an older client. An adults average blood pressure is 120/80 mm Hg. The systolic pressure may increase with age, but the blood pressure should not exceed 140/90 mm Hg. The range for an adults pulse is 60-100 beats/min. The expected respiratory rate is 16-25 breaths/min. BP = 104/52 mm Hg, P = 68 beats/min, R = 30 breaths/min; BP = 108/80 mm Hg, P = 112 beats/min, R = 15 breaths/min; and BP = 132/74 mm Hg, P = 90 beats/min, R = 24 breaths/min are not within the expected limits for a client of this age. DIF: A REF: 527 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 11. The student nurse is assessing the vital signs of a 10-year-old client. The expected values for a client of this age are:

P = 140 beats/min, R = 50 breaths/min, BP = 80/50 mm Hg

2 3

P = 100 beats/min, R = 40 breaths/min, BP = 90/60 mm Hg P = 80 beats/min, R = 22 breaths/min, BP = 110/70 mm Hg

P = 60 beats/min, R = 12 breaths/min, BP = 160/90 mm Hg

ANS: 3 These are expected findings of a 10-year-old client. The normal pulse range for a 10-year-old is 75-100 beats/min; the normal respiratory rate is 20-30 breaths/min. The expected blood pressure range for a 7-year-old is 87-117/48-64 mm Hg; children who are larger (e.g., heavier and/or taller) have higher blood pressures. The average blood pressure for a 10-year-old is 110/65 mm Hg mm Hg. P = 140 beats/min, R = 50 breaths/min, BP = 80/50 mm Hg; P = 100 beats/min, R = 40 breaths/min, BP = 90/60 mm Hg; and P = 60 beats/min, R = 12 breaths/min, BP = 160/90 mm Hg are not expected values of a 10-year-old client. DIF: A REF: 537 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 12. The nurse has just taken vital signs for a 30-year-old client. Based on the results, the nurse will report the following finding that is out of the expected range for a client of this age:

T = 37.4 C

P = 110 beats/min

R = 20 breaths/min BP = 120/76 mm Hg

ANS: 2 The expected pulse range for an adult is 60-100 beats/min. This clients pulse is elevated at 110 beats/min. This clients temperature is within the normal range of 36 to 38 C for an adult. This clients respiratory rate is within the normal range of 12-20 breaths/min for an adult. This clients blood pressure reading is within the normal range of 120/80 mm Hg for an adult. DIF: A REF: 527 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 13. When using a glass thermometer at home to accurately assess axillary temperature, the nurse should tell the parent of a 1 1/2-year-old child to:

Hold the thermometer at the bulb end

2 3

Cleanse the thermometer in hot water Assess the thermometer for 5 minutes

Allow the child to hold the thermometer

ANS: 3 When assessing a clients axillary temperature with a glass thermometer, the thermometer should be left in place for 3 to 5 minutes. The thermometer should be held at the opposite end of the bulb. The thermometer should be covered with a plastic sheath when in use and after used the plastic sheath is discarded. If the thermometer requires cleaning, the nurse should not use hot water, as it could cause the thermometer to break. The parent should hold the thermometer, not the child. A 1 1/2-year-old client may drop the thermometer, creating a mercury spill. DIF: A REF: 630 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 14. The postoperative vital signs of an average size adult client are: BP = 110/68 mm Hg, P = 54 beats/min, R = 8 breaths/min. The client appears pale, is disoriented, and has minimal urinary output. The nurse should:

Retake the vital signs in 30 minutes

Continue with care as planned

Administer a stimulant Notify the physician

4 ANS: 4

The nurse should notify the physician, as these are abnormal findings. The clients respirations are becoming dangerously low at 8 breaths/min (normal 12-20 breaths/min). The clients pulse rate is low at 54 beats/min (expected 60-100 beats/min), and the blood pressure should be =120/80 mm Hg, which it is at 110/68 mm Hg. The additional assessment findings are also not normal, and should be reported to the physician. The nurse should not wait another 30 minutes to retake vital signs. The present readings warrant notifying the physician. These are abnormal findings. The nurse should not continue with care as planned. The nurse should first notify the physician. Administering a stimulant would require a physicians order and may not be what the client requires. For example, the client may need a narcotic antagonist rather than a stimulant. DIF: B REF: 504 OBJ: Application TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 15. A client has just gotten out of bed to go to the bathroom. As the nurse enters the room, the client says, I feel dizzy. The nurse should:

1 2

Go for help Take the clients blood pressure

Assist the client into a sitting position

Tell the client to take several deep breaths

ANS: 3 The nurses primary concern should be the patients safety and preventing an accidental fall. If the client just got up from bed and is complaining of dizziness, the client may be experiencing orthostatic hypotension. The nurse should first assist the client to sit down before performing any other assessment. The nurse should not leave the client and go for help. The nurse should assist the client to a sitting position. If help is required, the nurse can then put on the clients call light. The nurse may take the clients blood pressure after assisting the client to a sitting position to prevent the client from falling. The nurse should first assist the client to sit down to prevent the client from falling accidentally. The nurse may then assess the client. If the nurse finds during the assessment that the clients pulse oximetry is low, the nurse may instruct the client to take deep breaths. DIF: B REF: 538 OBJ: Application TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 16. A false high blood pressure reading may be assessed, as the nurse explains to the nurse assistant, if the assistant:

Wraps the cuff too loosely around the arm

Deflates the blood pressure cuff too quickly

Repeats the blood pressure assessment too soon

Presses the stethoscope too firmly in the antecubital fossa

ANS: 1 If the cuff is wrapped too loosely or unevenly around the arm, the effect on the blood pressure measurement may be a false high reading. A false low systolic and false high diastolic blood pressure reading may occur if the cuff is deflated too quickly. A false high systolic reading may be obtained if the blood pressure assessment is repeated too soon. A false low diastolic reading may be obtained if the stethoscope is applied too firmly against the antecubital fossa. DIF: A REF: 541 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 17. The client is febrile, and the temperature needs to be reduced. The nurse anticipates that treatment will include:

An alcohol and water bath

2 3

Ice packs to the axillae and groin Tepid, plain water sponge down

Application of a cooling blanket

ANS: 4 Blankets cooled by circulating water delivered by motorized units increase conductive heat loss. Cooling blankets are used to reduce a fever. Bathing with an alcohol/water solution is not recommended because it may lead to shivering. Shivering is counterproductive and can increase energy expenditure up to 400%. Application of ice packs to the axillae and groin is no longer recommended because they may induce shivering (which is counterproductive and increases the clients energy expenditure), and because they have no advantage over antipyretic medications. Tepid sponge baths are no longer recommended because it may lead to shivering and is no more advantageous than administering antipyretics. DIF: A REF: 520 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 18. The nurse is alert to which of the following factors that lowers the blood pressure?

Stress-producing anxiety

Heavy alcohol consumption

Cigarette, cigar, or pipe smoking

Prescribed diuretic administration

ANS: 4 Diuretics lower blood pressure by reducing reabsorption of sodium and water by the kidneys, thus lowering circulating fluid volume. The effects of sympathetic nerve stimulation, such as with anxiety, increase blood pressure. Heavy alcohol consumption has been linked to hypertension. Cigarette smoking has been linked to hypertension. DIF: A REF: 537 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 19. While the nurse is taking the clients blood pressure, the client asks if the reading is high. In accordance with the newest guidelines, the nurse informs the client that a blood pressure measurement that is consistent with hypertension is:

120/70 mm Hg

130/84 mm Hg

120/78 mm Hg 118/80 mm Hg

ANS: 2 The diagnosis of prehypertension in adults is made when an average of two or more diastolic readings on at least two subsequent visits is between 80 and 89 mm Hg or when the average of multiple systolic blood pressures on two or more subsequent visits is between 120 and 139 mm Hg. Hypertension is noted with diastolic readings greater than 90 mm Hg and systolic readings greater than 140 mm Hg. According to the newest guidelines, this clients blood pressure reading (130/84 mm Hg) would fall into the pre-hypertension category. Normal is 120/80 mm Hg; this is a normal blood pressure reading. Normal is 120/80 mm Hg; this is a normal blood pressure reading. Normal is 120/80 mm Hg; this is a normal blood pressure reading. DIF: A REF: 537 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 20. After measuring the clients vital signs, the nurse obtains the following results: blood pressure = 180/100 mm Hg, pulse = 82 beats/min, R = 16 breaths/min, and rectal temp = 37.5 C. The nurse should:

Retake the blood pressure

Retake the clients temperature

Report all of the findings immediately Record the findings as within normal limits

ANS: 1 The normal blood pressure reading is 120/80 mm Hg. This clients blood pressure is significantly higher at 180/100 mm Hg, and may be an indication of hypertension. (One elevated blood pressure measurement does not qualify as a diagnosis of hypertension; it would have to be elevated on at least two separate occasions). The nurse should retake the blood pressure. The clients temperature is within normal limits for a rectal temperature. The average rectal temperature is 37.5 C. The nurse should repeat the blood pressure measurement to confirm the reading before reporting the findings. The blood pressure reading is not within normal limits. The pulse rate, respiratory rate, and temperature are within normal limits. DIF: B REF: 537 OBJ: Application TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 21. The client is identified by the nurse as having a remittent fever. The student asks what that means and the nurse explains that a remittent fever is:

A constant body temperature above 100.4 F with little fluctuation

Spikes that are interspersed with normal temperatures within 24 hours

Spikes and falls in temperature, but temperature does not return to the normal limits

Periods of febrile episodes interspersed with normal body temperatures

ANS: 3 A remittent fever spikes and falls without a return to normal temperature levels. A sustained fever is a constant body temperature continuously above 38 C (100.4 F) that demonstrates little fluctuation. An intermittent fever has fever spikes interspersed with usual temperature levels. Temperature returns to acceptable levels at least once in 24 hours. A relapsing fever has periods of febrile episodes interspersed with acceptable temperature values. DIF: A REF: 508 OBJ: Comprehension TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 22. The nurse is working in the newborn nursery. In planning for temperature measurement, the nurse will obtain the reading on the infants by using the:

1 2

Oral site Rectal site

Axillary site

Tympanic site

ANS: 3 The axillary site can be used with newborns and uncooperative clients. The oral site should not be used with infants. The rectal site should not be used for routine vital signs in newborns. The tympanic site is questioned as being accurate in newborns. DIF: A REF: 515 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 23. A client is being monitored with pulse oximetry. On review of the following factors, the nurse suspects that the values will be influenced by:

The placement of the sensor on the extremity

A diagnosis of peripheral vascular disease

A reduced amount of artificial light in the room The increased ambient temperature of the clients room

ANS: 2 Peripheral vascular disease can reduce pulse volume, which may affect the pulse oximetry reading. The sensor should be placed on an extremity site (such as an earlobe or digit) with adequate local circulation and the site should be free of moisture. Reduced light in the room will not affect the oximetry reading. Outside light sources can interfere with the oximeters ability to process reflected light. An increased temperature of the room will not affect the oximetry reading. If the room was very cold, the clients peripheral blood flow may decrease, affecting the oximetry reading. DIF: A REF: 533 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

24. An individual contacts the emergency department of the local hospital to ask what to do for a skiing partner who appears to be suffering from hypothermia. The victim is alert and able to respond to questions. The nurse instructs the individual who has called to have the victim:

Take sips of brandy

2 3

Drink a bowl of warm soup Drink a cup of very hot coffee

Run the affected extremities under hot water

ANS: 2 A conscious client benefits from drinking hot liquids such as soup. Alcohol should be avoided. Caffeinated fluids should be avoided. Extremities should be warmed gradually. Tissue damage could occur if placed under hot water. The entire body should be warmed, such as by putting heating pads next to the head and neck that lose heat the quickest. DIF: B REF: 508 OBJ: Application TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 25. A spouse assists the nurse evaluating the measurement of the clients blood pressure. The nurse feels additional teaching is required if the spouse is observed:

Deflating the cuff at 2 mm Hg/second

Having the client sit down for the measurement

Using the same time each day for the measurement Taking the blood pressure after the client comes back from a walk

ANS: 4 The clients blood pressure should not be measured after the client has exercised, smoked, or ingested caffeine. The client should wait 30 minutes before assessment of the blood pressure. The cuff should be deflated at a rate of 2 mm Hg per second. When possible, the client should be sitting in a chair. The blood pressure should be assessed at the same time each day. DIF: A REF: 537 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 26. The nurse measures the blood pressure in the leg due to the fact that the client has bilateral casts on the upper extremities. The nurse palpates the pulse before the measurement at the:

Popliteal fossa behind the knee

Inner side of the ankle below the medial malleolus Top of the foot between the extension tendons of the great toe

3 4

Inguinal ligament midway between the symphysis pubis and the anterior superior iliac spine

ANS: 1 The popliteal artery, palpable behind the knee in the popliteal space, is the site for auscultation when taking the blood pressure in the leg. The inner side of the ankle, top of the foot, and inguinal ligament are not the correct sites for assessment. DIF: A REF: 546 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 27. The clients apical pulse will be taken by a student. According to the nurse the stethoscope should be placed along the left clavicular line at the:

Second to third intercostal space

Third to fourth intercostal space

Fourth to fifth intercostal space

Fifth to sixth intercostal space

ANS: 3 An apical pulse should be assessed at the clients PMI. The PMI is located at the fourth to fifth intercostal space at the left midclavicular line. Second to third intercostals space is not the correct placement for auscultating a clients apical pulse. The PMI is higher and more medial in children under 8 years old, thus the third to fourth is incorrect. The client is not identified as being a child. Fifth to sixth is not the correct placement for auscultating a clients apical pulse. DIF: A REF: 525 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 28. The nurse enters the room to measure the clients pulse rate. The nurse recognizes that the clients rate may be increased as a result of:

A febrile condition

Administration of digoxin

The clients athletic conditioning

Unrelieved severe postoperative pain

ANS: 1 Fever and heat may increase a clients pulse rate. Digoxin is a negative chronotropic drug; it will decrease the clients pulse rate. A conditioned athlete who participates in long-term exercise will have a lower heart rate at rest. Unrelieved severe pain increases parasympathetic stimulation; decreasing the heart rate. DIF: A REF: 526 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 29. Upon entering the room, the nurse notes that the client has an irregular respiratory rate, with periods of apnea and increases in respiration, followed by a reversal of the pattern. The nurse reports this respiratory assessment as:

1 2

Biots respirations Kussmauls respirations

Hyperpneic respirations

Cheyne-Stokes respirations

ANS: 4 Cheyne-Stokes respirations are characterized by an irregular respiratory rate with alternating periods of apnea and hyperventilation. The respiratory cycle begins with slow, shallow breaths that gradually increase to an abnormal rate and depth. The pattern then reverses, breathing slows and becomes shallow, and the pattern climaxes in apnea before respiration resumes. Biots respirations are abnormally shallow for two to three breaths followed by an irregular period of apnea. Kussmauls respirations are abnormally deep, regular, and increased in rate. Hyperpneic respirations are labored, increased in depth, and increased in rate (>20 breaths/min); they normally occur during exercise. DIF: A REF: 532 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 30. The nurse has assigned the vital signs of the elderly clients residing in the facilitys assisted living unit to the nursing assistant. Which of the following statements made by the ancillary personnel requires immediate correction by the RN?

As you age your blood pressure may go up, but it doesnt have to if your vessels are healthy.

If anyones oral temperature is over 100 F, Ill let you know right away since that means they have a fever.

I always wait a good 30 minutes after returning the older client back to bed before I count their pulse. I watch the elderly clients stomach and count the number of times it rises when I am counting respirations.

ANS: 2 RAT: The temperature of older adults is at the lower end of the normal temperature range, 36 to 36.8 C (96.9 to 98.3 F) orally and 36.6 to 37.2 C (98 to 99 F) rectally. Therefore temperatures considered within normal range sometimes reflect a fever in an older adult. The normal range for blood pressure is the same for older adults and younger people, while older adults depend more on accessory abdominal muscles during respiration than on weaker thoracic muscles, so observing the rise and fall of the abdomen would not be inappropriate. Once elevated, the pulse rate of an older adult takes longer to return to normal resting rate, so waiting 30 minutes would not be inappropriate. DIF: C REF: 506 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 31. The nurse appropriately instructs trained ancillary personnel to avoid using an electronic blood pressure cuff to take the blood pressure of which of the following clients?

A 25-year-old who was admitted for depression and anxiety

A 69-year-old diagnosed with Parkinsons disease 5 years ago

A 57-year-old prescribed antihypertensive medication 6 weeks ago

An 80-year-old client whose systolic BP is routinely assessed in the low 90s

ANS: 2 Blood pressure less than 90 mm Hg systolic, irregular heart rate, peripheral vascular obstruction (e.g., clots, narrowed vessels), shivering, seizures, excessive tremors, and the inability to cooperate are reasons to avoid using an electronic BP monitor. The clients Parkinsons disease causes tremors, so a manual cuff should be used when assessing this clients BP. DIF: C REF: 546 OBJ: Comprehension TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 32. The nurse appropriately instructs trained ancillary personnel to use an electronic blood pressure cuff to take the blood pressure of which of the following clients?

1 2

A 25-year-old who was admitted for alcohol detoxification A 69-year-old diagnosed with Parkinsons disease 5 years ago

A 57-year-old placed on antihypertensive medication therapy 2 months ago

An 80-year-old client whose systolic BP is routinely assessed in the high 80s

ANS: 1 Blood pressure less than 90 mm Hg systolic, irregular heart rate, peripheral vascular obstruction (e.g., clots, narrowed vessels), shivering, seizures, excessive tremors, and inability to cooperate are reasons to avoid using an electronic BP monitor. The answer reflects the client whose BP is most stable and best assessable via electronic BP monitor. DIF: A REF: 546 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 33. The nurse has assigned nursing assistive personnel to obtain the blood pressures on the units clients. Which of the following statements made by the assistive personnel shows the best understanding regarding appropriate communication of the BP readings?

Ill ask the clients what their blood pressure usually runs.

Ill give you a list of all the readings I get before I chart them.

Ill chart the results and let you know whose pressure is high. Ill recheck any pressure that seems higher than their normal.

ANS: 2 The nurse is responsible for assessing the impact of changes in blood pressure and so must be aware of each clients reading, not merely the values that the assistive personnel believes to be high. Asking the client to share what their BP is routinely and/or retaking a questionable reading is appropriate but not directly related to effective communication of the findings. DIF: C REF: 539 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

34. The nurse has assigned nursing assistive personnel to obtain the blood pressures on the units clients. Which of the following statements made by the assistive personnel shows the greatest need for additional instruction regarding appropriate communication of the BP readings?

Ill give you a list of all the readings after I chart them.

May I ask the clients what their blood pressure usually runs?

Ill chart the results and let you know whose pressure is running high.

Do you want me to take the readings before they get their medications?

ANS: 3 The nurse is responsible for assessing the impact of changes in blood pressure and so must be promptly made aware of each clients reading, not merely the values that the assistive personnel believes to be high. The questions asked may reflect a need for further instruction, but the issues are not as critical as the need to report all readings for the nurse to evaluate. DIF: C REF: 539 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 35. The nurse has assessed a clients blood pressure (BP) using the left thigh because of bilateral upper arm casts. The clients precasting left arm BP was 108/70 mm Hg. The nurse expects the present BP reading to be:

10-40 mm Hg higher systolic pressure than before the casting

5-10 mm Hg higher reading in both systolic and diastolic pressures

Representative of the original baseline established before the casting A slight decrease in the diastolic pressure when compared to precasting pressure

ANS: 1 Systolic pressure in the legs is usually higher by 10 to 40 mm Hg than in the brachial artery, but the diastolic pressure is the same. DIF: A REF: 546 OBJ: Comprehension TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 36. The nurse is using a manual cuff to assess the blood pressure of a client experiencing hypertension. To best ensure accommodation for a possible auscultatory gap, the nurse should use which of the following as a guide for inflating the cuff appropriately?

Review the clients chart for his last blood pressure reading.

Ask the client what his typical blood pressure reading is when taken manually.

Inflate 30 mm Hg higher than where the radial pulse can no longer be palpated.

Take the clients blood pressure both sitting and standing and use the higher reading.

ANS: 3 The examiner needs to be certain to inflate the cuff high enough to hear the true systolic pressure before the auscultatory gap. Palpation of the radial artery helps to determine how high to inflate the cuff. The examiner inflates the cuff 30 mm Hg above the pressure at which the radial pulse was palpated. Taking the blood pressure in various positions will not help eliminate the possible loss of auditory sound between the systolic and diastolic sounds. While asking the client and/or reviewing the chart may provide information concerning the clients pressure, these options are not the recommended method for minimizing the effect of the auditory gap on the assessment process. DIF: C REF: 541 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 37. The nurse is assessing an elderly clients blood pressure during a routine visit. When asked, the client volunteers that when he took his pressure at home yesterday it was 126/72 mm Hg. The nurse determines that the clients pressure today is 134/70 mm Hg. The nurse recognizes that the most likely cause of the elevation is:

The difference between the monitoring equipment being used

The client may be experiencing mild anxiety regarding the check-up

The effects of aging on the clients ability to hear the first Korotkoff sound The client is not inflating the cuff sufficiently to detect the systolic pressure

ANS: 2 Blood pressure measurements taken at the clients place of employment or in a health care providers office are higher than those taken at the clients home. The remaining options may be a factor but they are not the most likely. DIF: C REF: 537 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 38. The nurse is assessing a clients blood pressure to establish a baseline. The pressure in the right arm is 12 mm Hg lower than that in the left arm. The nurse most appropriately realizes that these data:

Reflect a normal variation

Should be reported to the clients health care provider

Dictate that pressure should be monitored in the left arm

Indicate that the client may be experiencing vascular problems

ANS: 2 During the initial assessment, obtain and record the blood pressure in both arms. Normally there is a difference of 5 to 10 mm Hg between the arms (Lane and others, 2002). In subsequent assessments, measure the blood pressure in the arm with the higher pressure. Pressure differences greater than 10 mm Hg indicate vascular problems and are reported to the health care provider or nurse in charge. Reporting the assessment findings is the most appropriate outcome. DIF: C REF: 536 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 39. The nurse recognizes that which of the following clients present at the annual July 4th marathon is at greatest risk for hyperthermia and the resulting heatstroke?

A 34-year-old running for the first time in the July 4th marathon who is sweating profusely

A 16-year-old volunteer, with type 1, insulin-dependent diabetes, who is checking runners in for the marathon at the starting gate A 75-year-old who is prescribed medication for Crohns disease and who is sitting outdoors watching her granddaughter run the marathon

A 55-year-old diagnosed with bipolar disease and prescribed a phenothiazine (Serentil), who will be walking the marathon course

ANS: 2 Clients at risk include those who are very young or very old and those who have cardiovascular disease, hypothyroidism, diabetes, or alcoholism. Also at risk are those who take medications that decrease the bodys ability to lose heat (e.g., phenothiazines, anticholinergics, diuretics, amphetamines, and beta-adrenergic receptor antagonists) and those who exercise or work strenuously (e.g., athletes, construction workers, and farmers). While all the options represent risk factors, the degree of exercise, medical history, and age are greatest for the 16-year-old client with diabetes. DIF: C REF: 506 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 40. The nurse recognizes that which of the following clients present at the annual July 4th marathon is showing the most compelling signs of hyperthermia and the resulting heatstroke?

The 75-year-old who has forgot where the car is parked

The 16-year-old volunteer whose skin appears sunburned but dry

The 34-year-old who finished the race and is reporting leg cramps The 55-year-old observer who complains of nausea and being thirsty

ANS: 2 Signs and symptoms of heatstroke include giddiness, confusion, delirium, excess thirst, nausea, muscle cramps, visual disturbances, and even incontinence. Vital signs reveal a body temperature sometimes as high as 45 C (113 F) with an increase in heart rate and lowering of blood pressure. The most important sign of heatstroke is hot, dry skin. Victims of heatstroke do not sweat because of severe electrolyte loss and hypothalamic malfunction. If the condition progresses, the client with heatstroke becomes unconscious with fixed, unreactive pupils. Permanent neurological damage occurs unless cooling measures are rapidly started. DIF: C REF: 508 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

41. The nurse has assigned nursing assistive personnel to obtain the temperatures on the units clients. Which of the following statements made by the assistive personnel shows the greatest need for additional instruction regarding appropriate temperature monitoring orally?

Are all the clients cooperative enough to take the temperatures orally?

Do you want me to take the temperature tympanically on everyone? Ill wait until breakfast is over so I wont distract them from eating.

3 4

Ill chart the results and let you know whose temperature is running high.

ANS: 3 When taking oral temperature, wait 20 to 30 min before measuring temperature if the client has smoked or ingested hot or cold liquids or foods. The nurse needs to reinforce this information so that the assessment will occur before breakfast or to allow enough time to pass after breakfast so as not to affect the readings. The options containing a question reflect a need for knowledge but do not have priority over an obvious indication of possible poor assessment technique. The nurse needs to evaluate the readings and so should be sure to give the assistive personnel guidance as to what readings are running high. DIF: C REF: 510 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 42. Which of the following sites is best suited for measuring oxygen saturation (pulse oximetry)?

A polished ring finger of a client with pneumonia whose nail capillary refill time is 2.5 seconds

A pierced earlobe of a client with a closed head injury whose nail capillary refill time is 3.5 seconds

The ring finger of a client with Parkinsons disease that has a capillary refill time of less than 3 seconds An earlobe of a client who is experiencing moderate diaphoresis with a nail capillary refill time of 3.5 seconds

ANS: 2

Determine most appropriate client-specific site (e.g., finger, earlobe) for sensor probe placement by measuring capillary refill. If capillary refill is greater than 3 seconds, select an alternate site. Sites should be free of moisture and tremors, and the nail should be free of polish (no artificial nails). DIF: C REF: 534 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 43. The nurse has asked the assistive personnel to take the blood pressure of a client who experienced a left mastectomy 3 days ago. Which of the following statements by the assistive personnel shows the best understanding regarding the appropriate assessment technique for this particular client?

1 2 3 4

Is there anything affecting her right arm? Has she been experiencing any edema in that left arm? How long has it been since she had her breast removed? Ill wait until shes been medicated for pain before I take it.

ANS: 1 Avoid applying the cuff to the extremity when intravenous fluids are infusing; an arteriovenous shunt or fistula is present; breast or axillary surgery has been performed on that side; or the extremity has been traumatized, diseased, or requires a cast or bulky bandage. The answer reflects an understanding that the right arm is the extremity of choice for monitoring this clients blood pressure. DIF: C REF: 539 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs MULTIPLE RESPONSE 1. The nurse is assisting the wife of a client who has been diagnosed with hypertension to monitor his blood pressure. The nurse states that the blood pressure should be taken: (Select all that apply.)

At the same time each day

On the same arm each time

3 4

In the same position each time After the client has had a brief rest

After his blood pressure medication

Right before getting up in the morning

ANS: 1, 2, 3, 4 Instruct the client or primary caregiver to take BP at same time each day and after the client has had a brief rest. Take BP sitting or lying down; use the same position and arm each time pressure is taken. The other options are not necessary because they do not affect blood pressure readings. DIF: C REF: 537 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 2. Which of the following factors make using a pulse oximeter on an elderly client challenging? (Select all that apply.)

Possibility of decreased cardiac output

2 3

Potential for peripheral vascular disease Existence of decreased red blood cell count

Uncooperative behavior related to senility

Inability to comprehend rationale for monitoring

Vasoconstriction related to impaired heat regulation

ANS: 1, 2, 3, 6 Identifying an acceptable pulse oximeter probe site is difficult with older adults because of the likelihood of peripheral vascular disease, decreased cardiac output, cold-induced vasoconstriction, and anemia. It would be inappropriate to assume that the process is made more difficult because of the remaining options because they are not seen in the majority of the elderly population. DIF: C REF: 533 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 3. The nurse is providing a health promotion session regarding the factors that contribute to heatstroke for members of a college cross-country running team. Which of the following statements should the nurse include in the discussion? (Select all that apply.)

Take frequent breaks to rest out of the sun.

The greater the humidity, the greater the hazard. Wear clothing that will absorb the perspiration.

3 4 5

The higher the temperature, the higher the risk. The more fluids you drink, the fewer chances you take.

Pay attention to pacing yourself when its hot and muggy.

ANS: 2, 4, 5, 6 Teach clients risk factors for heatstroke: strenuous exercise in hot, humid weather; tight-fitting clothing in hot environments; exercising in poorly ventilated areas; sudden exposures to hot climates; poor fluid intake before, during, and after exercise. When paying close attention to avoiding risk factors for heatstroke, the remaining options are not required. DIF: C REF: 507-508 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 4. The nurse is discussing risk factors for hypertension with family members attending a selfhelp group meeting for clients in cardiac rehabilitation. Which of the following statements made by the nurse are relevant to this discussion on prevention of this disorder? (Select all that apply.)

1 2 3 4

Low fat foods are your blood pressures best friend. Have your triglycerides checked on a regular basis. Ideal weight is ideal for keeping blood pressure under control. Nicotine is a no-no when attempting to control blood pressure.

If they are prescribed, take your blood pressure medicine as suggested.

Keep alcohol consumption down and your blood pressure will be down.

ANS: 1, 2, 3, 4, 6 Persons with a family history of hypertension are at significant risk. Obesity, cigarette smoking, heavy alcohol consumption, high blood cholesterol and triglyceride levels, and continued exposure to stress are risk factors linked to hypertension. Medication compliance, while important, is related to the management of hypertension, not prevention. DIF: C REF: 537-538 OBJ: Analysis

TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 5. The nurse is discussing the correct technique for taking a blood pressure with clients and their caregivers. Which of the following nursing statements would appropriately identify the most likely causes for experiencing difficulty actually hearing the blood pressure? (Select all that apply.)

The cuff cannot be too small or too big.

Dont release the air out of the cuff to quickly.

Keep the arm you are using at the level of the heart.

If you are having difficulty, try taking it in the other arm. The stethoscope needs to be placed directly over a pulse point.

5 6

Remember to pump up the cuff until you can no longer feel the pulse.

ANS: 1, 2, 5, 6 Instruct the client or primary caregiver that if it is difficult to hear the pressure, the cuff is probably too loose, not big enough, or too narrow; the stethoscope is not over an arterial pulse; the cuff was deflated too quickly or too slowly; or the cuff was not inflated enough for systolic readings. The remaining options do not directly affect the actual hearing of the blood pressure. DIF: C REF: 539 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 6. The nurse is discussing the proper technique for obtaining an accurate blood pressure reading with assistive nursing personnel. Which of the following statements reflect techniques that will minimize the risk of a false high systolic reading? (Select all that apply.)

1 2 3

Slowly deflate the pressure from the cuff. Wrap the cuff snuggly around the clients arm.

Always support the clients arm at the level of the heart. Be sure that the cuff is wide enough for the clients arm.

Allow the arm to rest before repeating the blood pressure.

Make sure your stethoscope is fitted in your ears appropriately.

ANS: 2, 3, 4, 5

Using a bladder or cuff that is too narrow or too short, wrapping the cuff too loosely or unevenly, resting the arm below heart level, and repeating assessments too quickly all contribute to a falsely high systolic reading. The rapid deflation of the cuff and an ill-fitted stethoscope will likely result in a falsely low systolic reading. Chapter 30. Health Assessment and Physical Examination MULTIPLE CHOICE 1. The position that maximizes the nurses ability to assess the clients body for symmetry is:

1 2

Sitting Supine

Prone

Dorsal recumbent

ANS: 1 Sitting upright provides full expansion of the lungs and provides better visualization of symmetry of upper body parts. The supine position maximizes the nurses ability to assess pulse sites. The prone position is used only to assess extension of the hip joint. The dorsal recumbent position is used for abdominal assessment because it promotes relaxation of abdominal muscles. PTS: 1 DIF: A REF: 559 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 2. When assessing the pallor of a client with dark skin, the nurse will specifically look at the:

Buccal mucosa of the mouth

Dorsal surface of the hands

Ear lobe Sclera

ANS: 1 Pallor is more easily seen in the face, buccal mucosa of the mouth, conjunctiva, and nail beds. The palmar surface of the hands may be used to detect color hues in dark-skinned clients. The ear lobe is not a good site to assess for color changes, such as pallor, in a dark-skinned client. The best site to inspect for jaundice, not pallor, is the sclera. PTS: 1 DIF: A REF: 567 OBJ: Knowledge TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 3. A female client is seen in the outpatient clinic for numerous cuts, bruises, and apparent burns. In a discussion with the client, the nurse finds that the injuries are inconsistent with the stated cause. The client also states that she is having trouble sleeping, and she appears anxious. Based on these findings, the nurse suspects that the client may be experiencing:

Substance abuse

Domestic violence

Vascular disease

Mental illness

ANS: 2 Injuries and trauma that are inconsistent with the reported cause; multiple injuries including bruises, cuts, and burns; and behavioral findings of difficulty sleeping and appearing anxious are all indicators of possible domestic violence. The findings are not consistent with substance abuse. Indicators of substance abuse may include frequent missed appointments or emergency department visits, having a history of changing doctors, history of activities that place the client at risk for HIV infections, complaints of insomnia or chest pain, and a family history of addiction. People who abuse substances may have cuts, burns (especially of the fingers), needle marks, homemade tattoos, or increased vascularity of the face. These findings are not indicative of vascular disease. Symptoms of vascular disease may include edema, color changes of the lower extremities, and weakened pedal pulses. These findings are not indicative of mental illness. The client is coherent. PTS: 1 DIF: C REF: 563 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 4. A client in the clinic has been having severe headaches and some visual disturbances. The nurse performs an eye examination. Which of the following is true concerning the procedure for this assessment?

The red reflex should be assessed with the ophthalmoscope.

To evaluate the lower eyelids, the nurse uses a syringe with sterile water. Accommodation is tested by asking the client to comply with the nurses requests.

The lacrimal apparatus is assessed with a dull object to stimulate normal reflex conditions.

ANS: 1 To visualize internal eye structures, the nurse uses an ophthalmoscope to focus on the red reflex. To evaluate the lower eyelids, the nurse asks the client to open the eyes for inspection. A syringe and sterile water are not necessary for this assessment. Accommodation is tested by asking the client to gaze at a distant object and then at a test object held by the nurse approximately 10 cm from the clients nose. The pupils normally converge and accommodate by constricting when looking at close objects. The lacrimal apparatus is best assessed by inspecting for edema and redness; and palpating it gently to detect tenderness, which cannot be felt normally. PTS: 1 DIF: A OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 5. In preparing to conduct a physical examination on a client, the nurse plans to:

Perform painful procedures at the end of the exam

Take long, detailed notes of all the findings during the exam

Keep the TV or radio on to distract the client throughout the exam

Assess the dominant side of the clients body only in the examination

ANS: 1 In organizing a physical examination, the nurse should perform painful procedures near the end of the examination. The nurse should record quick notes during the examination to avoid keeping the client waiting. Observations can be completed at the end of the examination. The TV or radio should be turned off so as to not distract the client throughout the examination, and to provide an environment conducive to auscultation. Both sides of the body should be assessed for comparison to determine symmetry. A degree of asymmetry is normal in the dominant versus nondominant arm. PTS: 1 DIF: A REF: 562 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

6. The client has an enlarged thyroid gland and is currently admitted to a medical nursing unit. Which of the following is accurate regarding the procedure for a thyroid assessment for this client?

Deep palpation should be used anterior and posterior.

Swallowing sips of water causes the isthmus of the thyroid gland to rise. The posterior approach is used when the fingers are placed over the trachea.

3 4

The diaphragm of the stethoscope is best used for the auscultation of bruits.

ANS: 2 During assessment of the thyroid gland, the client holds a cup of water and takes a sip to swallow once instructed by the nurse. As the client swallows, the isthmus of the thyroid gland rises. The nurse should feel if it is enlarged. Normally the thyroid gland is small, smooth, and free of nodules. Light, gentle palpation is needed to feel any abnormalities. For the posterior approach, both of the nurses hands are placed around the neck, with two fingers of each hand on the sides of the trachea just beneath the cricoid cartilage. The bell of the stethoscope is best for auscultation of bruits. PTS: 1 DIF: A REF: 591 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 7. When auscultating the clients lungs, a nurse notes normal vesicular sounds as:

Medium-pitched blowing sounds with inspirations that equal expirations

Loud, high-pitched, hollow sounds with expiration longer than inspiration

Soft, breezy, low-pitched sounds with longer inspiration Sounds created by air moving through small airways

ANS: 3 Normal vesicular sounds are soft, breezy, and low-pitched. The inspiratory phase is 3 times longer than the expiratory phase. Medium-pitched blowing sounds with inspiration equaling expiration are bronchovesicular breath sounds. Loud, high-pitched, hollow sounds with longer

expiration are bronchial breath sounds. Vesicular sounds are created by air moving through smaller airways. Abnormal breath sounds result from air passing through narrowed airways. PTS: 1 DIF: A REF: 596 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 8. The nurse could best auscultate the point of maximum impulse (PMI) in an 8-year-old child at the:

1 2

Fourth intercostal space, left of the midclavicular line Fifth intercostal space, left of the midclavicular line

Second intercostal space, right of the midclavicular line

Third intercostal space, right of the midclavicular line

ANS: 2 By the age of 7, a childs PMI is in the same location as in adults; that is, the fifth intercostal space, left of the midclavicular line. The PMI of an 8-year-old child is more likely to be located at the fifth intercostal space, left of the midclavicular line. The PMI is not located to the right of the midclavicular line. The PMI of an infant is at the third or fourth intercostal space, left of the midclavicular line. PTS: 1 DIF: A REF: 598 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 9. The nurse suspects that the client may have vascular disease. During the examination, the nurse is alert to the clients complaints of:

Headache, dizziness, and tingling of body parts

Diplopia, floaters, and headaches

Leg cramps, numbness of extremities, and edema

Pain and cramping in the lower extremities relieved by walking

ANS: 3 Leg cramps, numbness or tingling in extremities, sensation of cold hands or feet, pain in legs, or swelling or cyanosis of feet, ankles, or hands are indicative of vascular disease.

Headache, dizziness, and tingling of body parts are more likely associated with a neurological problem, not vascular disease. Diplopia, floaters, and headaches are indicative of an eye problem, not vascular disease. Pain and cramping in the lower extremities are usually worsened with activity in vascular disease. PTS: 1 DIF: A REF: 602 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 10. A 21-year-old woman asks when she should perform a breast self-examination during the month. The nurse should inform the client:

Any time you think of it.

2 3

At the same time each month. On the first day of your menstrual period.

Two to three days after your menstrual period.

ANS: 4 The best time for a BSE is 2 to 3 days after the menstrual period ends, when the breast is no longer swollen or tender from hormone elevations. The woman should check her breasts the same time each month 2-3 days after the menstrual period ends. At the same time each month is partially true. The client also should be informed to perform the BSE 2 to 3 days after the menstrual period ends. On the first day of the menstrual period is not the best time for a woman to perform a BSE. The breasts will be enlarged and tender from hormone elevations. PTS: 1 DIF: A REF: 610 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 11. During an assessment of the clients integument, the nurse notes a flat, nonpalpable change in skin color that is smaller than 1 cm. This finding is documented by the nurse as a:

Macule

Papule

Vesicle

Nodule

ANS: 1

This finding is consistent with the definition of a macule. A papule is a palpable, circumscribed, solid elevation in skin, smaller than 0.5 cm. A vesicle is a circumscribed elevation of skin filled with serous fluid, smaller than 0.5 cm. A nodule is an elevated solid mass, deeper and firmer than a papule, 0.5-2.0 cm. PTS: 1 DIF: A REF: 570 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 12. The nurse asks a client to explain the meaning of the phrase, Every cloud has a silver lining. This part of the examination is designed to measure:

Knowledge

2 3

Judgment Association

Abstract thinking

ANS: 4 Interpreting abstract ideas or concepts, such as in explaining the meaning of this phrase, reflects the capacity for abstract thinking. The client with altered mentation will likely interpret the phrase literally or merely rephrase the words. An example of assessing knowledge would be asking the client their reason for seeking health care. This example is not designed to measure knowledge. The nurse is not attempting to measure judgment. An example of assessing judgment would be to ask the client what they would do if they suddenly became ill when alone at home. The nurse is not attempting to measure association. An example of assessing association would be to ask the client to complete a phrase, such as a dog is to a beagle as a cat is to a . PTS: 1 DIF: A REF: 633 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 13. Measurement of the clients ability to differentiate between sharp and dull sensations over the forehead tests which cranial nerve?

Optic

Facial

Trigeminal Oculomotor

ANS: 3 The trigeminal nerve is tested by lightly touching the cornea with a wisp of cotton, by assessing the corneal reflex, and by measuring sensation of light pain and touch across the skin of the face. The optic nerve is tested by using the Snellen chart or asking the client to read printed material. The facial nerve is tested by having the client smile, frown, puff out cheeks, and raise and lower eyebrows while looking for asymmetry. Also, having the client identify salty or sweet taste on the front of the tongue tests the facial nerve. The oculomotor nerve is tested by assessing directions of gaze and testing papillary reaction to light and accommodation. PTS: 1 DIF: A REF: 634 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 14. Assessment of the clients skin reveals a fluid-filled circumscribed elevation of 0.4 cm. The nurse identifies this as a:

Nodule

2 3

Macule Vesicle

Wheal

ANS: 3 This finding is consistent with the definition of a vesicle. A nodule is an elevated solid mass, deeper and firmer than a papule, 0.5-2.0 cm. A macule is a flat, nonpalpable change in skin color, smaller than 1 cm. A wheal is an irregularly-shaped, elevated area or superficial localized edema that varies in size. PTS: 1 DIF: A REF: 570 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 15. The expected appearance of the oral mucosa in a light-skinned adult is:

Pinkish-red, smooth, and moist

Light pink, rough, and dry

Cyanotic, with rough nodules Deep red, with rough edges

4 ANS: 1

Normal mucosa in a light-skinned adult is glistening, pinkish-red, soft, moist, and smooth. Oral mucosa may appear more dry in an older adult because of reduced salivation but is not rough. Cyanotic mucosa with rough nodules would be an abnormal finding. Oral mucosa should not appear deep red with rough edges in a light-skinned adult. PTS: 1 DIF: A REF: 587 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 16. The nurse notes an exaggeration of the posterior curvature of the thoracic spine, during the assessment of a 90-year-old client, as:

1 2

Lordosis Osteoporosis

Scoliosis

Kyphosis

ANS: 4 Kyphosis is an exaggeration of the posterior curvature of the thoracic spine (hunchback). Lordosis is an increased lumbar curvature (swayback). Osteoporosis is a metabolic bone disease that causes a decrease in quality and quantity of bone. Scoliosis is a lateral curvature of the spine. PTS: 1 DIF: A REF: 627 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 17. The best position for the nurse to position the client in order to auscultate the apical site, if a low-pitched murmur is suspected during prior assessment, is:

Sitting up

Standing

Lying on the left side Dorsal recumbent

ANS: 3 Extra heart sounds or heart murmurs are heard more easily with the client lying on the left side (lateral recumbent) with the stethoscope at the apical site. Sitting upright is used for assessing lung expansion and symmetry of the upper extremities. Standing is not the best position for

auscultating a heart murmur. The dorsal recumbent position is best used for abdominal assessment. PTS: 1 DIF: A REF: 559 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 18. As part of the examination, the nurse will be assessing the clients balance. The test that should be administered is the:

1 2

Weber test Allen test

Romberg test

Rinne test

ANS: 3 The Romberg test assesses the clients balance. The Weber test assesses for unilateral deafness. The Allen test assesses for patency of the arteries of the hand (usually before arterial puncture). The Rinne test compares bone conduction hearing with air conduction. PTS: 1 DIF: A REF: 636-637 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 19. Part of the neurological exam is evaluating the response of the cranial nerves. To test cranial nerve VIII, the nurse should:

Ask the client to read printed material

Assess the directions of gaze

Assess the clients ability to hear the spoken word

Ask the client to say ah

ANS: 3 To test cranial nerve VIII (auditory), the nurse should assess the clients ability to hear the spoken word. To test cranial nerve II (optic), the nurse should assess the clients ability to read printed material. To test cranial nerves III (oculomotor), IV (trochlear), and VI (abducens), the nurse should assess the clients directions of gaze. To assess cranial nerve X (vagus), the nurse should ask the client to say ah.

PTS: 1 DIF: A REF: 634 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 20. A student nurse is working with a client who has asthma. The primary nurse tells the student that wheezes can be heard on auscultation. The student expects to hear:

Coarse crackles and bubbling

High-pitched musical sounds

Dry, grating noises

Loud, low-pitched rumbling

ANS: 2 Wheezes are high-pitched, continuous musical sounds like a squeak heard continuously during inspiration or expiration; usually louder on expiration. Coarse crackles and bubbling are not descriptive of wheezes. Dry, grating noises are heard with a pleural friction rub. Loud, lowpitched rumbling is characteristic of rhonchi. PTS: 1 DIF: A REF: 596 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 21. The nurse instructs the male client that the protocol for testicular self-examination is to:

Perform the examination annually after age 35

Use both hands to roll the testicles and feel the consistency

Perform the examination before bathing or showering

Contact the physician if a cordlike structure is felt on the top and back of the testicle

ANS: 2 The nurse instructs the male client that the protocol for testicular self-examination is to use both hands to gently roll the testicle, feeling for lumps, thickening, or a change in consistency (hardening). All men 15 years and older should perform the testicular self-exam monthly. The examination should be performed after a warm bath or shower when the scrotal sac is relaxed. A cordlike structure on the top and back of the testicle is a normal finding. It is the epididymis. PTS: 1 DIF: A REF: 623 OBJ: Knowledge TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 22. The nurse uses olfaction in the clients assessment. If a sweet, fruity smell is noticed in the oral cavity, the nurse suspects:

Diabetic acidosis

Gum disease

Stomatitis

Malabsorption syndrome

ANS: 1 A sweet, fruity smell noticed in the oral cavity is indicative of diabetic acidosis. Halitosis of the oral cavity is indicative of gum disease. Stomatitis is characterized by oral pain, bad breath, inflammation, and oral ulcers in the mouth. Foul-smelling stools in the infant is indicative of malabsorption syndrome. PTS: 1 DIF: A REF: 557 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 23. A client with cardiopulmonary disease receives a physical examination performed by a nurse. Knowing the client history, the nurse is attentive when checking the nails for the presence of:

Clubbing

Paronychia

Beaus lines Splinter hemorrhages

ANS: 1 Clubbing of the nails is caused by a chronic lack of oxygen, such as occurs in heart or pulmonary disease. Paronychia is caused by local infection or trauma. Beaus lines are caused by systemic illness such as severe infection or by injury to the nail. Splinter hemorrhages are caused by minor trauma, subacute bacterial endocarditis, or trichinosis (infection by the roundworm). PTS: 1 DIF: A REF: 575 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

24. During the physical examination, the client tells the nurse that he has been told he has myopia. The nurse expects to find that the client:

1 2 3 4

Is nearsighted Has decreased peripheral vision Has diminished night vision Experiences more glare, flashes, and floaters

ANS: 1 Myopia is nearsightedness. Peripheral vision is not reduced with myopia. The client with myopia is able to see close objects, but not distant objects. Peripheral vision may be decreased in openangle glaucoma. Diminished night vision may occur with cataracts, not myopia. Problems with glare, flashes, and floaters may indicate eye disease and the client should be referred to a physician. PTS: 1 DIF: A REF: 577 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 25. The school-aged child is taken to the school nurse after experiencing a nosebleed during a softball game. The appropriate intervention is for the nurse to:

Have the child lean backward

Apply pressure to the anterior nose

Apply a warm cloth to the area Have the child close his mouth and blow his nose

ANS: 2 The nurse should have the child who is experiencing a nosebleed sit up and lean forward to avoid aspiration of blood, apply pressure to the anterior nose with the thumb and forefinger as the child breathes through the mouth, and apply ice or a cold cloth to the bridge of the nose if pressure fails to stop bleeding. The child should not lean backward as this may cause the child to aspirate blood. A cold cloth will slow bleeding and help blood to coagulate, not a warm cloth. The child should breathe through the mouth. Blowing his nose may only continue bleeding as it may disturb any clot formation PTS: 1 DIF: A REF: 586 OBJ: Comprehension TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 26. An older adult client is visiting the physicians office for a check-up. The client asks the nurse how often the influenza and pneumonia vaccines should be obtained. The nurse responds to the client that these vaccinations should be done:

Every 6 months

2 3

Annually Every 5 years

Every 7 years

ANS: 2 Older adults should be counseled to receive annual influenza and pneumonia vaccinations. It is not necessary to receive these vaccinations every 6 months. The influenza and pneumonia vaccines should be obtained annually in the older adult because of their greater susceptibility to respiratory tract infection. It is recommended that older adults receive the influenza and pneumonia vaccines annually because they have a greater susceptibility to respiratory tract infection. PTS: 1 DIF: A REF: Chapter 34, 649 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 27. A pregnant client is seen by the nurse in the antenatal clinic. On inspection, the nurse expects that this clients breasts will have:

Softer tissue

Flatter nipples

Darkened areola Diminished superficial veins

ANS: 3 Normal changes of the breasts during pregnancy include the areola becoming darker and the diameter increasing. Breast tissue becomes softer during menopause, not pregnancy. Nipples become flatter in older adulthood. Superficial veins become more prominent during pregnancy. PTS: 1 DIF: A REF: 612 OBJ: Comprehension TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 28. At a medical clinic, a client with vascular insufficiency is seen frequently. The nurse will give the client additional instruction about her condition if the client:

1 2 3 4

Walks regularly Wears knee-length stockings Elevates the feet when sitting Alternates periods of sitting and standing

ANS: 2 The client with risk or evidence of vascular insufficiency should not wear tight clothing over the lower body or legs, such as knee-length stockings. Walking regularly is recommended for the client with vascular insufficiency. The client with vascular insufficiency should elevate his or her feet when sitting. The client with vascular insufficiency should avoid sitting or standing for long periods. PTS: 1 DIF: A REF: 605 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 29. During the physical examination, the nurse should assess the clients glands by using the:

Dorsum of the hand

Pads of the fingers

Palmar surface of the hand

Fingertip grasp of the tissue

ANS: 2 To assess the clients glands, the nurse should use the pads of the fingers and palpate gently. The dorsum of the hand may be used to detect skin temperature, not to assess the clients glands. The palmar surface of the hand is not used to assess the clients glands. The nurse should not use a fingertip grasp of the tissue when assessing a clients glands. PTS: 1 DIF: A REF: 589 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

30. The nurse is evaluating the client for conduction deafness in the right ear. In using Webers test, the nurse appropriately places the tuning fork and confirms this type of deafness when:

1 2 3 4

Sound is not heard in either ear Sound is heard best by the client in the left ear Sound is heard best by the client in the right ear Sound is reduced and heard longer through air conduction

ANS: 3 In conduction deafness, sound is heard best in the impaired ear. Sound that is not heard in either ear is not indicative of conduction deafness. Sound would not be heard best by the client in the left ear if there was conduction deafness in the right ear. This option is describing the Rinnes test, not the Webers test. In conduction deafness, bone-conducted sound can be heard longer. In sensorineural loss, sound is reduced and heard longer through air. PTS: 1 DIF: A REF: 584 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 31. The presence of arterial insufficiency is suspected during an inspection of the lower extremities when the nurse observes:

Increased hair growth

Cooler skin temperatures

Marked edema

Brown pigmentation

ANS: 2 In the presence of arterial insufficiency, the client has signs resulting from an absence of blood flow, such as pain, pallor, and decreased or absent pulses in the lower extremities. The lower extremities become dusky red when the extremity is lowered. They feel cool to touch because blood flow is blocked to the extremity. Decreased hair growth or the absence of hair growth over the legs may indicate arterial insufficiency. Marked edema is seen in venous insufficiency, not arterial insufficiency. Brown pigmentation around the ankles is seen in venous insufficiency. Skin changes in arterial insufficiency include thin, shiny skin, decreased hair growth, and thickened nails. PTS: 1 DIF: A REF: 608 OBJ: Comprehension TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 32. The sounds heard over the trachea during the auscultation of the thorax, are expected to be:

1 2

Soft, low-pitched, and breezy Loud, high-pitched, and hollow

Moist, crackling, and bubbling

High-pitched and musical

ANS: 2 Sounds heard during auscultation over the trachea should be loud, high-pitched and hollow. Soft, low-pitched, and breezy sounds are heard over the lungs periphery. Moist, crackling, and bubbling sounds are adventitious sounds known as crackles and are caused by sudden reinflation of groups of alveoli and disruptive passage of air. They are most commonly heard in dependent lobes: right and left lung bases. High-pitched and musical sounds are wheezes. Wheezes can be heard over all lung fields. PTS: 1 DIF: A REF: 596 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 33. The nurse tests the function of the clients cranial nerves during the neurological component of the physical examination. In testing cranial nerve III, the nurse verifies the clients ability to:

Smile and frown

Read printed material

Identify sweet and sour tastes

React to light with changes in pupil size

ANS: 4 In testing cranial nerve III (oculomotor), the nurse determines the clients ability to react to light with changes in pupil size. Testing accommodation will also assess cranial nerve III. In testing cranial nerve VII (facial), the nurse determines the clients ability to smile and frown. In testing cranial nerve II (optic), the nurse determines the clients ability to read printed material. In testing cranial nerve IX (glossopharyngeal), the nurse determines the clients ability to identify sweet and sour tastes. PTS: 1 DIF: A REF: 634 OBJ: Knowledge TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 34. Which of the following statements made by a nurse reflects the best understanding of the health value of conducting a blood pressure (BP) screening at a senior citizens centers health fair?

This is a high risk group, so assessing BP allows us to identify clients at risk and send them for treatment.

Older adults enjoy health fairs, so its a good place to screen substantial numbers of clients for hypertension. Hypertension doesnt present symptoms early on, so screening elder adults is a wonderful preventive measure.

3 4

Blood pressure problems are common among this group, so its a good way to monitor the effectiveness of their medications.

ANS: 1 Health screenings focus on a specific physical problem. For example, blood pressure screenings detect the risk for high blood pressure. If this screening determines that a client has a risk for disease, the nurse refers the client for a more complete physical examination. While the other options are not incorrect, they do not show the most thorough understanding of the value of health screenings. PTS: 1 DIF: C REF: 553 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 35. Which of the following statements made by the RN preparing to conduct a clients initial health history shows the best understanding of the therapeutic objective of the interview?

Its all about finding out what the problems are and discovering the best way to fix them.

Clients are more comfortable when you take the time to get to know them and their problems. I use it as an opportunity to show the client that his care is very important to the hospitals staff.

3 4

It is the most appropriate way to initiate the therapeutic nature of the nurse-client relationship.

ANS: 1 The main objective of interacting with clients is to find out what their concerns are and to help them find solutions. While the other options are not incorrect, they do not express the primary objective of information gathering directed towards client care. PTS: 1 DIF: C REF: 553 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 36. A client reports pain in his left ankle since twisting it yesterday. Which of the following assessment findings best supports the clients claims of ankle pain?

The client grimaces when walking to the examination room.

The clients left ankle is swollen with noted bruising. The client reports a pain rating of 7 on a scale of 1 to 10.

3 4

The clients heart rate increases after walking to the examination room.

ANS: 2 A subsequent physical assessment can reveal information that refutes, confirms, or supplements the history. Think critically about the information the client provides, apply knowledge from previous clinical care, and methodically conduct the examination to create a clear picture of the clients status. The objective signs of swelling and bruising best support the possible spraining of the ankle and the resulting claim of pain. The increase in heart rate is subjective but can be a result of various factors, pain being only one. The remaining options reflect objective data. PTS: 1 DIF: C REF: 553 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 37. While bathing an elderly client who has limited abilities for self-care, the nurse notices several patches of dry skin on the clients heels, elbows, and coccyx. The nurse cleans and dries all the areas well and applies a moisturizing lotion. The most appropriate immediate follow-up by the nurse to ensure appropriate nursing care for this clients skin is to:

Revise the clients care plan to show the need for the application of moisturizing lotion

Assume personal responsibility to apply the moisturizing lotion daily to the clients skin

Encourage the client to tell whomever bathes her to apply the moisturizing lotion to her areas of dry skin

Inform the staff that the clients skin is showing signs of breakdown and moisturizing lotion needs to be applied daily

ANS: 1 The nurse revises the written care plan so that other nurses and nursing assistive personnel know the type of skin care to provide. The other options are less likely to convey the information effectively. PTS: 1 DIF: C REF: 553 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 38. Which of the following statements best reflects an understanding of the most effective means of showing nursing accountability for client care?

I always try to tailor client education to my clients care needs.

A clients care plan is never stagnate; it always needs updating.

Selecting the most appropriate interventions is the key to quality care.

By re-assessing the client regularly, I can tell if the interventions are working.

ANS: 4 Nurses demonstrate accountability for their nursing care through evaluating the results of nursing interventions. Nurses make accurate, detailed, objective measurements through physical assessment. These measurements determine whether the expected outcomes of care are met. The remaining options are correct but not as directly related to nursing accountability for effective client care. PTS: 1 DIF: C REF: 554 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 39. The nurse encourages the client to relax and take a deep, slow breath in order to prepare for a palpating assessment of the abdomen. The primary reason for this is to:

Encourage the client to be emotionally comfortable and relaxed

Distract the client from the actual possible discomfort the pressure may cause Facilitate the effectiveness of the palpating technique to detect abdominal masses

3 4

Allow the client an opportunity to cope with any bad feelings regarding the examination

ANS: 3 Before palpation, help the client relax and be comfortable because muscle tension during palpation impairs effective assessment. To promote relaxation, have the client take slow, deep breaths and place the arms along the side of the body. While the other options may be reasonable, they are not the primary reason for encouraging the client to relax. PTS: 1 DIF: C REF: 554 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 40. The nurse is about to palpate the clients abdomen to determine the margins of the liver. The primary reason for using the bimanual palpation method is to:

Minimize client discomfort

Minimize lower hand desensitivity

Assist in manipulation of the organ Facilitate quick assessment of the abdomen

ANS: 2 When using bimanual palpation, relax one hand (sensing hand) and place it lightly over the clients skin. Use the other hand (active hand) to apply pressure to the sensing hand. The lower hand does not exert pressure directly and thus remains sensitive to detect organ characteristics. This technique does assist in the effective, efficient assessment of the abdomen, but its primary purpose is directed towards hand sensitivity. PTS: 1 DIF: C REF: 555 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment

41. Which of the following statements made by a nursing student regarding assessment technique requires immediate follow-up by the clinical instructor?

I always rub my hands together before touching the client.

I found that both of the clients carotid arteries beat simultaneously.

It will take a lot of practice for me to be master the art of percussion. I always warm the stethoscopes diaphragm before listening for bowel sounds.

ANS: 2 Do not palpate a vital artery with pressure that obstructs blood flow nor assess both such arteries at the same time since this could result in a dangerous lack of blood flow to the brain. The remaining options are not inaccurate and so do not require immediate follow-up. PTS: 1 DIF: C REF: 602 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 42. The primary reason for encouraging a client to urinate before beginning a physical examination is:

It avoids stimulation of the bladder during palpation or percussion of the abdomen

It minimizes the possibility of urinary incontinence caused by embarrassment or awkward positioning

A full bladder can hinder the examination of the clients abdominal, genitalia, and rectal areas Voiding before the examination will encourage the client to relax, thus facilitating the assessment

ANS: 3 An empty bladder and bowel facilitate examination of the abdomen, genitalia, and rectum. The remaining options may be plausible reasons, but they are not the primary one. PTS: 1 DIF: C REF: 558 OBJ: Analysis TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 43. The nurse recognizes that which of the following clients should be thoroughly assessed for their ability to be safely placed in the supine position?

An 18-year-old who suffered a fractured elbow playing football

A 20-year-old hospitalized with abdominal pain to rule out an appendicitis

A 74-year-old client who requires 3 L of continuous oxygen via nasal cannula

A 37-year-old reporting complaints of vaginal bleeding between menstrual periods

ANS: 3 Clients who are experiencing any degree of respiratory distress will not find this position comfortable and should not be placed in this position because it will make breathing even more difficult. If the client becomes short of breath easily, raise the head of the bed. The other clients may not prefer this position, but there is no medical reason for avoiding it. PTS: 1 DIF: C REF: 558-589 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 44. A male nursing student is assigned to change the abdominal dressing of a 74-year-old female. The clinical nursing instructor asks that a female nurse assist him with the procedure. The primary reason for this decision is:

It diverts the clients attention during the assessment and procedure

It provides a third party to ensure proper conduct of all involved It facilitates a comfortable, efficient environment for the client

3 4

ANS: 2

It assists with the wound assessment and changing of the abdominal dressing

When the client and nurse are of opposite gender, it helps to have a third person of the clients gender in the room. The presence of a third person ensures the client that the examiner will behave ethically. This person is also a witness to the examiners conduct as well as the clients. While a second health care provider may be useful during the assessment and procedure, that is not the primary reason for their presence. PTS: 1 DIF: C REF: 560 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 45. The shift report states that a client has crackles in both lungs. Which statement by the nurse, preparing to assess the client, best reflects a thorough understanding of the recorded assessmentfinding?

1 2

I wonder if they are fine, medium, or coarse. Ill listen again and reassess after I ask him to cough.

That musical sound is hard to miss as they breathe out.

I wish it was recorded where in the lungs they were heard.

ANS: 2 Crackles are most common in dependent lobes: right and left lung bases. Fine crackles are highpitched, fine, short, interrupted crackling sounds heard during the end of inspiration and usually not cleared with coughing; medium crackles are lower, more moist sounds heard during the middle of inspiration and not cleared with coughing; and coarse crackles are loud, bubbly sounds heard during inspiration and not cleared with coughing. Reassessing and asking the client to cough provide the clearest understanding of this type of breath sound. Musical sounds are representative of wheezes, not crackles. PTS: 1 DIF: C REF: 596 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 46. The most appropriate method to use to assess a carotid artery for the presence of a bruit is to:

Palpate each artery lightly; first the right side and then the left

Have the client turn the head towards the side being auscultated

Place the bell of the stethoscope over the artery near the outer edge of the clavicle

Have the client hold the breath while auscultating with the stethoscope bell

ANS: 3 Place the bell of the stethoscope over the carotid artery at the lateral end of the clavicle and the posterior margin of the sternocleidomastoid muscle. Have the client turn the head slightly away from the side being examined. Ask the client to hold the breath for a moment so that breath sounds do not obscure a bruit. Normally you do not hear any sounds during carotid auscultation. Palpate the artery lightly for a thrill (palpable bruit) if you hear a bruit. PTS: 1 DIF: C REF: 603 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 47. The shift report states that a client has crackles in both lungs. Which statement by the nurse preparing to assess the client best reflects a thorough understanding of the recorded assessmentfinding?

I wonder if they are fine, medium or coarse.

Ill listen again and reassess after I ask him to cough.

That musical sound is hard to miss as they breathe out. I wish it was recorded where in the lungs they were heard.

ANS: 2 Crackles are most common in dependent lobes: right and left lung bases, Fine crackles are highpitched fine, short, interrupted crackling sounds heard during end of inspiration, usually not cleared with coughing. Medium crackles are lower, more moist sounds heard during middle of inspiration; not cleared with coughing and coarse crackles are loud, bubbly sounds heard during inspiration; not cleared with coughing. Reassessing and asking the client to cough provides the clearest understanding of this type of breath sounds. Musical sounds are representative of wheezes not crackles. PTS: 1 DIF: C REF: 553 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test Plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 48. The most appropriate method to use to assess for a carotid artery for the presence of a bruit is to:

Palpate each artery lightly; first the right side and then the left

Have the client turn the head toward the side being auscultated

Place the bell of the stethoscope over artery near outer edge of the clavicle Have the client hold the breath while auscultating with the stethoscope bell

ANS: 3 Place the bell of the stethoscope over the carotid artery at the lateral end of the clavicle and the posterior margin of the sternocleidomastoid muscle. Have the client turn the head slightly away from the side being examined. Ask the client to hold the breath for a moment so that breath sounds do not obscure a bruit. Normally you do not hear any sounds during carotid auscultation. Palpate the artery lightly for a thrill (palpable bruit) if you hear a bruit. PTS: 1 DIF: C REF: 553 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test Plan designation: Reduction of Risk Potential/Techniques of Physical Assessment MULTIPLE RESPONSE 1. The primary outcome for information collected during a nursing physical examination should be to: (Select all that apply.)

Establish the clients baseline of function Evaluate both nursing and client outcomes

Identify any changes in the clients health status

Provide rationale for client admission or discharge

Identify appropriate nursing diagnoses to determine nursing care

Determine accuracy of information obtained from the client interview

ANS: 1, 2, 3, 5, 6 Providing rationale for client admission or discharge is not an outcome of a nursing physical assessment. PTS: 1 DIF: C REF: 553 OBJ: Analysis TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 2. During the health history, the client reports back and knee pain. Which of the following interview questions should the nurse ask in order to further define the clients complaints? (Select all that apply.)

When did the pain start?

What, if anything, lessens the pain? Have you sought help for this pain before?

3 4 5

Can you describe the pain you feel to me? Is there anything that makes the pain worse?

Has the pain affected your ability to earn a living?

ANS: 1, 2, 4, 5 The health history involves a lengthy client interview to gather subjective data about the clients condition. Gather information about the clients health from the health history. The answers are questions designed to obtain subjective information related to the clients complaints. The remaining options are not of significant value related to the cause and treatment of the clients pain. PTS: 1 DIF: C OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 3. The nurse recognizes the importance of an accurate, thorough physical assessment and health history. Which of the following facets of care are directly dependent on the database of information collected? (Select all that apply.)

1 2 3

Identification of client likes and dislikes Support of the nurse-client relationship

Selection of client-centered interventions Revision of client care plan as appropriate

Evaluation of nursing and client outcomes

Identification of appropriate nursing diagnosis

ANS: 3, 4, 5, 6

The accuracy of the database allows for the development of an individualized nursing diagnosis. Physical assessment findings determine the etiology of the diagnosis so that the selection of interventions is appropriate for the care plan. Physical assessment is ongoing, and thus the care plan changes with the clients condition. Monitor the clients progress and responses to therapies to review existing diagnoses and identify new problems. PTS: 1 DIF: C REF: 554 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 4. Which of the following health history and physical assessment findings place an elderly client admitted for abdominal pain at risk for infection? (Select all that apply.)

1 2 3

Redness at the IV site Productive yellow cough

Foley catheter placement History of bipolar disorder

Oral temperature of 98.8 F

Recent radiation for prostate cancer

ANS: 1, 2, 3, 6 Learn to group significant findings into clusters of data that reveal actual or risk for nursing diagnoses. A history of bipolar disorder and an oral temperature of 98.8 F do not indicate the client is at risk for an infection. PTS: 1 DIF: C REF: 563 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 5. Which of the following nursing actions best shows an understanding of the guiding principles regarding the inspection method of physical assessment? (Select all that apply.)

Positioning the client so as to expose body parts adequately but with attention to modesty

Providing a general survey of the clients body, area by area and extremity by extremity

Comparing each area inspected with the same area on the opposite side of the clients body

Evaluating each body area for size, shape, color, symmetry, position, and abnormalities

Providing sufficient lighting to ensure adequate visualization of the clients body during the assessment Conducting the assessment in a time conscious manner to minimize the clients physical and emotional discomfort

ANS: 1, 3, 4, 5 The inspection portion of the assessment is detail-oriented and must be done thoroughly, which may be time-consuming. PTS: 1 DIF: C REF: 596 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 6. A 76-year-old adult female is brought to a neighborhood client after being found wandering around the local park. The client appears disheveled and reports being hungry. Which of the following assessment and interview findings would cause the nurse to suspect elder abuse? (Select all that apply.)

Keeps asking when she can go

Repeatedly states, Dont hurt me.

Chafing around wrists and ankles

4 5

Bruises in various stages of healing Falls asleep in the examination room

Cant name the President of the United States

ANS: 2, 3, 4 These findings and behaviors are consistent with those exhibited by older adults who have experienced physical and/or emotional abuse. The remaining options are not as directly connected with abuse and may be a result of other physical or cognitive disorders. Chapter 31. Medication Administration MULTIPLE CHOICE 1. A client is nauseated, has been vomiting for several hours, and needs to receive an antiemetic (anti-nausea) medication. The nurse recognizes that which of the following is accurate?

An enteric-coated medication should be given.

2 3 4

Medication will not be absorbed as easily because of the nausea. A parenteral route is the route of choice. A rectal suppository must be administered.

ANS: 3 The parenteral route provides a means of administration when oral medications are contraindicated. Onset of action is quicker. There is less cause for embarrassment than with a rectal suppository. An enteric-coated medication is given orally. Because the client is vomiting, the oral route should not be used. Nausea does not affect the rate of absorption. It is inaccurate to state that a rectal suppository must be administered. A rectal suppository is one option. The disadvantage of a rectal suppository is that insertion often causes embarrassment for the client. It is contraindicated if there is rectal bleeding or if the client had rectal surgery. Stool in the rectum can impair absorption. DIF: A REF: 694 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 2. The client receiving an intravenous infusion of morphine sulfate begins to experience respiratory depression and decreased urine output. This effect is described as:

Therapeutic Toxic

Idiosyncratic

Allergic

ANS: 2 Toxic levels of morphine may cause severe respiratory depression. Toxic effects may develop after prolonged intake of a medication or when a medication accumulates in the blood because of impaired metabolism or excretion. The client with a decreased urine output is not excreting the morphine. The therapeutic effect is the expected or predictable physiological response a medication causes. Respiratory depression and decreased urine output are not the desired (i.e., therapeutic) effects of morphine. An idiosyncratic effect is when a medication causes an unpredictable outcome, such as when a client overreacts or underreacts to a medication. This is not an example of an idiosyncratic effect. When a client experiences an allergic response to a medication, the medication acts as an antigen, triggering the release of the bodys antibodies. The client may experience itching,

urticaria, or a rash, or, in more severe cases, may have difficulty breathing. The clients response to morphine is not an example of an allergic effect. DIF: A REF: 691 OBJ: Comprehensive TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 3. The client is to receive a medication via the buccal route. The nurse plans to implement which of the following actions?

1 2

Place the medication inside the cheek. Crush the medication before administration.

Offer the client a glass of orange juice after administration.

Use sterile technique to administer the medication.

ANS: 1 Administration of a medication by the buccal route involves placing the solid medication in the mouth and against the mucous membranes of the cheek until the medication dissolves. Crushing the medication is not necessary because it is designed to dissolve in the clients cheek. Clients are not to take any liquids with, or immediately after, medications given by buccal administration. The mouth is not sterile. Sterile technique is not necessary for buccal administration. DIF: A REF: 693 OBJ: Comprehensive TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 4. The physician orders a grain and a half of Seconal to help a client sleep. The label on the medication bottle reads Seconal 100 mg. How many capsules should the nurse give the client?

1 2

3 4

ANS: 2 To calculate this problem, the nurse should first convert the measurements to one system. Because 1 grain = 60 mg, the nurse may multiply 1 by 60 to equal 90 mg. The nurse may then use the following formula for calculating a drug dosage: 90 mg

100 mg x 1 capsule = 0.9 capsules Because 0.9 of a capsule cannot be administered, it is rounded to 1 capsule. The nurse will administer 1 capsule. Options 1 and 3 are not correct dosage calculations. Furthermore, capsules cannot be halved. Option 4 is not a correct dosage calculation. DIF: B REF: 696 OBJ: Application TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 5. The physician has ordered 6 mg of morphine sulfate every 3 to 4 hours prn for a clients postoperative pain. The unit dose in the medication dispenser has 15 mg in 1 mL. How much solution should the nurse give?

1/5 mL

2 3

1/3 mL 2/5 mL

1/4 mL

ANS: 3 The nurse should use the following formula to calculate a drug dosage: 6 mg 15 mg x 1 mL = 2/5 mL Options 1, 2, and 4 are not correct dosage calculations. DIF: B REF: 697 OBJ: Application TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 6. To determine proper drug dosages for children, calculations are most precisely made on the basis of the childs:

Weight

Height

Age Body surface area

ANS: 4 The most accurate method of calculating pediatric doses is based on a childs body surface area.

Drug calculations are not most precise when made on the basis of a childs weight. Height and weight do not always correlate with the maturity of the childs organs, such as the liver for metabolizing a drug. Drug calculations are not most precise when made on the basis of a childs height. Drug calculations are not most precise when made on the basis of a childs age. Children vary widely in size and maturity for chronological age. DIF: A REF: 698 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 7. The nurse is documenting administration of a medication that is given at 10:00 AM, 2:00 PM, and 6:00 PM. The medication that the nurse is documenting is:

1 2 3 4

Morphine sulfate 10 mg q4h prn Inderal 10 mg PO bid Diazepam 5 mg PO tid Keflex 500 mg PO q8h

ANS: 3 The medication is being given 3 times a day, 4 hours apart. The medication the nurse is documenting is diazepam 5 mg PO tid. Although the medication is being given 4 hours apart, it is not being given every 4 hours. If it were given every 4 hours, it could be given 6 times in 24 hours, not 3, as with tid administration. Bid means twice a day. The client is receiving the medication 3 times a day. The medication is not administered every 8 hours. DIF: A REF: 699 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 8. The nurse is working on the pediatric unit. In preparing to give medications to a preschool-age child, an appropriate interaction by the nurse is:

Do you want to take your medication now?

Would you like the medication with water or juice?

Let me explain about the injection that you will be getting.

If you dont take the medication now, you will not get better.

ANS: 2

Allowing the child the choice of taking a medication with water or juice may have greater success because the child is involved. The child should not be given the option of not taking a medication. The nurse should explain the procedure to a child, using short words and simple language appropriate to the childs level of comprehension. Long explanations may increase a childs anxiety. Option 4 is not a motivation for a child to take a prescribed medication. Giving the child a star or token afterward would be more motivating for a child. DIF: A REF: 715 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 9. In preparing two different medications from two vials, the nurse must:

Inject fluid from one vial into the other

Uncap the syringe and wipe the needle with an alcohol preparation before inserting into either vial

Discard the medication from vial number 2 if medication from vial number 1 is pushed into it Insert air into the first vial, but not the second vial

ANS: 3 If a vial becomes contaminated with another medication, it should be discarded. Fluid from one vial should not be injected into another, as it would contaminate the second vial. The needle should not be wiped with alcohol. It is considered sterile and does not require to be wiped with alcohol. Wiping the needle would place the nurse at risk for a needle stick. Air should be inserted into both vials, making sure the needle does not touch the solution in the first vial. DIF: B REF: 715 OBJ: Application TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 10. The nurse is teaching the client how to prepare 10 units of regular insulin and 5 units of NPH insulin for injection. The nurse instructs the client to:

Inject air into the regular insulin and then into the NPH insulin

Withdraw the regular insulin first

Inject air into and withdraw the NPH insulin immediately

Inject air into both vials and withdraw the regular insulin first

ANS: 4 The client should be taught to inject air into both vials and withdraw the regular insulin first. Air should be injected into the vial of NPH insulin and then the vial of regular insulin. The regular insulin should be withdrawn after air has been injected into both vials. Air should be injected into the vial of NPH insulin and then the vial of regular insulin. The regular insulin should be withdrawn immediately after injecting the air into the vial of regular insulin. The NPH insulin is then withdrawn. DIF: A REF: 742 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 11. A client has a prescription for a medication that is administered via an inhaler. To determine if the client requires a spacer for the inhaler, the nurse will determine the:

Dosage of medication required

Coordination of the client

Schedule of administration

Use of a dry powder inhaler

ANS: 2 Spacers are especially helpful when the client has difficulty coordinating the steps involved in self-administering inhaled medications. The use of a spacer is not dependent on the dosage of medication. The use of a spacer is not dependent on the schedule of administration. Spacers are not required with the use of a dry powder inhaler. DIF: A REF: 729 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 12. The student nurse reads the order to give a 1-year-old client an intramuscular injection. The appropriate and preferred muscle to select for a child is the:

Deltoid

Dorsogluteal

Ventrogluteal

Vastus lateralis

ANS: 3

Research that has investigated complications associated with IM injection sites indicates that the ventrogluteal site is the preferred site for most injections given to adults and children over 7 months. The deltoid muscle is not developed enough for an IM injection in the 1-year-old client. The dorsogluteal site is not recommended because of the risk of the needle hitting the sciatic nerve. The vastus lateralis is a preferred site for infants less than 12 months old. DIF: A REF: 751 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 13. The nurse administers the intramuscular medication of iron by the Z-track method. The medication was administered by this method to:

1 2 3 4

Provide faster absorption of the medication Reduce discomfort from the needle Provide more even absorption of the drug Prevent the drug from irritating sensitive tissue

ANS: 4 The Z-track method is used to minimize local skin irritation by sealing the medication in muscle tissue. The Z-track method does not provide faster absorption of the medication. The Z-track method does not reduce discomfort from the needle. The Z-track method does not provide a more even absorption of the drug. DIF: A REF: 753 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 14. The client is ordered to have eye drops administered daily to both eyes. Eye drops should be instilled on the:

Cornea

Outer canthus

Lower conjunctival sac

Opening of the lacrimal duct

ANS: 3 Eye drops should be instilled into the lower conjunctival sac. The conjunctival sac normally holds 1 or 2 drops and provides even distribution of medication across the eye. The cornea is

very sensitive. If drops were instilled onto the cornea it would stimulate the blink reflex. The outer canthus would not hold the eye drop, medication would be wasted, and it would not be distributed evenly across the eye. The opening of the lacrimal duct is not the correct site for eye drops to be instilled. It would not provide even distribution of drops across the eye, and medication would most likely be wasted because this area could not contain the drops. DIF: A REF: 723 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 15. Following the administration of ear drops to the left ear, the client should be positioned:

Prone

2 3

Upright Right lateral

Dorsal recumbent with hyperextension of the neck.

ANS: 3 The client should remain in the side-lying position, in this case the right lateral position, for 2 to 3 minutes after ear drops are administered. The prone position is not recommended following administration of ear drops. The upright position is not recommended following ear drop administration. The ear drops would run out of the ear canal. The dorsal recumbent position with the neck hyperextended is not recommended following the administration of ear drops. DIF: A REF: 728 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 16. The order is for eye medication, ii gtt OD. The nurse administers:

2 mL to the right eye

2 drops to the left eye

2 drops to the right eye

2 drops to both eyes

ANS: 3 ii = 2; gtt = drops. OD = right eye. gtt is the abbreviation for drops, not mL. OS = left eye. OU = both eyes.

DIF: A REF: 723 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 17. The most effective way in the acute care environment to determine the clients identity before administering medications is to:

Ask the clients name

Check the name on the chart

Ask the other caregivers

Check the clients name band

ANS: 4 To identify a client correctly, the nurse checks the medication administration form against the clients identification bracelet and asks the client to state his or her name to ensure that the clients identification bracelet has the correct information. The nurse may ask the client his or her name if the identification bracelet is missing or illegible and obtain a new identification bracelet for the client. The nurse should ask the client to state his or her full name. The nurse should not merely say the clients name and assume that the clients response indicates that he or she is the right person. Checking the name on the chart does not identify the right client. Asking other caregivers is not the most effective way to determine a clients identity before administering medications. The nurse should develop the habit of checking the clients name band. DIF: A REF: 708 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 18. An order is written for Demerol 500 mg IM q3-4h prn for pain. The nurse recognizes that this is significantly more than the usual therapeutic dose. The nurse should:

Give 50 mg IM as it was probably intended to be written

Refuse to give the medication and notify the nurse manager

Administer the medication and watch the client carefully

Call the prescriber to clarify the order

ANS: 4 The nurse should question the order if the written order is illegible, the dose seems unusually low or high, or the medication seems inappropriate for the clients condition. The nurse should call the prescriber to clarify the order. The nurse cannot independently change physicians orders. The

nurse would have to call the prescriber and receive the order for the change. The nurse should first call the prescriber and clarify the order. If the prescriber does not change the order, the nurse may then refuse to give the medication and notify the nurse manager. The nurse could be held accountable for administering an ordered medication that is knowingly inappropriate for the client. DIF: B REF: 705 OBJ: Application TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 19. An order is written for 80 mg of a medication in elixir form. The medication is available in 80 mg/tsp strength. The nurse prepares to administer:

1 2 3 4

2 mL 5 mL 10 mL 15 mL

ANS: 2 The nurse should first change the household measurement to a metric equivalent (5 mL = 1 tsp). Then the nurse should use the formula for calculating a medication dosage: 80 mg 80 mg 5 mL = 5 mL Option 1 is an incorrect dosage. Option 3 is an incorrect dosage. 10 mL would equal 2 teaspoons, in this case, 160 mg. Option 4 is an incorrect dosage. 15 mL would equal 3 teaspoons, in this case, 240 mg. DIF: B REF: 696-698 OBJ: Application TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 20. The client is to receive a Mantoux test for tuberculosis. This test is administered via an intradermal injection. The nurse recognizes that the angle of injection that is used for an intradermal injection is:

15 degrees

30 degrees

45 degrees

90 degrees

ANS: 1 The angle of injection for an intradermal injection is 5 to 15 degrees. 30 degrees is not the correct angle of injection. Subcutaneous injections may be administered at a 45-degree angle. Subcutaneous or intramuscular injections may be administered at a 90-degree angle. DIF: A REF: 753 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 21. The nurse prepares to administer an intradermal injection for the administration of medication for:

Pain

Allergy sensitivity

Anticoagulant therapy

Low-dose insulin requirements

ANS: 2 Pain medications are not administered intradermally. Intradermal injections are typically given for allergy testing or tuberculin screening. Anticoagulants are not administered intradermally. They are typically given subcutaneously. Intradermal injections are not used for low-dose insulin requirements. DIF: A REF: 753 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 22. The nurse is evaluating the integrity of the ventrogluteal injection site. The nurse finds the site by locating the:

Middle third of the lateral thigh

Greater trochanter, anterior iliac spine, and iliac crest

Anterior aspect of the upper thigh

Acromion process and axilla

ANS: 2 The nurse finds the ventrogluteal site by locating the greater trochanter with the heel of the hand, the anterior iliac spine with the index finger, and the iliac crest with the middle finger. The vastus

lateralis site is found by locating the middle third of the lateral thigh. The anterior aspect of the thigh may be used for subcutaneous injections; it is not how the ventrogluteal site is located. The acromion process and axilla may be used to locate the deltoid site. DIF: A REF: 751 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 23. The client is to receive heparin by injection. The nurse prepares to inject this medication in the clients:

Scapular region

Vastus lateralis

Posterior gluteal

Abdomen

ANS: 4 The abdomen is the site most frequently recommended for heparin injections is the abdomen.The scapular areas may be used for subcutaneous injections, but it is not recommended site for heparin injections. The vastus lateralis is used for intramuscular injections, not subcutaneous injections. The posterior gluteal site is not recommended for heparin injections. DIF: A REF: 750 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 24. A medication is prescribed for the client and is to be administered by IV bolus injection. A priority for the nurse before the administration of medication via this route is to:

Set the rate of the IV infusion

Check the clients mental alertness

Confirm placement of the IV line

Determine the amount of IV fluid to be administered

ANS: 3 A priority for the nurse before the administration of medication via the IV route is to confirm placement of the IV line. Confirming the placement of the IV catheter and the integrity of the surrounding tissue ensures that the medication is administered safely. The nurse should first confirm placement of the IV line. The nurse should first confirm placement of the IV line before

administering a medication by the IV route. The clients mental alertness may be something the nurse monitors after medication administration. The nurse should first confirm placement of the IV line before administering any IV fluids. DIF: C REF: 755 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 25. A client on the medical unit receives regular insulin at 7:00 AM. The nurse is alert to a possible hypoglycemic reaction by:

7:30 AM

10:00 AM

4:00 PM

8:00 PM

ANS: 2 Regular insulin reaches its peak in 2 to 4 hours after administration. If the client received regular insulin at 7:00 AM, the nurse should be alert for a possible hypoglycemic reaction from 9:00 AM to 11:00 AM. Regular insulin has an onset in 30 minutes. Intermediate-acting insulin (i.e., NPH insulin) would peak in 6 to 12 hours, not regular insulin. The client would not be at risk for a hypoglycemic reaction from regular insulin 13 hours after administration. Long-acting insulin would have an effect this length of time after administration. DIF: A REF: 743 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 26. A priority for the nurse in the administration of oral medications and prevention of aspiration is:

Checking for a gag reflex

Allowing the client to self-administer

Assessing the ability to cough Using straws and extra water for administration

ANS: 1 To protect the client from aspiration, the nurse should determine the presence of a gag reflex before administering oral medications. The nurse should first check for a gag reflex. Then, if

possible, the client should be allowed to self-administer oral medications. Checking for a gag reflex takes priority over assessing the ability to cough in preventing aspiration. Straws should be avoided because they decrease the control the client has over volume intake, which increases the risk of aspiration. Some clients cannot tolerate thin liquids such as water, and need for them to be thickened. DIF: C REF: 717 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 27. The nurse is to administer several medications to the client via the N/G tube. The nurses first action is to:

1 2 3 4

Add the medication to the tube feeding being given Crush all tablets and capsules before administration Administer all of the medications mixed together Check for placement of the nasogastric tube

ANS: 4 The nasogastric tube should be verified for placement before administering any medication through it. Medications should never be added to the tube feeding. Not all tablets can be crushed, such as sustained release tablets, nor all capsules should be opened. Medications should be reviewed carefully before crushing a tablet or opening a capsule. Medications should be dissolved and administered separately, flushing between 1 and 30 mL of water between each medication. DIF: C REF: 740 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 28. The nurse is administering an injection at the ventrogluteal site. On aspiration, the nurse notices that there is blood in the syringe. The nurse should:

Inject the medication

Pull the needle back slightly and inject the medication

Move the skin to the side and inject the medication slowly

Discontinue the injection and prepare the medication again

ANS: 4

If blood appears in the syringe, the nurse should remove the needle and dispose of the medication and syringe properly. The nurse should then prepare another dose of medication for administration. The medication should not be injected, as it would be entering a blood vessel. The needle should not be pulled back slightly and then injected, as there is no assurance of the needle being out of the vessel. The medication should not be injected, because there is no assurance of the needle being out of the vessel. DIF: A REF: 751 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 29. A 3-year-old child is to receive an iron preparation orally. The nurse should:

1 2 3 4

Use a straw Administer the medication by injection Mix the medication in water Ask the pharmacy to send up a pill for the child to swallow

ANS: 1 Straws may help children swallow pills. If it is a liquid iron preparation, the straw may help the child as they are less able to see the medication and may see drinking from a straw as desirable. The child is to receive the medication orally. The oral route is preferred unless contraindicated. The medication should not be mixed with water as the child may refuse to drink all of the larger mixture, and water does not mask the flavor of the medication. Juice, a soft drink, or a frozen juice bar may be offered after a medication is swallowed. Many 3-year-olds have difficulty swallowing pills, and liquid forms are safer to swallow to avoid aspiration. DIF: A REF: 715 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 30. The client has an order for 30 units of U-500 insulin. The nurse is using a U-100 syringe and will draw up and administer:

5 units

6 units

10 units 30 units

ANS: 2 U-500 insulin is 5 times as strong as U-100 insulin. Therefore the amount of U-500 insulin should be divided by 5. 30 units of U-500 insulin 5 = 6 units of insulin to draw into a U-100 syringe. Options 1, 3, and 4 are incorrect dosages. DIF: B REF: 742 OBJ: Application TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 31. The nurse is preparing to administer 8 mg of a 10 mg dose of an intravenous narcotic. Which of the following statements made by the nurse best reflects an understanding of the appropriate manner to handle this situation?

I will sign out the narcotic before the end-of-shift count is completed.

I need to get another RN to witness the waste and sign the narcotic sheet.

Narcotics are expensive, so it makes sense to save the unused portion for the next time they need the drug.

I always make sure someone sees me place the unused portion on the narcotic in the sharps container.

ANS: 2 If a nurse gives only part of a premeasured dose of a controlled substance, a second nurse witnesses disposal of the unused portion. If paper records are kept, both nurses sign their names on the form. Do not place wasted portions in the sharps containers. Instead, flush wasted portions of tablets down the toilet and wash liquids down the sink. Unused portions of narcotics must not be saved. DIF: C REF: 688 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 32. The nurse is caring for a client who is experiencing severe pain and is insistent about getting some relief quickly. Which of the following prescriptions is most likely to produce the quickest pain relief?

Percodan orally

Lidocaine topically

Demerol intramuscularly

Morphine sulfate intravenously

ANS: 4 Each route of medication administration has a different rate of absorption. When applying medications on the skin, absorption is slow because of the physical makeup of the skin. Medications placed on the mucous membranes and respiratory airways are quickly absorbed because these tissues contain many blood vessels. Because orally administered medications pass through the gastrointestinal tract, the overall rate of absorption is usually slow. Intravenous (IV) injection produces the most rapid absorption because medications are immediately available when they enter the systemic circulation. DIF: A REF: 689 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 33. A 78-year-old client with congestive heart failure (CHF) is reporting vascular pain in his lower legs and requests his oral narcotic analgesic. The nurse recognizes that the clients pain relief will be negatively affected primarily because of:

The clients age

2 3

The systemic effects of CHF The route of administration

The status of the peripheral vessels

ANS: 2 Clients with congestive heart failure have impaired circulation, which impairs medication delivery to the intended site of action. Therefore the efficacy of medications in these clients is delayed or altered. The other options reflect possible barriers, but they are not as directly responsible as is the hearts functional capacity DIF: C REF: 689 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 34. The nurse is aware that which of the following clients is at greatest risk for developing medication toxicity?

The 16-year-old anorexic

The 35-year-old with liver cancer

The 45-year-old chronic alcoholic The 73-year-old diagnosed with hepatitis B

ANS: 4 The degree to which medications bind to serum proteins such as albumin affects medication distribution. Older adults have a decrease in albumin levels in the bloodstream, probably caused by a change in liver function. The same is true for clients with liver disease or malnutrition. Because of the potential for more medication being unbound, some older adults are at risk for an increase in medication activity or toxicity or both. DIF: C REF: 691 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 35. A 20-year-old diagnosed with Crohns disease is experiencing severe pain and is requesting the prescribed morphine as often as it can be administered. The nurse is particularly concerned about opioid toxicity because of:

The clients frequent requests for the narcotic The clients compromised bowel absorption

The drugs seeming inability to control the clients pain

The drugs ability to produce marked respiratory depression

ANS: 2 Toxic effects develop after prolonged intake of a medication or when a medication accumulates in the blood because of impaired metabolism or excretion. For example, toxic levels of morphine, an opioid, cause severe respiratory depression and death. This clients gastrointestinal problem puts her at particular risk. The remaining options, while not incorrect, are not the primary cause for concern related to toxicity. DIF: C REF: 691 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 36. The nurse recognizes which of the following clients as being at greatest risk for anaphylactic shock?

A 69-year-old client receiving an antibiotic for a respiratory tract infection

A 45-year-old prescribed a decongestant as needed for seasonal allergies A 50-year-old client prescribed a therapeutic dose of an antihypertensive medication

3 4

A 26-year-old receiving intravenous steroids for the initial flare-up of rheumatoid arthritis

ANS: 1 Among the different classes of medications, antibiotics cause a high incidence of allergic reactions. DIF: C REF: 691 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 37. During the admission interview a client shares with the nurse that she is allergic to latex. The nurses immediate response is to:

Place an allergic to latex sticker on the clients Kardex

Verbally notify the staff of the clients allergy to latex

Notify the clients health care provider of the clients allergy to latex Place an identification bracelet on the client that identifies the latex allergy

ANS: 4 The client needs to wear an identification bracelet that alerts nurses and physicians to the allergy. While the other options are not incorrect, the application of the identification bracelet has priority. DIF: C REF: 691 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies

38. A client is observed swallowing a chewable form of aspirin. Which of the following statements made by the nurse shows the best understanding of the educational reinforcement needed by this client?

This aspirin is designed to be chewed, not swallowed.

This aspirin will not give you the desired effects if its swallowed. I realize that you usually swallow aspirin, but this form only works if its chewed.

3 4

I can see if your health care provider will order your aspirin in a form that can be swallowed.

ANS: 3 A medication given by the sublingual route should not be swallowed because the medication will not have the desired effect. The option suggesting a change in the medication routine is not necessarily appropriate while the remaining options do not give the client the total explanation. DIF: C REF: 693 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 39. To minimize the risk for injury to the oral mucosa, a client ordered a buccally administered medication is instructed to:

Alternate cheeks with each subsequent dose

Swallow the medication with a full glass of liquid

Chew the medication thoroughly before swallowing Avoid allowing the medication to dissolve on the tongue

ANS: 1 Administration of a medication by the buccal route involves placing the solid medication in the mouth and against the mucous membranes of the cheek until the medication dissolves. Teach clients to alternate cheeks with each subsequent dose to avoid mucosal irritation. The remaining options provide information that is not correct for the buccal route of medication administration DIF: A REF: 693 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies

40. To best prevent a systemic effect from a topically applied medication patch, the nurse must:

1 2

Alternate application sites regularly Avoid applying the medication to broken skin

Monitor the client for signs of an irritating rash

Remove residual medication with mild soap and water

ANS: 2 Systemic effects often occur if a clients skin is thin or broken, if the medication concentration is high, or if contact with the skin is prolonged. The remaining options are more directed towards preventing skin irritations. DIF: C REF: 695 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 41. The nurse assigns ancillary personnel the task of giving a client a pre-procedure enema. Which of the following statements made by the personnel requires immediate follow-up by the nurse?

I use all of the soap provided in the kit.

The soapy water just came right back out.

An enema is intended to clean out the rectum.

The client was able to hold the enema for 5 minutes.

ANS: 2 An enema is an example of an instillation whereby the fluid is retained for a period of time to facilitate a therapeutic response. What the ancillary personnel was describing was an irrigationthe liquid runs over or into the area and is allowed to immediately flow away. Options 1, 3, and 4 are correct and do not require follow-up. DIF: C REF: 729 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 42. Research has shown that the primary reason nurses make medication errors is related to:

The complexity of making accurate drug calculations

Events that distract the nurse during the administration process

The presence of multiple drugs with similar generic and trade names

Heavy client assignments that require massive medication administrations

ANS: 2 Many medication errors occur when nurses become distracted or lose focus during medication administration. While the remaining options may reflect risks for medication errors, the primary factor continues to be distractions that cause the nurse to fail to follow the established protocol for drug administration. DIF: C REF: 705 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 43. The nurse has taken a verbal order for a narcotic medication to be given to a client experiencing severe pain related to metastatic cancer of the bone. The nurses initial action regarding the order is to:

Prepare the medication for administration to the client

Properly sign for the narcotic analgesic in the narcotic records

Notify the client that a verbal order for a narcotic pain medication has been received

Write and then sign the complete order in the appropriate location in the clients chart

ANS: 4 All verbal orders should be converted immediately to writing and signed by the individual receiving the order. While the remaining options are not incorrect, they are not the immediate priority. DIF: C REF: 699 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 44. During the admission interview the client reports to the nurse that she is a little allergic to penicillin. Which of the following questions asked by the nurse is most likely to provide the most relevant information regarding the clients possible allergy to penicillin?

Who told you that you are allergic to penicillin?

What makes you think you are allergic to penicillin? Can you describe what happens when you take penicillin?

3 4

What do you take for an infection since you are allergic to penicillin?

ANS: 3 This question best allows for the client to describe the reaction and then affords the nurse the opportunity to assess the described reaction to determine the likelihood that it is an allergic reaction. DIF: C REF: 710 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 45. Policies for the proper storage and distribution of narcotics within a health care organization are written by:

Federal government

State government

Local governmental bodies

Health care organization

ANS: 4 Institutional policies are often more restrictive than governmental controls, but are written to at least meet the governmental regulations. Although the federal, state, and local governments have regulations that must be followed regarding the proper storage and distribution of narcotics, the individual health care organizations must establish their own policies to meet these regulations. DIF: C REF: 704 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection Control 46. The nurse is administering morphine sulfate to a client for pain. The order has been written so that the nurse can chose from several routes of administration. The nurse knows that the morphine sulfate be most rapidly absorbed by which of the following routes?

Oral

IM Rectal

ANS: 2 IV injections produce the most rapid absorption because they are immediately available when they enter systemic circulation. Oral medication must pass through the GI tract, making absorption slow. IM medications must be absorbed by the blood flow to the site of the injection, making it slower than IV. Rectal medications must be absorbed through the rectal mucosa are fairly quickly absorbed due to the many blood vessels within the tissue. DIF: A REF: 709 OBJ: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological and Parenteral Therapies 47. On beginning the administration of 500 mg of aztreonam IV to a client with a urinary tract infection, the client complains of difficulty breathing. The nurse quickly identifies this as a symptom of a(n):

Therapeutic effect

Anaphylactic reaction

Idiosyncratic reaction

Medication interaction

ANS: 2 Anaphylactic reactions are characterized by sudden constriction of bronchiolar muscles. Therapeutic effect is what is expected physiological response. Idiosyncratic reactions are those in which a client overreacts or underreacts to a medication or has a reaction different than normal. Medication interactions are when one medication modifies the action of another medication. DIF: A REF: 688 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological and Parenteral Therapies 48. In the event of a medication error, the nurses first responsibility is to:

Contact the physician

Fill out an incident report

Notify their supervisor

Ensure the clients safety

ANS: 4 The clients safety and well-being are the top priority. The nurse is responsible for contacting the physician, notifying the supervisor, and documenting the event only after assessing and examining the clients condition. DIF: A REF: 691 OBJ: Knowledge TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological and Parenteral Therapies 49. The nurse prepares to administer a table to a client who has difficulty swallowing pills. The nurse decides to crush the tablet and mix it with food. The nurse should mix the crushed medication:

In a large amount of food to mask the taste

With the clients favorite food

With grapefruit juice

In a very small amount of food

ANS: 4 A very small amount of food or fluid should be used to mix the medication to ensure the client consumes the entire amount of medication. Do not use the clients favorite food because the medications may alter the taste and decrease the clients desire for them. Grapefruit juice can interfere with the absorption of some medications and should be avoided. DIF: C REF: 703 OBJ: Application TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological and Parenteral Therapies 50. The nurse prepares to administer a prn pain medication by IM injection. The client refuses the injection stating that I dont like shots. The best reaction by the nurse is to:

Contact the physician for pain medication to be given by a different route

Instruct the client that he or she needs to be brave and take the shot

Contact the nursing supervisor to talk with the client

Inform the client that the injection is the only route that the pain medication is ordered

ANS: 1 It is the right of the client to receive medications safely without discomfort in accordance with the six rights of medication administration. DIF: B REF: 704-705 OBJ: Application TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological and Parenteral Therapies 51. When teaching a pediatric clients parents about administering his medication at home, the nurse states that the most accurate device for measuring the liquid medication is:

Cup

2 3

Teaspoon Oral plastic disposable syringe

Dropper

ANS: 3 A plastic, disposable syringe is the most accurate device for preparing liquid doses, especially those less than 10 mL. A cup can be hard to gauge liquids unless placed on a flat surface to read. Teaspoons can vary in the amount of volume they hold. Droppers are less accurate than plastic disposable syringes for preparing liquid medications. DIF: B REF: 688 OBJ: Application TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological and Parenteral Therapies 52. The nurse is preparing to administer a nasal instillation of medication to a client. The best position for accessing the posterior pharynx is to place the client in a supine position and tilt the clients head:

Backward

Over the edge of the bed with the head to one side

Over a small pillow and back

In a chin-down position

ANS: 1 Placing the clients head backward will allow the instillation to drop into the posterior pharynx. Turning the head to one side will allow the instillation to go into the frontal and maxillary sinuses. Putting the head over a pillow and placing it back will instill the drops in the ethmoid or sphenoid sinuses. A chin-down position will not allow the medication to enter the posterior pharynx. DIF: B REF: 689 OBJ: Application TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological and Parenteral Therapies 53. The nurse has an order for 325 mg acetaminophen p.r. q4h prn for pain for a 7-year-old client who has had surgery. In preparing the client for insertion of the suppository, the client states that she feels the need to have a bowel movement. The nurses best response is to:

1 2

Insert the suppository, knowing that it will dissolve quickly Allow the client to defecate first to clear the rectum of stool

Explain to the client that it is normal to feel the urge to defecate when a suppository is inserted into the rectum, but the urge will pass

Hold the medication and contact the physician for a p.o. order

ANS: 2 By allowing the client to defecate before the suppository being inserted, the nurse knows that absorption will be facilitated. Placing the suppository into a mass of fecal material will not allow it to be absorbed by the rectal mucosa. The suppository may be expelled before it has a chance to be absorbed if the client has the urge to defecate before the suppository is inserted. There is no indication that the client cannot tolerate the suppository. DIF: A REF: 691 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological and Parenteral Therapies MULTIPLE RESPONSE 1. The nurse plays a major role in which of the following aspects of medication therapy? (Select all that apply.)

Determining the necessity of a particular medication

Discontinuing prescribed medications when appropriate

Preparation of the clients prescribed dose of medication

Monitoring the pharmacological effects of the prescribed medication Delivering the medication in accordance with the prescribers directions

5 6

Instructing the client regarding the pharmacological effects of the medication

ANS: 3, 4, 5, 6 The nurse plays an essential role in medication preparation and administration, medication teaching, and evaluating clients responses to medications. The remaining options are not in the nursing scope of the RN. DIF: A REF: 705 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 2. The home health nurse is preparing to educate a client on his or her newly prescribed medications. Which of the following nursing statements are appropriate to be included in this discussion? (Select all that apply.)

This medication is designed to lower your blood pressure.

Do you have medical insurance that covers the cost of medication? The medication can make you dizzy especially if you stand up quickly.

3 4

What do you think will be the most difficult thing about taking this medication?

You will need to take this medication once a day; with breakfast seems to work best for most people.

It is important that you dont miss taking the medication, If you do, take it when you remember but never take two at a time.

ANS: 1, 3, 4, 5, 6

Teaching clients about their medications and their side effects, ensuring adherence with the medication regimen, and evaluating the clients ability to self-administer medications are nursing responsibilities. The remaining option does not relate to the actually medication regimen. DIF: C REF: 707 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 3. A nurse is accused of illegally abusing narcotic medications originally prescribed to clients. If found guilty this nurse is subject to: (Select all that apply.)

Years of imprisonment in a federal prison

Forced involvement in a drug rehabilitation program

Inclusion on the State Board of Nursing Suspended license list

Forfeiture of the professional license needed to practice nursing Monetary fines that can be in the hundreds of thousands of dollars Termination of employment from the institution where the abuse occurred

5 6

ANS: 1, 3, 4, 5, 6 Violations of the Controlled Substances Act are punishable by fines, imprisonment, and loss of nurse licensure. DIF: A REF: 709 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 4. Which of the following clients is likely to experience altered medication excretion with resulting possible toxicity? (Select all that apply.)

1 2 3

A 16-year-old with asthma A 34-year-old with hepatitis B

A 72-year-old with lung cancer A 20-year-old with Crohns disease

A 54-year-old in end-stage renal failure

A 50-year-old with early Alzheimers disease

ANS: 1, 2, 4, 5 After medications are metabolized, they exit the body through the kidneys, liver, bowel, lungs, and exocrine glands. DIF: C REF: 715 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 5. The pharmacist provides collaboration to the acute care nursing staff in the form of: (Select all that apply.)

Accurate dispersal of prescribed medications

Information regarding medication side effects

3 4

Appropriate labeling of prescribed medications Clarification regarding proper medication dosage

Education of clients regarding the therapeutic value of drugs

Answering questions related to potential drug incompatibilities

ANS: 1, 2, 3, 4, 6 Most medication companies deliver medications in a form ready for use. Dispensing the correct medication in the proper dosage and amount and with an accurate label is the pharmacists main task. The pharmacist also provides information about medication side effects, toxicity, interactions, and incompatibilities. Client education is not a collaborative action provided by the pharmacist; client education is a nursing responsibility. DIF: A REF: 724 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological & Parenteral Therapies 6. The nursing role regarding a medication error includes: (Select all that apply.)

1 2

Immediate assessment of the client Notification of the health care provider

Report the error to the appropriate institutional administrator

Notify the clients family or medical power of attorney of the error

Attach a written incident report to the clients chart within 24 hours Monitoring of the client as indicated by the potential effects of the medication

ANS: 1, 2, 3, 6 When an error occurs, the clients safety and well-being become the top priority. The nurse assesses and monitors the clients condition and notifies the physician or prescriber of the incident as soon as possible. Once the client is stable, the nurse reports the incident to the appropriate person in the institution. The nurse is responsible for preparing a written occurrence or incident report that usually needs to be filed within 24 hours of the error. The occurrence report is not a permanent part of the medical record and is not referred to anywhere in the record. Notification of the clients family is not required unless the clients condition warrants it. Chapter 32. Complementary, Alternative, and Integrative Therapies MULTIPLE CHOICE 1. In selecting alternative therapies, the nurse recognizes that therapeutic touch may be most effective with a:

Premature infant Headache sufferer

Pregnant woman

Psychiatric client

ANS: 2 Studies have found that therapeutic touch is effective in reducing headache pain. Clients such as premature infants, who are sensitive to energy repatterning, may need to avoid therapeutic touch. Clients such as pregnant women, who are sensitive to energy repatterning, may need to avoid therapeutic touch. Persons who are sensitive to human interaction and touch (e.g., those who have been physically abused or have psychiatric disorders) may misinterpret the intent of the treatment and may feel threatened and anxious by the treatment. DIF: A REF: 779 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/ Complementary and Alternative Therapies 2. The nurse is preparing a presentation on alternative therapies for a community group. The nurse should identify that herbal therapies are:

Approved by the Food and Drug Administration, under the Food, Drug, and Cosmetic Act

Sold as medicines in most stores because they lack major side effects Allowed to be packaged as dietary supplements if they are without health claims

3 4

Consistent in their standards for concentrations of major ingredients and additives

ANS: 3 The Dietary Supplement Health and Education Act passed in 1994 allows herbs to be sold as dietary supplements if there are no health claims written on their labels. Herbal medicines have not undergone the same rigorous testing as pharmaceuticals have; therefore the majority have not received approval for use as drugs. Many herbal medicines are sold as foods or food supplements in health food stores and through private companies because they do not have FDA approval to be sold as a drug. When herbal medicines are developed, concentrations of the active ingredients have been found to vary considerably. Not all companies follow strict quality control and manufacturing guidelines, which set standards for acceptable levels of pesticides, residual solvents, bacterial levels, and heavy metals. DIF: A REF: 781 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/ Complementary and Alternative Therapies 3. The client asks the nurse about different herbal therapies that may promote physical endurance and reduce stress. Based on the clients request, the nurse provides information on:

Ginseng

Ginger

Echinacea Chamomile

ANS: 1 Ginseng is believed to have an effect of increased physical endurance, balancing of the body, and increasing resistance to stress. Ginger is known for its effect as an antiemetic. Echinacea is known for stimulation of the immune system and as an antiinflammatory and antibacterial agent. Chamomile is believed to have an antiinflammatory, antispasmodic, and antiinfective effect.

DIF: A REF: 782 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/ Complementary and Alternative Therapies 4. The nurse recognizes that which one of the following statements is correct concerning complementary and alternative medicine?

One third to one half of the U.S. population uses one or more forms of alternative therapy.

Insurance coverage is available at the same amount as for traditional medicine.

Use of alternative therapies is still not incorporated into medical journals.

Use of alternative therapies is primarily by those who are less educated or in a lower socioeconomic group.

ANS: 1 Between one third and one half of the population in the United States uses one or more forms of complementary or alternative medicine. Insurance coverage of complementary and alternative medicine is increasing, but it is not available at the same amount as for traditional medicine. The interest in complementary and alternative medicine is evident in the increased number of articles about it in respected medical journals and the development of several journals that specifically focus on complementary and alternative medicine. Typically those who use alternative therapies are professional, well-educated, and from a higher socioeconomic standing. DIF: A REF: 772 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/ Complementary and Alternative Therapies 5. The nurse is aware of the positive responses that may be obtained with the use of alternative therapies. A benefit that the client can gain from relaxation therapy is a decrease in:

Receptivity

Peripheral skin temperature

Oxygen consumption Alpha brain activity

4 ANS: 3

The relaxation response is characterized by decreased heart and respiratory rates, decreased blood pressure, decreased oxygen consumption, and increased alpha brain activity and peripheral skin temperature. A cognitive benefit of relaxation therapy is increased receptivity (i.e., the ability to tolerate and accept experiences that may be uncertain, unfamiliar, or paradoxical). Relaxation therapy increases peripheral skin temperature, not decreases it. Relaxation therapy increases alpha brain activity, not decreases it. DIF: A REF: 775 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/ Complementary and Alternative Therapies 6. In selecting an appropriate alternative therapy, the nurse knows that the client who may benefit the most from the passive type of relaxation is one who is experiencing:

Hypertension

2 3

Terminal cancer Work-related stress

Dysfunctional grieving

ANS: 2 Passive relaxation is useful for persons for whom the effort and energy expenditure of active muscle contraction lead to discomfort or exhaustion, such as the person with terminal cancer. Relaxation has been shown to contribute significantly to cancer palliative care. The person with hypertension would not require the passive type of relaxation. The person with work-related stress would not require the passive type of relaxation. The client experiencing dysfunctional grieving would not require the passive type of relaxation. Therapeutic touch has been found effective in improving the mood in bereaved adults. DIF: A REF: 776 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/ Complementary and Alternative Therapies 7. In selecting an appropriate alternative therapy, the nurse knows that the client who has Raynauds disease with intermittent peripheral ischemia may benefit the most from:

Relaxation therapy

Imagery

Biofeedback

Acupuncture

ANS: 3 Biofeedback techniques are used to assist individuals in learning how to control specific autonomic nervous system responses. With Raynauds disease, clients experience intermittent vasospastic attacks of small arteries and arterioles of the hands (most commonly) and/or the feet. Biofeedback can be used to control this autonomic response. Relaxation therapy is not the best selection of an alternative therapy for the client with Raynauds disease. Imagery has not been proven to help the client with Raynauds disease. Acupuncture is not the best selection of an alternative therapy for the client with Raynauds disease. Acupuncture is more frequently used to treat pain. DIF: A REF: 778 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/ Complementary and Alternative Therapies 8. A nurse needs to be alert to possible negative responses to biobehavioral therapies. Clients who have reacted negatively have most often experienced:

Aggressive behaviors

2 3

Delusions Insomnia

Loss-of-control sensations

ANS: 4 A person who has a strong fear of losing control, or who has experienced sensations of loss of control, may perceive meditation as a form of mind control and thus may be resistant to learning the technique. Some clients may uncover repressed emotions or feelings they cannot cope with during relaxation and/or biofeedback sessions. A benefit of most biobehavioral therapies, such as meditation, is that it lowers irritability. Aggression is an unlikely response. Delusions are not a result of biobehavioral therapies. Many biobehavioral therapies, such as meditation, reduce insomnia. DIF: A REF: 777 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/ Complementary and Alternative Therapies 9. A practitioner or client who uses traditional Chinese medicine bases the therapy on the primary concept of:

Yin/yang

Meridians

Six evil senses

Acupoints

ANS: 1 The most important concept of Chinese medicine is the concept of yin and yang, which represent opposing, yet complementary phenomena that exist in a state of dynamic equilibrium. When there is an imbalance in these two-paired opposites, then it is thought that disease occurs. Meridians are the channels of energy that run in regular patterns through the body and over its surface. It is not the primary concept of traditional Chinese medicine. The six evil senses are external causes of disease according to traditional Chinese medicine. They are wind, cold, fire, damp, summer heat, and dryness. This is not the primary concept on which traditional Chinese medicine is based. Acupoints are certain points on the body where special needles are inserted to modify the perception of pain, normalize physiological functions, or treat or prevent disease. Acupuncture is just one healing modality used in traditional Chinese medicine. It is not the primary concept on which traditional Chinese medicine is based. DIF: A REF: 780 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/ Complementary and Alternative Therapies 10. The nurse is preparing to assist the client with meditation and breathing. In preparing to implement this therapy, the first step is to:

Position the client

2 3

Provide a warm environment Have the client close his/her eyes

Note areas of tension or pain

ANS: 1 The first step in assisting a client with meditation and breathing is to position the client comfortably. A quiet space is required, not necessarily a warm environment. The first step is not to have the client close his or her eyes, but to get the client in a comfortable position in a quiet environment. Furthermore, the client does not have to close his or her eyes to meditate and breathe. The first step is to assist the client into a comfortable position, not to note areas of tension or pain. DIF: A REF: 777 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/ Complementary and Alternative Therapies

11. During the admission history, the client informs the nurse that she follows a macrobiotic diet. The nurse knows that the clients diet includes:

1 2 3 4

Increased meats and other proteins A 30%/40%/30% protein/carbohydrate/fat ratio Increased intake of vitamin C and beta-carotene Whole grains, vegetables, and fish

ANS: 4 A macrobiotic diet is predominantly a vegan diet (no animal products except fish). Emphasis is placed on whole cereal grains, vegetables, and unprocessed foods. A macrobiotic diet does not include meats, only fish and plant proteins. The Zone is a dietary program that requires eating protein, carbohydrate, and fat in a 30%/40%/30% ratio. Orthomolecular medicine (megavitamin) diet includes an increased intake of vitamin C and beta-carotene. DIF: A REF: 773 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/ Complementary and Alternative Therapies 12. The client has a history of gastrointestinal problems and has used herbal remedies in the past. The nurse expects that this client will be taking:

Chamomile

St. Johns wort

Echinacea Ginkgo biloba

ANS: 1 Chamomile is used for inflammatory diseases of the gastrointestinal and upper respiratory tracts, and for gastrointestinal spasms. It may also be used to treat infections and inflammation of the skin and mucous membranes. St. Johns wort is used to treat mild to moderate depression and viral infections, and to aid wound healing. Echinacea is used to treat upper respiratory tract infections and allergic rhinitis, and to aid wound healing. Ginkgo biloba has been used for many health conditions including Alzheimers disease, dementia, eye disease, heart disease, poor circulation, varicose veins, anxiety, and age-related diseases. DIF: A REF: 782 OBJ: Comprehension TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/ Complementary and Alternative Therapies 13. A client at the clinic informs the nurse during an examination that he has been taking chaparral as an anticancer agent. The client asks if there is any reason why this remedy should not be taken. The nurse responds accurately when telling the client that chaparral:

Should not be taken with coffee or other caffeinated beverages

2 3

May induce veno-occlusive disease Contains a carcinogenic substance

Is associated with liver toxicity

ANS: 4 Chaparral is an herb used for an anticancer effect. It has no proven efficacy and may induce severe liver toxicity. There are no contraindications for taking chaparral with coffee or other caffeinated beverages. Ephedra should be avoided with the consumption of caffeine. Chaparral does not induce veno-occlusive disease. However, comfrey may do so. Chaparral is not known to contain a carcinogenic substance. Sassafras and calamus may contain a carcinogenic substance. DIF: A REF: 783 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/ Complementary and Alternative Therapies 14. The nurses most informed response to the clients question What is a complementary therapy? would be:

Relaxation is an example of a complementary therapy.

It is any intervention that increases your ability to cope with illness.

Massage therapy is complementary to muscle relaxant medications.

They are therapies that are used in addition to what your PCP orders.

ANS: 4 Complementary therapies are those therapies used in addition to conventional treatment recommended by the persons health care provider. The remaining options, while providing examples, do not thoroughly define the term for the client. DIF: C REF: 772 OBJ: Analysis

TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/ Complementary and Alternative Therapies 15. The client asks Is there anything else we can do to help control my pain? The nurses most informed suggestion concerning complementary therapies is:

Massage therapy may help you; it certainly helped me.

Most complementary therapies will help decrease your pain.

Have you ever thought about seeing a chiropractor? Manipulation often helps decrease pain.

Acupressure uses appropriately applied pressure to specific body points, thus decreasing pain.

ANS: 4 Acupressure is a therapeutic technique of applying digital pressure in a specified way on designated points on the body to relieve pain, produce analgesia, or regulate a body function. The remaining options make assumptions concerning the origin of the pain and may suggest inappropriate therapies. It is also inappropriate to include such a personal comment as to refer to ones own pain. DIF: C REF: 773 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/ Complementary and Alternative Therapies 16. Which of the following clients is most likely to experience the best response from a complementary therapy?

A 5-year-old receiving a painful injection

A 35-year-old having a diagnostic spinal tap

A 55-year-old being catheterized post surgery

A 15-year-old being casted for a wrist fracture

ANS: 1 While most complementary therapies are successful to some degree with most age groups, most complementary therapies successfully reduced discomfort among children. DIF: A REF: 772 OBJ: Comprehension TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/ Complementary and Alternative Therapies 17. Research currently identifies which of the following as the primary reason nurses do not use complementary therapies?

1 2 3 4

Workloads prevent routine implementation Client reluctance to participate appropriately General bias regarding effects of the therapies Lack of education regarding their appropriate uses

ANS: 4 Nurses lack of education about how to apply complementary techniques seems to be a barrier to their use of effective nonpharmacological interventions. DIF: A REF: 772 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/ Complementary and Alternative Therapies 18. A client is dealing with chronic pain. The nurse suggests implementation of relaxation techniques. The nurses most informed response to the clients question How is relaxing going to help my pain? would be:

What have you got to lose? It could certainly help.

It will increase the effectiveness of the pain medication youre taking.

Relaxing has been very helpful for people, especially those in severe pain.

Relaxing your muscles is a better way for your body to respond to the pain.

ANS: 4 Complementary therapies teach individuals ways in which to change their behavior to alter physical responses to stress and improve symptoms such as muscle tension, gastrointestinal discomfort, pain, or sleep disturbances. While one of the options appears too flippant an answer, the remaining options may be true but do not address the question as thoroughly. DIF: C REF: 775 OBJ: Analysis TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/ Complementary and Alternative Therapies 19. Which of the following statements, made by a client experiencing anxiety who practices relaxation techniques regularly, requires follow-up by the nurse?

1 2 3 4

I want to share this with my sister; her life is stressful, too. Relaxation gives me a sense of being in control of my anxiety. Relaxation helps me feel less physically tense so my blood pressure is lower. If I practice relaxation techniques often enough, I wont need my antianxiety medication anymore.

ANS: 4 Complementary therapies are those therapies used in addition to conventional treatment recommended by the persons health care provider. They do not replace the prescribed treatment plan. DIF: C REF: 775 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/ Complementary and Alternative Therapies 20. A client diagnosed with hypertension and diabetes shares with the nurse that he has been using meditation to deal with the chronic pain he experiences from an old back injury. Which of the following questions shows the best understanding of the effects of meditation on the clients systemic functions?

How many times a day do you meditate?

Have you monitored your blood pressure lately?

Have you had any improvement with your pain? Are you currently taking blood pressure medication?

ANS: 4 Meditation may increase the effects of certain drugs. For example, monitor individuals taking antihypertensive medications or thyroid-regulating, antidepressant, or antianxiety medications. Prolonged practice of meditation techniques sometimes leads to the reduced need for certain medications such as antihypertensive medications. Whatever the case, monitor individuals learning meditation closely for physiological changes with respect to their medications. Adjustment of the medication is sometimes necessary. While the remaining options are not inappropriate, they do not assess the primary issue regarding medication.

DIF: C REF: 777 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/ Complementary and Alternative Therapies 21. A nurse and client are engaged in imagery training. The nurse shows the best understanding of the importance of selecting an appropriate focus when stating:

Lets discuss how to select todays focus.

2 3

Todays focus will be auditory rather than visual. What do you find to be most effective as your focus?

Review this list and select a focus for todays session.

ANS: 3 People typically respond to their environment according to the way they perceive it, as well as by their own visualizations and expectancies. Therefore individuals learn to regulate themselves by selecting appropriate visualizations and expectations. The remaining options do not allow the client to control the selection process. DIF: C REF: 778 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/ Complementary and Alternative Therapies 22. Acupuncture is contraindicated for which of the following clients?

A 72-year-old asthmatic

A 10-year-old hemophiliac

A 23-year-old with Crohns disease A 40-year-old who is clinically depressed

ANS: 2 This treatment is contraindicated in persons who have bleeding disorders, thrombocytopenia, or skin infections or who have a fear of needles. The remaining options represent individuals who may experience benefit from the therapy. DIF: C REF: 781 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/ Complementary and Alternative Therapies

23. A client undergoing chemotherapy treatment for lung cancer drinks ginger tea to help manage the resulting nausea. Which of the following medications should the nurse review for interactions?

Loop diuretics

2 3

Anticoagulants Antidepressants

Antihypertensives

ANS: 2 Ginger interacts with warfarin and other blood thinners, aspirin, and NSAIDs. The remaining options reflect interactions with chamomile, aloe, and licorice. DIF: A REF: 782 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/ Complementary and Alternative Therapies 24. Which of the following statements made by a nurse shows the most appropriate understanding of skin hunger?

For skin to be healthy, it must be fed.

Being touched is as important as being fed.

Touch provides emotional comfort to a client. Skin requires adequate nutrients and hydration.

ANS: 1 Touch is a primal need, as necessary as food, growth, or shelter. Think of touch as a nutrient transmitted through the skin and skin hunger as a form of malnutrition that has reached epidemic proportions in the United States, especially among older adults. While the remaining options are not incorrect, they do not express the most appropriate appreciation for the need of human touch. DIF: C REF: 779 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/ Complementary and Alternative Therapies 25. Which of the following nursing statements best reflects the most therapeutic intervention regarding the clients need for human touch?

I always ask my clients if they need a hug.

It is important to use a light touch when giving a bath.

I offer my clients a backrub whenever giving them bedtime care. When I meet a client for the first time, I always try to shake his or her hand.

ANS: 3 Touch is a primal need, as necessary as food, growth, or shelter. This answer provides the most appropriate manner in which a nurse can provide touch from among the options. DIF: C REF: 779 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/ Complementary and Alternative Therapies 26. The nurse is discussing the importance of human touch with the family of a comatose client. The daughter states I love my mother but I find it so hard to touch her when shes like this. Which of the following nursing statements reflects the most therapeutic response?

Maybe it will get easier each time you touch her.

Touch is a human need, just like food, so please try.

Do you think it would be more comfortable to try washing her face and hands?

Your mother certainly wouldnt want you to do something that you find so difficult.

ANS: 3 Touch is a primal need, as necessary as food, growth, or shelter. This answer is the only option that attempted to provide an acceptable solution for the family members problem. DIF: C REF: 779 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/ Complementary and Alternative Therapies 27. A client diagnosed with osteoarthritis has been practicing tai chi regularly. Which of the following statements best shows the clients understanding of the value of this complementary therapy?

It is a great way to socialize and exercise at the same time.

I dont like to exercise, but Tai Chi doesnt seem like exercise.

The moves are so beautiful, and I feel so graceful when I practice them. The gentle, slow movements exercise my joints without straining them.

ANS: 4 Tai chi incorporates breathing; gentle, flowing movements; and meditation to cleanse, strengthen, and circulate vital life energy and blood. Therapy stimulates the immune system and maintains external and internal balance. DIF: C REF: 773 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/ Complementary and Alternative Therapies 28. A client is discussing his use of biofeedback. Which of the following client statements shows the best understanding of success?

I have set aside one hour a day for practice.

My appointments are very important; I keep them all.

I find it empowering that I can do something to help myself.

Goals are important; setting them gives me something to work toward.

ANS: 3 Clients who are compliant with appointments, practice times, and goal setting and basically take responsibility for their treatment tend to be the most successful since it provides a sense of control over the situation. The remaining options identify individual aspects of that control. DIF: C REF: 779 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/ Complementary and Alternative Therapies 29. A client recently experienced the loss of their significant other and has symptoms of distress. In selecting a complementary therapy, the nurse knows that the client may benefit the most from:

1 2

Relaxation therapy Acupuncture

Feldenkrais method

Chiropractic medicine

ANS: 1 Relaxation techniques effectively reduces symptoms of distress in persons experiencing a variety of situations by giving them some control over their lives. An alternative method of producing analgesia. An alternative therapy based on body movements. An alternative therapy focused on restoring structural and functional imbalances. DIF: A REF: 772 OBJ: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Grief and Loss 30. In gathering information for the admission data base, the nurse discovers that a client who was admitted to the hospital for a total hip replacement has been taking ginkgo biloba to help with their memory. The nurse knows that this may cause an interaction with which of the medications that will likely be ordered for the client?

1 2

Morphine sulfate Warfarin

Docusate sodium

ANS: 2 Increases the risk of bleeding. DIF: A REF: 773 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological and Parenteral Therapies 31. An elderly client in a nursing home describes to the nurse that they are lonely. Based on this information, the nurse believes the patient may benefit from which of the following complementary therapies?

Therapeutic Touch

Chinese medicine

Dance therapy

Guided imagery

ANS: 1 Touch helps enhance self-esteem and sense of worth. DIF: A REF: 775 OBJ: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Behavioral Interventions 32. A client seeking care for stress tells the nurse that he is interested in seeking holistic care that incorporates body, mind, and spirit. The nurse knows that which of the following CAM therapies may be beneficial to him?

Chiropractic medicine

2 3

Chinese medicine European phytomedicine

Allopathic medicine

ANS: 2 Includes many modalities including acupuncture, herbs, touch, moxibustion, and qigong. Physiotherapy by manipulation of spinal column. Herbal medicine. Traditional western medicine focusing on physical ailments. DIF: A REF: 776 OBJ: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Behavioral Interventions 33. Nurses who are interested in practicing CAM therapy can, with minimum preparation, incorporate which of the following into their nursing practice?

Biofeedback

Ayurveda

Therapeutic Touch

Acupressure

ANS: 3 Therapeutic Touch is the laying of hands on a clients body. Biofeedback requires advanced preparation and the use of instruments. Ayurveda is a traditional Hindu system of medicine. Acupressure, a Chinese method of producing analgesia, requires advanced preparation. DIF: A REF: 782 OBJ: Knowledge TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort

34. The nurse notes that the clients blood pressure is substantially higher than it was on their last annual checkup. On questioning, the nurse learns that the client has been taking herbal therapy. The nurse understand that which of the following herbs is a central nervous stimulant that can cause a rise in blood pressure?

Calamus

Ginseng

Feverfew

Ephedra

ANS: 4 Ephedra is a central nervous stimulant. DIF: A REF: 784 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Pharmacological and Parenteral Therapies MULTIPLE RESPONSE 1. The nurses most informed response to a clients question concerning what allopathic medicine (Western medicine) is least effective at dealing with should include: (Select all that apply.)

Managing stress

Disease prevention

Treating chronic illness

Meeting emotional needs

Curing bacterial infection

Treating acute emergencies

ANS: 1, 2, 3, 4 Allopathic medicine is effect in dealing with the management of bacterial infections and treating acute emergencies, while the remaining options represent conditions that are not as effectively managed. DIF: A REF: 772 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/ Complementary and Alternative Therapies

2. When discussing complementary medical therapies with a client, a nurse should include: (Select all that apply.)

1 2 3

Herbalism Hypnotherapy

Guided imagery Therapeutic touch

Respiratory therapy

Chiropractic therapy

ANS: 1, 2, 3, 4, 6 Complementary therapies include therapeutic touch, guided imagery and breath work, relaxation; exercise; massage; reflexology; prayer; biofeedback; hypnotherapy; creative therapies, including art, music, or dance therapy; meditation; chiropractic therapy; osteopathy; and herbalism. Respiratory therapy is not considered a complementary therapy. DIF: A REF: 773 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/ Complementary and Alternative Therapies 3. Which of the following objective assessment findings are likely to be seen in clients who have successfully implemented relaxation techniques? (Select all that apply.)

Slower respirations

Lower blood sugar levels

Decreased heart rate

4 5

Lower blood pressure Decreased deep reflexes

Warmer skin temperature

ANS: 1, 3, 4, 6 Decreased heart and respiratory rates, decreased blood pressure and oxygen consumption, and increased alpha brain activity and peripheral skin temperature characterize the relaxation response. The remaining options are not typical characteristics of the relaxed state. Chapter 33. Self-Concept MULTIPLE CHOICE

1. The client has just learned that his motorcycle accident has resulted in his left leg being amputated. When helping this client form goals and strategies for realistic goals, the nurse needs to assess the clients:

Ideal and perceived self-concept

2 3

Intellectual and spiritual strengths Involvement with significant others

Interests and past accomplishments

ANS: 1 What individuals think and how they feel about themselves affects the way in which they care for themselves. A physical change in the body, such as an amputation, can lead to an altered body image affecting identity and self-esteem. The nurse should assess the clients ideal and perceived self-concept in order to help the client establish realistic goals and implementation strategies. Intellectual and spiritual strengths may be important when determining a clients ability to cope. However, when developing goals and implementation strategies, the process is going to begin with the clients perception of self-concept, because this will greatly impact his response to the amputation. When assessing coping behaviors of an individual, involvement with significant others may be an indication of available resources as well as a source of strength for a client. Assessing a clients interests and past accomplishments may provide information regarding a clients identity. Identity is only one component of self-concept. The nurse needs to determine the clients ideal and perceived self-concept in order to get the big picture as this will greatly impact his response to the amputation. DIF: A REF: 413 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 2. A client is manifesting behaviors that are consistent with a negative self-concept. The nurse that is working with him has observed that the client maintains:

Frequent eye contact

Independence in self-care

A passive personal attitude An interest in the surroundings

ANS: 3 A passive attitude is a behavioral characteristic suggestive of a negative self-concept. Avoidance of eye contact would be a behavior suggestive of a negative self-concept. Being excessively

dependent is characteristic of a negative self-concept. A lack of interest in what is happening in ones surroundings is characteristic of a negative self-concept. DIF: A REF: 412-413 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 3. A 76-year-old client who recently lost his wife is admitted for surgery. The nurse is using Erikson as a psychosocial framework for client assessment. Which of the following behaviors would alert the nurse that the client has an alteration in the integrity stage of his psychosocial development?

1 2 3 4

Accepting his own limitations Verbalizing fear about the surgery Expressing his thoughts about his care Demanding excessive assistance from his daughter

ANS: 4 Being angry, being excessively dependent, and having a passive attitude are all behaviors suggestive of an altered self-concept. The older client, who has lost a spouse and is now demanding excessive assistance from a child, is demonstrating an alteration in the integrity stage of his psychosocial development. Accepting ones limitations is not consistent with a disturbance in the integrity stage of psychosocial development. Verbalizing fear about the surgery is not consistent with a disturbance in the integrity stage of psychosocial development. Expressing thoughts about ones care is not consistent with a disturbance in the integrity stage of psychosocial development. DIF: A REF: 418 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 4. A client, while receiving therapies for lung cancer, has been hospitalized for an extended period of time. She has become very depressed, refuses visitors, and does not participate in personal grooming. In order for the nurse to assist in achieving resolution of the clients problem, he should have the client:

Get washed and dressed independently

Think positively instead of negatively

Contact a support group and explore a psychological consultation

Become more physically independent and return to prior activities

ANS: 3 Consultation with significant others, mental health clinicians, and community resources can result in a more comprehensive and workable plan. Clients who are experiencing threats to or alterations in self-concept often benefit from collaboration with mental health and community resources to promote increased awareness. The clients problem of a negative self-concept must be addressed first. As a result, the client may begin to bathe and dress independently. The client needs to express his negative feelings. This would be one step in addressing his self-concept problem. Stating the client should think positively instead of negatively, at this point, is unrealistic. A long-term goal may be that the client will become more independent and return to prior activities. It is not realistic at this time. DIF: A REF: 420 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 5. The client is on the orthopedic unit following back surgery. He states, I feel like I cant do anything anymoreand I wont be able to continue my landscaping business. This is predominantly an example of a problem in which of the following components of self-concept?

Body image

Self-esteem

Identity Role

ANS: 4 A physical health deficit that prevents role assumption can create a problem in the role performance component of self-concept. A client who is verbalizing concern about continuing a previous occupation is not demonstrating a problem in body image, but rather in the role performance component of self-concept. Self-esteem is closely related to self-concept, but is not a component of self-concept. Identity involves the internal sense of individuality, wholeness, and consistency of a person over time and in various circumstances. The client is verbalizing concern about role performance, not necessarily identity. DIF: A REF: 414 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment

6. A recently divorced client, who is a lawyer, comes to the clinic. She has gotten custody of her two teenagers and states, It is going to impossible for me to raise my children the way Id like and keep working as hard as I do. This is an example of:

Role strain

2 3

Role conflict Role ambiguity

Gender role stereotype

ANS: 2 Role conflict results when a person is required to simultaneously assume two or more roles that are inconsistent, contradictory, or mutually exclusive. The single mother who is having difficulty managing working long hours and trying to raise her children as she perceives she would like to, is experiencing role conflict. Role strain is a feeling of frustration when a person feels inadequate or feels unsuited to a role, such as with gender role stereotypes. Role ambiguity involves unclear role expectations. The client is not expressing doubt as to what her roles are. A gender role stereotype is where there is an expectation that something is a mans role or a womans role because the position has been typically held by a man or woman. The client is not expressing concern about a gender role stereotype, but rather in managing two contradictory roles. DIF: A REF: 415 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 7. A prostitute with HIV and severe complications is being cared for on a medical unit. The nurse is seeking to develop a therapeutic relationship with the client. Which of the following statements best reflects the nurses attempt to support the clients self-exploration?

What type of support do you feel you need?

Dont be embarrassed by your former occupation.

What type of schedule could allow you to eat without being nauseated? The people who work here are professionals; well not judge your past actions.

ANS: 1 Encouraging the clients self-exploration by asking about the type of support needed is achieved by accepting the clients thoughts and feelings, by helping the client to clarify interactions with others, and by being empathetic. Telling the client not to be embarrassed does not encourage selfexploration. It also assumes that the client is embarrassed, which may not be the case. Asking

about the type of schedule involves the client in a decision-making process related to the clients care, but does not support the clients self-exploration. Self-exploration expands self-awareness. Telling the client that staff will not try to judge the clients past is not therapeutic and implies judgment is due and does not encourage open communication and self-exploration. DIF: A REF: 418 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 8. A school-age client has just been diagnosed with juvenile diabetes. The client is very angry about the new disease. Which of the following statements is most appropriate for the nurse counselor working with this client?

Try not to be angry. You are receiving the best care possible.

You appear upset about the diagnosis. Lets talk about your feelings. You learn quickly and will probably handle the difficult treatments very well.

3 4

It is all right to be angry with your friends, but try not be angry with your parents.

ANS: 2 Stating that the client appears to be upset and then suggesting a discussion clarifies the meaning of verbal and nonverbal communication. This response also demonstrates acceptance of the clients thoughts and feelings and encourages open communication. Telling the client to try not to be angry and that he is receiving the best care possible is not therapeutic. It does not address the clients feelings of anger and conveys a message that feeling angry is not acceptable. Saying that the client is a quick learner and will probably handle the treatment well is not therapeutic. It does not encourage the client to communicate his or her feelings. Explaining that it is all right to be angry with friends but to try to not be so with parents is not therapeutic. It is not addressing the cause of the anger but is putting limits on how the anger may be expressed. DIF: A REF: 417 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 9. A clients biggest concern is about the interactions that she has with her family, and she is in the process of establishing a positive view of herself. Which group is the client meeting the developmental needs of:

12- to 20-year-old age-group

Early 20s to mid-40s age-group

Mid-40s to mid-60s age-group

Late 60s and older age-group

ANS: 2 The developmental needs of the early 20s to mid-40s age-group include the establishment of intimate relationships with family and significant others; having stable, positive feelings about self; and experiencing successful role transitions and increased responsibilities. The self-concept developmental needs of the 12- to 20-year-old age-group include accepting body changes, examining attitudes and beliefs, establishing goals for the future, and interacting with those whom he or she finds sexually attractive or intellectually stimulating. The self-concept developmental tasks of the mid-40s to mid-60s age-group include accepting changes in appearance and endurance, reassessing life goals, and showing contentment with aging. The selfconcept developmental needs of the late 60s and older age-group include feeling positive about ones life and its meaning, and being interested in providing a legacy for the next generation. DIF: A REF: 412 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 10. In developing role behavior, the child learns which of the following through substitution?

1 2

Internalizing beliefs and values of role models Refraining from behavior even though tempted

Avoiding unacceptable behavior because it is punished

Engaging in an acceptable behavior instead of another unacceptable one

ANS: 4 In the process of substitution, an individual replaces one behavior with another that provides the same personal gratification. The child has learned to substitute one behavior for another for a positive outcome. In the process of identification, an individual internalizes the beliefs, behavior, and values of role models into a personal, unique expression of self. In the process of inhibition, an individual learns to refrain from behaviors, even when tempted to engage in them. Avoiding unacceptable behavior because it is punished is seen in the process of reinforcement-extinction. DIF: A REF: 414 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 11. The nurse recognizes that self-concept develops throughout an individuals lifetime. Which developmental task associated with self-concept is expected in an assessment of an individual from the 12- to 20-year-old age-group?

Identifying with a gender

2 3

Exploring goals for the future Distinguishing oneself from the environment

Feeling positive about ones life achievements

ANS: 2 The developmental tasks associated with self-concept in the 12- to 20-year-old age-group include accepting body changes; examining attitudes, values, and beliefs; and establishing goals for the future. Identifying with a gender is an expected developmental task associated with self-concept in the 3- to 6-year-old age-group. Distinguishing oneself from the environment is an expected developmental task associated with self-concept in the newborn to 1-year-old age-group. Feeling positive about ones life achievements is an expected developmental task associated with selfconcept for the late 60s and older age-group. DIF: A REF: 412 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 12. The nurse is working with a client and wants to learn about the individuals perception of identity. What question should the nurse use to assess this?

What changes would you make in your appearance?

What activities do you enjoy doing?

How would you describe yourself? What is your usual day like?

ANS: 3 Asking, How would you describe yourself? is an example of a question a nurse could use to assess a clients perception of identity. Asking, What changes would you make in your appearance? is an example of a question a nurse could use to assess a clients perception of body image. Asking, What activities do you enjoy doing? is an example of a question a nurse could use to assess a clients perception of self-esteem. Asking, What is your usual day like? is an example of a question a nurse could use to assess a clients role performance. DIF: A REF: 412 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 13. The client has very recently been let go from his place of employment and is very upset about the loss. The nurse is establishing a plan of care for the client, she determines that an appropriate outcome for this client with situational low self-esteem is:

Client will recognize his inability to make decisions

Client will respond to anxiety with decreased amounts of stress Client will use therapeutic communication skills to discuss his needs

3 4

Client will discuss a minimum of two areas where he is functioning well

ANS: 4 An appropriate outcome for the client with situational low self-esteem would be for the client to discuss a minimum of two areas where he is functioning well. Having the client recognize his inability to make decisions would not be an appropriate outcome for the client with low selfesteem. The focus should be on his abilities, not inability. Client responding to the anxiety with decreased amounts of stress does not address the issue of low self-esteem. Being able to use therapeutic communication is always an asset, but the focus should be on improving his selfesteem by determining his strengths, recognizing his worth as a person, realizing what he is able to control, and providing support from others who are having, or had, the same experience. DIF: A REF: 423 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 14. Which of the following statements best reflects an understanding of the definition of negative client self-concept?

Acne is very difficult to deal with, especially for a youngster.

Managing type 2 diabetes can be very challenging for the client. An above the knee amputation requires extensive physical therapy.

3 4

Clinical depression can make things like going to work quite difficult.

ANS: 1 Self-concept is an individuals conceptualization of himself or herself. It is a subjective sense of self and a complex mixture of unconscious and conscious thoughts, attitudes, and perceptions. Self-concept directly affects ones self-esteem, or how one feels about himself or herself.

Adolescence is a particularly critical time when many variables affect self-concept and selfesteem. The remaining options are not necessarily directly reflective of self-concept issues. DIF: A REF: 412 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 15. The nurse recognizes which of the following clients is at greatest risk of developing negative self-esteem?

A 35-year-old woman who has been diagnosed morbidly obese

A 53-year-old male avid golfer who has lost two fingers on his right hand

A 63-year-old man experiencing erectile dysfunction post prostatectomy

A 14-year-old girl with a facial scar resulting from an automobile accident

ANS: 4 Adolescence is a particularly critical time when many variables affect self-concept and selfesteem. The adolescent experience appears to adversely affect self-esteem, more strongly for girls than for boys. The remaining options, while depicting issues that can affect self-esteem, all relate to the older, more developmentally advanced individual. DIF: A REF: 411 OBJ: Analysis TOP: Nursing Process: Analysis MSC: NCLEX test plan designation: Safe, Effective Care Environment 16. A 73-year-old client who is no longer working as a cabinetmaker begins to make statements that suggest negative self-concept. This is most likely related to:

The prospect of limited financial and health care resources

The loss of family members and friends to death and illness

The physical changes the aging process has had on his health and body The perceived loss of respect others once had for his woodworking abilities

ANS: 3

Evidence suggests that sense of self is often negatively affected in older adulthood because of the intensity of emotional and physical changes associated with aging. The remaining options can be factors in the self-concept of the older client but are not as predictable as the effect of physical aging. DIF: C REF: 411 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 17. A client is seen in a walk-in clinic for a sinus infection. Which of the following statements made by the client shows the most positive attitude regarding personal health?

I havent missed work due to illness in over 15 years.

When do I need to return to the clinic for a follow-up?

I dont like taking medications unless I really need them.

Should I be concerned about giving this infection to someone else?

ANS: 1 How individuals view themselves and their perception of their health are closely related. A clients belief in personal health often enhances his or her self-concept. Statements such as I can get through anything or Ive never been sick a day in my life indicate that a persons thoughts about personal health are positive. The remaining options may reflect the clients personal opinion regarding aspects of health and health care but not as directly as pride in past good health. DIF: C REF: 411 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 18. The nurse expects which of the following healthy clients to present with the best view of selfesteem?

8-year-old boy

18-year-old male adolescent

38-year-old woman

58-year-old woman

ANS: 1

Self-esteem is usually highest in childhood, drops during adolescence, rises gradually throughout adulthood, and declines again in old age. Although variability exists, in general this pattern holds true across gender, socioeconomic status, and ethnicity. DIF: A REF: 412 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 19. The nurse is assessing a 16-year-old who has been diagnosed with a sexually transmitted disease (STD). The nurse realizes that such risk-taking behavior (e.g., unprotected sex) is most often a result of:

1 2 3 4

Peer pressure Poor self-esteem Social expectation Lack of information

ANS: 2 For some adolescents, a decline in self-esteem results in increased risk-taking behavior. This is demonstrated in unsafe behaviors such as premature sexual activity, unprotected sex, risky driving, or substance abuse. The remaining options represent factors that may affect decision making but they do not have as big an impact on this age-group as is poor self-esteem. DIF: C REF: 412 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 20. The nurse is assessing a 16-year-old who has been diagnosed with a sexually transmitted disease (STD). The nurse realizes that such risk-taking behavior is often a predictor of even more serious self-destructive behaviors, and so this client should be:

Screened for illegal drug use

Assessed for suicidal ideations

Interviewed regarding alcohol consumption

Provided information regarding birth control

ANS: 2 Low self-esteem and stressful life events significantly predict suicidal ideations in adolescents. Nurses in all health care settings need to initiate suicide screening and implement nursing interventions directed toward suicide prevention and early detection. Although the remaining

options are areas that should be addressed, suicidal ideations are the most serious possible risktaking behavior. DIF: C REF: 416 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 21. A 73-year-old client shares with the nurse that she feels so useless, especially now that arthritis makes her life-long hobby of hand sewing so painful as to make it almost impossible. Which of the following nursing responses is most therapeutic given the clients current poor selfesteem image?

What is it about sewing that makes it so enjoyable for you?

Im sure your sewing is beautiful; have you ever considered teaching others to sew?

Maybe you can find something else that will give you as much satisfaction about yourself.

We can attempt to find the proper pain management plan to minimize the discomfort so you can sew again.

ANS: 2 Researchers have reported a sharp decline in self-esteem around age 70. Based on Eriksons stages of development, a decline in self-concept at this advanced age reflects a diminished need for self-promotion and a shift in self-concept to a more modest and balanced view of the self. The nurse is acknowledging the clients talent as well as providing a possible alternate avenue to improve self-esteem. The remaining options all deal with the issue but either do not provide guidance or may propose unrealistic alternatives. DIF: C REF: 416 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 22. Which of the following statements best reflects the clients perception of the female role?

My wife bakes the best bread.

All of my daughters are stay-at-home moms.

I dont understand why a woman would want to be a coal miner. We are so proud; our granddaughter got accepted into law school.

ANS: 4 Gender identity is a persons private view of maleness or femaleness. This option reflects a sense of pride in a female accomplishment that may be typically viewed as being male-oriented, thus showing the clients atypical perception of the female role. The remaining options are either general statements or examples of less predominant perceptions of traditional roles. DIF: A REF: 414 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 23. Research has shown that Caucasian girls and women appear to experience more pressure to be physically thin than do African American girls and women. The most likely reason for this variation in attitude is the:

Caucasian culture values physical thinness

African American culture does not value physical thinness

Caucasian girls and women are genetically programmed for physical thinness

African American girls and women are not genetically programmed for physical thinness

ANS: 2 Culture and society dictate the accepted norms of body image and influence ones attitudes (Figure 27-2). Racial and ethnic background plays an integral role in body satisfaction in adolescent girls as reflected in the higher incidence of body satisfaction among African American girls compared to Caucasian girls (Kelly and others, 2005). Further, African American girls described more favorable views about physical appearance, reported less social pressure for thinness, and exhibited less tendency to base self-esteem on body image than did Caucasian girls (White and others, 2003). The value placed on thinness by the African American culture would not influence the Caucasian girl or woman, and the options related to genetics are not proven. DIF: A REF: 413 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 24. A 12-year-old girls expressed goal to be super thin is a body image issue influenced primarily by:

Peer pressure

Societal values

Teenage role modeling

Normal developmental changes

ANS: 2 Cultural and societal attitudes and values influence body image. Culture and society dictate the accepted norms of body image and influence ones attitudes. Peer pressure and role modeling are influenced by the perceived social preference. Normal physical developmental changes resulting from puberty do not typically result in super thin body types. DIF: A REF: 413 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 25. Which of the following statements best reflects a clients healthy sense of identity?

My name is Susan.

My children are my world.

Im looking for my perfect job. Im happiest when I get to exercise regularly.

ANS: 4 Identity involves the internal sense of individuality, wholeness, and consistency of a person over time and in different situations. Identity implies being distinct and separate from others. Being oneself or living an authentic life is the basis of true identity. Knowing what makes oneself happy is a sign of identify. While looking for the perfect job infers some self-awareness, it is as of yet unfulfilled. Identifying so closely with ones child is not an indicator of a healthy sense of identity nor is simply stating ones name. DIF: C REF: 412 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 26. Which of the following physical changes that are commonly seen during puberty would be most likely to cause body image problems for a 12-year-old girl?

Having her first menstrual period

Growing 3 inches over the summer

Experiencing a substantial increase in breast size

Experiencing hair growth on legs and underarms

ANS: 3

The development of secondary sex characteristics and changes in body fat distribution have a tremendous impact on the self-concept of an adolescent. The visible changes to the body would likely have more impact than the more covert event of a menstrual period. Although the remaining options might affect the clients body image, the effect is likely to have less of an impact. DIF: C REF: 415 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 27. Which of the following statements, regarding the physical changes that are associated with the normal aging process, made by a 63-year-old female client best reflects a negative sense of body image?

I felt old when I had to by bifocal glasses.

My aging joints just dont allow me to hike like I used to.

In order to be successful at my work, I need to dye away the gray hair.

Its much more difficult to socialize with friends now that I cant hear as well.

ANS: 3 Changes associated with aging (e.g., wrinkles; graying hair; and decrease in visual acuity, hearing, and mobility) also affect body image in an older adult. Expressing the concern that gray hair would negatively affect her career is the most negative statement regarding body image. The remaining options suggest limitations and personal attitudes about adapting to the changes of aging, but they do not suggest such strong negative personal feelings as does the correct answer. DIF: C REF: 415 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 28. Which of the following statements best reflects a clients healthy sense of self-esteem?

I always try to do the best I can

Ill keep trying till I get it right.

Im not good at it but I enjoy playing guitar If I cant build it, it isnt worth being built.

4 ANS: 1

Self-esteem is positive when one feels capable, worthwhile, and competent. Recognizing that one does the best one can is the best reflection of self-esteem. The other options either state a sense of perseverance, an expression of a lack of talent, or an unrealistic view of self-worth and esteem. DIF: C REF: 411 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 29. The best indication that a client will regain a good sense of self esteem after experiencing a second below the knee (BTK) amputation is:

The client stating, Ill get over this setback

A solid, caring relationship with family and friends

A healthy sense of self esteem after the first amputation

The client telling his wife, Ill still be able to work from a wheelchair.

ANS: 3 Once established, basic feelings about the self tend to be constant, even though a situational crisis temporarily affects self-esteem. While the remaining options reflect positive behaviors or situations, they are dependent to a large degree on the clients previously established sense of self-esteem. DIF: C REF: 416 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 30. Which of the following nursing actions will have the most therapeutic impact on the selfesteem of a client with HIV?

Dealing with the clients needs in a nonjudgmental manner

Being aware of how the client will react based on the clients culture Providing care that will meet the clients emotional and physical needs

3 4

ANS: 1

Being careful to avoid nonverbal communication that could be misinterpreted

A nurses acceptance of a client with an altered self-concept helps promote positive change. The nurse must have the ability to convey a nonjudgmental attitude toward clients so as to convey an accepting attitude. The remaining options are therapeutic but they are all outcomes of a nonjudgmental attitude on the part of the nurse. Chapter 34. Sexuality MULTIPLE CHOICE 1. The nurse is aware that sexuality is part of growth and development. The preschoolers interest in gender sexuality is characterized by an interest in:

Exploring his or her own genitalia

Learning how and why his or her anatomy differs from other children

Playing and developing friendships with children of the opposite sex Spending most of his or her time with the parent of the opposite sex

ANS: 1 The first step of gender identity development occurs as the child becomes aware of the differences of the sexes and perceives that he or she is male or female. This is characterized by an interest in his or her genitalia. This is not characteristic of the preschool child. Learning how and why his or her anatomy differs from other children would require a higher level of cognitive ability. Children of this age-group primarily focus on their parents and family, not other children. According to Freud, the preschool child identifies with the parent of the same sex and develops a complementary relationship with the parent of the opposite sex. The preschool child does not spend most of his or her time with the parent of the opposite sex. DIF: A REF: 427 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 2. While working with a male client and administering medications, the female nurse is approached sexually. The nurse should:

Have a male nurse assume care for this client

Immediately report the incident to the clients physician

Tell the client that his behavior is offensive and leave the room Review and define the limits of a professional relationship for the client

ANS: 4 The nurse should convey a message of acceptance of the client, but not the inappropriate behavior. Reviewing and defining the professional relationship with the client can accomplish this. Matching the gender of the health care worker with the gender of the client may be beneficial when dealing with assessment of sexual needs or sex education. However, in this instance, the client needs to be informed that inappropriate sexual behavior is unacceptable. To turn the clients care over to a male nurse would not resolve the problem, and would convey a message of dislike and lack of acceptance of the client. Reporting the incident immediately to the clients physician would not be the nurses best action. The client needs to be made aware of the problem in order to discontinue such behavior. Telling the client his behavior is offensive and then leaving the room is not therapeutic. The client needs to be reminded of the professional relationship he shares with the nurse. DIF: A OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 3. A client is concerned that she and her husband, now that they have a baby in the house, will be unable to maintain a healthy sexual relationship. To assist these clients, it would be most helpful for the nurse to know:

1 2

If they share parenting beliefs How long they have been married

How comfortable they are in communicating their feelings to each other

The level of knowledge they have regarding healthy sexual relationships

ANS: 3 In response to identified concerns, the nurse may initiate discussion. Knowing of the comfort level in communicating their feelings provides an open dialogue enabling the client to talk freely with the nurse to address the concerns. To assist the clients in their situational change, the nurse needs to explore communication and sexual patterns of the couple. Having similar parenting beliefs will have less impact on their sexual relationship. To assist the couple in adjusting to the change of becoming a family, the nurse needs to explore communication patterns of the couple. How long they have been married would be less significant. The level of knowledge they have regarding healthy sexual relationships would not be as impacting on their sexual relationship as would their ability to discuss their feelings with one another. DIF: A REF: 428 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment

4. The nurse, after completion of an assessment in the medical clinic of a client, the nurse documents that the client has dyspareunia based on the clients experience of:

1 2 3 4

Delay or absence of an orgasm Deficient or absent sexual desire Involuntary constriction of the vagina Recurrent genital pain during intercourse

ANS: 4 Dyspareunia is recurrent or persistent genital pain in either a male or a female before, during, or after sexual intercourse that is not associated with vaginismus or with lack of lubrication. Orgasmic disorder is the recurrent delay in, or absence of, orgasm following normal sexual excitement. Hypoactive sexual desire disorder is the persistent or recurrent deficiency or absence of sexual fantasies and desire for sexual activity. Vaginismus is an involuntary constriction of the outer one third of the vagina that prevents penile insertion and intercourse. DIF: A REF: 432 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 5. An adolescent female student, who is sexually active, visits the office of the school nurse. Which of the following statements best reflects her understanding of the effective use of contraception devices?

My boyfriend is able to withdraw before ejaculation, and that prevents me from getting pregnant.

I take my temperature every morning; when it goes down for at least two days, we have unprotected sex. We always use foam before each time that we have sex and as you can see I havent gotten pregnant yet.

3 4

We have decided that I should have a diaphragm inserted and to use contraceptive cream with each intercourse.

ANS: 4 In order to be an effective contraceptive method, the diaphragm should be used with a contraceptive cream or jelly. The client is verbalizing understanding. Any act of unprotected intercourse can result in pregnancy. The boyfriend withdrawing prior to ejaculation is not an effective contraceptive method. Any act of unprotected intercourse can result in pregnancy. This statement is not demonstrating understanding of the basal body temperature method of

contraception. Using spermicidal foam alone is not recommended. The client should use a condom and foam to be more effective in preventing pregnancy. DIF: A REF: 429 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 6. A school nurse is responsible for teaching adolescents about sexually transmitted diseases (STDs). When discussing chlamydia, the nurse instructs the students that it is:

1 2 3 4

A viral infection that cannot be cured Treated with a full course of antibiotics Contracted via blood-borne exchange Prevented with the use of spermicidals

ANS: 2 Diseases that are caused by bacteria and that can usually be cured with antibiotics include gonorrhea, chlamydia, syphilis, and pelvic inflammatory disease. All clients need to understand that antibiotics need to be taken for the full course of treatment. Chlamydia is caused by bacteria that can be treated, not a virus. Sexually transmitted diseases, such as chlamydia, are transmitted from infected individuals to partners during intimate sexual contact. It is not contracted via blood-borne exchange, but rather through body fluids. Chlamydia is not prevented with the use of spermicidals. DIF: A REF: 430 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 7. A client is scheduled for cardiac surgery. The nurse is conducting a sexual history and is told that he is nervous about resuming sexual activities. The nurse uses therapeutic communication with the client when responding:

You can have sexual intercourse after your surgery, but there are serious risks.

Your partner will be nervous about resuming sexual activities, but that is only normal.

Dont worry. In about 2 months you will be able to return to your normal sexual patterns. You are expressing a very normal concern, Perhaps we could discuss your feelings further.

ANS: 4 Open communication and positive self-esteem, such as explaining that their concern is very normal and offering to discuss further are essential factors in effectively resolving concerns. Telling the client that there are serious risks may only worry the client more. Stating that the clients partner will be nervous about resuming sexual activities does not focus on the client and, therefore, does not encourage the client to express his concerns. Telling the client not to worry is nontherapeutic. At this point, not even knowing the outcome of the surgery, the nurse should not predict resumption of sexual activity for the client. Furthermore, this response does not encourage the client to communicate his feelings. DIF: A REF: 427 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 8. The nurse is teaching sexuality to a group of senior adults. Which of the following comments by a participant reflects that he or she has an understanding of the changes in sexuality that occur with aging?

So, sexual intercourse will be more painful for my wife, and we should have sex less frequently?

We have recently seen the need to begin using a lubricant. Thats because we make love less often.

My orgasms seem to not last as long, but my husband and I are probably more satisfied now than when we were younger.

I understand that it is natural not to have such an interest in sex anymore. People our age shouldnt still have those feeling.

ANS: 3 Orgasms may not last as long in the older adult as a result of aging. Older adults may feel more sexually satisfied because they no longer have to be concerned with contraception and are not experiencing the pressures of raising children and working. Decreased levels of estrogen may lead to diminished vaginal lubrication and decreased vaginal elasticity, making intercourse more painful. The couple should not be advised to have sex less frequently, but rather to use a vaginal lubricant and allow more time for caressing. The need to use a lubricant is not due to having sex less often, but is due to decreasing levels of estrogen in the woman. Saying that people of a certain age shouldnt still have sexual feelings is not a true statement. Sexual feelings in older adulthood are normal. Sexuality and continued interest in sex throughout late life generally reflect life patterns. DIF: A REF: 439 OBJ: Comprehension TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment 9. The nurse has completed an assessment on an adult male client and finds that he is having difficulty having an erection and has less interest in sex. The nurse notes that the client has recently started taking an antihypertensive medication. A nursing diagnosis of sexual dysfunction related to side effects of antihypertensive is identified by the nurse. An appropriate outcome for this client is:

Client will avoid taking medication before intercourse

Client will relate renewed interest in sex within 1 month

Client will be interviewed by a sexual therapist immediately

Client will seek out other satisfying substitute activities or hobbies

ANS: 2 An appropriate expected outcome for the nursing diagnosis of sexual dysfunction related to side effects of antihypertensive would be client will relate renewed interest in sex within 1 month. An appropriate goal would be client will express satisfaction with sexual relationship with wife within 1 month. The client should not avoid taking his antihypertensive medication before intercourse, but should be taught that there are other blood pressure medications available that can maintain blood pressure control and that do not negatively affect sexual function. He can then discuss this with his physician. Being interviewed by a therapist is not an appropriate expected outcome. Seeing a sexual therapist immediately is not necessary and may only intensify his concern. Seeking out substitute activities or hobbies is not an appropriate expected outcome. It does not address or resolve the problem. DIF: A REF: 434 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 10. A 58-year-old woman asks the nurse what she can do to promote healthy physical sexual relations. Based on the clients age, the nurse responds by saying:

Using a water-based lubricant may be helpful.

Reducing the frequency of intercourse may help you.

I will refer you to a sexual therapist to better assist you. Continue what youve been doing. Nothing should have changed.

ANS: 1

The perimenopausal and menopausal woman may have diminished vaginal lubrication as a result of decreased levels of estrogen, thus using a water-based lubricant may help. Decreasing the frequency of intercourse would not promote healthy sexual relations. If a nurse is uncomfortable discussing sexual issues with a client, then he or she should get another nurse who is comfortable to talk with the client. A sex therapist is not necessary in this situation. Sex therapists address more complex sexual issues. There are some physical changes with aging that may affect sexuality. The client should be educated on the expected changes and how to best address them. DIF: A REF: 428 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 11. The nurse is putting together a presentation on the prevention of sexual abuse. She should incorporate which of the following?

Abusers fit into easily identified, classic profiles.

Intensity is generally increased during pregnancies.

Sexual abuse is found primarily in lower socioeconomic groups.

Most of the incidents occur with strangers or unknown assailants.

ANS: 2 Sexual abuse may begin, continue, or even intensify during pregnancy. The abuser may not fit any classic description. Sexual abuse crosses all gender, socioeconomic, age, and ethnic groups. Most often sexual abuse is at the hands of a former intimate partner or family member. DIF: A REF: 432 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 12. To increase the tone and sensation of the pelvic floor for a female client, the nurse teaches:

Kegel exercises

Vaginal dilation

Stop-start techniques

Sensate focus exercises

ANS: 1 Kegel exercises increase the tone and sensation of the pelvic floor (pubococcygeus muscle) for the female client. Vaginal dilation will not increase the tone and sensation of the pelvic floor.

Stopping urination may help identify proper muscle contraction, but once the muscle is identified, Kegel exercises should not be repeated during urination. Stopping urination midstream may create a backflow of urine into the bladder, predisposing a person to infection. Sensate focus exercises do not increase muscle tone. DIF: A REF: 428 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 13. The nurse is discussing the physical changes that occur during puberty with a group of 11- to 12-year-olds. The most therapeutic statement the nurse could make directed toward minimizing their anxiety would be:

Youll be fine. Everyone survives puberty.

Dont worry because everyone goes through the changes.

Dont be afraid to talk about the changes with an adult; we all know about puberty.

Puberty is a normal stage of development. Remember, its simply a part of growing up.

ANS: 3 School-age children generally have questions regarding the physical and emotional aspects of sex. They need accurate information from home and school about changes in their bodies and emotions during this period and what to expect as they move into puberty. Knowledge about normal emotional and physical changes associated with puberty will decrease anxiety as these changes begin to happen. It is of little value to tell the child that all will be fine since that tends to send a message that you are minimizing their concerns and so is a barrier to communication. Keeping the responses short and in terms the child will understand is best. DIF: C REF: 427 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 14. Teenagers tend to engage in risky sexual behavior primarily because they:

Feel invincible

Lack factual information

Emulate poor social models

Possess immature decision-making skills

ANS: 1

Adolescents tend to think they are invincible and do not expect bad things to happen to them. While the other options can be factors in some teens decisions to engage in unprotected sex, the age-group generally lacks the insight that they are not invincible and that they will suffer the consequences of poor decision making. DIF: A REF: 427 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 15. Sexual experimentation is common among adolescents and should primarily be:

1 2

Discouraged Encouraged

Accepted as normal adolescent behavior

Viewed as a means of determining sexual orientation

ANS: 4 Adolescence is often a time when individuals explore their primary sexual orientation. Although the behavior should not be discouraged or encouraged, in order to avoid undo stress on the adolescent, the experimentation should be viewed as an acceptable way to determine sexual orientation. DIF: A REF: 428 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 16. The nurse is discussing various sexual issues with a group of military personnel who have experienced spinal cord injuries. Which of the following statements best addresses the issue of alternative methods of personal sexual gratification?

People do whatever works best for them and their partner.

You dont need anyone else to approve how you engage in sex.

Sex practices are private and need only to be discussed with your sexual partner. Any form of stimulation that is mutually agreed upon and satisfying is acceptable sexual practice.

ANS: 4 As sexually active adults develop intimate relationships, they learn techniques of stimulation that are satisfying to both themselves and their sexual partners. Some adults need permission or affirmation that alternative ways of sexual expression other than penile-vaginal intercourse are

normal. While the other options prove acceptance, they are not as sensitive in their wording or address the issue as completely. DIF: C REF: 440 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 17. The middle adult couple is most likely to experience a change in their sexual intimacy when:

The changes of normal aging occur

2 3

One or both retire from the work force Chronic illness affects sexual performance

The children no longer reside full time in the home

ANS: 4 Children leaving home usually creates a change in intimate relationships. This results in either a time of renewed intimacy between partners or a time when formerly intimate partners realize that they no longer care for each other or have common interests. While changes of aging and chronic illness can affect performance and retirement usually requires an adjustment in expectations and attitudes, these options do not appear to have the same degree of impact on intimacy as does the empty nest. DIF: C REF: 428 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 18. The nurse knows that studies of sexuality in older adults have shown:

To be inconsistent in their overall findings

That this population is reluctant to discuss their sexual practices That there is a decline of sexual interest and behavior among older adults

3 4

That older adults retain an interest in sexual function and are sexually active

ANS: 1 Studies of sexuality in older adults are limited and inconsistent in their findings. Many studies suggest that older adults retain an interest in sexual function and are sexually active while other studies conclude that there is a decline of sexual interest and behavior among older adults.

DIF: A REF: 428 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 19. Which of the following statements made by a client concerning birth control requires immediate correction by the nurse?

My partner is responsible for our birth control; he uses a condom.

Ive gained some weight so I should have my diaphragm refitted. My husband is reluctant to have a vasectomy since it is permanent.

3 4

I prefer the cervical cap since I can leave it in for a longer period of time.

ANS: 1 Barrier methods include over-the-counter spermicidal products and condoms. Spermicidal products (e.g., creams, jellies, foams, and sponges) are put into the vagina before intercourse to create a spermicidal barrier between the uterus and ejaculated sperm. A condom is a thin rubber sheath that fits over the penis to prevent entrance of sperm into the vagina. Vaginal spermicides and condoms are most effective when instructions are carefully followed; their combined use is more effective in preventing pregnancy than the use of either one alone. While a vasectomy may be reversed, it is very difficult and results cannot be guaranteed. The remaining options are correct. DIF: C REF: 429 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 20. Which of the following statements best educates the client regarding the transmission of sexually transmitted diseases (STDs)?

Always have protected sex, and you will be safe.

Be careful to avoid coming into contact with a partners semen or vaginal secretions. STDs are spread from person to person by coming into contact with their sperm or vaginal secretions.

3 4

STDs can be transmitted through any open sore that comes into contact with a partners semen or vaginal secretions.

ANS: 4 Any contact with another persons body fluids or an open lesion on the skin, anus, or genitalia can transmit an STD. The remaining options do not provide complete information of the possible means of transmitting STDs. DIF: C REF: 429-430 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 21. The most common reason for clients with sexually transmitted diseases (STDs) to remain untreated is:

Embarrassment and guilt

Inability to access health care services

Lack of knowledge concerning signs and symptoms

Insufficient respect for the seriousness of the disease

ANS: 1 People often do not seek treatment because they are embarrassed to discuss sexual symptoms or concerns. They are also often hesitant to talk about their sexual behavior if they believe that it is not normal. Any sexual behavior that embarrasses the client often hinders the detection of an STD. While the remaining options may be factors for some individuals, they are not the most common reason for failure to seek treatment. DIF: C REF: 429-430 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 22. The nurse is counseling a woman who has multiple sexual partners and has recently been diagnosed with the human papillomavirus (HPV). The importance of regularly scheduled Pap smears is discussed primarily because:

This woman has a high risk for cervical cancer

Her sexual practices also put her at risk for HIV

This womans age puts her at risk for uterine cancer Regular screening results in improved client outcomes

4 ANS: 1

Researchers estimate that 80% to 90% of cervical cancer cases are linked to HPV infection. It is true that regular screenings do improve client outcomes; the purpose of the Pap smear is directly related to cervical cancer. HPV does not increase the risk of uterine cancer nor would it be detected by a Pap smear. While having multiple sexual partners does increase the risk of contracting HIV, it would not be diagnosed with a Pap smear. DIF: C REF: 430 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 23. The nurse is interviewing a client who is concerned about the possibility of contracting the human immunodeficiency virus (HIV) from unprotected sex with a known IV drug user. The nurse knows that if the client is infected:

The clients life expectancy is 3 to 5 years

There are no effective treatment modalities

Symptoms of the disease will be assessable within the first month post exposure

Blood work will confirm the diagnosis 6 weeks to 3 months after the initial exposure

ANS: 4 The primary infection stage lasts for about a month after contracting the virus. During this time, the person often experiences flu-like symptoms. Then, the person enters the clinical latency phase; at this time, the person has no symptoms of infection. HIV antibodies appear in the blood about 6 weeks to 3 months following infection. If left untreated, people who are infected with HIV will live about 10 years. The last stage, acquired immunodeficiency syndrome (AIDS), occurs when the person begins to show symptoms of the disease. Highly active antiretroviral therapy (HAART) has greatly increased the survival time of persons who live with HIV/AIDS. DIF: A REF: 430 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 24. Which of the following interview questions asked by the nurse is best directed at assessing a common symptom of chlamydia?

Do you have any sores on your genitals (privates)?

Remember that a fever can be a sign of this sexually transmitted disease (STD).

Have you been experiencing any problems with urinating (making your water)?

If you notice a red rash on your perineal area (between your legs) notify your doctor.

ANS: 3 Symptoms in women include dysuria, urinary frequency, and purulent vaginal discharge. In men, it usually infects the urethra and causes dysuria and urethral discharge. The remaining options suggest symptoms/signs that are not commonly associated with chlamydia. DIF: A REF: 430 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 25. The nurse knows that when a society or culture supports sexual abstinence outside of marriage, it avoids providing sex education to its children because it is believed that to do so would:

1 2

Erode traditional family values Promote premarital sexual activity

Be too emotionally traumatic for both parent and child

Put the child at an increased risk for disease and pregnancy

ANS: 2 When a culture supports a belief in abstinence until marriage, there is usually a belief that teaching children about sex will promote sexual activity. While the other options may represent beliefs held by the culture as well, its primary concern appears to be sexual activity. DIF: A REF: 427 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 26. The nurse realizes that a woman who has experienced a voluntary abortion will be most likely to experience a sense of:

Loss and sadness

2 3

Remorse and regret Relief and confidence

Peace and contentment

ANS: 1 When a woman chooses abortion as a way of dealing with an unwanted pregnancy, the woman, and often her partner, experiences a sense of loss, grief, and/or guilt. While individuals may experience those emotions identified in the other options, the most universal feelings are of loss, grief, sadness, and guilt. DIF: A REF: 431 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 27. Which of the following statements best reflects the nurses understanding regarding strong personal feelings against voluntary abortions?

It would be difficult, but I would try to care for the client in a professional manner.

I chose not to work in areas that would require me to deal with the issue of abortion. I will need to separate my personal values in a manner so as to not appear to be judgmental.

3 4

I would just ask another registered nurse to care for the client who is recovering from an abortion.

ANS: 2 Nurses are entitled to their personal views and should not be forced to participate in counseling or procedures contrary to beliefs and values. It is essential to choose specialties or places of employment where personal values are not compromised and the care of a client in need of health care is not jeopardized. The other options represent impractical or unrealistic solutions to the dilemma. DIF: C REF: 431 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment MULTIPLE RESPONSE 1. The nurse who is discussing safe sex with a group of teenage students must realize that safe sex practice includes: (Select all that apply.)

Having sex with only partners you know well

Willingness to resist peer pressure to have sex

Insisting upon the use of barrier protective devices

An understanding that the goal is to prevent the spread of STDs

Openly discussing a history of STDs (sexually transmitted diseases) Not making the decision to be sexually active while using drugs or alcohol

ANS: 1, 3, 4, 5, 6 Safe sex is a term that describes responsible sexual behavior aimed at preventing the spread of STDs, including HIV/AIDS. Responsible sexual behavior includes knowing ones sexual partner, being able to openly discuss sexual and drug-use history with the partner, not allowing drugs or alcohol to influence decision making, and using protective devices. DIF: C REF: 431 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 2. In order to therapeutically counsel clients regarding issues related to sexuality, a nurse should have knowledge on which of the following topics? (Select all that apply.)

Abortion Birth control

Sexual techniques

Sexual orientation

Sexual development

Sexually transmitted diseases (STD)

ANS: 1, 2, 4, 5, 6 Nurses help clients achieve sexual health by having a sound scientific knowledge base regarding sexuality. A basic understanding of sexual development, sexual orientation, contraception, abortion, and sexually transmitted diseases (STDs) is necessary. A sex therapist would be better suited to discuss sexual techniques with a client. DIF: C REF: 427 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 3. The most common characteristics shared by individuals most likely to contract a sexually transmitted disease (STD) are that they: (Select all that apply.)

Use illegal drugs

Possess poor reading skills Are economically deprived

3 4 5

Have multiple sexual partners Have ineffective immune systems

Frequently engage in unprotected sex

ANS: 4, 6 People most likely to be infected share one key characteristic: unprotected sex with multiple partners. Additionally, social factors such as poverty, low literacy, discrimination, use of illegal drugs (e.g., crack cocaine, meth), incarceration, sexual abuse, and racial segregation contribute to racial disparities in rates of STDs. DIF: C REF: 429 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 4. Which of the following sexually transmitted diseases (STDs) are considered curable with antibiotic treatment? (Select all that apply.)

Syphilis

Gonorrhea

Chlamydia

4 5

Genital warts Genital herpes

Pelvic inflammatory disease (PID)

ANS: 1, 2, 3, 6 Gonorrhea, chlamydia, syphilis, and pelvic inflammatory disease (PID) are caused by bacteria and are usually curable with antibiotics. All clients need to understand that antibiotics need to be taken for the full course of treatment. Genital herpes and genital warts are viral and are not curable. DIF: A REF: 429-430 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment

5. When discussing sexually transmitted diseases (STDs) with a group of college students, the nurse identifies which of the following as the more common signs and symptoms? (Select all that apply.)

Fever

Joint pain Genital rash

3 4 5

Anal discharge Genital lesions

Painful urination

ANS: 1, 4, 5, 6 Common symptoms of an STD include discharge from the vagina, penis, or anus; pain during sex or when urinating; blisters or sores in the genital area; and fever. The remaining options are not typical signs or symptoms of STDs. DIF: A REF: 429-430 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 6. Which of the following conditions should the nurse discuss as possible outcomes of untreated chlamydia with a client newly diagnosed with the disease? (Select all that apply.)

1 2 3

Infertility Uterine cancer

Ectopic pregnancy Neonatal complications

Pelvic inflammatory disease (PID)

Human immunodeficiency virus (HIV)

ANS: 1, 3, 4, 5 If it is not treated, chlamydia can cause PID, ectopic pregnancy, infertility, and neonatal complications. Either uterine cancer or HIV is directly connected to chlamydia. Chapter 35. Spiritual Health MULTIPLE CHOICE 1. A nurse should be aware that adolescent clients who are discussing spirituality often:

Have a good concept of a supreme being

Question religious practices and/or values

Fully accept the higher meaning of their faith Often give themselves over to spiritual tasks

ANS: 2 Adolescents often reconsider their childlike concept of a spiritual power, and in the search for an identity, they may either question practices and values or find the spiritual power as the motivation to seek a clearer meaning to life. Adolescents do not necessarily have a good concept of a supreme being. Adolescents do not necessarily fully accept the higher meaning of their faith. Older adults, not adolescents, often turn to important relationships and the giving of themselves to others as spiritual tasks. DIF: A REF: 446 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 2. A nurses knowledge about spirituality begins with him or her:

Researching all popular religions

Looking at his or her own beliefs

Sharing his or her faith with the clients

Providing prayers and religious articles for clients

ANS: 2 Knowledge about spirituality begins with nurses insight about their own spirituality. This selfexploration may occur through reading, religious involvement, or activities such as meditation to understand their own beliefs and values. Researching popular religions may add to the nurses knowledge, but knowledge of spirituality begins with the nurse examining his or her own beliefs. It is essential for the nurse to be aware of his or her own beliefs so as to not impose them on others, and to be able to recognize and understand a clients spiritual needs. The nurses knowledge about spirituality does not begin with the nurse sharing his or her faith with clients. Providing prayers and religious articles for clients may be an intervention to meet a clients spiritual needs; however, it is not how the nurses knowledge about spirituality begins. DIF: A REF: 444 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 3. The client experienced a near-death experience and was successfully resuscitated. The nurse wants to provide the opportunity for the client to discuss the near-death experience. The most appropriate response by the nurse is:

This is a common experience that is easily explained.

That must have been a very awful experience for you.

Have you ever heard of other persons having a near-death experience?

What was your experience like, and how did it make you feel?

ANS: 4 After a client has experienced a near-death experience, it is important for the nurse to remain open, such as asking about the experience and how it made the client feel, and give the client a chance to explore what happened. This is not a common experience that can be easily explained. The client should be encouraged to discuss it as he or she may find meaning from this powerful experience. The nurse should not assume this was an awful experience for the client. Many people who have had a near-death experience report positive aftereffects, including a positive attitude and spiritual development. Asking if the client had ever heard of other persons having a near-death experience would not be the most appropriate response. It does not help the client explore his or her own experience. DIF: A REF: 447 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 4. A 76-year-old client has just been admitted to the nursing unit with terminal cancer of the liver. The nurse is assessing the clients spiritual needs and responds best by saying:

I notice you have a Bible; is that a source of spiritual strength to you?

What do you believe will happen to your personal spirit when you die? We would allow members of your church to visit you whenever you desire.

3 4

Has hearing about your terminal condition made you lose your faith or beliefs?

ANS: 1 Stating the observation of a client having a Bible opens communication regarding the clients source of strength. Assessing a clients source of strength and faith can direct interaction with the client, including medical treatment plans. Asking what the belief about the spirit upon death is not the best response. It does not provide information that would assist the nurse in meeting the clients spiritual needs. Allowing fellow church members is not the best response. It implies the

client goes to church or should go to church, and assumes that church members are a source of strength for the client. It does not provide assessment information to determine the clients spiritual needs. Asking if this has caused a loss in faith or beliefs is not the best response. It has a negative connotation, and does not assess the clients source of strength or the beliefs of the client. DIF: A REF: 447 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 5. A client with diabetes is being cared for in the home, with the assistance of a home health nurse and a family member. The client asks you if eating a vegetarian diet will conflict with the disease. The nurse anticipates that the client will follow a vegetarian diet because he is a member of which of the following religions?

1 2

Hinduism Judaism

Islam

Sikhism

ANS: 1 Some sects of Hindus are vegetarians. The belief is not to kill any living creature. Followers of Judaism may observe the kosher dietary restriction of avoiding pork and shellfish and not preparing and eating milk and meat at the same time. People of Islamic faith do not consume pork and alcohol. Fasting is done during the month of Ramadan. Members of the Sikhism religion do not necessarily follow a vegetarian diet. DIF: A REF: 450 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 6. A tool that may be used effectively with clients who have terminal diseases is hope. Hope provides a:

Relationship with a divinity

System of organized beliefs

Cultural connectedness Meaning and purpose

4 ANS: 4

Hope provides a sense of meaning and purpose. When a person has hope, he or she has an attitude of something to live for and look forward to. Faith is a relationship with a divinity. Religion is a system of organized beliefs. Spirituality provides a cultural connectedness. DIF: A REF: 446 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 7. The nurse, while working with a client to support and assess spirituality should first:

Refer the client to the agency chaplain

Assist the client to use faith to get well

Provide a variety of religious literature

Determine the clients personal belief system

ANS: 4 While working with a client to assess and support spirituality, the nurse should first determine the clients perceptions and belief system. Exploring the clients spirituality may reveal responses to health problems that require nursing intervention, or it may reveal the existence of a strong set of resources that enable the client to cope effectively. Although the agency chaplain may be a source for referral, it is not the first action the nurse should take in assessing and supporting a clients spirituality. The nurse needs to first assess a clients spirituality to determine the clients perceptions and belief system before attempting to assist the client to use faith to get well. Providing a variety of religious literature may be ineffective as it does not address the client as an individual and does not assess the clients personal spiritual needs. The nurse should first assess the clients perception and belief system before implementing any intervention. DIF: A REF: 444-445 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 8. If a client is identified as following the traditional health care beliefs of Judaism, the nurse should prepare to incorporate the following into care:

Faith healing

Regular fasting

Ongoing group prayer Observance of the Sabbath

4 ANS: 4

Observance of the Sabbath is important to a client who follows the traditional health care beliefs of Judaism. This client my refuse treatments scheduled on the Sabbath. Followers of the Islamic or Christian faith may use faith healing in response to illness. Regular fasting may be seen with some Roman Catholics or with followers of the Russian Orthodox Church. Ongoing group prayer may be seen with the Islamic faith. Christians also use prayer. DIF: A REF: 451 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 9. The nurse is conferring with the nutritionist about the needs of a Native American. The nurse anticipates that the client will:

Follow a strict vegetarian diet

2 3

Avoid the use of alcohol and tobacco Expect to avoid pork-related products

Follow a diet according to individual tribal beliefs

ANS: 4 Food practices of Native Americans are influenced by individual tribal beliefs. Some Hindus and Buddhists are vegetarians. Buddhists, Mormons, and some Baptists, Evangelicals, and Pentecostals avoid the use of alcohol and tobacco. Members of Hinduism, Islam, and Judaism may avoid pork products. DIF: A REF: 457 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 10. The nurse has identified the following nursing diagnoses for his assigned clients. Of the following diagnoses, which one indicates the greatest potential need to plan for the clients spiritual needs?

Altered health maintenance

Ineffective individual coping

Impaired long-term memory

Decreased adaptive capacity

ANS: 2 Ineffective individual coping is a nursing diagnosis that may apply to clients in need of spiritual care. The nursing diagnosis of altered health maintenance does not indicate the greatest potential need for spiritual care. The nursing diagnosis of impaired long-term memory does not imply the

need for spiritual care. The nursing diagnosis of decreased adaptive capacity does not indicate the greatest potential need for spiritual care. DIF: A REF: 446 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 11. The nurse is working in the labor and delivery area with parents who are members of the Shinto and Buddhist religions. The nurse expects that after the birth of the child:

1 2

Baptism will be performed immediately Special prayers will be said over the child

Special preparations will be made for the umbilical cord and placenta

No particular rituals will usually be performed in the postpartum period

ANS: 4 No special rituals are usually performed in the immediate postpartum period with members of the Shinto, Buddhist, or Hindu religions. Many Christians will baptize their infants. Followers of Islam will say special prayers after birth over the child. Navajos make special preparations for the umbilical cord and placenta after the birth of a child. DIF: A REF: 451 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 12. The nurse may incorporate similarities of nutritional needs into the plan of care for clients who are Mormon and Buddhist. Members of these religions both:

Fast on Fridays

Follow vegetarian diets

Avoid alcohol and tobacco

Avoid mixing dairy and meat products

ANS: 3 Both Mormons and Buddhists avoid alcohol and tobacco. Some Roman Catholics and Russian Orthodox members may fast on Fridays. Both Hindus and Buddhists may follow vegetarian diets. Followers of Judaism may avoid eating milk and meat at the same time. DIF: A REF: 457 OBJ: Comprehension

TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 13. The nurse anticipates the gender-related needs of the clients and tries to accommodate those needs whenever possible. A female nurse is arranged for the female client who practices:

1 2 3 4

Sikhism Judaism Hinduism Buddhism

ANS: 1 Females are to be examined by females according to the Sikhism religion. Followers of Judaism view visiting the sick as an obligation. They have no restrictions on gender-related care. Followers of Hinduism view illness as being caused by past sins. Prolonging life is discouraged. There are no restrictions on care related to gender. Buddhists believe in Dharma, which teaches that life is impermanent and all persons have to age and die. There are no restrictions on care related to gender. DIF: A REF: 451 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 14. The nurse working in the labor and delivery area is aware that special care is provided for the umbilical cord after the childs birth for the clients who are:

Catholic

Navajo

Shinto Hindu

ANS: 2 After a Navajo childs delivery, the umbilical cord is taken from the newborn, dried, and buried near a place that symbolizes what parents want for the childs future. Catholics do not have special care of the umbilical cord after delivery. They may want their newborn baptized if there is any chance of the newborn not surviving. Shintos have no special rituals related to birth, including the umbilical cord. Hindus have no special rituals related to birth, including the umbilical cord. DIF: A REF: 451 OBJ: Comprehension TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe, Effective Care Environment 15. A client diagnosed with an autoimmune disorder uses guided imagery to help control anxiety. Which of the following assessment data supports the effectiveness of the intervention on the actual management of the disease?

A noticeable increase in the clients appetite

A decrease in the clients HDL cholesterol level

A white blood cell count at the low-normal range

A blood glucose level at the low end of the normal range

ANS: 3 Current evidence has shown that relaxation exercises and guided imagery improve immune function. So a normal white cell count in a client diagnosed with an autoimmune disorder would be considered evidence of the therapeutic nature of the guided imagery. There is no known connection to these other options. DIF: C REF: 444 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 16. Which of the following statements made by a client diagnosed with terminal renal failure best expresses the clients sense of hope?

My father lived for years with this disease.

Ive had a good life, and Ill live each day as it comes.

Research is always coming up with new treatments and cures. My daughter is getting married in 4 months, and Im going to walk her down the aisle.

ANS: 4 When a person has the attitude of something to live for and look forward to, hope is present. The plan to attend and participate in the daughters wedding provides the focus for living. The other options are lacking that component of focus. DIF: C REF: 446 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 17. The wife of a client diagnosed with Alzheimers disease shares with the home health nurse that, We always went to church on Wednesday evenings. I miss that a lot. Which of the following statements made by the nurse has the greatest therapeutic value at this time?

Was religion as important to your husband as well?

Please tell me more about the role religion plays in your lives.

May I help arrange for a sitter so you can attend church services again?

Attending church services has always been very important to me as well.

ANS: 3 Encourage caregivers to participate in spiritual behaviors or practices (e.g., prayer, attending religious services) to enhance spiritual well-being when appropriate. Since the client has introduced the wish to attend services, it is appropriate for the nurse to make a suggestion to help that happen. Some of the remaining options do encourage the caregiver to discuss the couples spiritual needs but do not directly deal with the verbalized need. The final option is merely the nurses statement of religious practice. DIF: C REF: 445-446 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 18. A client who recently required advanced cardiac life support after experiencing a myocardial infarction shares with the nurse that, I could hear voices talking about me dying and then there was this brightly lighted tunnel. Which of the following statements made by the nurse shows the best understanding of therapeutic communication regarding a clients near-death experience?

Tell me more about what you saw and heard.

What you are describing is called a near-death experience.

Many clients who have been clinically dead have those types of memories.

What you are describing is most likely a result of the drugs you were given.

ANS: 1 Clients who have a near-death experience are often reluctant to discuss it, thinking family or caregivers will not understand. However, individuals experiencing a near-death experience who discuss it with family or caregivers find acceptance and meaning from this powerful experience. By encouraging the client to discuss the experience, the nurse is providing therapeutic care in an accepting manner. The remaining options close the communication opportunity by providing a reason for the event.

DIF: C REF: 13 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 19. Which of the following statements made by a nurse regarding spiritual support provided displays an inappropriate intervention or attitude?

1 2 3 4

I offer to pray with my clients as I prepare them for transport to surgery. I always try to tell my Catholic clients when Mass is being held in the chapel. When caring for a client for the first time, I always check to see their religious affiliation. Im not very comfortable interviewing a client concerning their religious beliefs or practices.

ANS: 1 It is essential to promote an environment that respects clients values, customs, and spiritual beliefs. Routinely implementing nursing interventions such as prayer or meditation is coercive and/or unethical. Therefore determine which interventions are compatible with the clients beliefs and values before selecting nursing interventions. To routinely offer to pray with a client without first establishing the appropriateness of that intervention is unethical and so requires immediate instruction of that to the nurse. Two options are not inappropriate and so require no intervention while the third reflects the nurses discomfort with a task but does not indicate any failure to provide effective, appropriate nursing care. DIF: C REF: 448 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 20. When asked about his or her religious affiliation, a client responds, Thats personal; why do you want to know? The most appropriate nursing response is:

You need not answer my question if you prefer not to share that information.

All information you provide will be kept in strict confidence.

By knowing your religious preferences, I can best meet your spiritual needs.

I did not mean to offend you; we ask that question of all our new admissions.

ANS: 3 The Joint Commission requires health care organizations to acknowledge clients rights to spiritual care and provide for clients spiritual needs through pastoral care or others who are certified, ordained, or lay individuals. The Joint Commission requires nurses to assess their clients denomination, beliefs, and spiritual practices. Informing the client of this requirement and the purpose for which the information will be used is the most appropriate response. The remaining options fail to fully answer the clients question. DIF: C REF: 448 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 21. Which of the following interview questions will best determine a clients readiness for enhanced spiritual well-being?

Are you a religious person?

Are you satisfied with your life?

To whom do you turn when you have a problem to deal with?

Do you tend to rely on prayer during times of personal stress?

ANS: 3 Readiness for enhanced spiritual well-being is based on defining characteristics that show a persons ability to experience and integrate meaning and purpose in life through connectedness with self and others. A client with this nursing diagnosis has potential resources to draw on when faced with illness or a threat to well-being. By asking the client to identify his or her coping strategy for times of stress, the nurse can begin to assess the clients spiritual well-being. The remaining options are more directed towards assessing faith, or life satisfaction. DIF: C REF: 452 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 22. The nurse is caring for a terminally ill client who frequently engages in prayer with her family. The most therapeutic nursing intervention for this client regarding this practice would be to:

Move the family into the units sunroom for the ritual

Ask the client and her family to be allowed to pray with the group Offer to arrange for the facilitys chaplain to attend the prayer session

Schedule the clients physical therapy treatments to avoid being an interruption

ANS: 4 Spiritual priorities do not need to be sacrificed for physical care priorities. For example, when a client is in acute distress, focus care to provide the client a sense of control, but when a client is terminally ill, spiritual care is possibly the most important nursing intervention. By arranging for the PT treatment at a time that will not interrupt the clients prayers, the nurse is showing attention to the clients spiritual needs most therapeutically. While the other options may be appropriate, they do not address the facilitation of the clients expressed need regarding prayer. DIF: C REF: 444 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 23. A client who has been severely burned has been taught meditation techniques to help manage the stress of his recovery period. The nurse recognizes which of the following assessment findings as most conclusive of the effectiveness of the intervention?

The client stating, I like to meditate

Observing the client in a meditative pose

The client heard telling his son that he has learned to meditate

A 10-point drop in the clients systolic blood pressure after meditation

ANS: 1 The most conclusive evidence of the effectiveness of the intervention is the clients verbalization of its worth. The client stating his positive feelings regarding meditation is the best option. The remaining options may indicate effectiveness but not as personally as the clients statement. Chapter 36. Loss and Grief MULTIPLE CHOICE 1. A client has a terminal illness and is discussing future treatments with the nurse. The nurse notes that he has not been eating and his response to the nurses information is, What does it matter? The most appropriate nursing diagnosis for this client is:

Denial

Hopelessness

Social isolation

Spiritual distress

ANS: 2 A defining characteristic for the nursing diagnosis of hopelessness may include the client stating, What does it matter? when offered choices or information concerning themselves. Also, the clients behavior of not eating is an indicator of hopelessness. The clients behavior and verbalization do not indicate denial. This is not an example of social isolation. The client is not avoiding or restricted from seeing others. Spiritual distress is not the most appropriate nursing diagnosis for this client. The focus needs to be on the clients lack of hope. PTS: 1 DIF: A REF: 470 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 2. One of the benefits of anticipatory grieving to a client or family is that it can:

Be done in private

2 3

Be discussed with others Promote separation of the ill client from the family

Help a person progress to a healthier emotional state

ANS: 4 The benefit of anticipatory grief is that it allows time for the process of grief (i.e., to say goodbye and complete life affairs). Anticipatory grief allows time to grieve in private, to discuss the anticipated loss with others, and to let go of the loved one. Anticipatory grief can help a person progress to a healthier emotional state of acceptance and dealing with loss. It is not most beneficial for grieving to take place only in private. It is important for grief to be acknowledged by others, and to be able to receive the support of others in the grieving process. Anticipatory grieving can be discussed with others in most circumstances. However, there may be times when anticipatory grief is disenfranchised grief as well, meaning it cannot be openly acknowledged, socially sanctioned, or publicly shared, such as a partner dying of AIDS. The benefit of anticipatory grieving is not so much that it can be discussed in most circumstances, as this discussion can also occur with normal grief when the actual loss has occurred. Anticipatory grief is the process of disengaging or letting go that occurs before an actual loss or death has occurred. The benefit is not the separation of the ill client from the family as much as it is the process of being able to say good-bye and to put life affairs in order, and as a result, it can help a client or family to progress to a higher emotional state. PTS: 1 DIF: A REF: 463 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 3. A newly graduated nurse is best prepared for the assignment of his first dying patient if he:

Completed a course dealing with death and dying

Is able to control his own personal emotions about death Has previously experienced the death of a dear loved one

3 4

Has developed a personal understanding of his own feelings about death

ANS: 4 When caring for clients experiencing grief, it is important for the nurse to assess his or her own emotional well-being and to understand his or her own feelings about death. The nurse who is aware of his or her own feelings will be less likely to place personal situations and values before those of the client. Although coursework on death and dying may add to the nurses knowledge base, it does not best prepare the nurse for caring for a dying client. The nurse needs to have an awareness of his or her own feelings about death first, as death can raise many emotions. Being able to control ones own emotions is important; however, it is unlikely the nurse would be able to do so if he or she has not first developed a personal understanding of his or her own feelings about death. Experiencing the death of a loved one is not a prerequisite to caring for a dying client. Experiencing death may help an individual mature in dealing with loss, or it may invoke many negative emotions if there is complicated grief present. The nurse is best prepared by first developing an understanding of his or her own feelings about death. PTS: 1 DIF: C REF: 465 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 4. The family of a client with a terminal illness will be able to help provide some psychological support to their family member. To assist the family to meet this outcome, the nurse plans to include in the teaching plan:

Demonstration of bathing techniques

Application of oxygen delivery devices

Recognition of the clients needs and fears Information on when to contact the hospice nurse

ANS: 3 A dying clients family is better prepared to provide psychological support if the nurse discusses with them ways to support the dying person and listen to needs and fears. Demonstration of bathing techniques may help the family meet the dying clients physical needs, not in providing psychological support. Application of oxygen devices may help the family provide physical needs for the client, not in providing psychological support for the client. Information on when to

contact the hospice nurse is important knowledge for the family to have and may help them feel they are being supported in caring for the dying client. However, contact information does not help the family provide psychological support to the dying client. PTS: 1 DIF: A REF: 474 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 5. A client that was recently diagnosed with a terminal illness asks his nurse about organ donation. The nurse should:

Have the client first discuss the subject with the family

Suggest the client delay making a decision at this time

Assist the client to obtain the necessary information to make this decision

Contact the clients physician so consent can be obtained from the family

ANS: 3 No topic that a dying client wishes to discuss should be avoided. The nurse should respond to questions openly and honestly. As client advocate, the nurse should assist the client to obtain the necessary information to make this decision. The nurse should provide the client with information in order to make such a decision. Although the nurse may suggest that the client discuss this option after having obtained information, it is up to the client to discuss the subject with the family. The nurse should respect the client and provide the necessary information for him or her to make a decision rather than dismissing the clients question. It is not necessary to contact the physician or the family for consent for organ donation if the client is capable of making this decision. PTS: 1 DIF: A REF: 469-470 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 6. A client, who is receiving chemotherapy on a medical unit due to a recent diagnosis of terminal cancer of the liver, has an in-depth conversation with the nurse. The client says, This cannot be happening to me. The nurse identifies that this stage is associated with, according to Kbler-Ross:

Anxiety

Denial

Confrontation

Depression

ANS: 2 According to Kbler-Ross, the client is in the denial stage of dying. The client may act as though nothing has happened, may refuse to believe or understand that a loss has occurred, and may seem stunned, as though it is unreal or difficult to believe. There is no stage of anxiety in the five stages of dying of Kbler-Ross. There is no stage of confrontation in the five stages of dying of Kbler-Ross. During depression the individual may feel overwhelmingly lonely and withdraw from interpersonal interaction. PTS: 1 DIF: A REF: 464 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 7. A client who is Chinese American has just died on the unit. The nurse is prepared to provide after-death care to the client and anticipates the probable preferences of a family from this cultural background will include:

Pastoral care

2 3

Preparation for organ donation Time for the family to bathe the client

Preparation for quick removal out of the hospital

ANS: 3 Some families of Chinese Americans will prefer to bathe the client themselves. They often believe the body should remain intact; organ donation and autopsy are uncommon. Chinese Americans do not prefer pastoral care for after-death care of a family member. Organ donation is uncommon for Chinese Americans. Chinese Americans may desire time to bathe the client. Quick removal from the hospital is not preferred. PTS: 1 DIF: A REF: 466 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 8. The nurse is providing care to a dying client. Which of the following is the primary concern? The nurse should:

1 2

Promote optimism in the client and be a source of encouragement Promote dignity and self-esteem in as many interventions as is appropriate

Allow the client to be alone and expect isolation on the part of the dying person

Intervene in the clients activities and promote as near normal functions as possible

ANS: 2 The focus in planning nursing care is to support the client physically, emotionally, developmentally, and spiritually in the expression of grief. When caring for the dying client, it is important to devise a plan that helps a client to die with dignity and offers family members the assurance their loved one is cared for with care and compassion. Optimism should not be the primary focus when caring for the dying client. The nurse should promote the clients self-esteem and allow the client to die with dignity. The client does not need to be left alone. The nurses or familys presence may be comforting to the client by showing that he or she is being cared for and is worthy of attention. The client should be allowed to make choices and perform as many activities of daily living independently as possible. This allows the client to maintain self-esteem and dignity. PTS: 1 DIF: A REF: 481 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 9. There is a different focus for the client with hospice nursing care. The nurse is aware that client care provided through a hospice is:

Designed to meet the clients individual wishes, as much as possible

Aimed at offering curative treatment plans intended for client recovery

Involved in teaching families and/or caregivers to provide postmortem care

Offered primarily for hospitalized clients for whom at-home care is not possible

ANS: 1 The nurses role in hospice is to meet the primary wishes of the dying client and to be open to individual desires of each client. The nurse supports a clients choice in maintaining comfort and dignity. Hospice care is for the terminally ill. It is not aimed at offering curative treatment, but rather the emphasis is on palliative care. Hospice care may provide bereavement follow-up for the family after a clients death, but hospice nurses typically do not teach the family postmortem care. Hospice care is primarily for home care, but a client in a hospice may become hospitalized.

PTS: 1 DIF: A REF: 475 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 10. To provide comfort for the client, while preparing to assist the client in the end stage of her life in response to anticipated symptom development, the nurse plans to:

Decrease the clients fluid intake

Limit the use of over-the-counter analgesics

Provide larger meals with more appealing seasoning

Determine valued activities and schedule rest periods

ANS: 4 To promote comfort in the terminally ill client, the nurse should help the client to identify values or desired tasks; then help the client to conserve energy for those tasks. Decreasing the clients fluid intake may make the terminally ill client more prone to dehydration and constipation. The nurse should take measures to help maintain oral intake, such as administering antiemetics, applying topical analgesics to oral lesions, and offering ice chips. The use of analgesics should not be limited. Controlling the terminally ill clients level of pain is a primary concern in promoting comfort. Nausea and vomiting and anorexia may increase the terminally ill clients likelihood of inadequate nutrition. The nurse should serve smaller portions and bland foods, which may be more palatable. PTS: 1 DIF: A REF: 471 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 11. To maintain the clients sense of self-worth during the end of life while working with a client in an inpatient hospice unit, the nurse should:

Leave the client alone to deal with final affairs

Call upon the clients spiritual advisor to manage care

Include regular visits throughout the day into the clients care plan

Facilitate the arrangements to have a grief counselor visit the client

ANS: 3 Spending time to let clients share their life experiences, particularly what has been meaningful, enables the nurse to know clients better. Knowing clients then facilitates choice of therapies that

promote client decision-making and autonomy. Planning regular visits also helps the client maintain a sense of self-worth, because it demonstrates that he or she is worthy of the nurses time and attention. The client should not be left alone to feel abandoned or isolated. Nurses can help clients meet spiritual needs by facilitating connections to a spiritual practice or community and supporting the expression of culturally held beliefs. A clients spiritual advisor may also be called upon but is not the only source of spiritual support. The nurse who turns care over to the spiritual advisor is not promoting the clients sense of self-worth, as it may imply the client is not worthy of the nurses time or attention. A grief counselor may be requested to visit if the client is experiencing complicated grief. Having a grief counselor visit is not an intervention that will help maintain a clients sense of self-worth. PTS: 1 DIF: A REF: 477 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 12. A nursing intervention to assist the client with a nursing diagnosis of sleep pattern disturbance related to the loss of spouse and fear of nightmares should be to:

1 2 3 4

Administer sleeping medication per order Refer the client to a psychologist or psychotherapist Have the client complete a detailed sleep pattern assessment Sit with the client while encouraging verbalization of feelings

ANS: 4 A nursing intervention to facilitate grief work is to offer the client encouragement to explore and verbalize feelings of grief. This encouragement refocuses the client on current needs and minimizes dysfunctional adaptation behaviors (e.g., not sleeping) by facilitating resolution of grief through problem-solving skills. Administering sleeping medication may help the client get to sleep but does not resolve the issue of grief. Without addressing the grief, the client may develop another dysfunctional adaptation behavior. It is not necessary to refer the client to a psychologist or psychotherapist at this time. The client needs to be encouraged to verbalize his or her feelings. Having the client complete a detailed sleep pattern assessment may help the nurse identify the number of hours of sleep the client is obtaining, but it does not address the issue causing the sleep disturbance, which is grief from the loss of the spouse. PTS: 1 DIF: A REF: 468 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 13. To promote comfort for the terminally ill client specific to nausea and vomiting, the nurse should:

Provide mouth care

Offer high-protein foods

Increase the fluid intake Offer a high-residue diet

ANS: 2 To promote comfort for the terminally ill client specific to nausea and vomiting, the nurse should administer antiemetics, provide oral care at least every 2 to 4 hours, offer clear liquid diet and ice chips, avoid liquids that increase stomach acidity (such as coffee, milk, and citrus acid juices), and offer high-protein foods in smaller portions and of a bland nature. Oral care should be provided every 2 to 4 hours. Increasing the fluid intake may help prevent constipation. A lowresidue diet may help prevent diarrhea. PTS: 1 DIF: A REF: 476 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 14. A nurse-initiated or independent activity for promotion of respiratory function in a terminally ill client is to:

Limit fluids Position the client upright

Reduce narcotic analgesic use

Administer bronchodilators as needed

ANS: 2 Positioning the client upright is an independent nursing intervention for the promotion of respiratory function in a terminally ill client. Limiting fluids may not promote respiratory function, and unless a client is on a fluid-restricted diet, the nurse should not do so. Reducing narcotic analgesic use is not a nurse-initiated activity to promote respiratory function. A respiratory rate should be assessed before administering narcotics to prevent further respiratory depression. Management of air hunger involves judicious administration of morphine and anxiolytics for relief of respiratory distress. The administration of bronchodilators would require a physicians order. It is not an independent nursing activity. PTS: 1 DIF: A REF: 476 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 15. The nurse is using Bowlbys phases of mourning as a framework for assessing the clients response to the traumatic loss of her leg. During the yearning and searching phase, the nurse anticipates that the client may respond by:

Crying intermittently

2 3

Becoming angry at the nurse Acting stunned by the eventual loss

Discussing the change in role that will occur

ANS: 1 During the yearning and searching phase of Bowlbys phases of mourning, the nurse anticipates the client may have outbursts of tearful sobbing and acute distress. During Bowlbys disorganization and despair phase of mourning, the nurse anticipates the client may express anger at anyone who might be responsible, including the nurse. During the numbing phase of Bowlbys phases of mourning, the nurse anticipates the client may act stunned by the loss. During the reorganization phase of Bowlbys phases of mourning, the nurse anticipates the client may discuss the change in role that will occur. PTS: 1 DIF: A REF: 464 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 16. The nurse finds a client who has been diagnosed with terminal lung cancer quietly crying. Which of the following nursing responses most reflects a need for additional guidance regarding therapeutic communication with a dying client?

If there is anything I can do to help, just ask.

Would you like some medication to help you sleep?

Do you want me to call your wife so you two can talk?

Try not to be sad; lets find something to be thankful for.

ANS: 4 Avoid communication barriers such as denying the clients grief, providing false reassurance, or avoiding discussion of sensitive issues. Remember that a clients emotions are not something you can fix. Instead, view emotional expression as a necessary part of the clients adjustment to significant life changes and development of effective coping skills. PTS: 1 DIF: C REF: 468 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 17. A terminally ill client shares with the nurse that he, needs to tell someone what I want when the end comes. The nurses most therapeutic response is:

We can talk about that now if you want to. Let me close the door and pull up a chair.

I imagine you would like to discuss matters with your primary care provider. Ill let him know you want to talk. Let me finish with my client care, Ill be back in 10 minutes, and we can talk as long as you need to.

3 4

If you havent discussed your feelings with your family yet, Id suggest you do that when they visit this evening.

ANS: 1 Avoid communication barriers such as denying the clients grief, providing false reassurance, or avoiding discussion of sensitive issues. When you sense that a client wants to talk about something, make time right then, if at all possible. PTS: 1 DIF: C REF: 469-470 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 18. The wife of a client recently diagnosed with end-stage renal failure shares with the nurse that, He just accepts this; I want a second opinion. The nurse recognizes that while the client has reached the acceptance stage of grieving, his wife is experiencing the:

Anger stage

Denial stage

Depression stage

Bargaining stage

ANS: 1 In the denial stage, a person acts as though nothing has happened and refuses to accept the fact of the loss. The person shows no understanding of what has occurred. When experiencing the anger stage of adjustment to loss, a person expresses resistance and sometimes feels intense anger at God, other people, or the situation. Bargaining cushions and postpones awareness of the loss by trying to prevent it from happening. Grieving or dying people make promises to self, God, or loved ones that they will live or believe differently if they can be spared the dreaded outcome. When a person realizes the full impact of the loss, depression occurs. Some individuals feel overwhelmingly sad, hopeless, and lonely. Resigned to the bad outcome, they sometimes withdraw from relationships and life. In acceptance, the person incorporates the loss into life and finds ways to move forward.

PTS: 1 DIF: A REF: 464 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 19. The mother of a child who was killed in an automobile accident is diagnosed with excessive grief. The nurse realizes that this diagnosis increases her risk of:

Attempting suicide

2 3

Developing anorexia nervosa Becoming chronically depressed

Developing a psychiatric phobia

ANS: 1 Normal grief responses, when experienced in excess, become overwhelming. People who exhibit very intense emotions and severe symptoms lose control, appear deeply traumatized, or may become suicidal, requiring medication or stabilization before they are able to begin the healing process. Depression is possible but is triggered by a variety of events. Grief is not the typical trigger for either anorexia nervosa or phobias. PTS: 1 DIF: A REF: 463 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 20. The nurse recognizes that which of the following clients is at greatest risk for complicated (dysfunctional) grief?

A 26-year-old who is diagnosed with rheumatoid arthritis

The 58-year-old only child whose mother recently died of cancer A teenage parent whose child died of sudden infant death syndrome (SIDS)

3 4

A 50-year-old diabetic client who has experienced an abovethe-knee amputation

ANS: 3 Loss associated with homicide, suicide, sudden accidents, or the loss of a child has the potential to become complicated. PTS: 1 DIF: C REF: 463 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment

21. Experiencing normal grief over losses allows the adolescent to successfully:

1 2

Move past the loss Regain a sense of security

Develop effectual coping skills

Deal with an actual loss later in life

ANS: 3 Normal grief experiences often help persons to mature and develop coping methods for dealing with other losses in the future. The remaining options are facets of successfully coping with loss. PTS: 1 DIF: A REF: 463 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 22. A client who recently experienced an amputation of the left thumb has a perceived loss of physical attractiveness. The nurse recognizes that such a loss is:

More easily assessed than actual losses

Much less personal than an actual loss

Universally experienced by all amputees

Capable of producing grief similar to an actual loss

ANS: 4 Perceived losses are easy to overlook because they are so internally and individually experienced, although they are grieved in the same way as an actual loss. The express of grief over a loss, perceived or real, is a very individualized, personal response. PTS: 1 DIF: C REF: 463 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 23. Which of the following nursing assessment data best reflects the successful achievement of the dying clients right to be pain free?

1 2

Introducing the client to effective alternative pain management techniques Educating the client on the appropriate use of a patientcontrolled analgesia device

Pain rated as a 3 out of 10 after the administration of the prescribed pain medication

Informed the primary care provider of the clients need for additional pain medication.

ANS: 3 The client is entitled to a pain free death. The most reflective assessment data supporting such a situation is a pain rating of 3 out of 10. The remaining options are all directed toward to that end. PTS: 1 DIF: C REF: 462 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 24. Which of the following interventions best reflects the nurses attempt to honor the terminally ill clients cultural values?

Interviewing both the client and the family to identify preferred end-of-life care

Talking openly and without biases about the clients end-of-life care preferences

Providing the family with the opportunity to realize the clients end-of-life wishes

Becoming familiar with the death rituals most common among the nurses client population

ANS: 3 Care provided at the end-of-life within the client and familys cultural context draws on the resources of their entire lives. Honoring client and family cultural values characterizes expert end-of-life care. Actually facilitating the opportunity to have the clients wishes fulfilled is the best reflection of expert end-of-life care. The other options are all facets of being successful at facilitating this care. PTS: 1 DIF: C REF: 475 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 25. Which of the following statements, made by a nurse regarding the means by which older adults usually express and manage grief, reflects a need for further instruction and clarification?

The greater the loss the greater the sense of grief.

Managing depression will help the grieving adult cope.

Having lived a long, happy life makes grieving easier to deal with. The longer you live, the more experience you have with grieving a death.

ANS: 3 There is little evidence that grief experiences differ due to age alone. Responses to loss are more likely related to the nature of the specific loss experience. Increased age increases the likelihood that older adults have faced multiple lossesloved ones, friends, valued objects, outliving a child, or declining health. Depression does make dealing with grief more difficult. PTS: 1 DIF: C REF: 478 OBJ: Analysis TOP: Nursing Process: Analysis MSC: NCLEX test plan designation: Safe, Effective Care Environment 26. A terminally ill client is reporting a sense of anxiety and dyspnea. The nurses initial intervention is to:

1 2 3 4

Assess the clients vital signs and administer the prescribed antianxiety medication Determine the cause of the clients dyspnea and provide both emotional and physical support Position the client in a semi-Fowlers position and provide supplemental oxygen via nasal cannula Remain with the client and encourage him to express the concerns he is experiencing regarding his death

ANS: 3 Position for comfort and maximal respiratory excursion, provide supplemental O2. Then provide comforting, reduce anxiety or fever; provide effective pain management as appropriate. The initial intervention when a client is experiencing respiratory difficulties, no matter what the potential cause it to facilitate breathing through appropriate positioning and administration of oxygen. PTS: 1 DIF: C REF: 463 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment

27. The nurse most effectively addresses the protection of a terminally ill, incontinent clients skin from irritation and breakdown by:

1 2 3 4

Using adult diapers and changing them as soon as they become wet or otherwise soiled Assessing the clients bed frequently for wetness and assuring clean, dry linens and clothing Securing an order for an indwelling catheter and keeping the perineal area free of fecal matter Offering the client frequent opportunities to toilet and responding promptly to requests to toilet

ANS: 2 Progressive disease and decreased level of consciousness can result in both urinary and fecal incontinence. The most effective means of protect skin from irritation or breakdown is by maintaining dry linens and clothing. The remaining options are not inappropriate, but a client may not be able to respond to the need to urinate or defecate. While adult diapers and an indwelling catheter are viable interventions, the client must still be provided with care that ensures that skin will be clean and dry. PTS: 1 DIF: C REF: 476 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 28. In order to most effectively address the discomfort of limited oral fluid intake for a client in the latter stages of the dying process, the nurse should:

Provide mouth care at least every 2 hours

Offer ice chips each time the client is visited

Provide the client frequent sips of a favorite beverage

Moisten the clients lips with an appropriate water based lubricant

ANS: 1 Client is less willing or able to maintain oral fluid intake reduce discomfort from dehydration by providing mouth care at least every 2 to 4 hours. Lubricating the clients lips should be included in mouth care while the other options may be impractical if the client is unable or unwilling to take fluids orally.

PTS: 1 DIF: C REF: 476 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 29. The son of a client in the initial stage of the dying process is concerned that, Mom just isnt eating much. The nurse responds most therapeutically by answering:

1 2 3 4

Her body systems are beginning to shut down and she just doesnt need as much food. Her pain medication may be making her nauseated. Has she complained or been vomiting? We can off her frequent, small portions of her favorite foods. Can you suggest some things she might enjoy? Right now solid foods are not as important as drinking. Just be sure she continues to take in plenty of fluids.

ANS: 3 Medications, depression, decreased activity, decreased blood flow to the gastrointestinal tract; nausea produces anorexia. Offer smaller portions of client preferred foods. Treat underlying cause of anorexia. Do not force food on actively dying client. While the other options are not inaccurate, the most therapeutic response offers the son an appropriate action that might encourage his mothers eating. PTS: 1 DIF: C REF: 476 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 30. The nurse is caring for a terminal ill client in the final stages of the death process when the clients daughter asks, Why are you putting drops in dads eyes? The nurse responds more accurately by telling the daughter that:

His blinking reflex is gone and these drops lubricate his corneas.

The drops will keep the corneas moist since you have donated them. They are artificial tears that will keep his eyes from becoming dry and painful.

3 4

They were prescribed for him but I wont instill them if you prefer that I dont

ANS: 3 Blinking reflexes diminish near death, causing drying of the cornea. Optical lubricants or artificial tears reduce corneal drying. While the other options are accurate, they do not address the daughters question as thoroughly as the identification of and reasoning for the drops. PTS: 1 DIF: C REF: 476 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 31. A terminal ill clients pain is being managed with opioid analgesics. When he reports experiencing constipation, the nurses most therapeutic response is:

Its a side effect of the pain medication you are taking.

Ill discuss adding some additional bulk to your diet with your wife.

Try drinking more liquids while you are awake to help soften your stool.

Ill see about getting a prescription for a laxative in order to avoid the problem.

ANS: 4 While constipation is a common side effect of opioid analgesics, the most therapeutic nursing response to the clients report is to offer an appropriate intervention. While the other options are appropriate, the use of a laxative is likely to produce the most effective, timely solution to the problem especially since a terminally ill client is not likely to be eating and drinking sufficiently. PTS: 1 DIF: A REF: 476 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 32. Which of the following statements shows the best understanding of Kbler-Rosss Five Stages of Dying?

Crying is an expected behavior of the Depression Stage.

There are tasks the client completes as they work toward acceptance.

People grieve in the manner in which they are most culturally comfortable Given enough time and support, most achieves acceptance of their own death.

ANS: 2 Survivors move back and forth through a series of stages and/or tasks many times, possibly extending over a long period of time. Theorists described stages of the grieving process and a series of tasks for survivors to successfully complete their bereavement and adapt to life with a loss. Why the other options are true, they do not show the best overall understanding of the Five Stages of Dying. PTS: 1 DIF: C REF: 476 OBJ: Analysis TOP: Nursing Process: Analysis MSC: NCLEX test plan designation: Safe, Effective Care Environment MULTIPLE RESPONSE 1. The daughter of a terminally ill client is grieving the inevitable death of her parent. The expression and depth of her grieve is most likely impacted by her: (Select all that apply.)

1 2 3

Spiritual beliefs Chronological age

Developmental stage Culturally influences

Past experiences with loss

Level of formal education

ANS: 1, 4, 5 Grief is the emotional response to a loss, manifested in ways unique to an individual, based on personal experiences, cultural expectations, and spiritual beliefs. The remaining options have minimal effect on individual grieving Chapter 37. Stress and Coping MULTIPLE CHOICE 1. For a lifestyle stress indicator and reduction in the incidence of heart disease a recommended intervention would be:

Regular physical exercise

Attendance at a support group

Self-awareness skill development

Effective time management techniques

ANS: 1

A regular exercise program reduces tension, promotes relaxation, increases ones resistance to stress, and reduces the risk of cardiovascular disease. Support systems may benefit a person experiencing stress but do not reduce the incidence of heart disease. Self-awareness skill development may enable a person to recognize when they are experiencing stress and need to implement stress-reducing strategies, but they will not reduce the incidence of heart disease. Time management, including setting priorities, helps individuals identify tasks that are not necessary or can be delegated to someone else. Effective time management will help lower ones level of stress, but does not reduce the incidence of heart disease. DIF: A REF: 494 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 2. An adolescent child, who is having behavioral problems has had added responsibilities put upon her because the father has just loss his job and is experiencing periods of depression and the mother has a chronic debilitating illness. The nurse is involved in crisis intervention and intervenes to specifically focus the family on their feelings by:

1 2

Pointing out the connection between the situation and their responses Encouraging the use of the familys usual coping skills

Working on time management skills

Discussing past experiences

ANS: 1 When using a crisis intervention approach, pointing out the connections between situation and responses, the nurse helps the client make the mental connection between the stressful event and the clients reaction to it. Because an individuals or familys usual coping strategies are ineffective in managing the stress of the precipitating event in a crisis situation, the use of new coping mechanisms is required. Time management skills will not help reduce the stress of the precipitating event in a crisis situation. What may have worked in past experiences is ineffective in managing the stress of the precipitating event in a crisis situation. DIF: A REF: 498 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 3. A mother and her child sit in a playroom on the pediatric unit. The boy wants to play with a toy that another child has but the mother says no. The child cries, throws a block, and runs over to kick the door. This child is using a mechanism known as:

Displacement

2 3

Compensation Conversion

Denial

ANS: 1 Displacement is transferring emotions, ideas, or wishes from a stressful situation to a less anxiety-producing substitute. Compensation is making up for a deficiency in one aspect of selfimage by strongly emphasizing a feature considered an asset. Conversion is unconsciously repressing an anxiety-producing emotional conflict and transforming it into nonorganic symptoms. Denial is avoiding emotional conflicts by refusing to consciously acknowledge anything that might cause intolerable emotional pain. DIF: A REF: 488 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 4. Clients undergoing stress may have periods of regression. The nurse assesses this regressive behavior in the situation where:

An adult client exercises to the point of fatigue

An 8-year-old child sucks his thumb and wets the bed

An adult client avoids speaking about health concerns An 11-year-old child experiences stomach cramps and headaches

ANS: 2 Regression is coping with a stressor through actions and behaviors associated with an earlier developmental period, such as an 8-year-old child sucking his thumb and wetting the bed. An adult client who exercises to the point of fatigue is not demonstrating regression. An adult client who avoids speaking about health concerns may be using denial as a coping mechanism. An 11year-old who develops stomach cramps and headaches is an example of conversion. DIF: A REF: 488 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management

5. During the end-of-shift report the nurse notes that a client had been very nervous and preoccupied during the evening and that no family visited. To determine the amount of anxiety that the client is experiencing, the nurse should respond:

Would you like for me to call a family member to come support you?

Would you like to talk with another client who had the same surgery? How serious do you think the illness you are experiencing really is?

3 4

You seem worried about something. Would it help to talk about it?

ANS: 4 The nurse learns from the client both by asking questions and by making observations of nonverbal behavior and the clients environment. To determine the amount of anxiety the client is experiencing, the nurse gathers information from the clients perspective. Noting that he seems worried and offering to discuss it is the correct response. Asking if the client desires for family to be called is not assessing the clients level of anxiety. The nurse should first focus on developing a trusting relationship with the client. If the nurse takes the client to visit someone who had the same surgery, the nurse would not be able to assess the clients current level of anxiety. Asking the client about how serious he deems the illness to be is not the best response. It does not assess the amount of anxiety the client is currently experiencing. DIF: A REF: 491 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 6. A 23-year-old man who recently had a head injury from a motor vehicle accident (MVA) is in a state of unconsciousness. Which of the following physiological adaptations is primarily responsible for his level of consciousness?

Pituitary gland

Medulla oblongata

Reticular formation External stress response

4 ANS: 3

The reticular formation is primarily responsible for an individuals level of consciousness. The pituitary gland supplies hormones that control vital functions. The pituitary gland produces hormones necessary for adaptation to stress (e.g., adrenocorticotropic hormone). The medulla oblongata controls vital functions such as heart rate, blood pressure, and respiration. The external stress response is not primarily responsible for a persons level of consciousness. DIF: A REF: 486 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 7. Clients experiencing post-traumatic stress disorder (PTSD) following the World Trade Tower bombing work with nurses in the medical center. An approach that is appropriate and should be incorporated into the plan of care is:

1 2

Suppression of anxiety-producing memories Reinforcement that the PTSD is short term

Promotion of relaxation strategies

Focus on physical needs

ANS: 3 Teaching the client relaxation strategies can help reduce the stress of anxiety-provoking thoughts and events, as seen in PTSD, and reinforces an adaptive coping strategy. Suppression would be a maladaptive coping mechanism. PSTD persists longer than 1 month. The focus should be on developing adaptive coping mechanisms and lowering the individuals anxiety. The focus is not on physical needs for the client who is experiencing PTSD. DIF: A REF: 489 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 8. A client is experiencing job-related stress. The nurse is working with the client in an outpatient health care setting. The nurse believes this client is dissociated as a result of observing the client:

Avoid discussion of job problems

Act like another colleague on the job

Experience chronic headaches and stomach aches Sit quietly and not interacting with any of the staff

4 ANS: 4

Dissociation is experiencing a subjective sense of numbing and a reduced awareness of ones surroundings. The client who is sitting quietly and not interacting with any of the staff may be displaying dissociation. The client who avoids discussion of the problem may be using denial as an ego-defense mechanism. The client who acts like another colleague on the job is using identification as an ego-defense mechanism. The client who experiences headaches and stomach aches is using the ego-defense mechanism of conversion. DIF: A REF: 488 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 9. A 72-year-old client is in a long-term care facility after having had a cerebrovascular accident. The client is noncommunicative, enteral feedings are not being absorbed, and respirations are becoming labored. Which of the stages of the GAS is the client experiencing?

Alarm reaction

Resistance stage

Exhaustion stage

Reflex pain response

ANS: 3 The exhaustion stage occurs when the body can no longer resist the effects of the stressor and when the energy necessary to maintain adaptation is depleted. During the alarm reaction, rising hormone levels result in increased blood volume, epinephrine and norepinephrine amounts, heart rate, blood flow to muscles, oxygen intake, and mental alertness. During the resistance stage, the body stabilizes. Reflex pain response is not a stage of GAS. DIF: A REF: 487 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 10. A client recently lost a child in a severe case of poisoning. The client tells the nurse, I dont want to make any new friends right now. This is an example of which of the following indicators of stress?

Spiritual indicator

Emotional indicator

Intellectual indicator

Sociocultural indicator

ANS: 4 The client who recently experienced a loss and does not want to meet new people is an example of a sociocultural indicator of stress. Spiritual indicator is not an example of a spiritual indicator of stress. The client is not restless or verbalizing discontent with a higher being. Emotional indicator is not an example of an emotional indicator of stress. The client is not displaying anger or crying. Intellectual indicator is not an example of an intellectual indicator of stress. DIF: A REF: 490 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 11. A corporate executive works 60 to 80 hours/week. The client is experiencing some physical signs of stress. The practitioner teaches the client to include 15 minutes of biofeedback. This is an example of which of the following health promotion interventions?

1 2

Guided imagery Regular exercise

Time management

Relaxation technique

ANS: 4 Relaxation technique is correct. Biofeedback is a training program designed to develop ones ability to control the autonomic (involuntary) nervous system. Clients learn to monitor their functioning such as heart rate, blood pressure, skin temperature, or muscle tension, and learn to relax in response in order to create desired changes. Guided imagery is a relaxed state in which a person actively uses imagination in a way that allows visualization of a soothing, peaceful setting. This is not an example of guided imagery. Regular exercise is not an example of a regular exercise program. It does not improve muscle tone and reduce the risk of cardiovascular disease. Time management techniques include developing lists of tasks to be performed in order of priority. This is not an example of time management. DIF: A REF: 497 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 12. It appears to the nurse the client is experiencing a crisis. The nurse plans to:

Allow the client to work through independent problem-solving

Complete an in-depth evaluation of stressors and responses

Focus on immediate stress reduction

Recommend ongoing therapy

ANS: 3 The nurses focus for a client experiencing a crisis is immediate stress reduction. The client experiencing a crisis is unable to work through independent problem solving. Completing an in-depth evaluation of stressors and responses to the situation would be inappropriate for the client who is experiencing a crisis. A person who has experienced a crisis has changed, and the effects may last for years or for the rest of the persons life. If a person has successfully coped with a crisis and its consequences, he or she becomes a more mature and healthy person, and ongoing therapy may not be necessary. DIF: A REF: 498 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 13. What priority assessment area has been noticed by a nurse while working with clients who are experiencing a significant degree of stress?

The clients primary physical needs

What else is happening in the clients life

How the stress has influenced the clients activities of daily living

Determining whether the client is thinking about harming self or others

ANS: 4 A priority assessment is to determine if the person is suicidal or homicidal by asking directly. The priority assessment for the client who is experiencing a significant degree of stress is not the clients physical needs. The nurse should first determine if the client is a danger to self or others. After determining if the client is suicidal or homicidal, the nurse can begin the problem-solving process and assess what else is happening in the clients life. The nurse should first determine if the client is a danger to self or others. Then the nurse can examine the degree of disruption in the persons life, such as in activities of daily living. DIF: A REF: 494 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management

14. The response to stress for older adults may be manifested differently than in younger adults. The nurse recognizes that. For the older adult client, the nurse is aware that:

1 2 3 4

Losses are more stress-provoking Anxiety disorders are most prevalent Psychosocial factors are the greatest threats Timing of stress-inducing events is not significant

ANS: 2 Anxiety disorders are the most prevalent disorders in later life and are continuations of life-long illnesses. Losses in later life may be less stress provoking than generally assumed, partly because certain life transitions are anticipated and people prepare by coping in advance. The effect of psychosocial factors on health status is not altered by age. The timing of stress-inducing events can significantly influence older adults ability to cope. The fact that older adults may have several stressful events (e.g., loss of a spouse and new medical diagnosis) occur with a short period of time can result in detrimental effects on coping. DIF: A REF: 491 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 15. A client who has experienced massive soft tissue trauma is handling both the physical and emotional stressors via the generalized adaptation syndrome (GAS). The major benefit of this defense mechanism is through the:

Identification of foreign antigens on invading bacteria

Production of endorphins that decrease awareness of pain

Increased epinephrine, resulting in improved cardiac output Increased norepinephrine directed towards sustaining blood pressure

ANS: 2 Endorphins, hormones that act on the mind like morphine and opiates, produce a sense of wellbeing and reduce pain. It is the bodys immune system that recognizes antigens on the surface of the bacteria cells and thus identifies bacteria as invaders. During the alarm reaction stage of the GAS process, rising epinephrine and norepinephrine levels result in increased heart rate and blood flow. DIF: A REF: 486-487 OBJ: Comprehension

TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 16. The nurse is caring for a client who was admitted with various physical traumas resulting from an assault by a stranger attempting to steal her purse. Which of the following statements made by the nurse is most therapeutic in assessing the degree of stress the event has caused the client?

Would you like to talk about the attack?

2 3

What may I do to help you emotionally? Has being attacked been traumatic for you?

How has this experience affected your life?

ANS: 4 The vital question for a person in crisis is, What does this mean to you; how is it going to affect your life? What causes extreme stress for one person is not always stressful to another. The perception of the event, the situational supports, and the coping mechanisms all influence return of equilibrium or homeostasis. The other options are not as effective at opening up clientdirected communication concerning the effects of the event. DIF: C REF: 488 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 17. Which of the following clients shows the greatest risk factor for stress coping related to situational stressors?

An 18-year-old high school athlete who breaks his leg just before college football tryouts

A 75-year-old widow whose only son is severely injured in an automobile accident

A 36-year-old who loses his job days after his marriage to his high school sweetheart A 60-year-old who is diagnosed with prostate cancer after deciding to retire from his job of 26 years

ANS: 2 The timing of stress-inducing events significantly influences older adults ability to cope. The fact that older adults have several stressful events (i.e., loss of a spouse and new medical diagnosis)

occur within a short period of time often results in negative effects on coping ability. The remaining options reflect stressful situations but to lesser degrees. DIF: C REF: 489 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 18. Which of the following client behaviors best reflects Neuman Systems Model of primary prevention? The client who:

Swims daily to strengthen muscles weakened as a result of shoulder surgery

Follows a low-fat diet in order to bring her high-density lipids to under 200 mg/dL

Walks 1 mile daily to keep her blood pressure from rising higher than 130/70 mm Hg

Attends a survivor support group after the loss of a spouse in an automobile accident

ANS: 3 According to Neumans theory, the goal of primary prevention is to promote client wellness by stress prevention and reduction of risk factors. Secondary prevention occurs after symptoms appear. At the tertiary level of prevention, the nurse supports rehabilitation processes involved in healing, moving the client back to wellness and the primary level of disease prevention. DIF: C REF: 489 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 19. The son of a client diagnosed with moderately advanced Alzheimers disease shows concern over the care his mother will receive after making the decision to institutionalize her. Which of the following statements made by the admitting nurse is most therapeutic in addressing the sons concerns?

We care deeply for all our clients and take great pride in the care and attention we give each one of them.

Please feel free to talk to our staff and to the other clients about the care and attention we give to each of our clients.

I hope that you will be able to visit your mother often and offer us suggestions on how best to meet her physical and emotional needs.

I know it has been a difficult decision, and you must have concerns about leaving her, but rest assured we have her best interest at heart.

ANS: 3 The decision to institutionalize a family member and the aftermath of that decision cause emotional distress and are a threat to family members psychological well-being. When their role shifted from primary caregiver to advocate for the patient, the family members felt empowered. Previous studies showed that institutionalized residents have a better quality of life when family members are involved. By encouraging frequent visits and including them in the clients care, the familys concerns will be best managed. DIF: C REF: 490 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 20. Which of the following statements reflects the correct interpretation of the effect of age on coping strategies?

The young adult client generally handles stress more effectively than does the elder adult.

Life provides the older adult with more opportunities to effectively manage their stressful events.

Children appear to be less aware of stressors in their lives and so are less negatively affected by it.

Stress is evident in everyones life and we all learn to cope with it regardless of our age or life experiences.

ANS: 4 There are very few age-related differences in coping strategies, and older adults are just as effective at coping as younger adults (Varcarolis and others, 2006). DIF: A REF: 489 OBJ: Comprehension TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 21. Which of the following client behaviors best reflects Neuman Systems Model of tertiary prevention? The client who:

Swims daily to strengthen muscles weakened as a result of hip surgery

Follows a low-fat diet in order to bring her high-density lipids to under 200 mg/dL

Walks 1 mile daily to keep her blood pressure from rising higher than 130/70 mm Hg

Attends a survivor support group after the loss of a spouse in an automobile accident

ANS: 1 According to Neumans theory, the goal of primary prevention is to promote client wellness by stress prevention and reduction of risk factors. Secondary prevention occurs after symptoms appear such as muscle strengthening post surgery. At the tertiary level of prevention, the nurse supports rehabilitation processes involved in healing, moving the client back to wellness and the primary level of disease prevention. DIF: C REF: 494 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 22. The husband of a client with terminal cancer has expressed a high degree of stress over his role as caregiver. When asked whether he has suicidal or homicidal thoughts he answered, Sometimes. Which of the following nursing statements is most therapeutic initially?

What is the hardest part about your wifes impending death?

Can you describe your plan for killing yourself and your wife?

What can I do to help make caring for your wife less stressful? Can you tell me how caring for your wife has affected you personally?

ANS: 2 If a client indicates suicidal or homicidal ideations, the nurse should first determine in a caring and concerned manner if the person has a plan and determine how lethal the means are. The

remaining options represent appropriate questions but only after the safety issues have been addressed. DIF: C REF: 497 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 23. Which of the following statements made by the nurse shows the best understanding of the therapeutic value of a support system for a client experiencing stress?

They will be there when you need them and make sure you will have your needs met.

They will provide you with someone to talk with about your problems and support your decisions.

When you are experiencing stress, it is always comforting to have people who care about you nearby.

These individuals have experienced what you are going though and can offer you effective suggestions.

ANS: 2 A support system of family, friends, and colleagues who will listen, offer advice, and provide emotional support benefits a client experiencing stress. The individuals need not have actually experienced the same stressors nor is it necessary or reasonable to expect that they will meet all your needs. DIF: C REF: 486 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management MULTIPLE RESPONSE 1. The nurse recognizes that a client experiencing anxiety related to a traumatic injury and the resulting pain is likely to experience the fight or flight response, which would cause which of the following assessment findings? (Select all that apply.)

1 2

Rectal temperature of 102.2 F Pulse Ox of 97% on room air

Respirations of 30 breaths per minute

Heart rate greater than 100 beats per minute

Fasting glucose level of 118 mg/dL

Systolic blood pressure 26 mm Hg above baseline

ANS: 3, 4, 5, 6 This reaction prepares a person for action by increasing heart rate; diverting blood from the intestines to the brain and striated muscles; and increasing blood pressure, respiratory rate, and blood sugar levels. Body temperature and oxygen saturation are not typically affected by fight or flight. Chapter 38. Activity and Exercise MULTIPLE CHOICE 1. A client has been prescribed bed rest for a prolonged time. To specifically promote the use of resistive isometric exercise for the client, the nurse will initiate:

Quadriceps setting

2 3

Gluteal muscle contraction Moving the arms and legs in circles

Pushing against a footboard

ANS: 4 Resistive isometric exercises are those in which the individual contracts the muscle while pushing against a stationary object or resisting the movement of an object. An example of a resistive isometric exercise is pushing against a footboard. Quadriceps setting is an example of an isometric exercise. Gluteal muscle contraction is an example of an isometric exercise. Moving the arms and legs in a circle is an example of isotonic exercise. DIF: A REF: 788 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 2. The nurse is assessing the body alignment of an alert and mobile client. The first action that the nurse should take is to:

Observe gait

Put the client at ease

Determine activity tolerance

Determine range of joint motion

ANS: 2

The first step in assessing body alignment is to put the client at ease so unnatural or rigid positions are not assumed. When assessing body alignment, the first action of the nurse is to put the client at ease. Later, the nurse may assess the clients gait to observe the clients balance, posture, and ability to walk without assistance. Activity tolerance is the kind and amount of exercise or activity a person is able to perform. It is not the first step in assessing a clients body alignment. Assessing ROM is one of the first assessment techniques used to determine the degree of damage or injury to a joint. It is not the first step in assessing a clients body alignment. DIF: A REF: 787 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 3. An average-size male client has right-sided hemiparesis. The nurse helps this client to walk by:

1 2 3 4

Standing at his left side and holding his arm Standing at his left side and holding one arm around his waist Standing at his right side and holding his arm Standing at his right side and holding one arm around his waist

ANS: 4 The nurse provides support at the waist so the clients center of gravity remains midline. The nurse should be on the clients weaker side to assist him with ambulation. The nurse should hold onto the clients waist, not his arm, and should be on his weaker side, not his strong side. The nurse should be on the clients weaker side. The nurse should hold onto the clients waist to help steady him in maintaining his center of gravity midline so that he does not lose his balance and fall. DIF: A REF: 794 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 4. The nurse is working with a client who has left-sided weakness. After instruction, the nurse observes the client ambulate in order to evaluate the use of the cane. Which action indicates that the client knows how to use the cane properly?

The client keeps the cane on the left side.

Two points of support are kept on the floor at all times.

There is a slight lean to the right when the client is walking. After advancing the cane, the client moves the right leg forward.

ANS: 2 Two points of support, such as both feet or one foot and the cane, should be on the floor at all times. The cane should be kept on the stronger side, the clients right side. The client should keep his or her body upright and midline. Leaning can cause the client to lose his or her balance and fall. After advancing the cane, the client should move the weaker leg, the clients left leg, forward to the cane. DIF: A REF: 803 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 5. A client with a fractured left femur has been using crutches for the past 4 weeks. The physician tells the client to begin putting a little weight on the left foot when walking. Which of the following gaits should the client be taught to use?

Two-point

2 3

Three-point Four-point

Swing-through

ANS: 1 The two-point gait requires at least partial weight bearing on each foot. The client moves a crutch at the same time as the opposing leg, so that the crutch movements are similar to arm motion during normal walking. In a three-point gait, weight is borne on both crutches and then on the uninvolved leg. The four-point gait gives stability to the client but requires weight bearing on both legs. Each leg is moved alternately with each opposing crutch so that three points of support are on the floor at all times. This client is only supposed to use partial weight bearing, so this gait would not be appropriate. Paraplegics who wear weight-supporting braces on their legs use the swing-through gait. It would not be appropriate for this client. DIF: A REF: 805 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 6. The client needs to use crutches at home, and will have to manage going up and down a short flight of stairs. The nurse evaluates the use of an appropriate technique if the client:

Uses a banister or wall for support when descending

Uses one crutch for support while going up and down

Advances the crutches first to ascend the stairs

Advances the affected leg after moving the crutches to descend the stairs

ANS: 4 To descend stairs, the crutches are placed on the stairs and the client moves the affected leg, then the unaffected leg to the stairs with the crutches. The client should continue to use the crutches for support, not the banister or wall. The client should continue to use both crutches for support when going up or down stairs. When ascending stairs, the client moves the unaffected leg up the stair, then the crutches and affected leg. DIF: A REF: 805 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 7. While ambulating in the hallway of a hospital, the client complains of extreme dizziness. The nurse, alert to a syncopal episode, should first:

Support the client and walk quickly back to the room

Lean the client against the wall until the episode passes

Lower the client gently to the floor Go for help

ANS: 3 If the client has a syncopal episode or begins to fall, the nurse should assume a wide base of support with one foot in front of the other, supporting the clients weight, and then extend the leg, allowing the client to slide against the leg while gently lowering the client to the floor and protecting the clients head. The nurse should not attempt to walk the client quickly back to the room. The nurse should not lean the client against a wall as the client may fall. The nurse should not leave the client alone and go for help. DIF: A REF: 802 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 8. A client is admitted to the medical unit following a CVA (stroke). There is evidence of leftsided hemiparesis and the nurse will be following up on range-of-motion and other exercises performed in physical therapy. The nurse correctly teaches the client and family members which one of the following principles of range-of-motion exercises?

Flex the joint to the point of discomfort.

Work from proximal to distal joints.

Move the joints quickly.

Provide support for distal joints.

ANS: 1 Flexing the knees and keeping the feet wide apart provide a broad base of support and increase stability. The nurse should position himself or herself close to the client or object being lifted to minimize the force (10 pounds held at waist height close to the body is equal to 100 pounds held at arms length). Having the client or object close to the center of gravity also helps maintain balance. Twisting should be avoided because it increases the risk of back injury. The leg muscles should be used for lifting or moving. They are stronger, larger muscles capable of greater work without injury. DIF: A REF: 794 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 9. Nurses need to implement appropriate body mechanics in order to prevent injury to themselves and their clients. Which principle of body mechanics should the nurse incorporate into client care?

Flex the knees and keep the feet wide apart.

2 3

Assume a position far enough away from the client. Twist the body in the direction of movement.

Use the strong back muscles for lifting or moving.

ANS: 1 The correct answer is to flex the knees and keep the feet wide apart. This will create a wide base of support, providing greater stability for the nurse and reducing the risk of back injury. The nurse should be positioned close to the client and use the arms and legs. Dividing balanced activity between arms and legs reduces the risk of back injury. Facing the direction of movement prevents abnormal twisting of the spine, also reducing the risk of back injury. DIF: C REF: 801 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe and Effective Care Environment 10. The nurse is presenting a teaching session on exercise for a group of corporate executives. An appropriate recommendation is that

Continuous activity is required in order for the exercise to be worthwhile

3000 to 4000 calories may be easily expended each week

Lower-intensity activities need to be done more often for value Only formal exercise activities are counted in a regular plan

ANS: 3 Lower intensity activities should be done more often, for longer periods of time, or both. The activity does not have to be continuous; benefits can be realized with short bouts of activity over the course of the day. Answer 2 is inaccurate; 1000 to 1400 calories may be easily expended each week. All types of activity can be applied in an exercise plan; it does not have to be formal exercises. DIF: A REF: 788 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 11. Following an assessment of the client, the nurse identifies the nursing diagnosis activity intolerance related to increased weight gain and inactivity. An outcome identified by the nurse should be:

Resting heart rate will be 90 to 100 beats/minute

Blood pressure will be maintained between 140/80 and 160/90 mm Hg

Exercise will be performed 3 to 4 times over the next 2 weeks

Achievement of a rating of 3 for activity endurance

ANS: 3 An appropriate outcome for activity intolerance related to increased weight gain and inactivity is that the client will perform exercise 3 to 4 times over the next 2 weeks. This outcome is realistic, measurable, and addresses the problem. A resting heart rate of 90-100 beats/minute is too high, and it does not address the need to increase activity. This outcome does not state whether this blood pressure is at rest or after exercising. It also does not address the need to increase activity. A more appropriate outcome is that the client will increase his or her activity (over the next 2 weeks). DIF: A REF: 796 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 12. The primary purpose for placing an immobile clients arms across his or her chest when preparing to transfer the client up in the bed is to:

Increase the stability of the clients body

Protect the clients arms from being hurt during the transfer Produce a more compact form that facilitates the transfer

3 4

Reduce the amount of body surface area that is in contact with the bed.

ANS: 4 The greater the surface area of the object you are moving, the greater the friction. For example, when a client is unable to assist in moving up in bed, place the clients arms across the chest. This decreases surface area and reduces friction. DIF: A REF: 788 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/ Immobility 13. Which of the following nursing interventions is likely to have the most impact on reducing friction when positioning an immobile client?

Involving at least two personnel in the actual transfer

Lubricating all body parts that are in contact with the bed

Dressing the bed with a lift sheet to be use during the transfer

Thoroughly explaining the process to the client before the move

ANS: 3 The use of the more common lift sheet reduces friction because the client is more easily moved along the beds surface. Lubricating the body will not reduce friction if the body is improperly handled. The remaining options are not incorrect but do not have an impact on the risk of friction damage to the client as does using the lift sheet. DIF: C REF: 788 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/ Immobility 14. A postmenopausal client is experiencing mild osteopenia and has been encouraged to walk 1 mile daily. Which of the following statements made by the client shows the best understanding of the positive effects of exercise on her condition?

It makes me stronger and healthier.

2 3

It helps make all my bones stronger. Walking increases the muscle mass in my legs.

Regular walking improves my stamina and endurance.

ANS: 2 Regular physical activity and exercise enhances functioning of all body systems, including cardiopulmonary functioning (endurance), musculoskeletal fitness (flexibility and bone integrity), weight control and maintenance (body image), and psychological well-being. Osteopenia, the precursor of osteoporosis, results in weakened bones that are easily damaged. Walking helps stimulate bone cell production, which in turns helps produce stronger bones. While the other options are not incorrect, they do not address the issue of osteopenia. DIF: C REF: 788 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/ Immobility 15. A client who is confined to a wheelchair is encouraged to engage in resistive isometric exercises to increase muscle strength and decrease the development of pressure ulcers. Which of the following is the most appropriate example of such an exercise for this client?

Hip lifting

Gluteal contraction

Foot pressure off-loading

Bicep-tricep compression

ANS: 1 An example of a resistive isometric exercises is hip lifting. In hip lifting, the client, who is in a sitting position, pushes with the hands against a surface such as the seat of a chair and raises the hips. Resistive isometric exercises help promote muscle strength and provide sufficient stress against bone to promote osteoblastic activity while temporarily reducing the pressure that can damage skin and produce pressure ulcers. The remaining options are primarily directed towards muscle strengthening, not pressure reduction. DIF: C REF: 788 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/ Immobility

16. The nurse is caring for a client diagnosed with bilateral middle ear infections. Which of the following statements made by the nurse best reflects an understanding of the effects of this condition on the clients ability to move appropriately?

He hasnt reported any nausea or vomiting.

His ability to hear doesnt seem to be affected.

Ill identify the client as a high falls risk by noting it on his Kardex.

I believe he is capable of using his call bell when he needs assistance.

ANS: 3 Within the inner ear are the semicircular canals, three fluid-filled structures that assist in maintaining balance. An inner ear infection would interfere with the proper functioning of the semicircular canals and place the client at risk for falling. The remaining options do not deal as directly with mobility. DIF: C REF: 788 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/ Immobility 17. An obese quadriplegic client has requested being transferred to a chair so he can be fed lunch sitting upright. Which of the following statements made by the ancillary personnel assigned the task reflects the best understanding of the implementation of this transfer?

Ill reserve the mechanical lift for right before lunch.

Ill certainly need someone to help me with this transfer.

Eating in an upright position will certainly make lunch more enjoyable for him.

Maybe he would enjoy being transferred into the dayroom to eat with the others.

ANS: 1 Mechanical lifts and lift teams are essential when the client is unable to assist. The clients weight makes the mechanical lift the most appropriate option for the transfer. The remaining options are not directly related to the implementation of the actual transfer. DIF: C REF: 789 OBJ: Analysis TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/ Immobility 18. During a musculoskeletal assessment of a 20-month-old toddler, the nurse expects to observe:

A swayback and outwardly turned feet

A spine that is flexed and lacking anteroposterior curves

Widened hips and fat deposits on the thighs and buttocks

A stance with moderately spaced foot placement and a slightly rounded abdomen

ANS: 1 The toddlers posture is awkward because of the slight swayback and protruding abdomen. As the child walks, the legs and feet are usually far apart and the feet are slightly everted (turned outward). DIF: A REF: 789 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/ Immobility 19. The nurse recognizes that the older adults tendency to take smaller steps with feet kept closer together will most likely:

Increase the clients risk of injury resulting from falls

Result in less stress on the clients knees, hips, and ankles

Decrease the amount of energy the client expends on movement

Allow for mobility in spite of the effects of aging on the clients joints

ANS: 1 The older adult may take smaller steps, keeping their feet closer together, which decreases the base of support. Thus body balance is unstable, and they are at greater risk for falls and injuries. The remaining options are not necessarily true. DIF: A REF: 790 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/ Immobility

20. Which of the following statements made by a woman recently diagnosed with osteoporosis indicates the greatest degree of readiness to begin a daily walking routine?

The tests showed that I have osteoporosis and need to walk.

Ive walked around the local park three times, and that measures 1.75 miles.

My sister has this problem, and she walks one mile a day around her neighborhood. I can join the spa and use the treadmill when the weather gets too cold to walk outside.

ANS: 2 Recording baseline fitness scores such as pulse rate, how long it takes to walk 1 mile, waist circumference, and body mass index are indicators of readiness. The remaining options do not show the most definite level of readiness as does actually walking. DIF: C REF: 791 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/ Immobility 21. Which of the following statements made by an older adult reflects the best understanding of the need to exercise no matter ones age?

You are never too old to start exercising.

My grandson and I walk together around the park 3 times a week.

I got my granddaughter a subscription to a runners magazine for her birthday. Kids today just dont seem to get the exercise we did when I was growing up.

ANS: 2 Strategies for physical activity incorporated early into a childs daily routine may provide a foundation for lifetime commitment to exercise and physical fitness. This answer shows the best understanding of the need to exercise across the life span. DIF: C REF: 791 OBJ: Analysis TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/ Immobility 22. Which of the following nursing assessment questions will best determine the nature of an exercise-related injury?

Do you experience the pain during or after your workout?

Tell me what is included in your typical workout routine.

How long does it hurt after you have stopped exercising?

On a scale of 1 to 10, please rate your postexercise pain for me.

ANS: 2 Questions such as Describe for me your typical daily exercise routine and activity best trigger a discussion that allows for the client to offer information regarding the activities that could be responsible for the injury. The remaining options are more directed toward the pain the client is experiencing. DIF: C REF: 791 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/ Immobility 23. The nurse encourages a noninsulin-dependent diabetic client to engage in a regular exercise program primarily because to do so will most likely improve the clients:

Gastric motility, thus affecting glucose digestion

Respiratory recovery time, thus decreasing breath load

Average cardiac output, thus decreasing resting heart rate Use of glucose and fatty acids, thus decreasing blood glucose level

ANS: 4 While all the options are correct, regular exercise does tend to increase effective use of glucose and fatty acids; this would be the primary benefit for the diabetic client. DIF: C REF: 793 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/ Immobility

24. Which of the following assessment questions is most likely to result in pertinent information regarding the clients expectations of the outcomes of a regular exercise program?

1 2

What is your greatest barrier to regular exercise? What is your idea of a workable exercise program?

What do you want to happen from exercising regularly?

How much time can you comfortably dedicate to exercise daily?

ANS: 2 In assessing the clients expectations concerning activity and exercise, first determine the clients perception of what is normal or acceptable in regard to physical fitness. While the remaining options are not incorrect, they are not as likely to provide as much pertinent information regarding expectations. DIF: C REF: 808 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/ Immobility 25. The nurse has determined that a client reporting general fatigue is experiencing activity intolerance. Which of the following assessment findings, observed after the client ambulates to the bathroom, best confirms this nursing diagnosis?

Dyspnea

Diaphoresis

Hypotension Mental confusion

ANS: 1 Further review of assessed defining characteristics (e.g., abnormal heart rate or dyspnea) will possibly lead to the definitive diagnosis (activity intolerance). The remaining options may be a result of other factors. DIF: C REF: 795 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/ Immobility

26. A client with a nursing diagnosis of activity intolerance has developed reddened areas on both heels and his coccyx. Which of the following nursing interventions will most likely have the greatest impact on this diagnosis?

Ambulating him to the bathroom before returning to bed

Encouraging him to change position every 2 hours while in bed Including active range-of-motion exercises in both AM and PM care

3 4

Planning a rest period after AM care but before walking to the dining room for lunch

ANS: 4 Rest periods will allow for the client to recuperate before expending additional energy. The remaining options are more directed towards the skin breakdown problem. DIF: C REF: 795 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/ Immobility 27. The nurse has delegated the task of ambulating a client who is experiencing activity intolerance. Which of the following statements made by the nurse best reflects an understanding of the nurses role to properly instruct the ancillary personnel regarding this task?

Stop the walking if the client complains of pain or weakness.

Please be sure she has proper footwear on before starting out.

Be sure to document the time spent and the distance she walked. Take her blood pressure and pulse both before and after walking.

ANS: 1 The assigned staff must be instructed to notify the nurse of client reports of pain or any other condition that might result in physical harm. While the other options are not incorrect, they do not have the priority that the answer has. DIF: C REF: 796 OBJ: Analysis TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/ Immobility 28. A client is discussing an exercise program that includes running 1.5 miles 3 times a week. Which of the following suggestions made by the nurse is most likely to result in minimizing the clients risk for injury?

Stretching before and after running

2 3

Alternating running paths every week Hydrating well with sports drinks during and after running

Wearing running shoes that have been professionally fitted

ANS: 1 The warm-up period usually lasts about 5 to 10 minutes and may include stretching, calisthenics, and/or the aerobic activity performed at a lower intensity. The warm-up activity prepares the body and decreases the potential for injury. While the remaining options contain appropriate suggestions, they are not as directly related to the most common forms of running injuriesmuscle strain. DIF: C REF: 795 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/ Immobility 29. The first rule of safety when managing client transfers is:

Flex your knees and plant your feet far apart

Keep your back aligned with your neck, pelvis, and feet

Use lift teams or mechanical lifts when the transfer requires it Always use the large muscles of the arms and legs, not the small muscles of the back

ANS: 3 Use lift teams and patient-handling equipment, such as mechanical lifts, to prevent injury to yourself and the client whenever the client is incapable of helping. While the remaining options are correct, they are not directed towards the primary concernclient and staff safety. DIF: C REF: 795 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/ Immobility

30. The nurse is discussing the benefits of regular walking with a group of senior citizens. Which of the following statements shows the best understanding of the positive impact of exercise on the older adult?

Remember to warm up and cool down with stretching exercises.

Find a walking partner that will accompany you on a regular basis. Be sure to hydrate yourself well before, during, and after your walk.

3 4

Talk with your health care provider before starting a regular walking program.

ANS: 4 Consult a health care provider before beginning an exercise program, particularly in the presence of heart or lung disease and other chronic illnesses. While the remaining options are not incorrect, they do not show the best overall understanding of the effects of exercise on the body systems of an older adult. DIF: C REF: 797 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/ Immobility 31. A client who is immobilized in bed due to skeletal traction tells the nurse that they miss their exercise regimen that they had started prior to the accident that resulted in their hospitalization. The nurse knows that which of the following is a good form of exercise that this client can still perform while immobilized?

Isotonic exercise

Isometric contraction

Resistive isometric exercise Aerobic exercise

ANS: 2 Isometric exercise involves tightening of muscles without moving body parts. DIF: B REF: 789 OBJ: Application TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort

32. A client who will be going home will need to use crutches for ambulation. Following teaching, the nurse notes that the client complains of pain under his arms. How much room should be between the crutch pad and clients axilla?

Axilla should lightly touch the crutch pad

2 3

1 to 2 finger widths from the axilla 3 to 4 finger widths from the axilla

4 to 5 finger widths from the axilla

ANS: 3 3 to 4 finger widths from the axilla prevents pressure on the axilla. DIF: B REF: 801 OBJ: Application TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection Control 33. When planning care for a client with newly diagnosed hypertension, the nurse knows that which form of exercise would be most beneficial in lowering both systolic and diastolic blood pressure?

Lifting weights

Running

Bicycling Competitive swimming

ANS: 3 Low-moderate intensity exercise is the most effective in lowering blood pressure. Weight training and high-intensity aerobic exercise seem to have minimal benefit on lowering blood pressure. DIF: B REF: 788 OBJ: Application TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort 34. In teaching a newly diagnosed 17-year-old client with type 1 diabetes, the nurse knows that the exercise is an important component in care. Which of the following activities would be most appropriate for the previously sedentary client?

Kick-boxing class

Football

Bicycling

Soccer

ANS: 3 Low to moderate intensity exercise is most appropriate for clients with type 1diabetes. DIF: B REF: 804 OBJ: Application TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Health and Wellness 35. A newly diagnosed client with type 2 diabetes expresses concern that he will not be able to maintain his active lifestyle, which includes bicycling. The nurse instructs the client about risks and precautions regarding exercise including which of the following?

To avoid leisurely bicycling day trips

To avoid strenuous bicycling for long periods of time

It is better for them to exercise for 1 to 2 hours once a week than for 20 minutes 3 days per week

As long as he is not participating in strenuous exercise, there is no need to include warm-up or cool-down exercises

ANS: 2 The client with type 2 diabetes can do aerobic exercise at 50% to 75% of maximal oxygen uptake. DIF: B REF: 808 OBJ: Application TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Health and Wellness 36. A client with coronary heart disease has been meeting with a cardiac rehabilitation nurse for the past 5 weeks. The nurse has provided the client with interventions to increase the clients activity level. The client states that they dont know if the exercise program is helping. The nurse can assess the effectiveness of the interventions by:

Comparing baseline vital signs with current vital signs

Weighing the client

Asking the client if he feels that he has met his goals

Telling the client that the exercise will only help if the client has a positive attitude

ANS: 1 To evaluate the effectiveness of nursing interventions to enhance activity and exercise, make comparisons with baseline measures that include blood pressure, pulse, strength, endurance and psychological well-being. DIF: B REF: 808 OBJ: Application TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Health Promotion Programs 37. Passive range-of-motion exercises are most important for which of the following clients?

Pediatric client with a broken femur

Diabetic client with a total knee replacement

Unconscious client in ICU

Elderly client with a bowel obstruction

ANS: 3 The nurse should perform passive range of motion exercises with this client because the client cannot perform the exercises alone. These clients in the remaining options should be encouraged to perform active range-of-motion exercises. DIF: B REF: 808 OBJ: Application TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort 38. One of the most debilitating health hazards among nurses is musculoskeletal injuries. In order to eliminate these injuries, the American Nurses Association is advocating which of the following?

Mandate that physical therapists do all patient transfers.

Require minimum staffing levels in health care organizations.

Request the use of assistive equipment and devices. Require a minimum number of staff to be involved in all patient transfers.

ANS: 3 The use of assistive equipment and continued use of proper body mechanics can significantly reduce the risk of musculoskeletal injuries. DIF: C REF: 808 OBJ: Analysis

TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection Control 39. The nurse is working with a nursing assistive personnel to provide care for a group of clients. The nurse can delegate which of the following activities to the nursing assistive personnel?

Assess for medical limitations before beginning the exercise activity. Teach the clients breathing skills to help reduce their anxiety. Obtain preexercise and postexercise vital signs.

Document the clients progress.

ANS: 3 The nursing assistive personnel can obtain vital signs and report them to the nurse. Answers 1, 2, and 4 are activities that are nursing responsibilities and should never be delegated. DIF: B REF: 800 OBJ: Application TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe and Effective Care Environment/Management of Care 40. A client with cancer expresses interest in increasing his activity level. The nurse begins by assessing baseline data regarding the clients current activity patterns. The nurse uses professional standards to develop a plan of care for this client. Professional standards are important because they:

Are developed by government agencies

Establish scientifically proven guidelines

Shift responsibility for the plan of care from the nurse Are required by all healthcare organizations

ANS: 2 Standards of care often establish scientifically proven guidelines for selecting effective nursing interventions. DIF: C REF: 800 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/ Immobility 41. When moving a client who is unable to assist, what is the most important principle for the nurse to remember to avoid injury?

Face opposite of the direction of movement.

Keep your feet close together.

The higher the center of gravity, the greater the stability of the nurse.

Try to avoid lifting the patient if possible.

ANS: 4 Leverage, rolling, turning or pivoting requires less work than lifting. Facing the direction of movement prevents abnormal twisting of the spine. The wider the base of support, the greater stability of the nurse. The lower the center of gravity, the greater stability of the nurse. DIF: C REF: 799 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection Control MULTIPLE RESPONSE 1. When discussing the benefits of physical activity and exercise with a client, the nurse identifies which of the following as a positive outcome to the client? (Select all that apply.)

Stress management

Enhanced cardiac output

Improved bone integrity

Facilitation of weight control

Increased cognitive function

Increased musculoskeletal flexibility

ANS: 1, 2, 3, 4, 6 Regular physical activity and exercise enhances functioning of all body systems, including cardiopulmonary functioning (endurance), musculoskeletal fitness (flexibility and bone integrity), weight control and maintenance (body image), and psychological well-being. Effects on cognitive function are not consistent. DIF: A REF: 795 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/ Immobility 2. The general goal of exercise and activity for all clients is to: (Select all that apply.)

Encourage weight loss

Improve joint flexibility Minimize social isolation

3 4 5

Improve motor function Foster personal independence

Maintain the optimal level of function

ANS: 3, 5 The general goal related to exercise and activity is to improve or maintain the clients motor function and independence. While the other options are not inappropriate, they do not reflect the general goals for all clients. Chapter 39. Immobility MULTIPLE CHOICE 1. A client has been on prolonged bed rest, and the nurse is observing for signs associated with immobility. In assessment of the client, the nurse is alert to a(n):

Increased blood pressure

Decreased heart rate

Increased urinary output

Decreased peristalsis

ANS: 4 Immobility causes gastrointestinal disturbances such as decreased appetite and slowing of peristalsis. In the immobilized client, decreased circulating fluid volume, pooling of blood in the lower extremities, and decreased autonomic response occur. These factors result in decreased venous return, followed by a decrease in cardiac output, which is reflected by a decline in blood pressure. Recumbency increases cardiac workload and results in an increased pulse rate. Fluid intake can diminish with immobility, and this combined with other causes, such as fever, increases the risk for dehydration. Urinary output may decline on or about the fifth or sixth day after immobilization, and the urine is often highly concentrated. PTS: 1 DIF: A REF: 1225 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility 2. A 61-year-old client recently suffered left-sided paralysis from a cerebrovascular accident (stroke). In planning care for this client, the nurse implements which one of the following as an appropriate intervention?

Encourage an even gait when walking in place.

Assess the extremities for unilateral swelling and muscle atrophy. Encourage holding the breath frequently to hyperinflate the clients lungs.

3 4

Teach the use of a two-point crutch technique for ambulation.

ANS: 2 Because edema moves to dependent body regions, assessment of the immobilized client should include the sacrum, legs, and feet. Unilateral increases in calf diameter can be an early indication of thrombosis. The client who has suffered a cerebrovascular accident with left-sided paralysis may not be capable of an even gait. To prevent stasis of pulmonary secretions, the clients position should be changed every 2 hours, and fluids should be increased to 2000 mL, if not contraindicated. The client should deep breathe and cough every 1 to 2 hours to promote chest expansion. The client would most likely ambulate safely with a walker, or a cane. If crutches are used, the client should use a three-point support. PTS: 1 DIF: A REF: 1238 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility 3. Two nurses are standing on opposite sides of the bed to move the client up in bed with a drawsheet. Where should the nurses be standing in relation to the clients body as they prepare for the move?

Even with the thorax

Even with the shoulders

Even with the hips Even with the knees

ANS: 2 The nurses should be standing even with the clients shoulders when they prepare to move the client up in bed. PTS: 1 DIF: A REF: 1253 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility 4. A client is leaving for surgery and because of preoperative sedation needs complete assistance to transfer from the bed to the stretcher. Which of the following should the nurse do first?

Elevate the head of the bed.

Explain the procedure to the client.

Place the client in the prone position. Assess the situation for any potentially unsafe complications.

4 ANS: 4

Before transferring the client from the bed to the stretcher, the nurse should assess the situation for any potentially unsafe complications. The sedated client is transferred most easily in the supine position, unless contraindicated. The head of the bed should be at the same level as the head of the stretcher. This client has had preoperative sedation, which may impair his or her cognition. The nurse should simplify instructions when explaining the procedure to the client, but this should be done immediately before transferring the client. PTS: 1 DIF: C REF: 1268 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility 5. A client has sequential compression stockings in place. The nurse evaluates that they are implemented appropriately by the new staff nurse when the:

Initial measurement is made around the clients calves

Intermittent pressure is set at 40 mm Hg

Stockings are wrapped directly over the leg from ankle to knee

Stockings are removed every hour during application

ANS: 2 Inflation pressures average 40 mm Hg. Initial measurement is made around the largest part of the clients thigh. A protective stockinette is placed over the clients leg; then the stocking is wrapped around the leg, starting at the ankle, with the opening over the patella. For optimal results, sequential compression devices (SCDs) or intermittent pneumatic compression (IPC) are used as soon as possible and maintained until the client becomes fully ambulatory. Stockings are not removed every hour but should be removed periodically to assess the condition of the clients skin. PTS: 1 DIF: A REF: 1238 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility 6. The nurse assesses that the client has torticollis and that this may adversely influence the clients mobility. This individual has a(n):

Exaggeration of the lumbar spine curvature

Increased convexity of the thoracic spine

Abnormal anteroposterior and lateral curvature of the spine

Contracture of the sternocleidomastoid muscle with a head incline

ANS: 4 Torticollis is inclining of the head to the affected side, in which the sternocleidomastoid muscle is contracted. Lordosis is an exaggeration of the lumbar spine curvature. Kyphosis is an increased convexity in the curvature of the thoracic spine. Kyphoscoliosis is an abnormal anteroposterior and lateral curvature of the spine. PTS: 1 DIF: A REF: 1224 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility 7. An immobilized client is suspected of having atelectasis. This is assessed by the nurse upon auscultation as:

Harsh crackles

Wheezing on inspiration

Diminished breath sounds

Bronchovesicular whooshing

ANS: 3 Atelectasis is the collapse of alveoli. In atelectasis, secretions block a bronchiole or a bronchus, and the distal lung tissue (alveoli) collapses as the existing air is absorbed, producing hypoventilation. If the client were suspected of having atelectasis, the nurse would expect diminished breath sounds in the area of hypoventilation. Harsh crackles indicate excessive airway secretion. Wheezing on inspiration indicates narrowing of the lumen of a respiratory passageway. Bronchovesicular sounds are a mixture of bronchial and vesicular sounds. Bronchovesicular whooshing would not be an expected sound indicating atelectasis. PTS: 1 DIF: A REF: 1226 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility 8. The best approach for the nurse to use to assess the presence of thrombosis in an immobilized client is to:

Measure the calf and thigh circumferences

Attempt to elicit Homans sign

Palpate the temperature of the feet

Observe for a loss of hair and skin turgor in the lower legs

ANS: 1 Calf and thigh circumferences should be measured daily. Unilateral increases in calf or thigh circumference can be an early indication of thrombosis. Homans sign is not always positive in the presence of thrombosis. Assessing the temperature of the feet is not the best approach to determine the presence of thrombosis. Observing for hair loss and skin turgor of the lower legs is not the best approach to determine the presence of thrombosis. A lack of hair may indicate a chronic lack of oxygen. Skin turgor is a measure of hydration. PTS: 1 DIF: A REF: 1238 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility 9. A client is getting up for the first time after a period of bed rest. The nurse should first:

1 2 3 4

Assess respiratory function Obtain a baseline blood pressure Assist the client with sitting at the edge of the bed Ask the client if he or she feels light-headed

ANS: 2 When getting the client up for the first time after a period of bed rest, the nurse should document orthostatic changes. The nurse first obtains a baseline blood pressure. Assessing the clients respiratory function is not the nurses first intervention when getting a client up for the first time after prolonged bed rest. After the nurse assesses the clients blood pressure, the nurse can assist the client to a sitting position at the side of the bed. After the client is in the sitting position at the side of the bed, the nurse should ask the client if he or she feels light-headed. PTS: 1 DIF: C REF: 1238 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility 10. To promote respiratory function in the immobilized client, the nurse should:

Change the clients position every 4 to 8 hours

Encourage deep breathing and coughing every hour

Use oxygen and nebulizer treatments regularly

Suction the clients secretions every hour

ANS: 2 The nurse should actively work with the immobilized client to deep breathe and cough every 1 to 2 hours to promote chest expansion. The clients position should be changed every 2 hours to reduce stagnation of secretions. The health care provider must order oxygen and nebulizer treatments, which are primarily used to treat the client who is experiencing an impaired air

exchange, not to promote respiratory function in the immobilized client. The clients secretions should only be suctioned as needed. PTS: 1 DIF: A REF: 1247 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility 11. Antiembolic stockings (thromboembolic device [TED] hose) are ordered for the client on bed rest following surgery. The nurse explains to the client that the primary purpose for the TEDs is to:

Keep the skin warm and dry

2 3

Prevent abnormal joint flexion Apply external pressure

Prevent bleeding

ANS: 3 The primary purpose of antiembolic stockings is to maintain external pressure on the muscles of the lower extremities and thus promote venous return. Antiembolic stockings are not primarily used to prevent bleeding but are used to prevent clot formation caused by venous stasis. PTS: 1 DIF: C REF: 1248 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility 12. To provide for the psychosocial needs of an immobilized client, an appropriate statement by the nurse is which of the following?

The staff will limit your visitors so that you will not be bothered.

A roommate can be a real bother. Youd probably rather have a private room.

Lets discuss the routine to see if there are any changes we can make. I think you should have your hair done and put on some makeup.

ANS: 3 To meet the psychosocial needs of immobilized clients, the nurse should encourage clients to be involved in their care whenever possible. Asking the client if there are changes the staff can make in routine care is an appropriate question. Visitors should not be limited for the immobilized client. The client needs socialization throughout the day. If possible, the client should be placed in a room with others who are mobile and interactive. Clients should be

encouraged to wear their glasses or artificial teeth and to shave or apply makeup. These are activities through which people maintain their body image. The nurse provides for the psychosocial needs of an immobilized client by having the client perform as much self-care as possible. PTS: 1 DIF: A REF: 1229 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility 13. To reduce the chance of external hip rotation in a client on prolonged bed rest, the nurse should implement the use of a:

1 2

Footboard Trochanter roll

Trapeze bar

Bed board

ANS: 2 A trochanter roll prevents external rotation of the hips when the client is in a supine position. The footboard prevents footdrop by maintaining the feet in dorsiflexion. The trapeze bar allows the client to pull with the upper extremities to raise the trunk off the bed, to assist in transfer from bed to wheelchair, or to perform upper arm exercises. A bed board is used to increase back support and alignment, especially with a soft mattress. PTS: 1 DIF: A REF: 1251 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility 14. To reduce the chance of plantar flexion (footdrop) in a client on prolonged bed rest, the nurse should implement the use of:

Trapeze bars

High-top sneakers

Trochanter rolls

Thirty-degree lateral positioning

ANS: 2 High-top tennis shoes or an ankle-foot orthotic may be used to help maintain dorsiflexion and prevent footdrop. A trapeze bar is used to assist the client in mobility. A trochanter roll prevents external rotation of the hips when the client is in a supine position. Thirty-degree lateral positioning may be used for clients at risk for pressure ulcers. PTS: 1 DIF: A REF: 1254 OBJ: Comprehension TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility 15. Which of the following is the most important to consider when assisting the client in passive range-of-motion exercises?

Flex the joint to the point of discomfort.

Work from the proximal joints to the distal joints.

Quickly work through the range of motion.

Support the distal joints while performing range-of-motion exercises.

ANS: 4 While performing range-of-motion exercises, support should be provided for the distal joints. The joint should be flexed to the point of resistance, not to the point of discomfort. When performing range-of-motion exercises, begin at distal joints and work toward proximal joints. Joints should be moved slowly through their range of motion. Quick movement could cause injury. PTS: 1 DIF: A REF: 1274 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility 16. Which of the following clients is most at risk for losing his or her balance?

A woman who is 9 months pregnant walking down a flight of stairs

A 16-year-old skate boarding down a 15-degree slope

A 45-year-old taking hypertensive medication

A 4-year-old riding a tricycle

ANS: 1 Disease, injury, pain, physical development (e.g., age), and life changes (e.g., pregnancy) compromise the ability to remain balanced. Medications that cause dizziness and prolonged immobility also affect balance. Impaired balance is a major threat to physical safety and contributes to a fear of falling and self-imposed restrictions on activity. Although all the options represent a risk, the situation of the pregnant woman places her at greatest risk. PTS: 1 DIF: C REF: 1220 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility 17. It has been determined that all of the following clients are at risk for falling. Which one requires the nurses priority for ambulation?

A 16-year-old with a sprained ankle being discharged from the emergency department

A 54-year-old who has taken the initial dose of an antihypertensive medication A 45-year-old postoperative client up for the first time since knee surgery

3 4

An 81-year-old who is asthmatic and had a hip replaced 18 months ago

ANS: 3 Disease, injury, pain, physical development (e.g., age), and life changes (e.g., pregnancy) compromise the ability to remain balanced. Medications that cause dizziness and prolonged immobility also affect balance. Although all the options represent a potential risk for falling, the postoperative client has both prolonged immobility and physical injury (surgery) and so is at greatest risk. PTS: 1 DIF: C REF: 1220 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility 18. Which of the following statements made by ancillary staff reflects the most informed knowledge regarding the benefit of having a client assist with his or her own activities of daily living (ADLs) to that clients activity tolerance?

The more he does for himself, the more he will be able to do for himself.

He doesnt like washing and dressing himself, but it makes him stronger. Doing for himself makes him tired, but in the long run he has more energy and strength when he does.

3 4

By washing and dressing himself he is building muscle strength that lets him actually walk a little better.

ANS: 4 Muscle tone helps maintain functional positions such as sitting or standing without excess muscle fatigue and is maintained through continual use of muscles. ADLs require muscle action and help maintain muscle tone. When a client is immobile or on prolonged bed rest, activity level, activity tolerance, and muscle tone decrease. The remaining options do not explain the reason for the additional activity tolerance as does the answer. PTS: 1 DIF: C REF: 1250 OBJ: Analysis

TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility 19. Which of the following statements regarding physical activity and its effect on activity tolerance made by a client shows the most informed knowledge regarding the connection between the two?

I know I need to walk more if I want to get stronger.

I dont like walking, but I do it because I know it will make me stronger.

I try to walk a little farther each afternoon so I can dance at my grandsons wedding.

I walk with my son three evenings a week because its good for his weight and for my bones.

ANS: 3 Muscle tone helps maintain functional positions such as sitting or standing without excess muscle fatigue and is maintained through continual use of muscles. The better the muscle tone, the more stamina the client will experience. The remaining options do not state the connection between activity and stamina as well as the answer. PTS: 1 DIF: C REF: 1244 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility 20. A client recovering from hip surgery tells the nurse that she wants to get better so she can walk down the aisle to her seat at her granddaughters wedding. Which of the following nursing interventions will have the greatest impact on achieving that goal?

Informing physical therapists that the client has expressed that goal

Reminding the ancillary staff to offer to walk with the client after her bath

Regularly praising the client for the efforts she is making to reach her goal Walking with the client to and from the dining room where she eats her meals

ANS: 4 Muscle tone helps maintain functional positions such as sitting or standing without excess muscle fatigue and is maintained through continual use of muscles. ADLs require muscle action

and help maintain muscle tone. When a client is immobile or on prolonged bed rest, activity level, activity tolerance, and muscle tone decrease. The better the muscle tone, the more stamina the client will experience. Although all the interventions are appropriate, actually walking with the client will have the greatest impact on her ability to achieve the goal. PTS: 1 DIF: B REF: 1241 OBJ: Application TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility 21. An infant born via cesarean section because of a breech presentation is diagnosed with bilateral congenital hip dysplasia. The primary nursing intervention directed toward this diagnosis is:

Assessing the infant frequently to determine abduction of the thighs

Maintaining the infant in the position of continuous abduction of both hips

Educating the parents about the importance of positioning the infant so that the head of the femurs are in alignment with the hip sockets

Providing pain management so that the infant is comfortable in the therapeutic position required

ANS: 2 Maintenance of continuous abduction of the thigh so that the head of the femur presses into the center of the acetabulum is critical in the care and treatment of this infant. Although the other options are appropriate, they are not primary interventions in this scenario. PTS: 1 DIF: C REF: 1224 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility 22. A 16-year-old had a full leg cast for 4 months, and it is being removed today. Which of the following statements made by the client shows the most informed understanding of the effects of immobilization of a muscle on its strength and stamina?

Im hoping to be back at soccer practice in 3 weeks.

Walking and riding my bike will help regain the muscle.

Ill practice the strengthening routine the physical therapist taught me, so I can play baseball in the spring.

There was a good bit of muscle and strength loss, but Ill work at getting it back like it was before the break.

ANS: 3 Even this temporary immobilization results in some muscle atrophy, loss of muscle tone, and joint stiffness. When a client is immobile or on prolonged bed rest, activity level, activity tolerance, and muscle tone decrease. Appropriate general exercise and specific exercise of the atrophied muscle will increase both muscle tone and overall stamina. Although the remaining options are not incorrect, the answer shows the greatest insight because it provides both a plan and a time line for recovery. PTS: 1 DIF: C REF: 1223 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility 23. A staff member experienced a shoulder injury while assisting with a client transfer. The nurse managers most therapeutic response to this situation is to:

Thoroughly review the accident report filed by the injured personnel to determine the factors that contributed to the injury

Have a nonpunitive meeting with all the involved staff to discuss correcting the factors that resulted in the injury

Require that mechanical lifts be used in the transfer of all clients incapable of assisting with the transfer Implement new policies and procedures to correct the factors that resulted in the injury

ANS: 2 An after-action review allows the health care team to apply knowledge about safe client moving to the situation to identify safety factors contributing to the problem and make suggestions for the implementation of strategies to minimize risk to both client and staff. PTS: 1 DIF: C REF: 1225 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility 24. Which of the following statements made by a nurse caring for a client who experienced a myocardial infarction 8 hours ago shows the greatest insight as to the purpose for keeping the client on bed rest?

This has been exhausting; she needs a period of uninterrupted rest.

The pain she experienced is exhausting; its imperative that she rest.

Keeping her on bed rest decreases the need her body has for oxygen She needs complete rest; she is really very ill, especially her heart.

ANS: 3 Although all of the options are correct, the primary reason for bed rest in this scenario is to minimize the need for oxygen to both the heart and the body in general. PTS: 1 DIF: C REF: 1224 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility 25. The nurse recognizes that a client who is inactive is at a risk for decreased muscle mass as a result of increased muscle atrophy and:

Decrease metabolic rate Catabolic tissue breakdown

Inactivity-induced depression

Anorexia caused by decreased peristalsis

ANS: 2 Weight loss, decreased muscle mass, and weakness result from tissue catabolism (tissue breakdown). PTS: 1 DIF: A REF: 1227 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility 26. A 78-year-old inactive client diagnosed with acute renal failure is at risk for which of the following skeletal maladies?

Rickets

Osteomyelitis

Pathological fractures of long bones

Compression fractures of the spinal column

ANS: 3 Immobility causes the release of calcium into the circulation, where normally the kidneys excrete the excess calcium. If the kidneys are unable to respond appropriately, hypercalcemia results.

Pathological fractures occur if calcium reabsorption continues as the client remains on bed rest or continues to be immobile. Bed rest is not a direct causative factor for the other options. PTS: 1 DIF: A REF: 1228 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility 27. Prevention of plantar flexion (footdrop) through the application of high-topped shoes is a primary intervention for which of the following mobility-impaired clients?

1 2 3 4

A 54-year-old diagnosed with osteoarthritis in all lower extremity joints A 25-year-old with a fractured pelvis as a result of a motorcycle accident A 78-year-old who has experienced left-sided paralysis resulting from a cerebral vascular accident (CVA) A 15-year-old who has been comatose for 2 years as a result of a head injury sustained from a fall off a roof

ANS: 2 The client who has suffered a CVA with resulting left-sided paralysis (hemiplegia) is at risk for footdrop. In two of the options, the client would not damage the nerve necessary to cause the condition, and the remaining option is not the correct answer because there is little chance this client will ever be capable of mobility. PTS: 1 DIF: C REF: 1254 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility 28. The nurse is providing ancillary personnel with instructions regarding the performance of passive range-of-motion (ROM) exercises for a client experiencing paralysis from the waist down (paraplegia) as a result of an automobile accident. Which of the following statements made by the ancillary personnel reflects the greatest insight regarding the frequency with which the intervention should be provided for this client?

I will do a whole body range of motion as I complete her daily bath.

Bath time, bedtime, after lunch, and at least once more; she can pick when. It works well with her bath and when she is being prepared for bed at night.

Ill ask her when she wants me to exercise her joints in addition to bath time.

ANS: 2 If the client is unable to move part or all of the body, perform passive ROM exercises for all immobilized joints while bathing the client and at least 2 or 3 more times a day. PTS: 1 DIF: C REF: 1249 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility 29. The nurse is discussing joint mobility exercises with a client who experienced a stroke and now has left-sided weakness. Which of the following statements made by the client reflects the greatest insight regarding the best method for him to maintain mobility of the joints on his left side?

My wife knows how to do those exercises for the joints on my left side.

Physical therapy really exercises my left side when I go there every afternoon.

Ill remind the staff to exercise my left side when they come to help me with my bath and getting dressed.

I will do those passive range of motion exercises you taught me to my left side at least 3 times a day.

ANS: 4 If one extremity is paralyzed, teach the client to put each joint independently through its ROM. PTS: 1 DIF: C REF: 1261 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility 30. The nurse caring for a 38-year-old female client with multiple fractures in the trauma intensive care unit knows that this client is at high risk for pulmonary complications such as atelectasis from her immobility. One of the interventions that the nurse can do to help prevent this from occurring is to:

1 2 3 4

Keep the PaO2 level at or above 94% Instruct the client to deep breathe and cough every hour while awake Turn the client every 2 hours Keep the client on the ventilator as long as possible

ANS: 2 In atelectasis, secretions block a bronchiole or a bronchus, and the distal lung tissue (alveoli) collapses as the existing air is absorbed, producing hypoventilation. The site of the blockage affects the severity of atelectasis. Sometimes an entire lung lobe or a whole lung collapses. At some point in the development of these complications, there is a proportional decline in the clients ability to cough productively. Turning the client is an excellent way to help prevent the accumulation of mucus in the dependent regions of the airways causing hypostatic pneumonia. Mucus is an excellent place for bacteria to grow. Keeping a client on a ventilator longer than necessary has the potential to cause multiple other complications and is not the best choice. PTS: 1 DIF: A REF: 1220 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility 31. The nurse is caring for a 48-year-old male client who was involved in a motor vehicle accident and had a fractured pelvis, a ruptured spleen, and multiple contusions. The client has been in the hospital for 5 days on bed rest. The nurse knows that this client is at risk for venous thrombus formation because of prolonged bed rest, potential damage to vessel walls during surgery, and the platelets he received in the trauma unit. These three factors are also known as:

1 2 3 4

Trigeminy Virchows triad Trigone Hutchinsons triad

ANS: 2 There are three factors that contribute to venous thrombus formation: (1) damage to the vessel wall (e.g., injury during surgical procedures), (2) alterations of blood flow (e.g., slow blood flow in calf veins associated with bed rest), and (3) alterations in blood constituents (e.g., a change in clotting factors or increased platelet activity. These three factors are sometimes referred to as Virchows triad PTS: 1 DIF: A REF: 1260 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility 32. The nurse caring for a 73-year-old female client who has been hospitalized with a stroke instructs the clients daughter to continue to do passive range-of-motion exercises with her mother on her affected side to prevent contractures. The nurse explains to the daughter that this is very important in an immobile older adult client because contractures can form in as little as:

8 hours

24 hours

1 week

1 month

ANS: 1 Disuse, atrophy, and shortening of the muscle fibers cause joint contractures. When a contracture occurs, the joint cannot obtain full ROM. Contractures sometimes leave a joint or joints in a nonfunctional position, as seen in clients who are permanently curled in a fetal position. Early prevention of contractures is key; they can begin to form after only 8 hours of immobility in the older adult client. PTS: 1 DIF: B REF: 1225 OBJ: Application TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility 33. The nurse understands that a pressure ulcer is an impairment of the skin as a result of prolonged ischemia. One of the easiest ways to prevent a pressure ulcer from occurring in an immobile client is to:

Keep the skin dry

Provide range of motion every shift

Use lift equipment when transferring a client

Turn the client a minimum of every 2 hours

ANS: 4 Implement a comprehensive skin care program to prevent skin breakdown in all clients, from neonates to older adults. Effective skin care programs include accurate and consistent assessment and documentation as well as interventions to protect the skin (e.g., turn the client at least every 2 hours). Keeping the skin dry is very important in preventing skin breakdown, range-of-motion exercises will help prevent contractures from occurring, lift equipment will help decrease harm to both clients and staff, but turning the client will best help prevent pressure ulcers. PTS: 1 DIF: B REF: 1225 OBJ: Application TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility 34. The nurse caring for a 78-year-old male client recovering from hip replacement surgery is assessing for signs of improvement of the clients activity tolerance. The nurse determined a baseline for ongoing assessments by:

Determining how much time it takes the client to recover from an activity

Assessing how much the client can do at one time

3 4

Determining the level of pain experienced by the client during the activity Asking the client how much the client feels like doing

ANS: 1 When the client experiences decreased activity tolerance, carefully assess how much time the client needs to recover. Decreasing recovery time indicates improving activity tolerance. Pain should not be an assessment of activity tolerance. Asking the client how much he feels like doing before an activity will not tell the nurse if he is improving over time. The client may be able to do more (or less) than he thinks he is capable of doing before an activity. PTS: 1 DIF: A REF: 1225 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility 35. The nurse and a nursing assistive personnel (NAP) are going to move an older adult client up in bed. Before moving the client, the nurse explains to the NAP that they will need to lift the client off the bed with an assistive device instead of using the drawsheet. The most important reason for using the assistive device is:

1 2

To avoid frightening the client To avoid shearing the clients skin

To avoid getting written up for not following lift procedures

Because the nurse is tired

ANS: 2 The greater the surface area of the object that is moved, the greater the friction. A larger object produces greater resistance to movement. To decrease surface area and reduce friction when clients are unable to assist with moving up in bed, nurses use an ergonomic assistive device, such as a full body sling. It mechanically lifts the client off the surface of the bed, thereby preventing friction, tearing, or shearing of the clients delicate skin. The client may also be frightened by the use of the equipment. It is important to explain what will be going on and what the client can expect to experience when using any piece. Lift policies are put in place to protect both clients and staff; however, the nurse should not be as concerned with being written up as with protecting himself or herself, the NAP, and the client from harm. The most important reason for using the lift equipment is to protect the client and staff from harm. PTS: 1 DIF: B REF: 1220 OBJ: Application TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility 36. The nurse understands that using metabolic functioning, measures of height, weight, and skinfold thickness, to evaluate muscle atrophy in an immobilized client is known as:

Anthropometric measurements

2 3

Anhydrous measurements Balke test

Calorimetry

ANS: 1 When assessing metabolic functioning, use anthropometric measurements (measures of height, weight, and skinfold thickness) to evaluate muscle atrophy. Anhydrous means without water, the Balke test determines maximum oxygen utilization, and calorimetry is the determination of heat loss or gain. PTS: 1 DIF: A REF: 1247 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility MULTIPLE RESPONSE 1. The nurse recognizes that facilitating correct body alignment for a dependent client may well result in which of the following positive client outcomes? (Select all that apply.)

A comfortable nights sleep

Minimized activity intolerance

Muscle tone that promotes ambulation Reduction of falls caused by general weakness

4 5 6

Minimal strain placed on the spinal column Increased socialization, resulting in peace of mind

ANS: 1, 2, 3, 4, 5 Correct body alignment reduces strain on musculoskeletal structures, aids in maintaining adequate muscle tone, promotes comfort, and contributes to balance and conservation of energy. Although a client experiencing the benefits of proper body alignment and thus experiencing the positive outcomes may well experience increased peace of mind, there is not a clear connection between the two. PTS: 1 DIF: C REF: 1227 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility 2. The nurse chooses to use a mechanical lift to move an obese immobile client. The nurse recognizes that the positive outcomes for both the client and the staff resulting from this intervention will be: (Select all that apply.)

Less of the clients body will be dragged along the sheets during the transfer

There will be less chance of injuring the skin on the clients elbows and buttocks The staff involved in the transfer will have less likelihood of self-injury

3 4 5

The staff will have a greater degree of control over the move The client will feel physically safer during the transfer

The move will be accomplished more quickly

ANS: 1, 2, 3, 4 Mechanical lifts raise the client off the surface of the bed, thereby preventing friction, tearing, or shearing of the clients delicate skin; it also protects the nurse and other staff from injury. There is no guarantee that the move will be quicker or that the client will feel safer. PTS: 1 DIF: C REF: 1228 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility 3. A 16-year-old has had a full leg cast in place for 2 months, and it is being removed today. Which of the following assessment findings would be expected following the removal of the cast? (Select all that apply.)

1 2 3

Popliteal pulse equal in both legs Slight footdrop noted on affected leg

Swelling noted at ankle on affected leg Weight bearing less stable on affected leg

Calf circumference greater in unaffected leg

Greater range of motion of knee of unaffected leg

ANS: 1, 4, 5, 6 Even this temporary immobilization results in some muscle atrophy, loss of muscle tone, and joint stiffness. Pulses should be equal, and there should not be swelling or footdrop on either foot. PTS: 1 DIF: C REF: 1229 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility

4. Which of the following factors has an impact on the severity of physical impairment a client will experience from a period of immobility? (Select all that apply.)

1 2 3

The clients age Prior overall health

Length of immobility The degree of immobility

Situation requiring the inactivity

Clients mental attitude about the limitations

ANS: 1, 2, 3, 4 The severity of the impairment depends on the clients overall health, degree and length of immobility, and age. The resulting effects are not dictated by situation or attitude. PTS: 1 DIF: C REF: 1236 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/ Immobility 5. A client who experienced a myocardial infarction has been placed on bed rest. The nurse caring for the client recognizes that the inactivity will result in certain assessment findings that include: (Select all that apply.)

1 2 3

Lethargy Confusion

Depression Poor appetite

Hypoactive bowel sounds

Decrease in baseline respiratory rate

ANS: 1, 4, 5, 6 Immobility disrupts normal metabolic functioning; decreasing the metabolic rate; altering the metabolism of carbohydrates, fats, and proteins; causing fluid, electrolyte, and calcium imbalances; and causing gastrointestinal disturbances such as decreased appetite and slowing of peristalsis. Cognitive and psychological alterations are not directly caused by the inactivity. Chapter 40. Hygiene MULTIPLE CHOICE 1. The client has a red, raised skin rash. During the bath, the priority action of the nurse is to:

Assess for further inflammatory reactions

2 3 4

Discuss the body image problems created by the presence of the rash Wash the skin thoroughly with hot water and soap Moisturize the skin to prevent drying

ANS: 1 The first action the nurse should take is to assess for further inflammatory reactions to determine if it is localized or systemic. Discussing body image problems would not be the priority nursing action. Skin should be washed with warm water, not hot, as it may dry the skin. All soap should be rinsed well so not to leave residue that may cause further irritation. The rash may be caused by moisture; thus moisturizing the skin would not be appropriate. A lotion to help prevent itching may be applied. DIF: C REF: 855 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 2. The nurse is caring for a client who has right-sided paralysis following a stroke. Which of the following factors would be most likely to result in decubitus ulcer formation for this client?

Poor nutrition Immobility

Reduced hydration

Skin secretions

ANS: 2 The client, who has right-sided paralysis, is at increased risk for developing a pressure ulcer because of immobility. When restricted from moving freely, dependent body parts are exposed to pressure, reducing circulation to affected body parts. Also, the inability to turn or change position increases risk for pressure ulcers. Poor nutrition is a risk factor for developing a pressure ulcer but not for this client. This client is not identified as having reduced hydration. Skin secretions increase the risk for developing a pressure ulcer. However, this clients greatest risk factor is having impaired mobility. DIF: A REF: 855 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene

3. The nurse delegates the hygienic care of a male client to the nursing assistant. In reviewing the client assignment, the nurse instructs the assistant to make sure to use an electric razor to shave the client with:

Thrombocytopenia

2 3

Congestive heart failure Osteoarthritis

Pneumonia

ANS: 1 Clients prone to bleeding, such as the client with thrombocytopenia, must use an electric razor. Clients with congestive heart failure may use a razor blade to shave. Clients with osteoarthritis do not have to use an electric razor to shave. Clients with pneumonia may use a razor blade to shave. If the client is wearing oxygen, an electric razor should not be used as it could create a spark. Oxygen is flammable DIF: C REF: 893 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 4. The nurse delegates morning care to a new certified nursing assistant. Which of the following actions by the assistant would be evaluated as appropriate?

Placing dentures in a tissue while not worn

Cutting the clients nails with scissors

Using soap to cleanse the eye orbits

Washing the clients legs with long strokes from the ankle to the knee

ANS: 4 To promote venous return, the nursing assistant should use long strokes, washing the clients legs from the ankle to the knee and from the knee to the thigh. To prevent warping, dentures should be kept covered in water when they are not worn, and they should always be stored in an enclosed, labeled cup with the cup placed in the clients bedside stand. Nails should be clipped with nail clippers, straight across and even with tops of fingers, then filed. Scissors should not be used. The clients eyes should be washed with plain water as soap irritates eyes. DIF: C REF: 873 OBJ: Analysis TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 5. A 61-year-old client with diabetes mellitus has physicians orders for meticulous foot care. Which of the following is the best rationale for the order?

The aging process causes increased skin breakdown.

There is increased neuropathy with this pathology that places the client at risk.

The client probably has a history of poor hygienic care.

The lower extremities are difficult to see and therefore hard to maintain with good hygiene.

ANS: 2 Vascular changes associated with diabetes mellitus reduce the blood supply to the feet. Sensation in the feet can also be reduced as a result of damage to the nerves (i.e., as with diabetic neuropathy). Sensory loss in the feet may result in undetected injuries. These clients are especially at risk for the development of chronic foot ulcers. The best rationale for meticulous foot care for this client is because of the risks associated with the clients diagnosis of diabetes mellitus. There is no indication the client has a history of poor hygienic care. Poor vision may contribute to difficulty in providing foot care, but this clients greatest risk for developing a foot ulcer is diabetic neuropathy. DIF: C REF: 853 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 6. The client is unable to rest even after medication. The nurse decides to give the client a backrub. Which of the following strokes should the nurse use when finishing the backrub?

Long, firm strokes down the back

Light strokes while moving up the back in a circular motion

Kneading movements toward the sacrum Circular motion upward from buttocks to shoulders

ANS: 1 The nurse should end the backrub with long, firm strokes down the back. The backrub is not finished with light strokes while moving up the back in a circular motion. Kneading movements toward the sacrum are done before ending the backrub with long, firm strokes down the back.

The nurse should begin a backrub by massaging in a circular motion upward from buttocks to shoulders. DIF: A REF: 868 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 7. The nurse is instructing the client with peripheral vascular disease about daily foot care. The nurses instruction for the client includes:

1 2

Soaking the feet 5 to 10 minutes each day Filing the nails into a curve shape

Using commercial corn removers if needed

Applying lambs wool between the toes

ANS: 4 Wrapping small pieces of lambs wool around toes reduces irritation of soft corns between toes. Clients with peripheral vascular disease should not soak their feet. Soaking increases risk of infection caused by maceration of the skin. Nails should be filed straight across and square. The client with peripheral vascular disease should not cut corns or calluses or use commercial removers. The client should consult a podiatrist. DIF: C REF: 883 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 8. To administer oral care to a semi-comatose client, the nurse should place the client in which of the following positions?

Reverse Trendelenburg

High Fowlers with the head to the side

Side-lying with the head turned toward the nurse

Supine with the neck slightly forward

ANS: 3 For administering oral care, the nurse should place a semicomatose client on the side (Sims position) with the head turned well toward the dependent side to facilitate drainage of secretions from the mouth. The semicomatose client should not be placed in reverse Trendelenburg position for oral care. The semicomatose client should not be placed in the high-Fowlers position for oral

care. The semicomatose client should not be placed supine for oral care, as oral secretions would collect in the back of the pharynx. DIF: C REF: 888 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 9. The client is unable to perform self-care for the hair. The nurse is aware that which of the following is accurate when performing hair care?

Brushing the hair distributes the natural oils evenly.

2 3

Using a hot comb may be very helpful for straight and oily hair. Very tight braids keep the hair in good condition.

Shampooing should be done daily.

ANS: 1 Frequent brushing helps to keep hair clean and distributes oil evenly along hair shafts. A hot comb would not be helpful for straight or oily hair. Braids made too tightly can lead to bald patches. The frequency of shampooing depends on a persons daily routines and the condition of the hair. DIF: C REF: 890 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 10. A client has recently experienced difficulty hearing out of both ears. Which of the following is the best nursing response to the client?

Lets irrigate your ears with cool water.

Can you turn your head toward me when I am talking to you?

Your hearing aid should not need a new battery for at least 3 months.

Try to avoid putting a Q-Tip (cotton-tipped applicator) into your ears.

ANS: 4 Use of cotton-tipped applicators should be avoided because they can cause ear wax to become impacted within the canal. Warm water should be used to irrigate ears, not cool. Asking the client

to turn his or head toward the nurse is not the best response. Batteries last 1 week with daily wearing of 10 to 12 hours. DIF: C REF: 895 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 11. An adolescent client with acne should be taught by the nurse to:

Apply moisturizing lotions or creams

Wash the face and hair daily with very warm water and soap

Use a depilatory to remove excess hair

Add moisture to the air with the use of a humidifier

ANS: 2 The client with acne should be taught to wash the hair and skin thoroughly each day with very warm water and soap to remove oil. Moisturizing lotions or creams should not be used, as they tend to clog pores and make the acne worse. It is not recommended to use a depilatory to remove excess hair. Adding moisture to the air with the use of a humidifier is an appropriate intervention for the client with dry skin, not acne. DIF: A REF: 885 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 12. A client has severe right-sided weakness and is unable to complete bathing and grooming independently. Based on this observation, the nurse identifies a nursing diagnosis of:

Powerlessness

Self-care deficit

Tissue integrity impairment

Knowledge deficit of hygiene practices

ANS: 2 The client who is unable to complete bathing and grooming independently has a nursing diagnosis of self-care deficit. Being unable to complete bathing and grooming are not defining characteristics for the nursing diagnosis of powerlessness. Being unable to complete bathing and grooming are not defining characteristics for the nursing diagnosis of tissue integrity impairment. There is no indication this client has a knowledge deficit of hygiene practices.

DIF: A REF: 862 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 13. A different approach to traditional hygienic care is the bag bath. The best rationale for using this approach is because it is:

Less expensive than the traditional method

2 3

Takes less time to complete Leaves the skin softer

Reduces the risk of infection

ANS: 4 The bag bath is intended to reduce the risk of infection. Use of the traditional wash basin may increase the risk of infection, because if it is not cleaned and dried completely after use, gramnegative bacteria may contaminate the wash basin. Successive use of a contaminated basin may cause the clients skin to harbor more gram-negative organisms, increasing the clients risk of infection. The bag bath is typically more expensive than the traditional bed bath method. Using the bag bath does take less time, but it is not the best rationale for using this method. The bag bath does not leave the skin softer than traditional hygienic care. DIF: A REF: 868 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 14. The nurse is preparing to assist the adult female client with perineal care. The position of choice for this client is:

Dorsal recumbent

Side-lying

Supine Prone

ANS: 1 To perform female perineal care, the client should be assisted to the dorsal recumbent position. Side-lying is not the position of choice for performing perineal care of the female client. The supine position is the position of choice for performing perineal care of the male client, not the

female. The prone position is not the position of choice for performing perineal care of the female client. DIF: A REF: 868 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 15. A client who is suspected of having vascular insufficiency to the lower extremities is assessed by the nurse to have a(n):

1 2

Increased hair growth on the legs and feet Dull appearance of the skin

Erythema upon elevation of the feet

Diminished pedal pulses

ANS: 4 The client with vascular insufficiency of the lower extremities may exhibit diminished pedal pulses. The client with vascular insufficiency of the lower extremities would have decreased hair growth on the legs and feet, not increased hair growth. The client with vascular insufficiency typically has a shiny appearance of the skin of the lower extremities. The client with vascular insufficiency characteristically demonstrates blanching of the skin on elevation. DIF: A REF: 883 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 16. The nurse is completing a bed bath for a dependent adult male client. During the perineal care, the client has an erection. The nurse should:

Continue with the perineal care

Tell the client its okay and just to relax

Ask the client to try and do the care as well as he can

Defer the care until a little later in the bath

ANS: 4 If the client has an erection during perineal care, the nurse should defer the procedure until later. The nurse should not continue with the perineal care at this time. Telling the client its okay may increase the clients embarrassment. If the client is dependent in his care, the nurse should not ask the client to perform care he is unable to do. The nurse should maintain a professional attitude.

DIF: C REF: 879 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 17. A client receiving chemotherapy is experiencing stomatitis. The nurse advises the client to use:

1 2

A commercial mouthwash An alcohol and water mixture

Normal saline rinses

A firm toothbrush

ANS: 3 Normal saline rinses (approximately 30 mL) on awaking in the morning, after each meal, and at bedtime can effectively clean the oral cavity. The rinses can be increased to every 2 hours if necessary. Clients with stomatitis should be advised to avoid commercial mouthwash. Clients with stomatitis should be advised to avoid alcohol. Gentle brushing and flossing are important in preventing bleeding of the gums. A soft toothbrush, not a firm toothbrush, should be used. DIF: A REF: 885 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 18. The nurse has delegated the task of bathing a semicomatose client to ancillary personnel. The nurse suggests that the personnel multitask while completing the bath. Which of the following would be the most appropriate intervention for the ancillary personnel to accomplish while bathing this particular client?

Oral hygiene care

Moisturizing hands and feet

Passive range of motion exercises Care of the clients intravenous site

ANS: 3 You can integrate other nursing activities during hygiene care, including client assessment and interventions such as range-of-motion (ROM) exercises, application of dressings, or inspection and care of intravenous sites. While oral hygiene and moisturizing are done generally for all clients, ROM is particularly appropriate for this client. Care of an IV site is not a delegable task.

DIF: C REF: 863 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 19. Which of the following statements made by a nurse reflects the best understanding of the role of the bath in the nursing assessment process?

1 2 3 4

I work with my ancillary staff to be able to determine what is abnormal. The skin is easy to observe for abnormalities when you are giving the bath. I use the time to really look at my clients and determine whats normal and whats not. Bath time is an excellent time to get to know your clients and form that nurse-client relationship.

ANS: 3 Take this time to identify abnormalities and initiate appropriate actions to prevent further injury to sensitive tissues. It also provides an opportunity to assess other systems (e.g., circulatory, respiratory) and client behaviors as well. While the nurse is responsible for determining abnormalities, the ancillary staff should be instructed to report any suspicious factors they note. Answer 3 is the most thorough statement regarding the question. DIF: C REF: 869 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 20. Which of the following statements best reflects the nurses knowledge of the affect of skin integrity on a clients general state of health?

When I keep the skin healthy, the client is healthy.

If the skin isnt in good shape, illness isnt far away.

I believe cleanliness is a top priority for comfort and health. If a client is able to do their own hygiene care, they feel in control.

ANS: 2

The skin protects against water loss and injury and prevents entry of disease-producing microorganisms. While all the options are correct, this answer provides the most direct statement regarding the connection with a clients state of health. DIF: C REF: 854 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 21. The nurse best displays an understanding of the role the skin plays in monitoring the body systems and their ability to function properly when documenting which of the following regarding a 70-year-old client?

Skin appears generally jaundiced.

2 3

Dryness noted on heels and elbows bilaterally. Skin tears present on upper left and right arms.

Skin on the hands and feet is slightly cool to the touch.

ANS: 1 The skin often reflects a change in physical condition by alterations in color, thickness, texture, turgor, temperature, and hydration. The observation of the skins jaundice appearance reflects possible liver pathology. While the remaining options are appropriately related to abnormal skin, they are of less importance and/or seen in the older adult. DIF: C REF: 855 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 22. Which of the following statements made by the nurse reflects the best understanding of the effect of dry skin on a clients general health and well-being?

When her skin is cracked, she is so much more uncomfortable.

Keeping the skin moist is so much easier than making the skin moist.

She is such a proud lady; dry, cracked skin makes her feel unattractive. If I can keep her skin moisturized, it will be less likely to crack and bleed.

ANS: 4

Excessive dryness causes cracks and breaks in skin and mucosa that allow bacteria to enter, thus resulting in possible infection. While all of the options are correct, the answer reflects a better overall understanding of the effect of skin health on general client health. DIF: C REF: 855 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 23. Which of the following statements made by ancillary personnel regarding the bathing of a 79-year-old client requires immediate follow-up by the nurse?

At times you have to really work at getting her to agree to having a bath.

I learned that an evening bath is what she is used to, so Ill bathe her before bed.

She seemed to enjoy her morning bath; Ill bathe her again this evening after dinner.

She really enjoys that mildly scented vanilla soap her daughter brought her yesterday.

ANS: 3 Bathing removes excess body secretions, although if excessive, it causes dry skin. The use of heavily scented soaps is often discouraged. The remaining options do not require follow-up. DIF: C REF: 855 OBJ: Analysis TOP: Nursing Process: Comprehension MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 24. The nurse should expect that which of the following clients is most likely to have difficulty performing personal hygiene tasks?

The 54-year-old with osteoarthritis in his upper extremity joints

The 26-year-old new mother experiencing postpartum depression The 15-year-old client who fractured his left clavicle while skateboarding

The 36-year-old client who just learned that her lung cancer is inoperable

ANS: 1 Any condition that interferes with movement of the hand (e.g., superficial or deep pain or joint inflammation) impairs a clients self-help abilities. While the other options represent clients who may experience difficulty, the client in Option 1 will most likely not be self-sufficient with hygiene. DIF: C REF: 860 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 25. A client has developed several large mouth ulcers resulting from radiation treatments for oral cancer. The nurse recognizes that this condition will have its greatest immediate impact on the clients:

Comfort level

Nutritional status

Physical recovery Emotional well-being

ANS: 2 Difficulty with chewing and swallowing develops when surrounding gum tissues become inflamed or infected. The presence of these ulcerations will present immediate issues with nutritional and fluid intake. While the remaining options are not incorrect, the greatest problem is nutritional and fluid oriented. DIF: C REF: 851 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 26. The nurse is preparing to bathe an older adult client who is expecting a visit from out of town relatives. The client expresses reluctance to bathe because he does not want to make my sister wait to see me. Which of the following statements made by the nurse is most likely to provide the motivation to agree to the bath for this particular client?

1 2

I promise to hurry; you will be done before she gets here. You dont want your sister to see you unshaved and in your pajamas.

I know youve missed your sister and want to look your best for her visit.

Lets get cleaned up so your sister doesnt think you arent being well cared for.

ANS: 3 Motivation is a key factor in the importance of hygiene. Wanting to be acceptably bathed and dressed for the visit is the most likely motivation. DIF: C REF: 853 OBJ: Assessment TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 27. Which of the following assessment questions is most likely to determine the reason an older adult client refuses to remove and brush his dentures?

Why are you being difficult about cleaning your dentures?

Will you allow me to clean your denture if you dont want too? Are you concerned about damaging your dentures if you take them out?

3 4

Do you realize the problems that can occur when your dentures arent clean?

ANS: 4 It is important to know if a client perceives being at risk. For example, does the client perceive being at risk for dental disease, that dental disease is serious, and that brushing and flossing are effective in reducing risk? When clients recognize there is a risk and that they can take reasonable action with no negative consequence, they are more likely to be receptive to the nurses counseling and teaching efforts. DIF: C REF: 853 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 28. Which of the following interventions, regarding personal hygiene for a client who is unconscious, performed by ancillary personnel requires immediate follow-up by the RN?

Storing the damaged dentures in the clients bedside stand

Shaving the clients mustache to facilitate the nasogastric tube

Postponing the daily bath until the clients temperature has stabilized

Providing oral care with the flavored swabs provided by the clients family

ANS: 2 Do not cut or shave hair without discussion with the client or family. This would need to be a nursing decision, although it is not necessarily required in this situation. The remaining options are not incorrect and so do not need follow-up. DIF: C REF: 893 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 29. The nurse observes an adult client of Middle Eastern descent diagnosed with bipolar disorder attempting to bathe himself using only his left hand. The nurse assumes that the most likely reason for this behavior relates to:

A cultural preference

2 3

A personal idiosyncrasy His psychiatric diagnosis

A need for personal control

ANS: 1 Among Hindus and Muslims the left hand is used for cleaning, whereas the right hand is used for eating and praying. DIF: C REF: 860 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 30. Routine hygiene care can provide an opportunity for the nurse to assess the clients level of activity intolerance. Which of the following assessment questions is most likely to provide information that supports this nursing diagnosis?

Will you need my help to take a bath?

Does taking a bath or shower cause you any pain?

Can you bathe and dress yourself without needing help?

Do you find yourself getting tired before youre finished bathing?

ANS: 4 The remaining options are not as directed towards activity intolerance since a positive response to any of them may be a result of causes other than weakness. DIF: C REF: 863 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 31. The nurse is discussing skin care with a group of early teens (ages 13 to 15). Which of the following is the most therapeutic response to the question, How can I keep from getting bad skin?

Bad skin is a part of being a teenager; but dont make it worse with poor hygiene habits.

Bad skin is often affected by what you eat, so eat a healthy, well-balanced diet of low-fat foods.

If the acne gets really bad, then see your health care provider for a prescription for a topical antibiotic. If by bad skin you mean pimples, then wash your face regularly with soap and warm water, and keep your hair clean as well.

ANS: 4 Wash hair and skin thoroughly each day with warm water and soap to remove oil. The remaining options are not incorrect, but they are not addressing the primary problem. DIF: C REF: 855 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 32. A client with darkly pigmented skin reports that the intravenous site is uncomfortable. To thoroughly assess the complaint of this particular client, the nurse should:

Determine when the angiocatheter was inserted

Ask the client if the area appears reddened

Take an axillary temperature on the same side as the IV site

Use the back of the hand to assess skin temperature at the site

ANS: 4 Using the back of the hand to detect warmth helps in the assessment for inflammation when redness is not easily observed. It is the most reliable method among the options provided. DIF: C REF: 856 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 33. The nurse is discussing skin hygiene with a group of adolescent athletes. The nurse plans to discuss the prevention and management of athletes foot primarily because:

It is a common skin disorder among this particular population

It is both easily prevented and managed if you understand the problem

The condition can spread to other parts of the body if not managed well

The condition is often a source of social embarrassment for those who have it

ANS: 3 Athletes foot spreads to other body parts, especially hands. It is contagious and frequently recurs. While the other options are correct, they do not discuss the primary concern regarding the condition. DIF: C REF: 857 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 34. The nurse is discussing nail care with a group of teenage girls. Which of the following statements made by one girl in the audience requires immediate follow-up by the nurse?

My mother tells me that toe rings will cause me to develop calluses.

Its expensive buying new shoes just because your feet keep growing.

I throw my sneakers into the washing machine regularly to keep the inside surfaces clean.

I cut the discolored nails on both of my great toes really short to make them a little less noticeable.

ANS: 4 Ingrown nails often result from improper nail trimming. The remaining options are correct and do not require follow-up DIF: C REF: 857 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 35. The nurse is discussing hygiene issues with a group of mothers with young school-age children. When discussing the topic of head lice (pediculosis capitis), the nurse realizes that the most important motivation for preventing and/or managing this condition is that:

1 2

The lice may carry various other serious diseases The parasites are extremely difficult to remove and kill

The presence of lice typically reflects poor hygiene practices

The parasites are easily transferable from one person to another

ANS: 4 Head lice are difficult to remove, and they spread to furniture. The primary problem is that other people can be easily infested if the condition is not properly treated. The remaining options are not necessarily true. DIF: C REF: 858 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 36. The nursing assistive personnel reports to the nurse that the client refuses to wear deodorant after the bath. The nurses best answer to the nursing assistive personnel is:

I noticed that the client really had bad body odor when I assessed her.

2 3 4

The client is Eastern European; some social groups dont wear deodorant. Perhaps the client doesnt like our brand of deodorant. Ill try to talk with the client to get her to put on the deodorant.

ANS: 2 Some social groups do not wear deodorant or cosmetics. The nurse should not be judgmental regarding hygiene practices of different cultures. Answer 3 could be the issue, but the client did not ask the nursing assistive personnel if there were other types of deodorants that they could choose from. There is no need for the client to be coerced to put on deodorant, but is a personal choice that should be respected. DIF: A REF: 858 OBJ: Knowledge TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 37. On the clients admission to the hospital, the nurse notes that the client has halitosis, and when assessing the client, the nurse notes that the client has poor oral hygiene with several discolored teeth. The client shares he does not regularly brush or floss his teeth. The best reply from the nurse is:

You should brush and floss regularly.

Do you know that poor dental hygiene can lead to diseases beyond dental disease?

Ill get you a toothbrush and toothpaste that you can take home with you once you leave the hospital. Let me show you how to properly brush your teeth.

ANS: 2 Answer 2 provides the client with information regarding why it is important to him to brush and floss regularly. Answer 1 is a true statement, but the client probably knows that he should brush and floss regularly; the nurse can go from there and explain why he should. Although Answer 3 gives the client the equipment he needs, it does not provide him with any motivation to follow through. It is good for the nurse to demonstrate the skill of brushing and flossing, but that may not increase compliance by the client. DIF: A REF: 853 OBJ: Comprehension TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 38. The nurse notes that the elderly client she is caring for has dry, flaky skin on her hands, face, arms, and legs. The nurse knows that elderly clients may need bathing:

More frequently due to keeping their warmer environments

Less frequently than younger clients due to dry skin

With strong soap due to issues with incontinence

With very hot water and vigorous rubbing to remove dead skin cells

ANS: 2 The elderly may bathe less frequently and rinse body of all soap because residue left on skin can cause irritation and breakdown. The elderly frequently have their environments warm due to poor circulation. They dont necessarily perspire any more than do younger age-groups. They should bathe with mild soap and use lots of moisturizer to prevent the skin from further drying. Hot water depletes the skin of natural oils, drying it out. Vigorous rubbing can damage the skin. DIF: B REF: 853 OBJ: Application TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 39. The nurse notes that the client with diabetes mellitus that he is caring for has some edema in both lower extremities. The client also has a small open lesion on her right great toe. The nurse understands that this is a complication of diabetes mellitus and will additionally assess the clients sensation to light touch, pinprick, and temperature to determine if she has:

Glaucoma

Psoriasis

Neuropathy

Dermatitis

ANS: 3 Palpation of the dorsalis pedis and posterior tibial pulses indicates whether adequate blood flow is reaching peripheral tissues. Edema and changes in skin color, texture, and temperature indicate if the client requires special hygienic care. Also check persons with diabetes mellitus for neuropathy, degeneration of the peripheral nerves characterized by a loss of sensation. Assess the clients sensation to light touch, pinprick, and temperature. Glaucoma is diagnosed by an eye examination that measures intraocular pressure. Psoriasis and dermatitis are both skin conditions.

DIF: A REF: 884 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 40. On examining a clients fingernails, the nurse notes that they are excessively dry. The nurse knows that this can be caused by which of the following?

Fungal nail infections

2 3

Dry climates Washing dishes by hand

Polishing nails, and using polish remover

ANS: 4 Ask women whether they frequently polish their nails and use polish remover, because chemicals in these products cause excessive nail dryness. Inflammatory lesions and fungus of the nail bed cause thickened, horny nails, which separate from the nail bed. Dry climates and washing dishes do not cause excessively dry nails DIF: A REF: 867 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 41. The nurse knows that she needs to provide additional teaching to the client who makes which of the following statements?

Im so glad to find out that this is only a plantar wartI was afraid it was something contagious like athletes foot.

The health care provider will remove this plantar wart by first freezing it.

I had a planter wart in the past that the health care provider removed with acid.

The health care provider may remove my wart by burning it.

ANS: 1 Plantar warts are caused by a papilloma virus and can be spread. Answers 2, 3, and 4 are all methods by which plantar warts can be removed. DIF: A REF: 856 OBJ: Knowledge

TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 42. On assessment, the nurse discovers the dependent male client has athletes foot bilaterally. Before delegating the bathing of the client to the nursing assistive personnel, the nurse needs to instruct the nursing assistive personnel to:

1 2

Use a lot of friction when washing the feet to remove the dead skin cells Wash the clients feet last to avoid spreading the athletes foot

Leave the feet slightly damp after washing them to prevent further drying and cracking of the skin

Apply the tolnaftate to the lesions on the clients feet when she is done bathing the client

ANS: 2 Athletes foot can be spread to other areas of the body, so the affected areas should be bathed last to avoid cross-contamination. Excessive friction may irritate the skin and cause discomfort and further skin breakdown to the client. The skin needs to be kept dry to help prevent infection. The nurse cannot delegate the application of medication to nursing assistive personnel. DIF: A REF: 856 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 43. The nurse has been preparing the diabetic client with peripheral neuropathy for discharge. Which of the following statements by the client indicates that they need additional teaching?

I need to see my podiatrist to have my toenails trimmed.

I will inspect my feet daily using a mirror to see all areas.

I should make sure my feet are thoroughly dry after my bath. I will wear antiembolus stockings when I get home to prevent my ankles from swelling.

ANS: 4 Restrictive stockings should not be worn in order to decrease the risk of impeding circulation to the lower extremities. Clients with neuropathy is at risk for injury to their feet because of impaired sensation. By examining all areas of the feet daily, the client can identify potential

problems early. Thoroughly drying the feet minimizes risk for fungal infections and skin breakdown. DIF: A REF: 857 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 44. The nurse in a pediatricians office teaches the mother of a preteen client who was treated for strep throat to do which of the following to help prevent a reoccurrence?

1 2

Isolate the child from the their siblings until the child has been on antibiotics for at least 24 hours. Disinfect all the childs toys.

Wash all the childs laundry in hot bleach water.

Replace the childs toothbrush.

ANS: 4 Replacing the childs toothbrush will help prevent reinfecting the child with streptococcal bacteria. DIF: A REF: 857 OBJ: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 45. Which of the following statements by the client demonstrates that they need further teaching regarding oral hygiene?

I need to brush my teeth after meals.

I need to floss my teeth daily.

I should replace my toothbrush annually. I should a checkup every 6 months.

ANS: 3 Toothbrushes should be replaced every 3 months, or more often if the client has an oral infection such as strep throat. Answers 1, 2, and 4 all demonstrate appropriate information. DIF: A REF: 856 OBJ: Knowledge TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 46. The nurse is preparing a comatose client for oral hygiene. Unless contraindicated, the best position to place the client in is:

1 2 3 4

Sims Dorsal recumbent Prone Fowlers

ANS: 1 Turning the clients head to the side allows secretions to drain from mouth instead of collecting in back of pharynx, preventing aspiration. Moving the client close to the side of the bed facilitates proper body mechanics during the skill. DIF: B REF: 885 OBJ: Application TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene MULTIPLE RESPONSE 1. Which of the following is likely to result in damage to the clients skin? (Select all that apply.)

Dry shaving a client in preparation for discharge

Removing the tape when discontinuing a heparin lock

Frequently positioning the client on her favorite right side Applying moisturizing lotion on the heels of a diabetic client

4 5 6

Elevating the bed to 85 degrees so the client can easily watch a movie on TV Waiting until the mechanical lift is available to transfer an immobile client

ANS: 1, 2, 3, 5 Weakening of the epidermis occurs by scraping or stripping its surface (e.g., use of dry razors, tape removal, or improper turning or positioning techniques). The remaining options are not likely to cause skin damage DIF: C REF: 885 OBJ: Analysis TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Personal Hygiene 2. The nurse is assisting an older adult client with morning care. The client experienced a stroke 2 years ago and has right-sided weakness. The nurse should expect the client to require assistance with which of the following tasks? (Select all that apply.)

Combing her hair

Holding her toothbrush Wringing out the washcloth

3 4 5

Rinsing with mouthwash Removing her wristwatch

Wiping her face and neck

ANS: 1, 2, 3, 5 A weakened grasp resulting from arthritis, stroke, or muscular disorders prevents a client from using a toothbrush and comb and wringing out a washcloth. Any activity that requires strength and coordination may present a problem. Wiping her face and rinsing her mouth should not be problematic. Chapter 41. Oxygenation MULTIPLE CHOICE 1. The nurse has reviewed information about the cardiovascular system before caring for a client with heart disease. The nurse knows that which of the following statements is true concerning the physiology of the cardiovascular system?

Stimulating the parasympathetic system would cause the heart rate to go up.

When a person has heart muscle disease, the heart muscles stretches as far as is necessary to maintain function.

The QRS interval on the electrocardiogram represents the electrical impulses passing through the ventricles.

When stroke volume decreases, there is a resultant decrease in heart rate.

ANS: 3 The QRS complex indicates that the electrical impulse has traveled through the ventricles. Stimulating the parasympathetic system would cause the heart rate to decrease, not increase. In

the diseased heart, the stretch of the myocardium is beyond the hearts physiological limits. When stroke volume is decreased, there is an increase in heart rate. DIF: A REF: 910 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 2. The nurse is working on a respiratory care unit in the hospital. Upon entering the room of a client with emphysema, it is noted that the client is experiencing respiratory distress. The nurse should:

Instruct the client to breathe rapidly

Provide 20% oxygen at 2 L/min via nasal cannula

Place the client in the supine position

Go to contact the health care provider

ANS: 2 The nurse should provide a low concentration of oxygen to the client. The client should be instructed to use pursed-lip breathing. The most effective position for the client with cardiopulmonary disease is the 45-degree semi-Fowlers position, using gravity to assist in lung expansion and reduce pressure from the abdomen on the diaphragm. The nurses first priority should be to attend to the client who is in respiratory distress, not to contact the health care provider. DIF: B REF: 960 OBJ: Application TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 3. A 64-year-old client is seen in the emergency department for palpitations and mild shortness of breath. The electrocardiogram (ECG) reveals a normal P wave, P-R interval, and QRS complex with a regular rhythm and rate of 108 beats per minute. The nurse should recognize this cardiac dysrhythmia as:

Sinus dysrhythmia

Sinus tachycardia

Supraventricular tachycardia Ventricular tachycardia

4 ANS: 2

The client is experiencing sinus tachycardia. The rhythm is regular with a normal P wave, normal QRS complex, and a rate of 100 to 180 beats per minute. A sinus dysrhythmia has a rate of 60 to 100 beats per minute and slows during inspiration and increases with expiration. The client is not experiencing a sinus dysrhythmia. With supraventricular tachycardia, the heart rate is 150 to 250 beats per minute, the P wave may be buried in the preceding T wave, and the P-R interval is variable. This client is not experiencing supraventricular tachycardia. With ventricular tachycardia the rhythm is slightly irregular at a rate of 100 to 200 beats per minute, the P wave is absent, the P-R interval is absent, and the QRS complex is wide. This client is not experiencing ventricular tachycardia. DIF: C REF: 914 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 4. A client recently fractured his spinal cord at the C3 level and is at great risk for developing pneumonia primarily because the:

Resulting paralysis immobilizes him, and secretions will increase in his lungs

Innervation to the phrenic nerve is absent, preventing chest expansion

Resulting abnormal chest shape disallows efficient ventilatory movement

Trauma decreases the ability of his red blood cells to carry oxygen

ANS: 2 Cervical trauma at C3 to C5 can result in paralysis of the phrenic nerve, preventing chest expansion. Although the increase in lung secretions as a result of immobility is a risk factor, the clients greatest risk is related to the level of his fracture. There is no mention of an abnormal chest shape. This clients greatest risk for developing pneumonia is related to the level of his fracture. If the client were anemic as a result of blood loss from trauma, his oxygen-carrying capacity of blood would be decreased. There is no mention of excessive blood loss, nor would this place him at great risk for developing pneumonia. DIF: C REF: 910 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems

5. The client has experienced a myocardial infarction resulting in damage to the left ventricle. A possible complication the client may experience that the nurse is alert to is:

1 2 3 4

Jugular neck vein distention Pulmonary congestion Peripheral edema Liver enlargement

ANS: 2 Pulmonary congestion may be experienced in left-sided heart failure. Jugular neck vein distention is characteristic of right-sided heart failure. Peripheral edema is characteristic of rightsided heart failure. Hepatomegaly (liver enlargement) is characteristic of right-sided heart failure. DIF: A REF: 913 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 6. On admitting a client, the nurse finds that there is a history of myocardial ischemia. The most disconcerting dysrhythmia for electrocardiography to reveal is:

Sinus bradycardia

Sinus dysrhythmia

Ventricular tachycardia Atrial fibrillation

ANS: 3 Ventricular tachycardia would be the most disconcerting dysrhythmia of the four options. Ventricular tachycardia results in a decreased cardiac output; it may lead to severe hypotension and loss of pulse rate and consciousness. Sinus bradycardia would not be of concern for this client. It is of no clinical significance unless it is associated with signs and symptoms of a decreased cardiac output. Sinus dysrhythmia is of no clinical significance unless dizziness occurs with a decreased rate. Atrial fibrillation is not as detrimental as ventricular tachycardia. DIF: C REF: 915 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 7. A client develops acute renal failure and a resulting metabolic acidosis. The nurse recognizes that the respiratory system compensates through:

Hypoventilation and increase of bicarbonate levels in the bloodstream

Alternating periods of deep versus shallow breaths to maintain homeostasis of the serum pH Hyperventilation to decrease the serum CO2 level and thereby raise the pH

3 4

Expansion of the lung tissues to their fullest, which increases the inspiratory reserve volumes to provide more oxygen to the tissues

ANS: 3 The respiratory system tries to correct metabolic acidosis by increasing ventilation to reduce the amount of carbon dioxide and thereby raise the pH. The respiratory system would compensate for metabolic acidosis with increased respirations, not hypoventilation. Bicarbonate is the renal component of acid-base balance, not the respiratory component. The pH measures hydrogen ion concentration. Alternating deep versus shallow breaths is not a compensating mechanism of the respiratory system for metabolic acidosis. The respiratory system does not compensate by expanding the lung tissues to their fullest. In metabolic acidosis, the respiratory system compensates by exhaling a greater amount of carbon dioxide. DIF: A REF: 916 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 8. A client with a suspected narcotic (heroin) overdose is brought to the emergency department by the police. The nurse anticipates that assessment findings will reveal:

Agitation

Hyperpnea

Restlessness

Decreased level of consciousness

ANS: 4 With a narcotic overdose, the respiratory center is depressed, reducing the rate and depth of respiration and the amount of inhaled oxygen. The client may display signs of hypoventilation, such as a decreased level of consciousness. A narcotic (heroin) overdose would cause sedation and respiratory depression, not agitation. The client would experience bradypnea, not hyperpnea. A narcotic (heroin) overdose would cause sedation and respiratory depression, not restlessness.

DIF: A REF: 916 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 9. The nurse identifies that the client is unable to cough to produce a sputum specimen, and the clients secretions must be suctioned. Which suctioning route is preferred for obtaining this specimen?

Nasopharyngeal

Nasotracheal

Oropharyngeal

Orotracheal

ANS: 2 Nasotracheal suctioning is the preferred route for obtaining a sputum specimen when the client is unable to cough to produce a sputum specimen on his or her own. The nasopharyngeal route for suctioning is used when the client is able to cough but is unable to clear secretions by expectorating or swallowing. It is not the preferred route for obtaining a sputum specimen. The oropharyngeal route is used when the client is able to cough but is unable to clear secretions by expectorating or swallowing. It is not the preferred route for obtaining a sputum specimen. The orotracheal route is used when the client is unable to manage secretions by coughing. The nasotracheal route is preferred over the orotracheal route because stimulation of the gag reflex is minimal. DIF: A REF: 931 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 10. The nurse is checking the clients overall oxygenation. In assessment of the presence of central cyanosis, the nurse will inspect the clients:

Palms and soles of the feet

Nail beds

Earlobes

Tongue

ANS: 4

Central cyanosis is observed in the tongue, soft palate, and conjunctiva of the eye, where blood flow is high. Central cyanosis indicates hypoxemia. Peripheral cyanosis seen in the palms and soles of the feet, nail beds, or earlobes is often a result of vasoconstriction and stagnant blood flow. DIF: A REF: 917 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 11. A client has recently had mitral valve replacement surgery. To prevent excess serosanguineous fluid buildup, the nurse anticipates that care will include:

Increased oxygen therapy

2 3

Frequent chest physiotherapy Incentive spirometry on a regularly scheduled basis

Chest tube placement in the thoracic cavity

ANS: 4 Chest tubes are inserted to remove air and fluids from the pleural space, to prevent air or fluid from reentering the pleural space, and to reestablish normal intrapleural and intrapulmonic pressures. The client who had mitral valve replacement surgery would be expected to have a chest tube postoperatively to prevent excess fluid buildup in the pleural space. Increased oxygen will not prevent excess fluid buildup. Frequent chest physiotherapy may help facilitate removal of secretions but will not prevent excess fluid buildup. Incentive spirometry is used to promote deep breathing and to prevent or treat atelectasis in the postoperative client. It will not prevent excess fluid buildup. DIF: A REF: 950 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 12. The client is admitted to the emergency department with a pneumothorax. The nurse anticipates that the client will be experiencing:

Dyspnea

Eupnea

Fremitus Orthopnea

ANS: 1 The client with a pneumothorax (collapsed lung) will exhibit dyspnea and pain. Eupnea is normal, easy breathing. It would not be expected in the case of a pneumothorax. Fremitus is the vibration felt when the hand is placed on the clients chest and the client speaks (vocal fremitus). Fremitus would be decreased with a pneumothorax. Orthopnea is a condition in which the person must use multiple pillows when lying down or must sit with the arms elevated and leaning forward to breathe. The client with a pneumothorax would be exhibiting dyspnea. DIF: A REF: 951 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 13. The client with a chronic obstructive respiratory disease is receiving oxygen via a nasal cannula. Which of the following interventions does the nurse plan to include in the clients care?

Assess nares for skin breakdown every 6 hours.

Check patency of the cannula every 2 hours.

Inspect the mouth every 6 hours.

Check oxygen flow every 24 hours.

ANS: 1 The nurse caring for the client with a nasal cannula should plan to assess the clients nares and superior surface of both ears for skin breakdown every 6 hours. The nurse should check patency of the cannula every 8 hours. The nurse does not need to check the clients mouth in relation to the clients use of a nasal cannula. The nurse should continue providing oral hygiene and may assess the mouth (i.e., tongue) for cyanosis, along with other assessment measures. Oxygen flow should be checked every 8 hours, not every 24 hours. DIF: A REF: 957 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 14. All of the following clients are experiencing increased respiratory secretions and require intervention to assist in their removal. Chest percussion is indicated and appropriate for the client experiencing:

Thrombocytopenia

2 3

Cystic fibrosis Osteoporosis

Spinal fracture

ANS: 2 Chest percussion is indicated and appropriate for the client with cystic fibrosis to assist in mobilizing the thick pulmonary secretions. Percussion is contraindicated in clients with bleeding disorders, such as the client with thrombocytopenia. Percussion is also contraindicated in the client with osteoporosis and the client with a spinal fracture or with fractured ribs. DIF: A REF: 931 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 15. The nurse is working on a pulmonary unit at the local hospital. The nurse is alert to one of the early signs of hypoxia in the clients, which is:

Cyanosis

Restlessness

A decreased respiratory rate

A decreased blood pressure

ANS: 2 Mental status changes are often the first signs of respiratory problems and may include restlessness and irritability. Cyanosis is a late sign of hypoxia. A decreased respiratory rate is not an early sign of hypoxia. The respiratory rate will increase as the body attempts to compensate for the decreased level of oxygen. As the hypoxia worsens, the respiratory rate may decline. During early stages of hypoxia the blood pressure is elevated unless the condition is caused by shock. DIF: A REF: 916 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 16. It is suspected that the clients oxygenation status is deteriorating. The nurse is aware that the abnormal assessment finding that represents the most serious indication of the clients decreased oxygenation is:

Poor skin turgor

2 3

Clubbing of the nails Central cyanosis

Pursed-lip breathing

ANS: 3 Central cyanosis is the most serious finding because it indicates hypoxemia. Poor skin turgor indicates dehydration. It is not an indication of the clients decreased oxygenation. Clubbing of the nails is found in clients with prolonged oxygen deficiency, endocarditis, and congenital heart defects. It is a change that occurs over time and is not an indication of the clients current deterioration in oxygenation status. Pursed-lip breathing is used to slow expiratory flow. It is not the most serious indication of a clients decreased oxygenation. DIF: C REF: 917 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 17. In teaching a client about an upcoming diagnostic test, the nurse identifies that which one of the following uses an injection of contrast material?

Holter monitor

Echocardiography

Cardiac catheterization

Exercise stress test

ANS: 3 A cardiac catheterization involves the injection of contrast material in order to visualize the cardiac chambers, valves, the great vessels, and coronary arteries. It also is used to measure the pressures and volumes within the chambers of the heart. A Holter monitor is a portable ECG worn by the client. It does not require contrast media. An echocardiography is a noninvasive measure that graphically depicts overall cardiac performance. An exercise stress test evaluates the cardiac response to the physical stress of the client on a treadmill. Contrast material is not used for this test. DIF: A REF: 925 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems

18. At a community health fair the nurse informs the residents that the influenza vaccine is recommended for clients:

1 2 3 4

Only older than age 65 40 to 60 years of age In any age-group who have a chronic disease Who have an acute febrile illness

ANS: 3 Annual influenza vaccine is recommended for clients of any age with a chronic disease. Annual influenza vaccine is recommended for clients older than age 65, but this is not the only group. Annual influenza vaccine is recommended for any age-group, including those age 40 to 60, who have a chronic disease of the heart, lung, or kidneys; clients with diabetes; clients with immunosuppression or severe forms of anemia; or those in close or frequent contact with anyone in a high-risk group. Clients with an acute febrile illness should not be vaccinated. DIF: A REF: 927 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 19. The unit manager is orienting a new staff nurse and evaluates which of the following as an appropriate technique for nasotracheal suctioning?

Placing the client in a supine position

Preparing for a clean or nonsterile technique

Suctioning the oropharyngeal area first, then the nasotracheal area

Applying intermittent suction for 10 seconds during catheter removal

ANS: 4 Intermittent suction for up to 10 to 15 seconds should be applied during catheter removal to prevent injury to the mucosa. The client is not placed in a supine position. The client is usually placed in a semi-Fowlers position. The clients head is turned to the right to help the nurse suction the left mainstem bronchus, and the clients head is then turned to the left to help the nurse suction the right mainstem bronchus. Nasotracheal suctioning is a sterile procedure. The nasotracheal area should be suctioned first, then the oropharyngeal area. The mouth and pharynx contain more bacteria than the trachea.

DIF: A REF: 931 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 20. The client has chest tubes in place following thoracic surgery. In working with a client who has a chest tube, the nurse should:

Clamp the tubes except during client assessments

Remove the tubing from the connection to check for adequate suction power

Milk or strip the tubes every 15 to 30 minutes to maintain drainage Coil and secure excess tubing next to the client

ANS: 4 If the client is in a chair and the tubing is coiled, the tubing should be lifted every 15 minutes to promote drainage. Care should be taken to ensure the tubing remains secure. Clamping the tubes except during client assessments is an inaccurate statement. Clamping a chest tube is contraindicated when the client is ambulating or being transported. In a water-sealed system, gentle bubbling in the suction-control chamber indicates it is functioning. The suction source may be checked to verify it is on the appropriate setting. In a waterless system, the suction control (float ball) indicates the amount of suction the clients intrapleural space is receiving. The tubing should not be disconnected. The chest tube should be stripped or milked only if indicated (e.g., there is clotted drainage in the tube) (check institutional policy). It is believed that stripping the tube greatly increases intrapleural pressure, which could damage the pleural tissue and cause or worsen an existing pneumothorax. Milking causes less of a pressure change. DIF: A REF: 950 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 21. The client has supplemental oxygen in place and requires suctioning to remove excess secretions from the airway. To promote maximum oxygenation, an appropriate action by the nurse is to:

Suction continuously for 30-second intervals

Replace the oxygen and allow rest in between suctioning passes

Increase the amount of suction pressure to 200 mm Hg

Complete a number of suctioning passes until the catheter comes back clear

ANS: 2 To promote maximum oxygenation, the nurse should replace the oxygen and allow rest in between suctioning passes. Suctioning should be intermittent for up to 10 to 15 seconds. Wall suction is set at 80 to 120 mm Hg; portable suction is set at 7 to 15 mm Hg for adults. Elevated pressure settings, such as 200 mm Hg, increase the risk for trauma to mucosa and can induce greater hypoxia. The number of suctioning passes is determined by client assessment and need. Repeated passes can remove oxygen and may induce laryngospasm. The client is not suctioned until the catheter comes back clear. DIF: A REF: 936 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 22. A client with a chest tube in place is being transported via stretcher to another room closer to the nurses station. During the transport the collection unit bangs against the wall and breaks open. The nurse immediately:

Clamps the tube

Tells the client to hyperventilate

Raises the tubing above the clients chest level Places the end of the tube in a container of sterile water

ANS: 4 If the drainage unit is broken, the end of the chest tube can be quickly submerged in a container of sterile water to reestablish the seal. Clamping the chest tube may result in a tension pneumothorax. If the tubing becomes disconnected, the client should be instructed to exhale as much as possible and to cough. The client should not hyperventilate. Raising the tubing above the clients chest level will not help the situation. DIF: C REF: 950 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 23. The client is experiencing a sinus dysrhythmia with a pulse rate of 82 beats per minute. Upon entering the room, the nurse expects to find the client:

Extremely fatigued

Complaining of chest pain

Experiencing a fluttering sensation in the chest Having no clinical signs based on the assessment

ANS: 4 The nurse would expect to find the client experiencing a sinus dysrhythmia at a rate of 82 beats per minute to have no clinical symptoms. The client with atrial fibrillation may complain of fatigue. The client experiencing a sinus dysrhythmia would not be expected to complain of chest pain. The client with atrial fibrillation may complain of a fluttering sensation in the chest. DIF: A REF: 913 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 24. The electrical activity of the clients heart is being continuously monitored while the client is on the coronary care unit. Suddenly the nurse finds that the client is experiencing ventricular fibrillation. The nurse will prepare to:

Administer atropine

Prepare for cardiopulmonary resuscitation (CPR)

Prepare the client for surgical placement of a pacemaker

Instruct the client to perform the Valsalva maneuver

ANS: 2 The nurse should prepare for CPR for the client experiencing ventricular fibrillation. Atropine is used for sinus bradycardia with hypotension and decreased cardiac output. In this case, the nurse should prepare to administer CPR, not atropine. A pacemaker may be required for the client with sinus bradycardia. It is not the treatment for ventricular fibrillation. The Valsalva maneuver is used to treat supraventricular tachycardia, not ventricular fibrillation. DIF: B REF: 913 OBJ: Application TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 25. The client is admitted to the medical center with a diagnosis of right-sided heart failure. In assessment of this client, the nurse expects to find:

Dyspnea

Confusion

Dizziness

Peripheral edema

ANS: 4 Peripheral edema is an expected assessment finding in the client diagnosed with right-sided heart failure. Dyspnea is an expected assessment finding in the client diagnosed with left-sided heart failure. Confusion is a symptom of hypoventilation. Dizziness is an expected assessment finding in the client experiencing hypoxia. DIF: A REF: 913 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 26. The nurse is preparing to teach a group of adult women about the signs and symptoms of a myocardial infarction (heart attack). The nurse will include in the teaching plan the results of research that demonstrate women may experience specific symptoms, such as:

Visual difficulties

Epigastric pain

Loss of motor function unilaterally

Right scapular discomfort and stiffness

ANS: 2 Epigastric pain is a symptom of a myocardial infarction in women. Visual disturbances, loss of motor function unilaterally, and right scapular discomfort and stiffness are not symptoms of a myocardial infarction in women. DIF: A REF: 916 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 27. The nurse is reviewing the results of the clients diagnostic testing. Of the following results, the finding that falls within expected or normal limits is:

Palpable, elevated hardened area around a tuberculosis skin testing site.

Sputum for culture and sensitivity identifies Mycobacterium tuberculosis

Presence of acid fast bacilli in sputum

Arterial oxygen tension (PaO2) of 95 mm Hg

ANS: 4 A palpable, elevated, hardened area surrounding a tuberculosis skin testing site is indicative of an antigen-antibody reaction and is considered a positive skin test. Sputum for culture and sensitivity noted the presence of an organism and acid fast bacilli. Normal arterial oxygen tension (PaO2) ranges between 95-100 mmHg. DIF: A REF: 916 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 28. The nurse is completing a physical examination for a client who is anemic. In assessing the clients eyes, a sign assessed by the nurse that is consistent with the diagnosis is:

Xanthelasma

Petechiae

Corneal arcus

Pale conjunctiva

ANS: 4 Pale conjunctiva is an assessment finding consistent with the diagnosis of anemia. Xanthelasma is caused by hyperlipidemia. Petechiae appear on the skin in clients with platelet deficiency (thrombocytopenia). Petechiae on the conjunctivae is consistent with a fat embolus or bacterial endocarditis. Corneal arcus is caused by hyperlipidemia in young to middle-age adults. It is a normal finding in older adults with arcus senilis. DIF: A REF: 923 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 29. Several nursing students are discussing cardiac conduction with their clinical instructor. When asked where a heart rate of 56 beats per minute most likely originates, the most informed student replies:

The atrioventricular (AV) node

The sinoatrial (SA) node

The Purkinje network

The bundle of His

ANS: 1 The conduction system originates with the sinoatrial (SA) node, the pacemaker of the heart. The SA node is in the right atrium next to the entrance of the superior vena cava. Impulses are initiated at the SA node at an intrinsic rate between 60 and 100 beats per minute. The electrical impulses are transmitted through the atria along intraatrial pathways to the atrioventricular (AV) node. The AV node mediates impulses between the atria and the ventricles. The intrinsic rate of the normal AV node is between 40 and 60 beats per minute. The AV node assists atrial emptying by delaying the impulse before transmitting it through the bundle of His and the ventricular Purkinje network. The intrinsic rate of the bundle of His and the ventricular Purkinje network is between 20 and 40 beats per minute. DIF: A REF: 913 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 30. A client asks the nurse, I was told that my heart is beating in normal sinus rhythm (NSR). What does that mean? The nurse replies most therapeutically when responding with which of the following?

Are you worried about how your heart is working?

It means your heart is working just the way it is supposed to work.

A damaged heart doesnt beat in normal sinus rhythm like yours does.

Each beat starts in the SA node and then causes the chambers to contract.

ANS: 4 NSR implies that the impulse originates at the SA node and follows the normal sequence through the conduction system. DIF: C REF: 913 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 31. When the nurse is reviewing a clients laboratory results, a low calcium level is noted. When the nurse then reviews the clients electrocardiogram, the most likely change noted will be a(n):

Increased Q-T interval

2 3

Increased P-R interval Q-T interval less than 0.12 seconds

QRS interval greater than 0.12 seconds

ANS: 1 The normal Q-T interval is 0.12 to 0.42 second. Changes in electrolyte values, such as hypocalcemia, or therapy with drugs such as disopyramide or amiodarone increase the Q-T interval. The remaining options do not reflect a low calcium level. DIF: A REF: 910 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 32. The primary reason a client with chronic obstructive pulmonary disease (COPD) often experiences fatigue and activity intolerance is related to:

The increased presence of surfactant that results in sticky alveoli

The presence of chronic infections in the lungs and bronchial tree The extra energy that is needed to exhale the air from the damaged lungs

3 4

The clients elevated anxiety level related to the air hunger being experienced

ANS: 3 Clients with advanced COPD lose the elastic recoil of the lungs and thorax. As a result, the clients work of breathing increases. Although the remaining options are not incorrect, they are not the primary source of the clients fatigue. DIF: C REF: 911 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 33. The nurse is assessing a client with a history of chronic obstructive pulmonary disease. When assessing for the presence of air hunger, the nurse should:

Monitor the clients pulse oximetry reading

Measure the movement of air by counting respirations Auscultate breath sounds both anteriorly and posteriorly

3 4

Observe for the elevation of the clients clavicles during inspiration

ANS: 4 During an assessment, observe for elevation of the clients clavicles during inspiration. Elevation of the clavicles during inspiration can indicate ventilatory fatigue, air hunger, or decreased lung expansion. Although the remaining options are assessment methods, they are not as effective for determining air hunger. DIF: C REF: 911 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 34. Pregnancy affects a womans oxygenation needs primarily because of:

The increased metabolic demands required to support the fetus

The increased tendency to develop anemia as a result of low iron reserves The decreased ability to engage in the physical exercise required to promote circulation

3 4

The decreased lung capacity resulting from the pressure of the uterus on the diaphragm

ANS: 1 Increased metabolic demands, such as pregnancy or fever and infection, affect a clients oxygencarrying capacity (of the blood). The remaining options can affect respiratory function but are not the primary cause of increased oxygenation requirements. DIF: C REF: 912 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 35. The primary effect of chronic fevers on the bodys respiratory functioning is seen in:

Increased oxygen requirements that exceed the bodys ability to satisfy its needs

Increased respiratory rates that tax the bodys reserves of stored energy Breakdown of muscle mass, causing ineffective intercostal muscle function

3 4

The presence of a sense of general malaise that stresses the immune system

ANS: 3 When fever persists, the metabolic rate remains high and the body begins to break down protein stores, resulting in muscle wasting and decreased muscle mass. Respiratory muscles such as the diaphragm and intercostal muscles are also wasted. Although the remaining options are not incorrect, they do not represent the primary effect. DIF: C REF: 912 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 36. The nurse is caring for a client who experienced a flailed chest injury (multiple rib fractures) as a result of a motorcycle accident. The nurse realizes that pain management for this client will directly impact the effectiveness of his respiratory functioning primarily because:

Pain increases metabolic needs, thus increasing oxygen consumption

Pain increases emotional distress, which can lead to hyperventilation Pain will decrease the clients motivation to deep breathe, contributing to shallow, diminished inspirations

3 4

Pain will decrease the clients ability to both relax and recuperate, thus extending the period of recovery

ANS: 3 Chest wall trauma and upper abdominal incisions decrease chest wall movement as the client uses shallow respirations to minimize chest wall movement to avoid pain. DIF: C REF: 913 OBJ: Analysis

TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 37. The nurse observes that a clients pulse rate is 58 beats per minute and regular in rhythm. Which of the following statements made by the nurse shows the appropriate understanding of the clients further need for assessment?

Ill wait 15 minutes and reevaluate the clients pulse rate.

Her pulse rate is usually in the mid 60s, so there isnt a problem.

Ill need to assess her for the presence of chest pain and/or dizziness.

You run an electrocardiogram, and Ill notify her health care provider.

ANS: 3 A low but regular heart rate has no clinical significance unless associated with signs and symptoms of reduced cardiac output such as dizziness or syncope or the presence of chest pain. DIF: C REF: 914 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 38. The nurse suspects that a 59-year-old client has experienced angina pectoris. Which of the following assessment questions will most likely produce information that will assist in the diagnosis?

How long did the pain last?

Can you describe the pain for me?

Did the pain radiate into your left arm?

What were you doing when the pain started?

ANS: 1 Unlike the pain resulting from a myocardial infarction, anginal pain usually lasts from 1 to 15 minutes. The remaining questions could also relate to cardiac pain from other origins. DIF: C REF: 916 OBJ: Analysis TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 39. The nurse is preparing to discuss myocardial infarctions (MIs) with a womens group. Which of the following assessment findings should be included when discussing the typically observed signs and symptoms in females experiencing an MI?

Originates both at rest and upon exertion

2 3

Pain lasting longer than 30 minutes Pain radiating up into left jaw

Significant gastric indigestion

ANS: 4 There is a significant difference between men and women in relation to coronary artery disease. Womens symptoms differ from those seen in men. The most common initial symptom in women is angina, but atypical symptoms of fatigue, indigestion, vasospasm, shortness of breath, or back or jaw pain are also present. The remaining options are reflective of symptoms experienced by both men and women. DIF: A REF: 916 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 40. When assisting with PM care for an 82-year-old client recuperating from pneumonia, the nurse observes that the client appears to be uncharacteristically confused, asking Where am I? Which of the following interventions is the most therapeutic for this particular client?

Listen for lung sounds.

Reorient the client to place.

Ask some simple questions to confirm the confusion. Assess the clients pulse oximetry reading on room air.

ANS: 4 Because mental status changes are often the first signs of respiratory problems and often include forgetfulness and irritability, assessing the clients blood oxygen is the most therapeutic intervention. DIF: B REF: 916-917 OBJ: Application TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 41. When interviewing a newly admitted client, the nurse learns that the client is a cigarette smoker. It is determined that the client has a 50 pack-year history. This means that the client has smoked:

2 packs of cigarettes a day for 25 years

2 3

50 cigarettes a week for the last year 1 pack a week for the last year

50 packs within the last year

ANS: 2 If a client smoked 2 packs a day for 20 years, the client has a 40 pack-year history (packages per day x years smoked). DIF: A REF: 920 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 42. A client diagnosed with chronic bronchitis is awakened from sleep experiencing shortness of breath. The nurse suspects that he is experiencing orthopnea and suggests positioning him to minimize the dyspnea so he can sleep more peacefully. The nurse best describes this position to the client as:

Ill use pillows to take the pressure off your lungs so that they can expand more effectively.

By leaning forward and resting on these pillows, you will be least likely to be short of breath.

This is an upright position that you will be comfortable in and able to breathe more effectively. Well place two pillows behind your back so you are sitting more upright; that will let you rest better.

ANS: 4 Orthopnea is an abnormal condition in which the client uses multiple pillows when lying down or must sit with the arms elevated and leaning forward to breathe. The number of pillows used, such as two or three pillows, usually helps to quantify the orthopnea (e.g., two- or three-pillow orthopnea).

DIF: C REF: 920 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 43. The nurse is preparing an educational handout for older adults with chronic respiratory diseases. To best minimize the risk for infection, the nurse should include which of the following guidelines in the material?

Remember to take your respiratory medication on schedule.

If you are prescribed breathing treatments, take them as ordered. Avoid large, crowded places, especially during the winter months.

3 4

Remember to talk with your health care provider about a flu vaccination.

ANS: 3 Clients with cardiopulmonary alterations need to minimize their risk for infection, especially during the winter months. Teach clients to avoid large, crowded places; keep their mouth and nose covered; and be sure to dress warmly, including a scarf, hat, and gloves. This is especially important during the peak of the influenza season. A flu shot may be recommended, but it does not protect against the various other infections commonly encountered. The remaining options are not directly related to infection but are more relevant to general management DIF: C REF: 921 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 44. The nurse working on the cardiac unit notes that the client has an S2 murmur, which the nurse understands is caused by:

Pulmonic or aortic valve backflow or regurgitation

Mitral valve backflow or regurgitation

Tricuspid valve backflow or regurgitation Poor coronary arterial circulation

ANS: 1 Closure of aortic and pulmonic valves represents S2, or the second heart sound. Some clients with valvular disease have backflow or regurgitation of blood through the incompetent valve,

causing a murmur that you can hear on auscultation. During ventricular diastole the atrioventricular (mitral and tricuspid) valves open and blood flows from the higher-pressure atria into the relaxed ventricles. This represents S1, or the first heart sound. A murmur is caused by blood turbulence, not coronary artery disease DIF: A REF: 912-913 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 45. A client with coronary artery disease is being prepared for a coronary arterial bypass graft surgery. The nurse knows that the coronary artery that carries the most blood and can cause the most harm when blocked is the:

Left coronary artery

Posterior interventricular artery

Circumflex artery

Anterior interventricular artery

ANS: 1 The left coronary artery, the most abundant blood supply, feeds the left ventricular myocardium, which is more muscular and does most of the hearts work. The posterior and anterior interventricular arteries supply blood to the walls of both ventricles. The circumflex artery supplies blood to the walls of the left atrium and left ventricle. DIF: A REF: 912 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 46. A client who has a history of a major myocardial infarction is taking digoxin. The nurse explains this medication helps increase cardiac output by:

Increasing the heart rate

Reducing the resistance of pulmonary circulation

Increasing the force of the myocardial contraction

Increasing cardiac conduction

ANS: 3 Myocardial contractility affects stroke volume and cardiac output. Increased contraction increases the amount of blood ejected by the ventricles. Digoxin increases cardiac output by

inhibiting the sodium-potassium ATPase, which makes more calcium available for contractile proteins, which results in a positive inotropic effect. One of the adverse reactions of digoxin is bradycardia. Digoxin does not reduce the resistance of pulmonary circulation or affect the electrical conduction of the heart. DIF: A REF: 912 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 47. When obtaining vital signs, a nursing assistive personnel is concerned that the heart rate of 56 is too low for a 23-year-old client who has been training for a marathon. The nurse explains that:

A low heart rate is normal in well-conditioned athletes

The health care provider needs to be notified immediately

The heart rate needs to be rechecked before taking any action

The heart rate could be caused by hyperthyroidism

ANS: 1 A heart rate lower then 60 is a normal response to sleep or in a well-conditioned athlete; diminished blood flow to SA node, vagal stimulation, hypothyroidism, increased intracranial pressure, or pharmacological agents (e.g., digoxin, propranolol, quinidine, procainamide) sometimes cause abnormal drops in rate. Any action that the nurse is considering taking should occur only after verifying an abnormal vital sign. DIF: A REF: 913 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 48. During pretesting for an elective surgery, it is discovered that the older adult client has atrial fibrillation. The nurse knows that this is a common dysrhythmia in older people and can cause:

Fatigue, a fluttering in the chest, or shortness of breath if the ventricular response is rapid

Acute loss of pulse and respiration

Severe hypotension and loss of pulse and consciousness

Dizziness, syncope, or chest pain

ANS: 1

There is a loss of the atrial kick (portion of the cardiac output squeezed in the ventricles with a coordinated atrial contraction), pooling of blood in the atria, and development of microemboli. The client often complains of fatigue, a fluttering in the chest, or shortness of breath if the ventricular response is rapid. It is a commonly occurring dysrhythmia in the aging and older adult. Acute loss of pulse and respiration is indicative of ventricular fibrillation. Immediate defibrillation is needed after assessment of ABCs of CPR. Ventricular tachycardia results in decreased cardiac output due to decreased ventricular filling time and often leads to severe hypotension and loss of pulse and consciousness. Sinus bradycardia may present signs and symptoms of reduced cardiac output such as dizziness, syncope, or presence of chest pain. DIF: A REF: 908 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 49. A 47-year-old female client tells the nurse that her heart feels as though it is racing. The clients pulse is 160 beats per minute. The nurse knows that a vagal response will stimulate the parasympathetic nervous system to slow the heart rate and instructs the client to:

1 2

Bear down as though she is having a bowel movement Take a hot shower

Take a cold bath

Hold her breath

ANS: 1 Paroxysmal supraventricular tachycardia is a sudden rapid onset of tachycardia originating above the AV node. It often begins and ends spontaneously. Sometimes excitement, fatigue, caffeine, smoking, or alcohol use precipitates paroxysmal supraventricular tachycardia. When needed, treatment includes vagal stimulation such as carotid sinus massage or Valsalva maneuver to decrease the ventricular response. A hot shower would cause the heart to beat faster in order to cool down the body. A cold bath could cause additional stress and would not be appropriate. Holding the breath will increase the heart rate as it compensates for the lack of oxygen intake and buildup of carbon dioxide. DIF: B REF: 908 OBJ: Application TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 50. A client has been admitted to the emergency department with an aspirin overdose. The nurse anticipates that the client will be experiencing respiratory complications because the nurse knows that aspirin (salicylate) poisoning causes excessive stimulation of the respiratory system as the body attempts to compensate for:

Decreased hemoglobin

2 3

Excess carbon monoxide Decreased oxygen

Excess carbon dioxide

ANS: 4 The body is attempting to correct the acid-base balance, so the respiratory system causes the body to breathe faster in order to try to blow off the excessive carbon dioxide. The hemoglobin is not decreased but does not release oxygen to tissues as readily, and tissue hypoxia results. The body does not produce carbon monoxide. Oxygen levels are not decreased, but the body is attempting to compensate for metabolic acidosis by producing a respiratory alkalosis. DIF: A REF: 909 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 51. The nurse knows that the client who smokes is how much more likely to develop lung cancer than a nonsmoker?

Twice

Three times

Five times

Ten times

ANS: 4 According to the American Cancer Society, the risk for lung cancer is 10 times greater for a person who smokes than for a nonsmoker. Exposure to secondhand smoke increases the risk for lung cancer and cardiovascular disease. DIF: A REF: 909 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 52. A 45-year-old male client shares with the nurse that he has noticed that when he is anxious he feels short of breath. The nurse shares with the client that dyspnea can be caused by many conditions and that the client can make an objective assessment of the severity of the dyspnea by using which of the following?

Peak expiratory flow rate meter (PEFR)

Chest x-ray examination

Pulmonary function test Visual analog scale from 1 to 10

ANS: 4 The use of a visual analog scale (VAS) helps clients to make an objective assessment of their dyspnea. The visual analog scale is a 100-mm vertical line; 0 is equated with no dyspnea, and 100 is equated with the worst breathlessness the client has experienced. The use of the VAS to evaluate the level of a clients dyspnea is useful in evaluating nursing interventions designed to reduce dyspnea. The PEFR reflects changes in large airway sizes and is an excellent predictor of overall airway resistance in the client with asthma. Daily measurement is for early detection of asthma exacerbations. Chest x-ray examination is used to observe the lung fields for fluid, masses, fractures, pneumothorax, and other abnormal processes. The pulmonary function test determines the ability of the lungs to efficiently exchange oxygen and carbon dioxide. It is used to differentiate pulmonary obstructive from restrictive disease. DIF: C REF: 915 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 53. The nurse working on the pulmonary unit is asked to obtain an acid-fast bacillus (AFB) sputum specimen from a client. The nurse knows that this test is used to screen for:

Cancer Tuberculosis (TB)

Cystic fibrosis

Histoplasmosis

ANS: 2 The test is used to screen for the presence of AFB for detection of TB by early morning specimens on 3 consecutive days. Cancer would be tested by a sputum specimen for cytologic examination. Cystic fibrosis and histoplasmosis are not screened for through sputum tests. DIF: A REF: 913 OBJ: Knowledge TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 54. A humidity tent is frequently used for infants and young children to liquefy secretions and help reduce a fever. The nurse knows that humidified air puts the client at risk for:

Respiratory distress

2 3

Infection Skin breakdown

Hypothermia

ANS: 4 Air in the humidity tent sometimes becomes cool and falls below 20 C (68 F), causing the child to become chilled. Children in humidity tents require frequent changes of clothing and bed linen to remain warm and dry. Humidified air helps in keeping the airway open by providing hydration to liquefy secretions, and the cool environment helps reduce bronchospasms. Humidified air liquefies secretions, allowing the child to cough them up, which reduces the risk for an infection. Humidified air should not lead to skin breakdown as long as the linens and clothing are not allowed to remain wet. DIF: A REF: 916 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems MULTIPLE RESPONSE 1. Which of the following situations would cause the nurse to expect an increase in cardiac output in a client who is experiencing no health issues? (Select all that apply.)

After playing a set of doubles tennis

Being 31 weeks pregnant with twins

Upon rising from a 45-minute afternoon nap

During a panic attack resulting from an unknown trigger

Experiencing a 100 F temperature resulting from a bacterial infection Following a 60-minute session that included aerobic exercise

ANS: 1, 2, 4, 5, 6 Exercise, pregnancy, and fever increase cardiac output, but during sleep it decreases. DIF: A REF: 918 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems

2. Which of the following are factors that affect the bloods capacity to carry sufficient oxygen to the various body organs? (Select all that apply.)

1 2 3

The size of the individual The age of the individual

The gender of the individual The amount of oxygen present in the blood

The amount of hemoglobin present in the blood

The amount of oxyhemoglobin present in the blood

ANS: 4, 5, 6 Three things influence the capacity of the blood to carry oxygen: the amount of dissolved oxygen in the plasma, the amount of hemoglobin, and the tendency of hemoglobin to bind with oxygen. The remaining options are not directly involved. DIF: A REF: 920 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 3. The nurse caring for a morbidly obese client who is recovering from abdominal surgery recognizes that this client is at risk for respiratory complications specifically caused by: (Select all that apply.)

1 2 3 4 5 6

Poor muscle tone, resulting in decreased respiratory muscle function Increased risk for infection, resulting in increased oxygen requirements Deceased lung volume resulting from compression of abdominal organs Increased presence of pulmonary secretions in the lower lobes bilaterally Obesity-hypoventilation syndrome resulting from chronic carbon dioxide retention Pain resulting in reluctance to deep breathe and facilitate exchange of oxygen and carbon dioxide

ANS: 1, 2, 3, 4, 5 Morbidly obese clients have a reduction in compliance as a result of encroachment of the abdomen into the chest, increased work of breathing, and decreased lung volumes. In some clients an obesity-hypoventilation syndrome develops in which oxygenation is decreased and carbon dioxide is retained. The obese client is also susceptible to pneumonia after surgery or an upper respiratory tract infection because the lungs do not fully expand and the lower lobes retain pulmonary secretions. Pain is a universal barrier to effective breathing; it is not unique to the obese client. DIF: C REF: 924 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/ Alterations in Body Systems 4. The nurse expects to observe which of the following assessment findings in a client diagnosed with left-sided heart failure? (Select all that apply.)

Ankle edema

Bilateral crackles Mental confusion

3 4 5

Distended neck veins Activity-induced dyspnea

Being awakened by shortness of breath

ANS: 2, 3, 5, 6 Clinical findings of left-sided heart failure include crackles on auscultation, hypoxia, shortness of breath on exertion and often at rest, cough, and paroxysmal nocturnal dyspnea. The remaining options are more reflective of right-sided failure. Chapter 42. Fluid, Electrolyte, and Acid-Base Balance MULTIPLE CHOICE 1. When an excess of body fluid exists in the intravascular compartment, all of the following signs can be expected except:

1 2 3 4 ANS: 4

Rales A bounding pulse Engorged peripheral veins An elevated hematocrit level

An elevated hematocrit level would be expected with a deficit of body fluid in the intravascular compartment. When an excess of body fluid exists in the intravascular compartment, a decreased hematocrit would be expected. Crackles (in lungs) are consistent findings with fluid volume excess. An assessment finding associated with fluid volume excess is a bounding pulse. Engorged peripheral veins may be seen with fluid volume excess. DIF: A REF: 975 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 2. A homeless client is brought into the emergency department with indications of extremely poor nutrition. Arterial blood gas levels are assessed, and the nurse anticipates that this client will demonstrate which of the following results?

pH 7.3, PaCO2 38 mm Hg, HCO3 19 mEq/L

pH 7.5, PaCO2 34 mm Hg, HCO3 20 mEq/L

pH 7.35, PaCO2 35 mm Hg, HCO3 24 mEq/L

pH 7.52, PaCO2 48 mm Hg, HCO3 28 mEq/L

ANS: 1 Metabolic acidosis may be found in cases of starvation. The clients pH is below the normal of 7.35 (at 7.3), the PaCO2 is in the normal range of 35 to 45 mm Hg (at 38 mm Hg), and the HCO3 is below the normal of 22 mEq/L (at 19 mEq/L). These findings demonstrate metabolic acidosis. Values of pH 7.5, PaCO2 34 mm Hg, HCO3 20 mEq/L are consistent with respiratory alkalosis, compensated, which would not be typical of malnutrition. Values of pH 7.52, PaCO2 48 mm Hg, HCO3 28 mEq/L are consistent with metabolic alkalosis, compensated, which would not be an expected finding with extremely poor nutrition. DIF: C REF: 977 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 3. When a clients serum sodium level is 120 mEq/L, the priority nursing assessment is to monitor the status of which body system?

Neurological

Gastrointestinal

Pulmonary Hepatic

4 ANS: 1

Because sodium is necessary for nerve impulse transmission, the priority nursing assessment with hyponatremia is the neurological system. DIF: A REF: 973 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 4. An 8-year-old is admitted to the pediatric unit with pneumonia. On assessment the nurse notes that the child is warm and flushed, is lethargic, has difficulty breathing, and has moist rales. The nurse determines that the child is suffering from:

1 2

Metabolic acidosis Respiratory acidosis

Respiratory alkalosis

Metabolic alkalosis

ANS: 2 These assessment findings (i.e., warm and flushed skin, lethargy, and medical diagnosis of pneumonia) are indicative of respiratory acidosis. Lethargy and flushed skin may be seen with metabolic acidosis, but this child has a respiratory problem with difficulty breathing, which is consistent with respiratory acidosis. DIF: A REF: 977 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 5. Arterial blood gas levels are obtained for the client. If the clients results are pH 7.48, CO2 42 mm Hg, and HCO3 32 mEq/L, the client is exhibiting which one of the following acid-base imbalances?

Metabolic acidosis

Respiratory acidosis

Respiratory alkalosis Metabolic alkalosis

ANS: 4 The clients pH is elevated at 7.48 (normal 7.35 to 7.45), the CO2 is normal at 42 mm Hg (normal 35 to 45 mm Hg), and the bicarbonate is elevated at 32 mEq/L (normal 22 to 26 mEq/L). The client is experiencing metabolic alkalosis. In metabolic acidosis the clients pH would be below 7.35, and the bicarbonate would be below 22 mEq/L. In respiratory acidosis the clients pH would

be below 7.35, and the CO2 would be elevated above 45 mm Hg. In respiratory alkalosis the clients pH would be above 7.45, and the CO2 would be below 35 mm Hg. DIF: C REF: 976 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 6. The nurse is aware that the compensating mechanism that is most likely to occur in the presence of respiratory acidosis is:

Hyperventilation to decrease the CO2 levels

Hypoventilation to increase the CO2 levels

Retention of HCO3 by the kidneys to increase the pH level

Excretion of HCO3 by the kidneys to decrease the pH level

ANS: 3 The compensating mechanism in the presence of respiratory acidosis is retention of bicarbonate by the kidneys to increase the pH level. Hyperventilation would be the compensating mechanism in metabolic acidosis to decrease CO2 levels. Hypoventilation would be the compensating mechanism in metabolic alkalosis to increase CO2 levels. The compensating mechanism in the presence of metabolic alkalosis is excretion of bicarbonate to decrease the pH level. DIF: A REF: 977 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 7. Of all of the following clients, the nurse recognizes that the individual who is most at risk for a fluid volume deficit is:

A 6-month-old learning to drink from a cup

A 12-year-old who is moderately active in 80 F weather

A 42-year-old with severe diarrhea

A 90-year-old with frequent headaches

ANS: 3 The client at greatest risk for a fluid volume deficit is the client who has severe diarrhea. Any condition that results in the loss of gastrointestinal (GI) fluids predisposes the client to dehydration and a variety of electrolyte disturbances. The very young are at risk for a fluid volume deficit because their body water loss is proportionately greater per kilogram of weight. A 12-year-old who is moderately active in warm weather will lose body water through sweating.

The very old are at increased risk for fluid volume deficit as they have a decreased thirst sensation and a decreased number of filtering nephrons. DIF: C REF: 980 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 8. A client experiences a loss of intracellular fluid. The nurse anticipates that the intravenous (IV) therapy that will be used to replace this type of loss is:

0.45% normal saline (NS)

10% dextrose

5% dextrose in lactated Ringers

Dextrose 5% in NS

ANS: 1 The client will need a hypotonic solution, such as 0.45% NS. A hypotonic solution has an osmolality that is less than body fluids, so the cells will draw the fluid in, which is the desired effect when the client has experienced a loss of intracellular fluid. Dextrose 5% in NS, 10% dextrose, and 5% dextrose in lactated Ringers are all hypertonic solutions that will draw fluid into the vascular space by osmosis. The client needs a hypotonic solution to rehydrate the cells. DIF: A REF: 968 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 9. The client has been experiencing right flank and lower back pain. Which of the following laboratory values would be most desirable for the nurse to obtain based on the clients assessment?

Serum potassium

Serum sodium

Serum magnesium

Serum calcium

ANS: 4 Flank pain and lower back pain may be indicative of kidney stones from excess calcium. The laboratory value for the nurse to obtain would be a serum calcium level. DIF: A REF: 974 OBJ: Comprehension TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 10. The health care provider orders 1000 mL of D5LR with 20 mEq KCl to run for 8 hours. Using an infusion set with a drop factor of 15 gtt/mL, the nurse calculates the flow rate to be:

1 2

12 gtt/min 22 gtt/min

32 gtt/min

42 gtt/min

ANS: 3 1000 mL 8 hr = 125 mL/hr; (15 gtt/mL 60 min) x 124 mL = 32 gtt/min. DIF: A REF: 1007 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 11. The nurse will be starting a new intravenous infusion and needs to select the site for the insertion. In selection of a site, the nurse should:

Start with the most proximal site

Look for hard, cordlike veins

Use the dominant arm

Avoid sites on the extremity away from a dialysis graft

ANS: 4 The nurse should avoid veins in an extremity with compromised circulation, such as a dialysis graft. The nurse should use the most distal site in the nondominant arm, if possible, and should avoid hardened cordlike veins. DIF: A REF: 998 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 12. A client has intravenous therapy for the administration of antibiotics and is stating that the IV site hurts and is swollen. Which of the following information assessed on the client indicates the presence of phlebitis, as opposed to infiltration?

Intensity of the pain

Warmth of integument surrounding the IV site

Amount of subcutaneous edema

Skin discoloration of a bruised nature

ANS: 2 Signs of phlebitis may include increased temperature over the vein, erythema, pain, and edema. With phlebitis, the area is warm to the touch; with infiltration, the area is cool to the touch. The intensity of pain is not a differentiating factor between phlebitis and infiltration. Pain may occur with both. The amount of subcutaneous edema is not a differentiating factor between phlebitis and infiltration. Edema may occur with both. Skin discoloration of a bruised nature is not the best way to differentiate phlebitis from infiltration. With phlebitis, the area is typically reddened. With infiltration, the area is typically pale. DIF: A REF: 1012 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 13. A client complains of a headache, nausea, and vomiting during a blood transfusion. Which one of the following actions should the nurse take immediately?

Check the vital signs.

2 3

Stop the blood transfusion. Slow down the rate of blood flow.

Notify the health care provider and blood bank personnel.

ANS: 2 If a blood reaction is suspected, the nurse stops the blood transfusion immediately. The nurse should take the clients vital signs, but the initial action should be to stop the blood transfusion. Once the transfusion is stopped, the nurse could notify the health care provider and blood bank personnel. DIF: C REF: 1023 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 14. For a client with a nursing diagnosis of excess fluid volume, the nurse is alert to which one of the following signs and symptoms?

Weak, thready pulse

Hypertension

Dry mucous membranes

Flushed skin

ANS: 2 Hypertension is a symptom of fluid volume excess. A weak, thready pulse is associated with fluid volume deficit. A bounding pulse is a symptom of fluid volume excess. Dry mucous membranes and flushed skin are both symptomatic of fluid volume deficit, not excess. DIF: A REF: 1012 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 15. A client is currently taking Lasix and digoxin. As a result of the medication regimen, the nurse is alert to the presence of:

Cardiac dysrhythmias

Severe diarrhea

Hyperactive reflexes

Peripheral cyanosis

ANS: 1 Lasix is a nonpotassium-sparing diuretic. Without a potassium supplement the client may become hypokalemic. Hypokalemia increases the risk for digoxin toxicity. Both hypokalemia and digoxin toxicity can cause cardiac dysrhythmias. Clients with hypokalemia from diuretic use may experience intestinal distention and decreased bowel sounds. Severe diarrhea may be a cause of hypokalemia, not a result of hypokalemia. Clients with hyperactive reflexes may have hypocalcemia. Lasix and digoxin do not predispose a client to hypocalcemia. Peripheral cyanosis is not a potential problem related to the clients medication regimen. DIF: A REF: 973 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 16. A rapid infusion of citrated blood has been given to the client. The nurse observes for:

Diaphoresis

Anxiety

Chvosteks sign

Nausea and vomiting

ANS: 3 Chvosteks sign is seen with hypocalcemia. Rapid administration of blood transfusions containing citrate may cause hypocalcemia. Citrate solution is used to prevent clotting of the blood so that it can be stored in the refrigerator until it is needed for transfusion. Also, if blood that is cold is

administered too rapidly, it may cause cardiac dysrhythmias. If a client receives a rapid blood transfusion, the kidneys may not be able to excrete phosphorus quickly enough and the phosphorus level increases while the calcium level decreases. Sepsis may also increase the risk for developing hypocalcemia. The client who has a rapid blood transfusion of citrated blood would not be expected to experience excessive sweating. The client who experiences an anaphylactic reaction or sepsis typically has cool, clammy skin. Anxiety may be related to an anaphylactic or febrile, nonhemolytic reaction to a blood transfusion. However, it is not the best indication of a possible reaction because the client may be anxious because of receiving a blood transfusion, having nothing to do with a physiological reaction to the transfusion. Nausea and vomiting may or may not indicate a reaction to a blood transfusion. DIF: A REF: 973 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 17. For a child who has ingested the remaining contents of an aspirin bottle, the nurse suspects signs and symptoms consistent with:

1 2 3 4

Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

ANS: 4 A salicylate overdose may cause respiratory alkalosis because of hyperventilation. Aspirin overdose is not associated with metabolic acidosis, metabolic alkalosis or respiratory acidosis. DIF: A REF: 983 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 18. The single best indicator of fluid status is the nurses assessment of the clients:

Skin turgor

Intake and output

Serum electrolyte levels

Daily weight

ANS: 4

Daily weights are the single most important indicator of fluid status. Skin turgor is a measure of hydration, as are intake and output. Serum electrolyte levels help monitor fluid status; however, daily weights are the single best indicator of a clients fluid status. DIF: A REF: 983 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 19. An IV solution of 125 mL is to be infused over a 1-hour period. A microdrip infusion set will be used. The nurse calculates the infusion rate as:

32 gtt/min

2 3

60 gtt/min 125 gtt/min

250 gtt/min

ANS: 3 (60 gtt/mL 60 min) x 125 mL = 125 gtt/min. DIF: A REF: 1007 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 20. A client is admitted to the hospital with a diagnosis of adrenal insufficiency. In preparing to complete the admission history, the nurse anticipates that the client will have experienced:

Decreased muscle tone

Hypertension

Diarrhea Fever

ANS: 3 A cause of hyponatremia is adrenal insufficiency. The client with hyponatremia may experience diarrhea, abdominal cramping, and nausea and vomiting. Decreased muscle tone is a symptom of hypokalemia. A client with adrenal insufficiency is not likely to experience hypertension. Resultant hyponatremia with adrenal insufficiency may be exhibited as postural hypotension. Fever is a symptom of hypernatremia, not hyponatremia. Hypernatremia is not caused by adrenal insufficiency. DIF: A REF: 973 OBJ: Comprehension TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 21. In reviewing the results of the clients blood work, the nurse recognizes that the unexpected value that should be reported to the health care provider is:

1 2

Calcium 3.9 mEq/L Sodium 140 mEq/L

Potassium 3.5 mEq/L

Magnesium 2.1 mEq/L

ANS: 1 A calcium level of 3.9 mEq/L should be reported to the health care provider. A normal calcium level is 4.5 to 5.5 mEq/L. A sodium level of 140 mEq/L is within the normal range of 135 to 145 mEq/L. A potassium level of 3.5 mEq/L is within the normal range of 3.5 to 5.0 mEq/L. A magnesium level of 2.1 mEq/L is within the normal range of 1.5 to 2.5 mEq/L. DIF: A REF: 971 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 22. The nurse anticipates that the client with a fluid volume excess will manifest a(n):

Increased urine specific gravity

Decreased body weight

Increased blood pressure Decreased pulse strength

ANS: 3 Hypertension is manifested with fluid volume excess. The urine specific gravity would be decreased with fluid volume excess. The nurse would anticipate an increased urine specific gravity with fluid volume deficit, as well as an increase in body weight and an increase in pulse strength. DIF: A REF: 1021 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 23. The nurse recognizes that the client, based on the imbalance that is present, will require fluid replacement with isotonic solution. One of the isotonic solutions that may be ordered by the health care provider is:

0.45% saline

Lactated Ringers

5% dextrose in normal saline 5% dextrose in lactated Ringers

ANS: 2 Lactated Ringers is an isotonic solution. 0.45% saline is a hypotonic solution. 5% dextrose in normal saline and 5% dextrose in lactated Ringers are both hypertonic solutions. DIF: A REF: 968 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 24. A client has severe anemia and will be receiving blood transfusions. The nurse prepares and begins the infusion. Ten minutes after the infusion has begun, the client develops tachycardia, chills, and low back pain. After stopping the transfusion, the nurse should:

Administer an antipyretic

Begin an infusion of epinephrine

Run normal saline through the blood tubing

Obtain and send a urine specimen to the laboratory

ANS: 4 After stopping the blood transfusion, the nurse should obtain and send a urine specimen to the laboratory to determine the presence of hemoglobin as a result of red blood cell (RBC) hemolysis. In an acute hemolytic reaction, management of the reaction does not include the administration of an antipyretic. The nurse should be prepared to administer emergency drugs, such as diuretics, per the health care providers order. The nurse should not turn off the blood and simply turn on the normal saline that is connected to the Y-tubing set. This would cause blood remaining in the Y-tubing to infuse into the client. Even a small amount of mismatched blood can cause a major reaction. The nurse should run normal saline directly into the IV line (not through the blood tubing). DIF: C REF: 1022-1023 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 25. A client is prescribed 0.9% sodium chloride (normal saline), which is an isotonic solution. The nurse recognizes the primary goal of such intravenous therapy is to:

Expand the volume of fluid in the vascular system

Pull fluid from the cells

Keep protein levels normal

Move fluid into the cells

ANS: 1 Isotonic solutions such as normal saline, 0.9% sodium chloride, expand the bodys fluid volume without causing a fluid shift from one compartment to another. The remaining options describe the function of other types of fluids. DIF: A REF: 968 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 26. A client is prescribed 3% sodium chloride, which is a hypertonic solution. The nurse recognizes the primary goal of such intravenous therapy is to:

1 2

Expand the volume of fluid in the vascular system Pull fluid from the cells

Keep protein levels normal

Move fluid into the cells

ANS: 2 A hypertonic solution (a solution of higher osmotic pressure), such as 3% sodium chloride, pulls fluid from cells, causing them to shrink. The remaining options describe the function of other types of fluids. DIF: A REF: 968 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 27. A client is prescribed 0.45% sodium chloride, which is a hypotonic solution. The nurse recognizes the primary goal of such intravenous therapy is to:

Expand the volume of fluid in the vascular system

2 3

Pull fluid from the cells Keep protein levels normal

Move fluid into the cells

ANS: 4

Hypotonic solutions (a solution of lower osmotic pressure), such as 0.45% sodium chloride, move fluid into the cells, causing them to enlarge. The remaining options describe the function of other types of fluids. DIF: A REF: 968 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 28. The nurse recognizes which of the following clients is at the greatest risk for dehydration?

A 35-year-old client diagnosed with Crohns disease

A 15-year-old client who is following a low-carbohydrate diet

A 2-year-old client diagnosed with an allergy to milk proteins

A 79-year-old client who has been diagnosed with advanced Alzheimers disease

ANS: 4 Infants, clients with neurological or psychological problems, and some older adults who are unable to perceive or respond to the thirst mechanism are at risk for dehydration. DIF: C REF: 978-979 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 29. Which of the following clients is at greatest risk for insensible water loss?

A 37-year-old with a superficial burn to the left hand

A 15-year-old experiencing an asthmatic attack

A 50-year-old with type 2 diabetes

A 73-year-old with a history of pneumonia

ANS: 2 Insensible water loss is continuous and occurs through the skin and lungs. A person does not perceive the loss, but it can significantly increase with fever or burns. This insensible water loss increases in response to changes in respiratory rate and depth. In addition, devices for administering oxygen increase insensible water loss from the lungs. The teenager experiencing the asthmatic attack is at greatest risk because of the increased respiratory involvement and possible fever. Type 2 diabetes does not necessarily increase insensible water loss, and the remaining clients may have a small risk. DIF: C REF: 970 OBJ: Analysis

TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 30. Which of the following foods will have the greatest impact on the water balance of the person consuming it?

1 2 3 4

A pickle A banana A milkshake A spinach salad

ANS: 1 Sodium ions are the major contributors to maintaining water balance through their effect on serum osmolality, nerve impulse transmission, regulation of acid-base balance, and participation in cellular chemical reactions. Pickles are a high-sodium food. The remaining options are good sources of potassium, calcium, and magnesium. DIF: C REF: 970 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 31. Which of the following foods will have the greatest impact on the hearts conductivity of the person consuming it?

A pickle

A banana

A milkshake

A spinach salad

ANS: 2 Potassium is the major electrolyte and principal cation in the intracellular compartment. It regulates many metabolic activities and is necessary for glycogen deposits in the liver and skeletal muscle, transmission and conduction of nerve impulses, normal cardiac conduction, and skeletal and smooth muscle contraction. Bananas are a high-potassium food. The remaining options are good sources of sodium, calcium, and magnesium. DIF: C REF: 972 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 32. Which of the following foods will have the greatest impact on the blood-clotting mechanism of the person consuming it?

A pickle

2 3

A banana A milkshake

A spinach salad

ANS: 3 Calcium is necessary for bone and teeth formation, blood clotting, hormone secretion, cell membrane integrity, cardiac conduction, transmission of nerve impulses, and muscle contraction. Milk is a high-calcium food. The remaining options are good sources of sodium, potassium, and magnesium. DIF: C REF: 973-975 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 33. Which of the following foods will have the greatest impact on the neurochemical activity of the person consuming it?

A pickle

A banana

A milkshake

A spinach salad

ANS: 4 Magnesium is essential for enzyme activities, neurochemical activities, and cardiac and skeletal muscle excitability. Spinach is a high-magnesium food. The remaining options are good sources of sodium, potassium, and calcium. DIF: C REF: 974 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 34. Which of the following clinical assessment findings is most likely seen in a client experiencing partial-thickness burns over 35% of the body as a result of hyponatremia?

Dry, sticky tongue

Increased anxiety

Nausea and vomiting Decreased bowel sounds

ANS: 3 Physical examination of a hyponatremic client may reveal apprehension, personality change, postural hypotension, postural dizziness, abdominal cramping, nausea and vomiting, diarrhea, tachycardia, dry mucous membranes, convulsions, and coma. The remaining options are examples of hypernatremia, hypokalemia, and hyperkalemia. DIF: C REF: 973 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 35. Which of the following clinical assessment findings is most likely seen in a client experiencing hypernatremia as a result of diabetes insipidus?

Dry, sticky tongue

Increased anxiety

Nausea and vomiting

Decreased bowel sounds

ANS: 1 Physical examination of a hypernatremic client may reveal extreme thirst, dry and flushed skin, dry and sticky tongue and mucous membranes, postural hypotension, fever, agitation, convulsions, restlessness, and irritability. The remaining options are examples of hyponatremia, hypokalemia, and hyperkalemia. DIF: C REF: 973 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 36. Which of the following clinical assessment findings is most likely seen in a client experiencing hypokalemia as a result of the misuse of potassium-wasting diuretics?

Dry, sticky tongue

Increased anxiety

Nausea and vomiting

Decreased bowel sounds

ANS: 4 Physical examination of a hypokalemic client may reveal weakness and fatigue, muscle weakness, nausea and vomiting, intestinal distention, decreased bowel sounds, decreased deep

tendon reflexes, ventricular dysrhythmias, paresthesias, and weak, irregular pulse. The remaining options are examples of hypernatremia, hyponatremia, and hyperkalemia. DIF: C REF: 973 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 37. Which of the following clinical assessment findings is most likely seen in a client experiencing hyperkalemia as a result of adrenal insufficiency?

Dry, sticky tongue

Increased anxiety

Nausea and vomiting

Decreased bowel sounds

ANS: 2 Physical examination of a hyperkalemic client may reveal anxiety, dysrhythmias, paresthesia, weakness, abdominal cramps, and diarrhea. The remaining options are examples of hypernatremia, hyponatremia, and hypokalemia. DIF: C REF: 973 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 38. A client who takes furosemide presents at the emergency department with weakness and fatigue and complains of nausea and vomiting for 3 days. Upon assessment, the nurse finds that the client has decreased bowel sounds and ECG abnormalities including a flattened T wave and flattened ST segment. The nurse knows that these are signs of:

Hypokalemia

Hyperkalemia

Hyponatremia

Hypocalcemia

ANS: 1 Signs of hypokalemia include weakness and fatigue, muscle weakness, nausea and vomiting, intestinal distention, decreased bowel sounds, decreased deep tendon reflexes, ventricular dysrhythmias, paresthesias, and weak, irregular pulse. ECG abnormalities: flattened T wave, ST segment depression, U wave, potentiated digoxin effects (e.g., ventricular dysrhythmias). The most common cause of hypokalemia is vomiting and the use of potassium-wasting diuretics. Signs of hyperkalemia include anxiety, dysrhythmias, paresthesia, weakness, abdominal cramps,

and diarrhea. ECG abnormalities: peaked T wave and widened QRS complex (bradycardia, heart block, dysrhythmias); eventually QRS pattern widens and cardiac arrest occurs. Signs of hyponatremia include extreme thirst, dry and flushed skin, dry and sticky tongue and mucous membranes, postural hypotension, fever, agitation, convulsions, restlessness, and irritability, whereas signs of hypocalcemia include numbness and tingling of fingers and circumoral (around mouth) region, hyperactive reflexes, positive Trousseaus sign (carpopedal spasm with hypoxia), positive Chvosteks sign (contraction of facial muscles when facial nerve is tapped), tetany, muscle cramps, pathological fractures (chronic hypocalcemia), and ECG abnormalities: ventricular tachycardia. DIF: A REF: 979 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 39. A mother brings her 2-year-old daughter to the clinic with a 2-day history of a fever of unknown origin. The mother explains to the nurse that the air conditioning in her apartment is not working and it has been very hot; her daughter has been vomiting for 2 days and has had a fever, and the child is lethargic. The childs rectal temperature is 101.1 F. The nurse knows the child is probably dehydrated and should do which of the following first?

1 2 3 4

Give the child some juice to drink. Prepare to start an IV. Get an order for an antipyretic. Sponge the child to bring down the fever.

ANS: 2 Children ages 2 through 12 have less stable regulatory responses to imbalance, and in childhood illnesses they tend to operate within a more narrow range with less tolerance for severe fluid and electrolyte imbalance. Clients who have been exposed to temperature extremes may have clinical signs of fluid and electrolyte alterations. Exposure to environmental temperatures exceeding 28 to 30 C (82.4 to 86 F) results in excessive sweating with weight loss. A body weight loss over 7% decreases the ability of the cooling mechanism to conserve water. The nurses first priority is fluid volume replacement, then an antipyretic (because the fever is not dangerously high). If the child has been vomiting, she is likely to vomit the juice. DIF: A REF: 976 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 40. The nurse is caring for a 73-year-old female client who is 3 days postoperative for a bowel obstruction. The nurse knows that the stress response of surgery causes fluid-balance changes in the second to fifth postoperative day, when aldosterone, glucocorticoids, and antidiuretic

hormone (ADH) are increasingly secreted, causing sodium and chloride retention and potassium excretion. Because of this, it is important for the nurse to closely monitor:

1 2 3 4

Urine output Intake of sodium Activity level Oxygen level

ANS: 1 Recent surgery is a condition that places clients at high risk for fluid, electrolyte, and acid-base alterations. Clients continue to be at risk during the acute phase until the underlying process is resolved. For example, the stress response of surgery causes fluid-balance changes in the second to fifth postoperative day, when aldosterone, glucocorticoids, and ADH are increasingly secreted, causing sodium and chloride retention, potassium excretion, and decreased urinary output. The clients diet most likely has not advanced enough to be concerned about excess sodium intake. The clients activity level is important, and the nurse should encourage her to increase her activity level. The clients oxygen level is also important to monitor, but has no direct effect on the fluid, electrolyte, and acid-base alterations DIF: A REF: 976 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 41. Which of the following clients is most at risk for fluid volume deficit?

25-year-old male near-drowning victim

56-year-old woman with salicylate poisoning

45-year-old woman with second-degree burns over 20% of her body

13-year-old boy with an oral temperature of 103.4 F

ANS: 3 The greater the body surface burned, the greater the fluid loss. The burned client loses body fluids by one of five routes. First, plasma leaves the intravascular space and becomes trapped edema. This is also called the plasma-to-interstitial fluid shift. It is accompanied by a loss of serum proteins. Second, plasma and interstitial fluids are lost as burn exudate. Third, water vapor and heat are lost in proportion to the amount of skin that is burned. Fourth, blood leaks from damaged capillaries, adding to the intravascular fluid volume loss. Finally, sodium and water shift into the cells, further compromising extracellular fluid volume. A near-drowning victim may suffer from hypoxia and respiratory acidosis but would not be as likely to be at risk for fluid

volume deficit as the burn victim. Salicylate poisoning may cause some insensible fluid loss through the bodys hyperventilation to compensate for the increased PaCO2. Adolescents have increased metabolic processes and increased water production because of the rapid changes that occur in the anatomical and physiological process. DIF: A REF: 976 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 42. A 66-year-old female client is admitted to the hospital with diabetic ketoacidosis. The client has a running IV line through which she receives her medications and fluid maintenance. Which of the following would not be counted on the daily intake and output (I&O)?

IV fluids

2 3

Cream of mushroom soup Gelatin

Mashed potatoes

ANS: 4 Mashed potatoes do not contain enough liquid to be counted in the fluid intake of the client, whereas IV fluids are part of the liquid intake of the client and should be counted. Soups are high in the percentage of water that they contain, as is gelatin, and both should be counted in the daily fluid intake. DIF: A REF: 979 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 43. A client with transient atrial fibrillation has been taking 83 mg of aspirin daily for the past 3 years. When preparing the client for discharge from the hospital, the nurse discontinues his IV line. In order to prevent a hematoma, the nurse needs to hold pressure on the IV site for:

1 to 2 minutes

2 to 3 minutes

3 to 5 minutes

5 to 10 minutes

ANS: 4 Because the client is on a low-dose aspirin, it takes longer for his blood to form a clot, so the nurse needs to hold pressure for 5 to 10 minutes. Holding pressure for 2 to 3 minutes would be appropriate for a client who is not on anticoagulant therapy.

DIF: B REF: 972 OBJ: Application TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 44. The nurse is preparing to replace a bag of IV fluids for a client receiving fluid therapy. When assessing the client, the nurse notes that the IV solution is not dripping. Which of the following should the nurse do to assess the patency of the site?

Lower IV container below level of IV site for presence of blood return.

Use a large-volume syringe to apply negative pressure to achieve a blood return. Carefully adjust the roller clamp to see an increase in flow rate.

3 4

Massage the clients arm proximal to where the catheter is inserted.

ANS: 3 The catheter may be lodged against the vein wall; allowing additional pressure from the bag of fluid to flow into the vein may float the catheter into the vein, allowing the instillation of fluids. Using a large-volume syringe could cause the vein to collapse, and massaging the clients arm could dislodge a clot, causing an embolus. DIF: B REF: 973 OBJ: Application TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 45. A client has been hospitalized following a myocardial infarction. The client has an IV line running with multiple drips. The nurse assesses the clients medical record to determine the last time the IV tubing was changed, because the nurse knows that the Centers for Disease Control and Prevention (CDC) recommends that IV tubing be changed:

Every shift

Daily

Every 48 hours

Every 72 hours

ANS: 4

CDC and INS recommend tubing change no more often than 72-hour intervals or whenever tubing has been compromised. The more frequently a closed sterile system is opened, the more opportunities there are for microorganisms to be introduced into the system. DIF: B REF: 978 OBJ: Application TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 46. The nurse is assessing the client with an IV line. The nurse notes that the IV insertion site is red, edematous, and painful. The nurses first action should be to:

Immediately discontinue the IV line and remove the cannula

2 3

Put cool compresses on the IV site to decrease the edema Notify the health care provider of the situation

Put warm compresses on the IV site to decrease the pain

ANS: 3 The nurse should notify the health care provider to determine if the health care provider would like to culture the IV cannula. (Confirm before removal of IV line.) Wrapping the extremity in a warm, moist towel for 20 minutes promotes venous return, increases circulation, and reduces pain and edema. Heat therapy can be repeated three to four times during the day. DIF: B REF: 969-970 OBJ: Application TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 47. Blood replacement or transfusion is the IV administration of whole blood or a component such as plasma, packed red blood cells (RBCs), or platelets. The minimum gauge IV cannula necessary for administering a blood transfusion is:

24 gauge

22 gauge

20 gauge

18 gauge

ANS: 3 A large cannula such as an 18 gauge or 19 gauge is preferred because blood is more viscous than IV fluids, although smaller gauge sizes will accommodate transfusions. However, a catheter no smaller than a 20 gauge should be used to transfuse blood; 22- and 24-gauge cannulas are not recommended because they are too small to allow the viscous blood to flow freely through them.

An 18 gauge is considered ideal, but the minimum-size cannula that should be used is a 20 gauge. DIF: B REF: 979 OBJ: Application TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 48. The nurse is discontinuing a clients IV line in preparation for the clients discharge home. Upon withdrawing the cannula from the peripheral site, the nurse notes that the tip of the cannula is missing. The first thing that the nurse should do is:

1 2

Notify the health care provider immediately Apply pressure to the IV site

Apply a tourniquet high on the extremity

Ask another nurse to double-check the cannula

ANS: 3 The first priority of the nurse is to apply a tourniquet high on the extremity to restrict mobility of catheter embolus. The health care provider needs to be notified after the tourniquet is applied. DIF: B REF: 990-991 OBJ: Application TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances MULTIPLE RESPONSE 1. A client with partial-thickness burns over 40% of the body is likely to lose body fluid via: (Select all that apply.)

Water vapor that is lost through the skin that is burned

Plasma and interstitial fluids that are lost as burn exudate

Blood leakage via damaged capillaries in the dermis

Respiratory acidosis resulting from altered respiratory function

Plasma that leaves the intravascular space and becomes trapped in blisters Sodium and water shift that out of the vessels because of increased permeability

ANS: 1, 2, 3, 5, 6 The greater the body surface burned, the greater the fluid loss. The burned client loses body fluids by one of five routes. First, plasma leaves the intravascular space and becomes trapped

edema. This is also called the plasma-to-interstitial fluid shift. It is accompanied by a loss of serum proteins. Second, plasma and interstitial fluids are lost as burn exudate. Third, water vapor and heat are lost in proportion to the amount of skin that is burned. Fourth, blood leaks from damaged capillaries, adding to the intravascular fluid volume loss. Finally, sodium and water shift into the cells, further compromising extracellular fluid volume. DIF: C REF: 1017 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 2. A client experiencing respiratory alkalosis as a result of asthma is likely to present with which of the following clinical signs? (Select all that apply.)

1 2

A respiratory rate of 36 breaths per minute Complaints of numbness in fingers and toes

Dizziness when attempting to sit upright

Difficulty holding a cup because of tremors

An irregular heartbeat on an electrocardiogram (ECG)

Warm, flushed skin

ANS: 1, 2, 3, 4 Physical examination of a client experiencing respiratory alkalosis may reveal dizziness, confusion, dysrhythmias, tachypnea, numbness and tingling of extremities, convulsions, and coma. DIF: C REF: 1013 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 3. A client experiencing respiratory acidosis as a result of pneumonitis is likely to present with which of the following clinical signs? (Select all that apply.)

Tingling fingers

Difficult to arouse

Warm, flushed skin

4 5

Tremors in the hands Reporting a terrible headache

Repeatedly asking Where am I?

ANS: 2, 3, 4, 5, 6 Physical examination of a client experiencing respiratory acidosis may reveal confusion, dizziness, lethargy, headache, ventricular dysrhythmias, warm and flushed skin, muscular twitching, convulsions, and coma. The remaining option is not reflective of respiratory acidosis. DIF: C REF: 1012 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 4. A client experiencing diabetic ketoacidosis is likely to present with which of the following clinical signs? (Select all that apply.)

Red, flushed skin

Verbally aggressive

Complaints of dry mouth

Crackles in both lung fields

Oral temperature of 102.8 F Requiring frequent linen changes

ANS: 1, 2, 3, 5, 6 Physical examination of a client experiencing diabetic ketoacidosis may reveal dry and sticky mucous membranes, flushed and dry skin, thirst, elevated body temperature, irritability, convulsions, and coma. The remaining option is not reflective of diabetic ketoacidosis. DIF: C REF: 1021 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 5. A client experiencing acute congestive heart failure (CHF) is likely to present with which of the following clinical signs? (Select all that apply.)

Flat neck veins

Bilateral crackles +2 ankle edema bilaterally

3 4 5

Urine output of 790 mL in 24 hours History of a 5-pound weight gain in 3 days

Systemic blood pressure 15 mm Hg above usual baseline

ANS: 2, 3, 5, 6

Physical examination of a client experiencing CHF may reveal rapid weight gain, edema (especially in dependent areas), hypertension, polyuria (if renal mechanisms are normal), neck vein distention, increased blood and venous pressure, crackles in lungs, and confusion. The remaining options are not reflective of CHF. DIF: C REF: 1022 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances 6. Which of the following clients is at risk for fluid, electrolyte, and acid-base imbalances? (Select all that apply.)

50-year-old with hypertension

36-year-old with schizophrenia

40-year-old with a fractured femur

4 5

15-month-old with diarrhea for 2 days 76-year-old with advanced Alzheimers disease

25-year-old with partial-thickness burns over 40% of the body

ANS: 1, 3, 4, 5, 6 When there is a loss of body fluids because of burns, illnesses, or trauma, the client is also at risk for electrolyte imbalance. In addition, electrolyte imbalance may occur from vomiting, diarrhea, or a clients inability to communicate fluid needs, resulting in acid-base disturbances. Trauma, disease, and medications (e.g., diuretics) all contribute to alterations in fluid, electrolyte, and acid-base balance. Schizophrenia itself is not a risk for fluid, electrolyte, or acid-base imbalances. Chapter 43. Sleep MULTIPLE CHOICE 1. The physiology of sleep is complex. Which of the following is the most appropriate statement in regard to this process?

1 2 3 4

Ultradian rhythms occur in a cycle longer than 24 hours. Nonrapid eye movement (NREM) refers to the cycle that most clients experience when in a high-stimulus environment. The reticular activating system is partly responsible for the level of consciousness of a person. The bulbar synchronizing region (BSR) causes the rapid eye movement (REM) sleep in most normal adults.

ANS: 3 The ascending reticular activating system (RAS) located in the upper brain stem is believed to contain special cells that maintain alertness and wakefulness. Infradian rhythms, not ultradian rhythms, occur in a cycle longer than 24 hours. Nonrapid eye movement refers to the sleep cycle that most clients experience in a low-stimulus environment. The bulbar synchronizing region is the area of the brain where serotonin is released to produce sleep. It is not responsible for REM sleep. DIF: C REF: 1029 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 2. Which of the following symptoms should the nurse assess with a client who is deprived of sleep?

Elevated blood pressure and confusion

Confusion and irritability

Inappropriateness and rapid respirations

Decreased temperature and talkativeness

ANS: 2 Psychological symptoms of sleep deprivation include confusion and irritability. Elevated blood pressure is not a symptom of sleep deprivation. Rapid respirations are not a symptom of sleep deprivation. There may be a decreased ability of reasoning and judgment that could lead to inappropriateness. Decreased temperature is not a symptom of sleep deprivation. The client with sleep deprivation is often withdrawn, not talkative. DIF: A REF: 1034 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 3. A new mother is concerned that her 2-week-old daughter is not sleeping through the night. The nurse should respond that infants usually develop a nighttime pattern of sleep by:

1 month

2 months

3 months 6 months

ANS: 3 Infants usually develop a nighttime pattern of sleep by 3 months of age. DIF: A REF: 1035 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 4. The mother of a 2-year-old child is frustrated because the child does not want to go to bed at the scheduled bedtime. The nurse should suggest that the parent:

Offer the child a bedtime snack

2 3

Eliminate one of the naps during the day Allow the child to sleep longer in the mornings

Maintain consistency in the same bedtime ritual

ANS: 4 The nurse should advise the parent to maintain a regular bedtime and wake-up schedule and to reinforce patterns of preparing for bedtime. A bedtime routine (e.g., same hour for bedtime, quiet activity) used consistently helps young children avoid delaying sleep. It is most important that the parent maintains a consistent bedtime routine. If a bedtime snack is already part of that routine, then this is allowable. If it is not, then the child may only use having a snack as a measure of procrastination. After 3 years of age the child may give up daytime naps. A bedtime routine used consistently will be more effective in helping the child who resists going to sleep. The same regular bedtime and wake-up schedule should be maintained. DIF: A REF: 1035 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 5. An 11-year-old boy in middle school is currently experiencing sleep-related fatigue during classes. Which of the following is the most appropriate response by the school nurse when counseling the childs parents regarding this assessment?

What are the childs usual sleep patterns?

Establish bedtimes for the child, and withhold his allowance whenever those times are not adhered to.

We need to explore other health-related problems, because sleep problems are not likely the cause of his fatigue.

The bulbar synchronizing region of the childs central nervous system is causing these insomniac problems.

ANS: 1 A school-age child will be tired the following day if allowed to stay up later than usual. The nurse should ask a question to assess the childs usual sleep patterns. The nurse should first assess the childs usual sleep pattern to determine if the child is adhering to a bedtime. A sleep problem is often the cause of fatigue. DIF: C REF: 1035 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 6. The nurse recognizes that the sleep patterns of older adults differ and older adults generally:

Are more difficult to arouse

Require more sleep than middle-age adults

Take less time to fall asleep Have a decline in stage 4 sleep

ANS: 4 As people age, there is a progressive decrease in stages 3 and 4 NREM sleep; some older adults have almost no stage 4, or deep, sleep. Older people do not become more difficult to arouse, not do they require more sleep than the middle-age adult. An older adult awakens more often during the night, and it may take more time for an older adult to fall asleep. DIF: A REF: 1035 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 7. Teaching for a client who is currently taking a diuretic should include information that he or she may experience:

Nocturia

Nightmares

Increased daytime sleepiness Reduced REM sleep

4 ANS: 1

For the client who is currently taking a diuretic, the nurse should inform the client that he or she might experience nighttime awakening caused by nocturia. Diuretic use does not cause nightmares or daytime sleepiness or reduce REM sleep. DIF: A REF: 1036 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 8. New research indicates that to increase safety the nurse should instruct parents to do which of the following?

Provide a stuffed toy for comfort.

Cover the infant loosely with a blanket.

Place the infant on his or her back.

Use small pillows in the crib.

ANS: 3 Infants are usually placed on their backs to prevent suffocation or on their sides to prevent aspiration of stomach contents. To reduce the chance of suffocation, pillows, stuffed toys, or the ends of loose blankets should not be placed in cribs. Infants should not be covered loosely with a blanket because infants might pull them over their faces and suffocate. To reduce the chance of suffocation, pillows should not be placed in cribs. DIF: A REF: 1045 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 9. A 74-year-old client has been having sleeping difficulties. To have a better idea of the clients problem, the nurse should respond:

What do you do just before going to bed?

Lets make sure that your bedroom is completely darkened at night.

Why dont you try napping more during the daytime? Do you eat a small snack before going to bed?

ANS: 1 To assess the clients sleeping problem, the nurse should inquire about predisposing factors, such as by asking What do you do just before going to bed? Assessment is aimed at understanding the

characteristics of any sleep problem and the clients usual sleep habits so that ways for promoting sleep can be incorporated into nursing care. Older adults sleep best in softly lit rooms. Napping more during the daytime is often not the best solution. The nurse should first assess the clients sleeping problem. The client does not always have to eat something before going to bed. DIF: C REF: 1039 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 10. Which of the following information provided by the clients bed partner is most associated with sleep apnea?

1 2

Restlessness Talking during sleep

Somnambulism

Excessive snoring

ANS: 4 Partners of clients with sleep apnea often complain that the clients snoring disturbs their sleep. Restlessness is not most associated with sleep apnea. Sleep talking is associated with sleep-wake transition disorders; somnambulism is associated with parasomnias (specifically, arousal disorders and sleep-wake transition disorders). DIF: A REF: 1036 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 11. The nurse should instruct the client to do which of the following to promote good sleep hygiene at home?

Use the bedroom only for sleep or sexual activity.

Eat a large meal 1 to 2 hours before bedtime.

Exercise vigorously before bedtime. Stay in bed if sleep does not come after hour.

ANS: 1 The nurse should explain that, if possible, the bedroom should not be used for intensive studying, snacking, TV watching, or other nonsleep activity, besides sex. The nurse should instruct the client to avoid heavy meals for 3 hours before bedtime; a light snack may help. The nurse should

also instruct the client to try to exercise daily, preferably in morning or afternoon, and to avoid vigorous exercise in the evening within 2 hours of bedtime. Getting out of bed and doing some quiet activity until feeling sleepy enough to go back to bed if the client does not fall asleep within 30 minutes of going to bed may also help. DIF: A REF: 1045 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 12. The nurse knows that which of the following habits may interfere with a clients sleep?

Listening to classical music

Finishing office work

Reading novels

Drinking warm milk

ANS: 2 At home a client should not try to finish office work or resolve family problems before bedtime. Noise should be kept to a minimum. Soft music may be used to mask noise if necessary. Reading a light novel, watching an enjoyable television program, or listening to music helps a person to relax. Relaxation exercises can be useful at bedtime. A dairy product snack such as warm milk or cocoa that contains L-tryptophan may be helpful in promoting sleep. DIF: A REF: 1045 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 13. It is determined that the client will need pharmacological treatment to assist with the clients sleep patterns. The nurse anticipates that treatment with an anxiety-reducing, relaxationpromoting medication will include the use of:

Barbiturates

Amphetamines

Benzodiazepines Tricyclic antidepressants

ANS: 3 The benzodiazepines cause relaxation, antianxiety, and hypnotic effects by facilitating the action of neurons in the central nervous system (CNS) that suppress responsiveness to stimulation,

therefore decreasing levels of arousal. Withdrawal from CNS depressants, such as barbiturates, can cause insomnia and must be managed carefully. Barbiturates can cause tolerance and dependence. Central nervous system stimulants, such as amphetamines, should be used sparingly and under medical management. Amphetamine sulfate may be used to treat narcolepsy. Prolonged use may cause drug dependence. Tricyclic antidepressants can cause insomnia when withdrawn and should be managed carefully. They are used primarily to treat depression. DIF: A REF: 1036 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 14. The nurse is completing an assessment of the clients sleep patterns. A specific question that the nurse should ask to determine the potential presence of sleep apnea is:

How easily do you fall asleep?

2 3

Do you have vivid, lifelike dreams? Do you ever experience loss of muscle control or falling?

Do you snore loudly or experience headaches?

ANS: 4 To assess for sleep apnea (unlike assessing for narcolepsy or insomnia), the nurse may ask, Do you snore loudly? and Do you experience headaches after awakening? A positive response may indicate the client experiences sleep apnea. DIF: C REF: 1033 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 15. Which of the following may improve the sleep of an older adult client?

Drinking an alcoholic beverage before bedtime

Using an over-the-counter sleeping agent

Eliminating naps during the day

Going to bed at a consistent time even if not feeling sleepy

ANS: 3 To promote sleep, daytime naps should be eliminated. If naps are used, they should be limited to 20 minutes or less twice a day. Alcohol should be limited in the late afternoon and evening because it has an insomnia-producing effect. The use of nonprescription sleeping medications is

not advisable. Over the long term, these drugs can lead to further sleep disruption even when they initially seemed to be effective. Following a bedtime routine should be consistent, not necessarily going to bed. The client should engage in quiet activities that promote relaxation and then may go to bed. If the client has not fallen asleep in 30 minutes, the client should get up out of bed and do some quiet activity until feeling sleepy enough to go back to bed. DIF: A REF: 1034 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 16. A client is concerned that her habit of sleeping during the day and being awake at night is not healthy or normal. The nurses most therapeutic response to the clients concern is:

What makes you think that sleeping during the day and being up at night is unhealthy or abnormal?

Many people share your sleep habits. As long as you feel all right, I dont think there is anything to worry about.

Are you interested in changing your sleep habits for any particular reason? Is sleeping during the day a problem for you?

Everyone has a different biological clock that controls his or her sleep cycle. As long as you are sleeping and functioning well, your habit isnt abnormal or unhealthy.

ANS: 4 All persons have biological clocks that synchronize their sleep cycles. If the sleep pattern does not adversely affect the clients health or ability to function, it is not problematic. DIF: C REF: 1029 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 17. A client is discussing his recent restlessness and increased irritability. Which of the following assessment questions is likely to be most helping in determining the cause of these complaints?

When did you start noticing these changes?

Has anything caused you to change your usual routine lately?

Do you have any idea what might be causing these problems?

What makes you think that you are more irritable than is normal for you?

ANS: 2 When the sleep-wake cycle becomes disrupted (e.g., by working rotating shifts), other physiological functions usually change as well. For example, the person experiences a decreased appetite and loses weight. Anxiety, restlessness, irritability, and impaired judgment are other common symptoms of sleep cycle disturbances. Failure to maintain the individuals usual sleepwake cycle negatively influences the clients overall health. Although the other options are not inappropriate, they are not as directly aimed at determining the cause of the changes. DIF: C REF: 1030 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 18. The nurse and a client are discussing possible behaviors that might be interfering with the clients ability to fall asleep. Which of the following assessment questions is most likely to identify possible problems with the clients sleep routine that possibly are contributing to the difficulty?

When do you usually retire for the night?

2 3

What do you do to help yourself fall asleep? How much time does it usually take for you to fall asleep?

Have you changed anything about your presleep ritual lately?

ANS: 2 As people try to fall asleep, they close their eyes and assume relaxed positions. Stimuli to the RAS decline. If the room is dark and quiet, activation of the RAS further declines. At some point the BSR takes over, causing sleep. If the client engages in activities such as reading or watching television as a means of falling asleep, this could be causing the problem. Although the other questions are not inappropriate, they are not as directed toward the cause of the problem. DIF: C REF: 1029 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 19. An older adult client diagnosed as being in the early stage of Alzheimers disease shares with the nurse that her sleep is interrupted by the noises I hear all through the night. The nurse explains that the most likely reason for this problem is:

The clients age

A lack of presleep relaxation The amount of noise entering into the clients environment

3 4

A manifestation of the disease process causing the brain disorder

ANS: 1 With aging, sleep becomes more fragmented, and a person spends more time in lighter stages that are easily disturbed by noise. The remaining options may be a factor but not to the degree of normal aging. DIF: C REF: 1035 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 20. A 9-year-old client asks the nurse, Why do I need to sleep? The nurses most age-appropriate, informative response is:

Everyone needs to sleep to feel rested.

It gives your body a chance to really rest.

Youll be able to do so much better in school if youre rested.

Your body needs to rest in order to grow and be really healthy.

ANS: 4 Sleep contributes to physiological and psychological restoration, maintenance, and growth of the body at any age. The remaining options are not as effective at providing a thorough answer to the childs question. The body needs sleep to routinely restore biological processes. DIF: C REF: 1030 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 21. A client has reported to the nurse that his sprained ankle resulted from a careless accident. I seem so clumsy and unfocused lately. Which of the following assessment questions is most likely to reveal information regarding the cause of these symptoms?

How many accidents have you had lately?

Have the accidents resulted in serious injuries?

Have there been any changes in your daily routine lately?

Do you have any idea what is responsible for this lack of focus?

ANS: 4 A loss of REM sleep leads to feelings of confusion and suspicion. Various body functions (e.g., mood, motor performance, memory, and equilibrium) are altered when prolonged sleep loss occurs. Research estimates that traffic, home, and work-related accidents caused by falling asleep are often a result of sleep loss. This answer is the best question because it directly opens up the opportunity for the client to discuss possible sleep problems if they exist. The other questions are not inappropriate but are less likely to reveal the possible cause of the accidents. DIF: C REF: 1031 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 22. Which of the following clients is most likely to experience difficulty returning to sleep?

1 2

A 60-year-old with benign hypertropic prostatic disease A 15-year-old with type 1 diabetes

A 35-year-old diagnosed with hypothyroidism

A 55-year-old diagnosed with hypertension

ANS: 1 Nocturia, or urination during the night, disrupts sleep and the sleep cycle. This condition is most common in older people with reduced bladder tone or persons with cardiac disease, diabetes, urethritis, or prostatic disease. After a person awakens repeatedly to urinate, returning to sleep is difficult. Although all the clients may have difficulty falling back to sleep when awakened, the answer represents the client with the greatest tendency to be awakened during the night. DIF: C REF: 1032 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 23. Which of the following clients experiencing disrupted sleep patterns is most at risk for obstructive sleep apnea (OSA)?

A 15-year-old boy with type 1 diabetes

A 22-year-old diagnosed with Crohns disease

A 49-year-old man who is an avid cross-county runner

A 58-year-old woman diagnosed with chronic depression

ANS: 4 Many think OSA affects middle-age men more frequently, particularly when they are obese. However, obstructive sleep apnea is also common in postmenopausal women, younger women, and children. Although the clients in all of the options may experience OSA, the postmenopausal woman has the greatest risk. DIF: C REF: 1033 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 24. A client shares with the nurse that My wife complains about my snoring, and I never really feel rested. Which of the following responses best attempts to explain the cause of the problem to the client?

1 2 3

Sleep disturbances can really affect all aspects of your life. How long have you been experiencing this problem? You need to get help to breathe more effortlessly at night so both you and your wife can get sufficient deep stage sleep. Something is interfering with your ability to breathe while you are asleep. Have you talked with your health care provider about the problem? Your upper airway is blocked, and that is making it difficult for you to breathe effectively, so you are spending most of the night in the light sleep stage.

ANS: 4 The upper airway becomes partially or completely blocked, and diminished nasal airflow (hypopnea) can result for as long as 30 seconds. The person attempts to breathe, which often results in loud snoring and snorting sounds. The effort to breathe during sleep results in arousals from deep sleep, often to the stage 2 cycle, causing interference with deep sleep and thus the clients not feeling rested. The remaining options are not inappropriate, but they are not as directed at explaining the problem to the client. DIF: C REF: 1033 OBJ: Analysis TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 25. A client hospitalized for a myocardial infarction in a cardiac critical care unit (CCU) is most likely to experience sleep deprivation as a result of:

A drug-disrupted circadian sleep pattern

Generally diminished cardiac output

Unfamiliar environmental stimuli

Increased emotional stressors

ANS: 3 Hospitalization, especially in intensive care units, makes clients particularly vulnerable to the extrinsic and circadian sleep disorders that cause the ICU syndrome of sleep deprivation. Constant environmental stimuli within the intensive care unit (ICU), such as strange noises from equipment, the frequent monitoring and care given by nurses, and ever-present lights, confuse clients and lead to sleep deprivation. Although the other options may be contributing factors, they are not as directly responsible. DIF: C REF: 1034 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 26. The nurse is discussing child care strategies with a mother of a newborn. The mother asks the nurse, What causes sudden infant death syndrome (SIDS)? Which of the following responses is most likely to answer the mothers question therapeutically?

SIDS is a common fear for new mothers. The best advice is to put your baby to sleep on her back.

We arent sure exactly, but it may have something to do with undetected cardiac or oxygen problems.

Research is inconclusive, but its thought to be a result of a nervous system problem that occurs when the baby is asleep. Your pediatrician wants you to put your baby to sleep on her back because research has shown that more stomach sleepers are victims.

ANS: 3

Some have hypothesized that sudden infant death syndrome (SIDS) is caused by abnormalities in the autonomic nervous system that are manifested during sleep, resulting in apnea, hypoxia, and/ or cardiac dysrhythmias. This answer provides the most thorough answer to the mothers question, whereas the remaining options stress preventive measures. DIF: C REF: 1034 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 27. The client asks the nurse, How will I know if Im really rested? The nurses most therapeutic response is:

1 2 3 4

Everyones definition of rested is different. How would you define rested? When you arent tired when you get up in the morning or after an afternoon nap. When you are mentally, physically, and emotionally ready to go about your daily activities. You are rested if you fall asleep easily and sleep uninterruptedly for at least 6 to 8 hours.

ANS: 3 When people are at rest they are in a state of mental, physical, and spiritual activity that leaves them feeling refreshed, rejuvenated, and ready to resume the activities of the day. The remaining options ask questions or provide a limited view on what rested means. DIF: C REF: 1034 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 28. The nurse is caring for a 35-year-old father of three young children who has experienced a compound fractured femur as a result of a work-related incident. He has expressed great concern over both his physical recovery and his long-term ability to work again. This has affected both his emotional status and his sleeping patterns. The nurses most immediate concern is that:

The client needs medication to prevent depression

The lack of appropriate rest will affect his healing process

An occupational therapy consult should be ordered to help him regain his ability to return to his job

A psychiatric consult should be ordered to help the client deal with his various emotional concerns

ANS: 2 You must always be aware of the clients need for rest. A lack of rest for long periods causes illness or worsening of existing illness. Although the other options are appropriate concerns, they are not as immediate in nature as is the sleep problem. DIF: C REF: 1034-1035 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 29. A 63-year-old client is discussing the recent problem the client is experiencing with falling asleep. The nurse is discussing strategies to minimize this problem. Which of the following bedtime snacks would be the most likely to induce sleep?

One slice of cheese on four wheat crackers and a glass of skim milk

2 3

Two cups of air-popped popcorn and a glass of fruit juice Two fig cookies and a cup of decaffeinated tea

One small pear and a glass of soymilk

ANS: 1 One substance that promotes sleep in many people is L-tryptophan, a natural protein found in foods such as milk, cheese, and meats. DIF: C REF: 1036 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 30. A 70-year-old client is reporting to the nurse a concern over taking longer to fall asleep and waking up three to four times during the night. The most therapeutic nursing response to the clients concern is:

1 2

I think you need to mention your concerns to your health care provider. Older adults seem to need less sleep. Do you still feel rested in the morning?

I suggest that you plan for a nap in the afternoon to make up for that missed sleep.

As we age, those kinds of problems seem more common. Does this disruption in your sleep cause you to be tired or irritable?

ANS: 4 An older adult awakens more often during the night, and it takes more time for an older adult to fall asleep. The answer provides an opportunity for a discussion about the effect this problem may be creating. DIF: C REF: 1035 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 31. The nurse and the parents of a 3-year-old are discussing their childs sleep habits. They share a concern over the childs tendency to wake up several times during the night crying out loudly but not really being awake. The nurse addresses the parents concern most therapeutically by responding:

1 2 3 4

Have you ever tried reading a bedtime story before putting her to bed? If she does that only a few times a week, I wouldnt be too overly concerned. Children her age often become poor sleepers. Have you discussed this with her pediatrician? It is common for children to have trouble relaxing, and this behavior is the result. Its usually temporary.

ANS: 4 The preschooler usually has difficulty relaxing or quieting down after long, active days and has problems with bedtime fears, waking during the night, or nightmares. Partial wakening followed by normal return to sleep is frequent. In the waking period, the child exhibits brief crying, walking around, unintelligible speech, sleepwalking, or bed-wetting. The other options either ask questions or provide possible tactics for preventing the problems. DIF: C REF: 1035 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep

32. A 44-year-old female client shares with the nurse that she is having difficulty falling asleep at night, even though she is exhausted. The nurse knows that which of the following could be causing the sleeplessness?

Two cups of hot cocoa every evening

2 3

Vegetarian diet Afternoon exercise program

Hot bath in the evening

ANS: 1 Caffeine is a stimulant and can cause difficulty in falling asleep. There is about 30 mg of caffeine in two cups of hot cocoa. DIF: C REF: 1029 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 33. A 22-year-old male client shares with the nurse that he is always tired. In assessing the clients sleep pattern to determine the quantity of sleep the client is getting, the nurse should ask:

On a scale from 0 to 10, how much sleep to you think you get each night?

What time do you usually go to bed?

What time do you usually get up?

Do you have a bedtime ritual?

ANS: 1 This question helps quantify the length of sleep that the client receives. A brief subjective method to assess sleep is a numeric scale with a 0 to 10 sleep rating. Ask individuals to separately rate their quantity and quality of sleep on the scale. Instruct clients to indicate with a number between 0 and 10 their sleep quantity then their quality of sleep with 0 being the worst sleep and 10 being the best sleep DIF: A REF: 1033 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep

34. On a 2-week follow-up visit to the health care provider, a 64-year-old female postoperative client shares with the nurse that she is having difficulty sleeping and has never had a history of sleeping problems. The nurse shares with the client that:

Because of her age, the client should expect to begin having some problems sleeping

It may take a while to get used to sleeping in her bed at home after getting used to sleeping on a hospital bed The medications used for anesthesia can disturb sleep cycles for several weeks following surgery

3 4

She may not be sleeping as well with her partner after being in a bed by herself while being hospitalized

ANS: 3 If the client has recently had surgery, expect the client to experience some disturbance in sleep. Clients usually awaken frequently during the first night after surgery and receive little deep or REM sleep. Depending on the type of surgery, it takes several days to months for a normal sleep cycle to return. DIF: A REF: 1034 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 35. The night nurse goes quietly into the sleeping clients room to assess him. The client wakes up as soon as the nurse is in the room. The nurse knows that the client was most likely in which stage of sleep?

Stage 1: NREM

Stage 2: NREM

Stage 3: NREM Stage 4: NREM

ANS: 1 Stage 1 NREM includes the lightest level of sleep. Sensory stimuli such as noise easily arouses the person. The stage lasts a few minutes. Decreased physiological activity begins with gradual fall in vital signs and metabolism. Awakened, person feels as though daydreaming has occurred. Stage 2 NREM is a period of sound sleep. Stage 3 NREM involves initial stages of deep sleep. Stage 4 NREM is the deepest stage of sleep. It is very difficult to arouse the sleeper.

DIF: C REF: 1039 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 36. A 25-year-old clients wife complains to the nurse that he sleepwalks during the night. The nurse knows that this behavior normally occurs in which stage of sleep?

Stage 2: NREM

Stage 3: NREM

Stage 4: NREM

REM

ANS: 3 Stage 4 NREM sleep is the deepest stage of sleep. It is very difficult to arouse the sleeper. If sleep loss has occurred, the sleeper will spend a considerable portion of the night in this stage. Vital signs are significantly lower than during waking hours. The stage lasts approximately 15 to 30 minutes. Sleepwalking and enuresis (bed-wetting) sometimes occur. Stage 2 NREM is a period of sound sleep. Stage 3 NREM involves initial stages of deep sleep. REM sleep involves vivid, full-color dreaming. Loss of skeletal muscle tone occurs. It is very difficult to arouse the sleeper. Less vivid dreaming occurs in other stages. The stage is typified by autonomic response of rapidly moving eyes, fluctuating heart and respiratory rates, and increased or fluctuating blood pressure. DIF: C REF: 1037 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 37. The assistive nursing personnel reports that the heart rate of the sleeping 23-year-old athlete, who is hospitalized following complications of a tonsillectomy, is 56. The assistive nursing personnel states that this is 10 beats per minute slower than when she took it earlier in the evening. The nurse knows that this is considered:

Normal, and they will continue to monitor the vital signs as ordered

Abnormally slow, and the health care provider should be notified immediately Abnormally slow, and the nurse will recheck the heart rate before taking any action

Abnormally slow, signaling that the client may be hemorrhaging

ANS: 1 A healthy adults normal heart rate throughout the day averages 70 to 80 beats per minute or less if the individual is in excellent physical condition. However, during sleep the heart rate falls to 60 beats per minute or less. This means that the heart beats 10 to 20 fewer times in each minute during sleep or 60 to 120 fewer times in each hour. If the client were hemorrhaging, the heart rate would initially be tachycardic as the body attempts to compensate for the lost blood volume. DIF: C REF: 1038 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 38. A female client describes the most elaborate dreams to the nurse. She states that she could see colors, hear music, and even had the sensation of flying. The nurse replies to the client that her dreams indicate that she must be:

Depressed

Pragmatic

Creative Mentally ill

ANS: 3 Personality influences the quality of dreams; for example, a creative person has elaborate and complex dreams, whereas a depressed person dreams of helplessness. Most people dream about immediate concerns such as an argument with a spouse or worries over work. Sometimes a person is unaware of fears represented in bizarre dreams. DIF: C REF: 1039 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 39. A 73-year-old male client who normally sleeps on his right side recently underwent a rightside hip replacement surgery and now has trouble sleeping. One of the interventions that the nurse might try with this client is to:

Request medication to help the client sleep while in the hospital

Carefully prop the client on his operative side using pillows to support the hip

Schedule therapy for the evening to help the client become tired so he can sleep Question the client to learn more about his normal sleep pattern

ANS: 4 Knowing a clients usual, preferred sleep pattern allows a nurse to try to match sleeping conditions in a health care setting with those in the home. DIF: C REF: 1029 OBJ: Application TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep MULTIPLE RESPONSE 1. A nurse caring for a patient prior to surgery should recognize which of the following factors place a client at risk for obstructive sleep apnea? (Select all that apply.)

Heart disease

Respiratory tract infections

Nasal polyps

Obesity

ANS: 3, 4 Structural abnormalities, such as a deviated septum, nasal polyps, certain jaw configurations, or enlarged tonsils predispose a client to obstructive apnea. Individuals with mixed apnea often have signs and symptoms of right-sided heart failure. Respiratory tract infections do not predispose a client to obstructive sleep apnea. Clients with obstructive apnea are often middleage, obese men. Obesity itself does not predispose a client to obstructive sleep apnea. DIF: C REF: 1034 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 2. The nurse and a client are discussing the importance of an effective 24-hour sleep cycle. Which of the following responses by the client may be a direct result of an inadequate sleep pattern? (Select all that apply.)

Gaining weight

Usually feeling cold Always feeling tired

3 4 5

A heart that beats really fast Often feeling blue or depressed

Feeling dizzy when getting up from a chair

ANS: 2, 3, 4, 5, 6 The predictable changing of body temperature, heart rate, blood pressure, hormone secretion, sensory acuity, and mood depend on the maintenance of the 24-hour circadian cycle. Weight gain is not typically a result of poor sleep patterns. DIF: C REF: 1030 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 3. Although the most common effect of obstructive sleep apnea is a disrupted sleep pattern, the condition can cause a serious decline in arterial oxygen levels that may result in: (Select all that apply.)

1 2 3

Hypertension Angina attacks

Alzheimers disease Cardiac dysrhythmias

Cerebral vascular accidents

Type 2 diabetes

ANS: 1, 2, 4, 5 Obstructive apnea causes a serious decline in arterial oxygen saturation level. Clients are at risk for cardiac dysrhythmias, right-sided heart failure, pulmonary hypertension, angina attacks, stroke, and hypertension. The other options are not directly related to a diminished supply of arterial oxygen. DIF: A REF: 1030 OBJ: Comprehension TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 4. The nurse is preparing to discuss the management of the sleeping disorder narcolepsy. In addition to the prescription of stimulants and antidepressants, which of the following nonpharmaceutical strategies should be included and shared with the client? (Select all that apply.)

Wine with meals

Regular use of a sauna

Light but high-protein meals

4 5

Regular use of chewing gum Adoption of a regular exercise routine

Brief daytime naps of 20 minutes or less

ANS: 3, 4, 5, 6 Narcoleptics may be helped by brief daytime naps no longer than 20 minutes, a regular exercise program, avoiding shifts in sleep, eating light meals high in protein, practicing deep breathing, chewing gum, and taking vitamins. Clients with narcolepsy need to avoid factors that increase drowsiness (e.g., alcohol, heavy meals, exhausting activities, long-distance driving, and long periods of sitting in hot, stuffy rooms). DIF: C REF: 1031 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Rest and Sleep 5. Which of the following client statements made by young adults suggest a risk factor for sleep disturbance problems? (Select all that apply.)

1 2 3 4 5

I have a job that requires my attention 110% of the time. I really enjoy fishing; I wish we lived closer to a river or pond. My wife just found out she is pregnant for the third time in 5 years. My father recently suffered a heart attack, and Mom is so very worried about him. The kids are so active in after-school things that we never have an evening at home.

Gardening always gave me such a sense of accomplishment, but I dont have much free time now.

ANS: 1, 3, 4, 5 It is common for the stresses of jobs, family relationships, and social activities to lead frequently to insomnia and the use of medication for sleep. The remaining options reflect a sense of loss but not necessarily of stress. Chapter 44. Pain Management MULTIPLE CHOICE 1. Which one of the following nursing interventions for a client in pain is based on the gatecontrol theory?

Giving the client a back massage

2 3

Changing the clients position in bed Giving the client a pain medication

Limiting the number of visitors

ANS: 1 The gate-control theory suggests that cutaneous stimulation activates larger, faster-transmitting A-beta sensory nerve fibers. This decreases pain transmission through small-diameter A-delta and C fibers. A back massage is a nursing intervention based on the gate-control theory. Changing the clients position in bed is not a form of cutaneous stimulation used to relieve pain. Giving the client a pain medication is a pharmacological approach to relieving pain. Limiting the number of visitors may provide a quiet environment conducive to relaxation, but it is not based on the gate-control theory. DIF: A REF: 1053-1054 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 2. A priority nursing intervention when caring for a client who is receiving an epidural infusion for pain relief is to:

Use aseptic technique

Label the port as an epidural catheter

Monitor vital signs every 15 minutes Avoid supplemental doses of sedatives

4 ANS: 3

When clients are receiving epidural analgesia, monitoring occurs as often as every 15 minutes, including assessment of respiratory rate, respiratory effort, and skin color. Complications of epidural opioid use include nausea and vomiting, urinary retention, constipation, respiratory depression, and pruritus. A common complication of epidural anesthesia is hypotension. Assessing vital signs is the priority nursing intervention. Because of the catheter location, strict surgical asepsis is needed to prevent a serious and potentially fatal infection. To reduce the risk for accidental epidural injection of drugs intended for IV use, the catheter should be clearly labeled epidural catheter. Supplemental doses of opioids or sedative/hypnotics are avoided because of possible additive central nervous system adverse effects. DIF: C REF: 1078 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 3. The nurse should describe pain that is causing the client a burning sensation in the epigastric region as:

1 2 3 4

Referred Radiating Deep or visceral Superficial or cutaneous

ANS: 3 Deep or visceral pain is diffuse and may radiate in several directions. Visceral pain may be described as a burning sensation. Referred pain is felt in a part of the body separate from the source of pain, such as with a myocardial infarction, in which pain may be referred to the jaw, left arm, and left shoulder. Radiating pain feels as though it travels down or along a body part, such as low back pain that is accompanied by pain radiating down the leg from sciatic nerve irritation. Superficial or cutaneous pain is of short duration and is localized as in a small cut. DIF: A REF: 1056 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 4. Which of the following is most appropriate when the nurse assesses the intensity of the clients pain?

Ask about what precipitates the pain.

Question the client about the location of the pain.

Offer the client a pain scale to objectify the information.

Use open-ended questions to find out about the sensation.

ANS: 3 Descriptive scales are a more objective means of measuring pain intensity. Asking the client what precipitates the pain does not assess intensity, but rather it is an assessment of the pain pattern. Asking the client about the location of pain does not assess the intensity of the clients pain. To determine the quality of the clients pain, the nurse may ask open-ended questions to find out about the sensation experienced. DIF: A REF: 1063 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 5. The nurse on a postoperative care unit is assessing the quality of the clients pain. In order to obtain this specific information about the pain experience from the client, the nurse should ask:

What does your discomfort feel like?

What activities make the pain worse?

How much does it hurt on a scale of 0 to 10? How much discomfort are you able to tolerate?

ANS: 1 To determine the quality of the clients pain the nurse might say, What does your discomfort feel like? It is more accurate to have clients describe the pain in their own words whenever possible. Inquiring about what activities make the pain worse is a type of question directed at determining the pain pattern. Having the client rate his or her pain on a pain scale is a method of measuring the intensity of pain. To determine the clients expectations, the nurse may ask the client, How much discomfort are you able to tolerate? DIF: A REF: 1063-1065 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 6. When a clients husband questions how a patient-controlled analgesia (PCA) pump works, the nurse explains that the client:

Has control over the frequency of the intravenous (IV) analgesia

Can choose the dosage of the drug received

May request the type of medication received

Controls the route for administering the medication

ANS: 1 With a PCA system the client controls medication delivery. The PCA system is designed to deliver no more than a specified number of doses. The client does not choose the dosage. The health care provider prescribes the type of medication to be used. The advantage for the client is that he or she may self-administer opioids with minimal risk for overdose. The client does not control the route for administration. Systemic PCA typically involves IV drug administration but can also be given subcutaneously. DIF: A REF: 1076 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 7. An older client with mild musculoskeletal pain is being seen by the primary care provider. The nurse anticipates that treatment of this clients level of discomfort will include:

Fentanyl

Diazepam

Acetaminophen

Meperidine hydrochloride

ANS: 3 A nonopioid analgesic, such as acetaminophen, is used to effectively treat mild musculoskeletal pain. Fentanyl is about 100 times more potent than morphine. It is typically used for cancer pain, not mild musculoskeletal pain. Diazepam is given as an antianxiety agent. Meperidine hydrochloride is an opioid analgesic used to treat moderate to severe acute pain, not mild pain. DIF: A REF: 1073 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 8. Before inserting a Foley catheter, the nurse explains that the client may feel some discomfort. This is an example of:

Distraction

Reducing pain perception

Anticipatory response

Self-care maintenance

ANS: 3 Pain can be prevented by anticipating painful events. Before performing procedures, the nurse considers the clients condition, aspects of the procedure that may be uncomfortable, and techniques to avoid causing pain. The nurse who tells the client that the urinary catheter insertion may feel uncomfortable is an example of anticipatory response. Distraction directs a clients attention to something else and thus can reduce the awareness of pain and even increase tolerance. Reducing pain perception means to remove stimuli that are uncomfortable or to prevent stimuli that are painful, such as changing wet linens, or preventing constipation with fluids, diet, and exercise. Self-care maintenance implies the client is able to carry out necessary activities to care for himself or herself. This may include pain management measures. DIF: A REF: 1073 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 9. The nurse knows that a PCA pump would be most appropriate for the client who:

Has psychogenic discomfort

Is recovering after a total hip replacement

Experiences renal dysfunction Recently experienced a cerebrovascular accident (stroke)

ANS: 2 Patient-controlled analgesia is a safe method for postoperative pain management, such as the client recovering from total hip replacement surgery. PCA would not be the mode of choice for treating psychogenic pain or for the client with renal dysfunction. The client with renal impairment would be at increased risk for drug toxicity because of decreased drug excretion. Clients must be able to understand the use of the equipment and be physically able to locate and press the button to deliver the dose. The client who recently experienced a cerebrovascular accident may have difficulty managing the PCA system. DIF: C REF: 1076 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 10. A client with chronic back pain has an order for a transcutaneous electrical nerve stimulation (TENS) unit for pain control. The nurse should instruct the client to:

Keep the unit on high

Use the unit when pain is perceived

Remove the electrodes at bedtime Use the therapy without medications

ANS: 2 When a client feels pain, the TENS unit is turned on and a buzzing or tingling sensation is created. The tingling sensation can be applied until pain relief occurs. The client may adjust the intensity of skin stimulation. It does not have to remain on high. The electrodes do not have to be removed at bedtime. Medication can be administered with a TENS unit. DIF: A REF: 1071 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 11. The nurse caring for a terminally ill client with liver cancer understands which of the following goals would be most appropriate?

1 2 3 4

Increasingly administer narcotics to oversedate the client and thereby decrease the pain. Continue to change the analgesics until the right narcotic is found that completely alleviates the pain. Adapt the analgesics as the nursing assessment reveals the need for specific medications. Withhold analgesics because they are not being effective in relieving discomfort.

ANS: 3 The best choice of treatment often changes as the clients condition and the characteristics of pain change. It is realistic to expect that a terminally ill clients need for pain medication will change over time with disease progression. The goal is not to oversedate the client but to provide pain control without excessive sedation. It would be unrealistic to expect that the pain of terminal cancer will be completely alleviated. Analgesics should not be withheld, because this would only increase the clients level of pain. The medication regimen may need to be adapted to meet the clients needs. DIF: C REF: 1078-1079 OBJ: Analysis TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 12. A client is having severe, continuous discomfort from kidney stones. Based on the clients experience, the nurse anticipates which of the following findings in the clients assessment?

Tachycardia

Diaphoresis

Pupil dilation

Nausea and vomiting

ANS: 4 Acute severe or deep pain, as with kidney stones, will cause a parasympathetic response. The client would likely exhibit nausea and vomiting. Tachycardia is a response of sympathetic stimulation, commonly seen with pain of low to moderate intensity and superficial pain. Diaphoresis is a response of sympathetic stimulation, commonly seen with pain of low to moderate intensity and superficial pain. Pupil dilation is a response of sympathetic stimulation, commonly seen with pain of low to moderate intensity and superficial pain. DIF: A REF: 1064 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 13. Nurses working with clients in pain need to recognize and avoid common misconceptions and myths about pain. In regard to the pain experience, which of the following is correct?

The client is the best authority on the pain experience.

Chronic pain is mostly psychological in nature.

Regular use of analgesics leads to drug addiction. The amount of tissue damage is accurately reflected in the degree of pain perceived.

ANS: 1 A clients self-report of pain is the single most reliable indicator of the existence and intensity of pain and any related discomfort. Pain is individualistic. A misconception about pain is that chronic pain is psychological. The belief that administering analgesics regularly will lead to drug addiction is a misconception. Another misconception about pain is that the amount of tissue damage is accurately reflected in the degree of pain perceived. DIF: C REF: 1057 OBJ: Analysis

TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 14. A nonpharmacological approach that the nurse may implement for clients experiencing pain that focuses on promoting pleasurable and meaningful stimuli is:

Acupressure

2 3

Distraction Biofeedback

Hypnosis

ANS: 2 Pleasurable stimuli cause the release of endorphins. The nurse assesses activities enjoyed by the client that may act as distractions. Distraction directs a clients attention to something else and thus can reduce the awareness of pain and even increase tolerance. Acupressure does not focus on promoting pleasurable and meaningful stimuli. Acupressure is finger pressure applied therapeutically at selected points on the body. Biofeedback focuses on an individuals physiological responses (e.g., blood pressure or tension) and ways to exercise voluntary control over those responses. Hypnosis does not focus on promoting pleasurable and meaningful stimuli. Hypnosis is a condition resembling sleep in which the mind is susceptible to suggestions. DIF: A REF: 1071 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 15. Which of the following is the most appropriate nursing intervention for a client who is receiving epidural analgesia?

Change the tubing every 48 to 72 hours.

Change the dressing every shift.

Secure the catheter to the outside skin. Use a bulky occlusive dressing over the site.

ANS: 3 To prevent catheter displacement, the catheter should be secured carefully to the outside skin. The infusion tubing should be changed every 24 hours to prevent infection. To prevent infection, the dressing should not be routinely changed over the site. A transparent dressing should be used over the site to secure the catheter and aid inspection.

DIF: A REF: 1078 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 16. The client is experiencing breakthrough pain while receiving opioids. An order is written for the client to receive a transmucosal fentanyl unit. In teaching about this medication, the nurse should instruct the client to:

Swab the unit over the cheeks

Do not chew the unit after administration Take no more than two units per episode of discomfort

3 4

Allow the unit to dissolve slowly in the mouth over 15 minutes or more

ANS: 2 The unit needs to be left intact and not chewed. The unit is placed in the clients mouth and swabbed over the inside of the cheeks and lower gums. No more than two units should be used per breakthrough pain episode. The unit needs to be allowed to dissolve and absorb over a 15minute period. DIF: A REF: 1080 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 17. When caring for a client who is experiencing continuous severe pain, the nurse should expect that the pain management plan would include:

Focusing on intramuscular administration of analgesics

Waiting for pain to become more intense before administering opioids

Administering opioids with nonopioid analgesics for severe pain experiences Administering large doses of opioids initially to clients who have not taken the medications before

ANS: 3 To treat a client who is experiencing continuous severe pain, the nurse should expect the client to receive opioid and nonopioid analgesics for severe pain experiences. Intramuscular administration of analgesics is not expected because the injection itself is painful, and there may

be inconsistent erratic absorption of the drug. The nurse should administer opioids before the clients pain becomes intense. It is easier to maintain pain control than it is to get intense pain under control. Large doses of opioids are not given initially to clients who have not taken the medications before because they may cause respiratory depression. The expectation is to begin with lower doses and titrate upward. DIF: A REF: 1073-1074 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 18. Which of the following symptoms would the nurse expect with a client who is experiencing acute pain?

1 2 3 4

Bradycardia Bradypnea Diaphoresis Decreased muscle tension

ANS: 3 An expected assessment finding of a client experiencing acute pain would be diaphoresis resulting from sympathetic nerve stimulation. Additional assessment findings of a client experiencing acute pain would be an increased heart rate, respiratory rate, and muscle tension. DIF: A REF: 1054 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 19. Which of the following statements made by a nurse shows the greatest understanding of the personal nature of the pain experience?

I have experienced pain before, and so I have great compassion for anyone dealing with pain.

People handle pain differently, but everyone in pain is only interested in having the pain stop. Managing a clients pain is the single most important thing a nurse can do for a client experiencing pain.

3 4

I can only accept what the client reports concerning the pain being felt and attempt to intervene successfully in its management.

ANS: 4 The nurse cannot see or feel the clients pain. Pain is purely subjective; no two persons experience pain in the same way, and no two painful events create identical responses or feelings in a person. A nursing responsibility requires that the nurse make good faith attempts to help minimize the pain and to advocate for the client to this end. The remaining options, while not inappropriate, do not express the most therapeutic attitude toward the nursing role regarding client pain. DIF: C REF: 1057 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 20. Which of the following statements made by a nurse requires follow-up with additional instruction regarding the personal nature of pain?

I have experienced pain before, and so I have great compassion for anyone dealing with pain.

My postsurgical clients get the prescribed pain medications on schedule with no diversion from that schedule.

If I were experiencing severe pain, I certainly would want someone to devote their time to managing for me.

Clients dont always request pain medication, and so I always ask them if they want it according to the schedule.

ANS: 2 The nurse cannot see or feel the clients pain. Pain is purely subjective; no two persons experience pain in the same way, and no two painful events create identical responses or feelings

in a person. Flexibility is a necessary component in pain management. The remaining options do not require follow-up because they do not express any attitudes that are not compatible with good nursing care of the client in pain. DIF: C REF: 1057 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 21. Which of the following statements made by a client reporting severe pain expresses the most insight into how pain impacts a clients energy reserves?

I cant sleep if I dont get something for this pain.

If only I could get an hour when I was free of this pain.

Im exhausted physically and emotionally trying to live with this pain.

I dont see how I can continue to cope with this pain; I need some relief.

ANS: 3 Pain is exhausting and demands a persons energy. The remaining options do express this fact but not as directly as the answer. DIF: C REF: 1066 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 22. Which of the following statements made by a nurse caring for a client reporting severe pain expresses the most insight into how pain impacts a clients energy reserves?

If I cant get his pain under control, his recovery will take a lot longer.

Pain certainly interferes with the clients ability to rest and recuperate. Im going to call for another pain prescription so he can get some rest.

3 4

Trying to cope with pain is using up the energy that his recovery requires.

ANS: 4 Pain is exhausting and demands a persons energy. The remaining options do express this fact but not as directly as the answer. DIF: C REF: 1066 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 23. Which of the following statements made by the nurse regarding the clients self-assessment of pain requires immediate follow-up regarding the personal nature of pain?

The medication should be providing enough relief; try to ambulate her.

Ive never known anyone to have such pain after that procedure.

He should be able to ambulate with only minimal pain by now. She says shes in pain, but she doesnt act like she is in pain.

ANS: 4 It is not the responsibility of clients to prove that they are in pain; it is the nurses responsibility to accept clients report of pain. Although the other options appear to be insensitive to the clients pain, they are not as overtly critical. DIF: C REF: 1057 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 24. The nurse recognizes that the most likely reason a runner who has injured his ankle during a race is not aware of it until after he crosses the finish line is that:

The emotional exhilaration of running the race masked the pain of the injury

His endorphin levels were high as a result of the physical stressors of the race He was mentally distracted by the need to concentrate on the ever-changing nature of the race

3 4

The physical effects of the injury slowly increased during the race and reached pain-producing capacity only after the race

ANS: 2 Stress, exercise, and other factors increase the release of endorphins, raising an individuals pain threshold (the point at which a person feels pain). Because the amount of circulating substances varies with each individual, the response to pain will be different. Although the other options may have affected his pain perception, they did not exert as much influence as the answer. DIF: C REF: 1053 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 25. Which of the following statements by the nurse reflects a need for immediate follow-up regarding the physical effects of chronic pain on body function?

1 2 3 4

His pulse and blood pressure are within his normal baseline limits, so Im sure the pain medication is working. Please take his pulse and blood pressure, and let me know if they are elevated above his normal baselines. If his pulse and blood pressure are above his normal baseline, let me know, and I will medicate him for pain. Unmanaged pain usually manifests itself in both an elevated pulse and blood pressure.

ANS: 1 Except in cases of severe traumatic pain, which sends a person into shock, most people reach a level of adaptation in which physical signs return to normal. Thus clients in pain will not always have changes in their vital signs. Changes in vital signs are more often indicative of problems other than pain. Although the remaining options recognize the phenomena, they are not assuming that no elevation of vital signs means the absence of pain. DIF: C REF: 1054 OBJ: Analysis TOP: Nursing Process: Assessment/Planning MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 26. A client with a history of chronic back pain is questioning the need to keep asking for pain medication, fearing that he will be viewed as being weak by his family. The most therapeutic nursing response to this client would be:

Chronic back pain is very difficult to deal with; utilize the pain medication because thats what its there for.

Your family wont think youre weak; they want you to be comfortable, and the medication will help.

Taking the medication as prescribed will help you to be more active; your family will be happy you can do things with them again. Its important that you manage your pain as effectively as possible; it really doesnt matter what other people think about you.

ANS: 3 As a nurse, you encourage clients to accept pain-relieving measures so that they remain active. Clients who have a low pain tolerance (level of pain a person is willing to put up with) are sometimes inaccurately perceived as whiners or weak. The client needs to learn that effective, appropriate pain management is essential to his physical and emotional well-being. Although the remaining options are not incorrect, they do not display the degree of understanding the answer does. DIF: C REF: 1081 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 27. A client who is scheduled for the second in a series of painful dressing changes asks for my pain medication now so its working when the dressing is changed is most likely expressing:

1 2 3 4

A great fear of the expected pain A need to be in control of his pain An understanding that it is easier to prevent the pain than to stop the pain An acceptance of the pain that the dressing change will obviously cause him

ANS: 3 Clients often seek relief before pain occurs, having learned that pain is easier to prevent than to treat. Although the other options may not be incorrect, the likelihood is greater for the answer. DIF: C REF: 1055 OBJ: Analysis TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 28. The nurse inquires of a postoperative client as to the need for pain medication. The client denies the need then but 30 minutes later reports, I am really in a lot of pain. Can you bring me my pain pill now? The nurse recognizes that the most immediate need for client education is related to explaining that:

His oral medication will take approximately 30 minutes to affect his pain

There may be a need to administer his pain medication via the intravenous route

Pain medication is more effective if blood levels are maintained at a constant level

His pain will be more effectively managed if he reports a need for pain medication while the pain is still tolerable

ANS: 4 Teach clients the importance of reporting their pain sooner rather than later because the pain is better managed while it is still tolerable. Medication routes do affect the amount of time it will take to feel relief, and blood levels are a factor in pain management as well. The answer addresses the most general and immediate educational need. DIF: C REF: 1055 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 29. The nurse is caring for a cognitively impaired client who has experienced a painful procedure. The nurse is most effective in determining the clients pain medication needs when using which of the following assessment methods?

Medicating the client with the as-needed (prn) analgesic as often as ordered

Utilizing the pain face scale to assess the clients pain experience

Asking the client to rate his or her pain on a scale of 1 to 10, with 10 being the most severe pain Observing the clients body movements and facial expressions for typical pain behaviors

ANS: 4 Body movements and facial expressions that indicate pain include clenching the teeth, holding the painful part, bent posture, and grimaces. Some clients cry or moan, are restless, or make frequent requests of a nurse. You will soon learn to recognize patterns of behavior that reflect pain. This becomes especially important in clients who are unable to report their pain, such as the cognitively impaired. However, lack of pain expression does not necessarily mean that the client is not experiencing pain. The remaining options are not always as effective for the cognitively impaired or reflect inappropriate use of analgesics. DIF: C REF: 1067 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 30. The nurse is attempting to ambulate a postoperative client who continues to rate his pain as a 7 on a scale of 0 to 10, with 10 being the most severe. The client is reluctant to walk and consents to move only to the chair, reporting that it hurts too much to walk. The nurses primary concern regarding the clients recovery related to his pain experience is that:

His pain medications are not effectively managing his pain

He does not fully understand the importance of ambulation

He is expending too much of his energy dealing with the pain

He is not ready to participate in the activities needed to recover quickly

ANS: 4 Efforts aimed at teaching and motivating the client toward self-care are often hampered until the pain is successfully managed. Thus a primary nursing goal is to provide pain relief that allows clients to participate in their recovery. Although the remaining options are not inappropriate, they do not express the major concern regarding his recovery. DIF: C REF: 1070 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 31. The nurse is attempting to ambulate an older adult client who recently experienced a fall at the assisted living facility where he resides. The client is reluctant to walk and consents to move only to the chair, reporting that it hurts too much to walk. Which of the following nursing interventions is most therapeutic regarding this client?

Allow the client to remain in bed in order to conserve his energy.

Transfer him to the chair, realizing some activity is preferable to none. Call his health care provider to discuss the apparent ineffectiveness of his pain medications.

3 4

Assess the client for other factors that may be affecting his ability and motivation to ambulate.

ANS: 4 The perception of pain is affected by both physical and emotional factors. The client may be expressing concern over his ability or desire to return to the assisted living facility and so perceives the pain as a barrier to ambulating. Thus physical pain can cause psychological pain and vice versa. The other options are either not therapeutic or not the initial action to be taken. DIF: C REF: 1070 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 32. A client with chronic pain states, I just want to be pain-free. Do something to make that happen. The most therapeutic response is:

Together we will all work at making your pain tolerable.

I will do everything I can to manage your pain; I promise.

Are you feeling depressed or anxious because of your pain? You sound anxious. Would you like something for your nerves?

ANS: 1 Complete pain relief is not always achievable, but reducing pain to a tolerable level is realistic. The remaining options either address issues other than pain or make promises that may be difficult or impossible to keep. DIF: C REF: 1070 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 33. The greatest barrier to a 3-year-old clients ability to self-assess her pain is:

A limited vocabulary

2 3

Increased separation anxiety Reluctance to talk to strangers

Inability to grasp the concept of pain

ANS: 1 Young children who have not developed full vocabularies have difficulty verbally describing and expressing pain to parents or caregivers. Toddlers and preschoolers are unable to recall explanations about pain or associate pain with experiences that occur in various situations. The remaining options may have an effect on self-assessment of pain, but only to a limited degree. DIF: C REF: 1057 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 34. The nurse is discussing the effects of pain with an older adult client diagnosed with osteoarthritis. The most therapeutic response to the clients comment of, I wonder whether it would hurt if I took a nap in the afternoon? would be:

As long as it did not interfere with your getting a good nights sleep.

Id suggest taking your nap right after you take your pain medication. If it helps you cope better with the pain, I dont see any harm in taking a nap.

3 4

I think a nap is a good idea because we seem to feel pain more when we are tired.

ANS: 4 Fatigue heightens the perception of pain and decreases coping abilities. If fatigue occurs along with sleeplessness, the perception of pain is even greater. Pain is often experienced less after a restful sleep than at the end of a long day. The other options are not inappropriate but are not as informative regarding the benefit of rest on the perception or effects of pain. DIF: A REF: 1057-1059 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort

35. Which of the following statements is the most appropriate response to a clients statement, I thought you could tell I was in pain?

1 2 3 4

How do you express a need for pain medication if not by asking? Im so very sorry; may I get you your pain medication right now? I dont think its wise to assume I can effectively read your mind regarding the need for pain medication. I will make a point of asking you to rate your pain at least every 2 hours, so this miscommunication wont happen again.

ANS: 4 Be sensitive to variations in communication styles. Some cultures feel nonverbal expression of pain is sufficient to describe the pain experience, whereas others assume that if pain medication is appropriate, the nurse will bring it; thus asking is inappropriate. The remaining options are not as effective at addressing the root of the problem or providing a possible solution. DIF: C REF: 1061-1062 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 36. A 44-year-old client shares with the admitting nurse that the client is having epigastric pain that the client identifies as a 7 on a 0 to 10 scale. In order to plan for the pain management of this client, which is the most appropriate response from the nurse?

What would be a satisfactory level of pain control for us to achieve?

You dont look like youre in that much pain.

Youll be pain-free following your surgery. Ive cared for a client with a nail in his head who only rated his pain as a 5; are you sure your pain is a 7?

ANS: 1 Complete pain relief is not always achievable, but reducing pain to a tolerable level is realistic. Thus a primary nursing goal is to provide pain relief that allows clients to participate in their recovery. Successful pain management does not necessarily mean pain elimination, but rather attainment of a mutually agreed-upon pain-relief goal that allows clients to control their pain

instead of the pain controlling them. A person in pain feels distress or suffering and seeks relief. However, you as the nurse cannot see or feel the clients pain. It is realistic that the client will most likely experience postoperative pain. The nurse should not use a pain scale to compare the pain of one client to that of another client. DIF: B REF: 1060 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 37. The home care nurse notes that a 67-year-old female diabetic clients blood glucose level has been elevated since she strained her back the previous week. The client states that she cannot understand why her blood glucose level is elevated. The nurse suspects the most likely cause for the elevated blood sugar is:

The decreased activity level of the client since the injury

2 3

Parasympathetic stimulation from the bodys normal response to pain The client is consuming more food as a comfort measure

The client may not be taking her medication as ordered

ANS: 2 An increased blood glucose level is the bodys physiological response to pain, which is triggered by the parasympathetic nervous system in order to provide additional glucose for additional energy. DIF: A REF: 1067 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 38. A client with chronic pain presents in the emergency department of the local hospital stating I just cant take this anymore. On questioning the client, the nurse discovers that the client have experienced chronic pain since being involved in an accident 2 years previously. The client states that he has been labeled a drug seeker because he is looking for relief for the pain and feels hopeless, angry, and powerless to do anything about the situation. The nurse understands that this client is at risk for:

Criminal activity

Opioid abuse

Suicide

Drug addiction

ANS: 3 The possible unknown cause of noncancer pain, combined with the unrelenting pain and uncertainty of its duration, frustrates the client, frequently leading to psychological depression and perhaps suicide. There is no evidence to demonstrate a relationship between chronic pain and criminal activity. Health care workers are usually less willing to treat chronic noncancer pain with opioids, although a recent policy statement supports the use of opioids for noncancer pain. In addition, the American Society of Anesthesiologists developed the Practice Guidelines for Chronic Pain Management, which includes the use of opioids. Many health care providers and clients fear addiction when long-term opioid use is prescribed to manage pain, although this fear is often inappropriate. Because of this concern, health care providers require opioid agreements and random urine testing in clients who require long-term opioid therapy. The effectiveness of agreements is lacking, and there are ethical concerns about using them for all clients who require long-term opioid therapy. This raises the question as to whether agreements protect clients or health care providers. DIF: A REF: 1057 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 39. A client who had knee replacement surgery the previous day refuses to take any pain medication, even though he rates his pain as an 8 on a 0 to 10 scale. Upon questioning the client the nurse learns that the reason for refusing pain medication is because he is concerned about injuring the knee and not feeling it. The best information that the nurse can provide this client is to explain that:

The pain medication will help speed his recovery time

He need not worry about becoming addicted to the pain medication

He will not be perceived as weak for taking the pain medication

He is being a difficult client and needs to comply with the health care providers orders

ANS: 1 Acute pain seriously threatens a clients recovery by resulting in prolonged hospitalization, increased risks of complications from immobility, and delayed rehabilitation. Physical or psychological progress is delayed as long as acute pain persists, because the client focuses all

energy on pain relief. Thus a primary nursing goal is to provide pain relief that allows clients to participate in their recovery. DIF: A REF: 1057 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 40. A 38-year-old client presents to the pain clinic with complaints of phantom pain. The client was involved in a farming accident 3 years previously that resulted in a below-the-elbow amputation of his right arm. The nurse knows that phantom pain is categorized as:

1 2 3 4

Painful polyneuropathy Somatic pain Sympathetically maintained pain Deafferentation pain

ANS: 4 Deafferentation pain comes from injury to either the peripheral or central nervous system. Phantom pain reflects injury to the peripheral nervous system. In painful polyneuropathy the client feels pain along the distribution of many peripheral nerves; examples include diabetic neuropathy, alcohol-nutritional neuropathy, and Guillain-Barr syndrome. Somatic pain comes from bone, joint, muscle, skin, or connective tissue. It is usually aching or throbbing in quality and is well localized. Sympathetically maintained pain is associated with dysregulation of the autonomic nervous system; examples include pain associated with reflex sympathetic dystrophy/ causalgia (complex regional pain syndrome, type I, type II). DIF: A REF: 1054 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 41. The daughter of an 88-year-old female client tells the nurse that her mother has recently quit going on walks in the neighborhood because of pain in her legs. Which of the following is the best response from the nurse?

I would like to speak with your mother to get more information.

Older people frequently suffer from arthritis that can cause leg pain. Your mother probably has poor circulation in her legs, which is causing the pain.

3 4

She is lucky to be as healthy as she is at her age.

ANS: 1 The presence of pain in an older adult requires aggressive assessment, diagnosis, and management. Pain is not an inevitable part of aging. DIF: A REF: 1055 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 42. The nursery nurse is explaining postcircumcision care to a new mother. Which of the following statements by the new mother indicates that additional teaching needs to occur?

Babies dont experience pain, so I dont need to worry about hurting him when I touch the penis.

I need to be careful not to put his diaper on too tight to avoid discomfort.

I can comfort my baby following the procedure by holding him. The health care provider will numb the area before performing the procedure.

ANS: 1 Term neonates have the same sensitivity to pain as older infants and children. Preterm neonates have a greater sensitivity to pain than term neonates or older children. DIF: C REF: 1055 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort

43. Taking into consideration the hospice clients chronic pain from bone cancer, the most appropriate person to collaborate with regarding management of pain is:

Occupational therapist to devise a splint for the clients leg

Physical therapist to determine exercises to strengthen the leg muscles

Art therapist to provide creative therapy as a diversion An oncology nurse

ANS: 4 An oncology nurse specialist is very familiar with pharmacological and nonpharmacological interventions that are most effective for chronic/persistent pain. The client is terminally ill, and although occupational therapy, physical therapy, and art therapy are all important therapies to consider, in this case the most appropriate discipline is the nurse who cares for this type of client and is familiar with the interventions that would be most appropriate. DIF: C REF: 1056 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 44. In creating the plan of care for a newly diagnosed breast cancer client, the nurse is concerned about pain control. The client has expressed an interest in relaxation therapy as a complementary pain therapy. The nurse knows that the best time to teach the client is:

Immediately following the clients mastectomy

Before giving pain medication to evaluate if the complementary therapy works

Immediately preceding surgery When the client is comfortable

ANS: 4 For effective relaxation, teach techniques only when the client is not distracted by acute discomfort. The nurse would want to teach the client before the surgery so that the client could practice the technique before experiencing postsurgical pain. DIF: B REF: 1057 OBJ: Application TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort

45. A client who ruptured his spleen in a motor vehicle accident rates his postoperative pain as a level 8 on a 0 to 10 pain scale. After administering pain medication, the nurse discusses the use of complementary therapies with the client to explore ways to reduce the pain. The client would like to try a massage. The nurse delegates this task to the assistive personnel (AP). Which of the following instructions is most important for the nurse to share with the AP?

You need to warm the bottle of lotion before using it.

2 3

Report any changes in the clients skin condition to me immediately. Do not massage the clients legs.

Massage each body part at least 10 minutes.

ANS: 3 The nurse should instruct the AP not to massage the clients legs or calf muscles, because there is a risk for dislodging a vascular clot. The nurse needs to know about changes in the condition of the clients skin, but this can be obtained after the clients massageit is not as critical as the APs knowing not to massage the clients legs before beginning the massage. DIF: B REF: 1057 OBJ: Application TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort MULTIPLE RESPONSE 1. Which of the following client outcomes reflect the positive aspects of effective pain management? (Select all that apply.)

The client with arthritis in both hands knitting for pleasure

A client rating his chronic back pain as a 3 on a scale of 0 to 10

A client with type 2 diabetes walking 5 miles in a Fourth of July parade A client who has undergone surgery ambulating to the bathroom on the first postoperative day

4 5 6

A client with knee replacement surgery returning to his job as a mail carrier A client with terminal cancer going home on outpatient chemotherapy

ANS: 1, 2, 4, 5, 6 Effective pain management improves quality of life, reduces physical discomfort, promotes earlier mobilization and return to work, results in fewer hospital/clinic visits, and shortens hospital stays, thus reducing health care costs. The remaining option does not involve a client who is normally dealing with pain. DIF: C REF: 1068 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 2. The nurse recognizes which of the following client outcomes as being a result of ineffective pain management? (Select all that apply.)

1 2

Client expressing feelings of despair and hopelessness Inability to self-ambulate distance from bed to bathroom

Stage 1 pressure ulcer development on coccyx and left hip

Client rating pain as 4 on a scale of 0 to 10 30 minutes after pain medication Postponement of discharge because of the inability to perform activities of daily living Postponement of physical therapy because of clients inability to tolerate knee flexion

5 6

ANS: 1, 2, 3, 5, 6 Acute pain seriously threatens a clients recovery by resulting in prolonged hospitalization, increased risks of complications from immobility, and delayed rehabilitation. Physical or psychological progress is delayed as long as acute pain persists because the client focuses all energy on pain relief. A pain rating of 4 reflects tolerable pain, which may be a realistic expectation in some cases of chronic pain. DIF: C REF: 1070 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Pharmacological Therapies/Pharmacological Pain Management; Physiological Integrity/Basic Care and Comfort 3. Which of the following outcomes are directly related to functional impairment of the older client experiencing pain? (Select all that apply.)

Inability to prepare food to meet nutritional requirements

Inability to exit home quickly in the case of a fire

Development of skin breakdown on buttocks Development of an irregular heart rhythm

4 5 6

Displaying signs of clinical depression Feeling alone, unloved, and forgotten

ANS: 1, 2, 3, 5, 6 Once an older client suffers pain, there can be serious impairment of functional status. Pain has the potential to reduce mobility, activities of daily living (ADLs), social activities outside the home, and activity tolerance. There is no apparent connection between pain and the development of a dysrhythmia. Chapter 45. Nutrition MULTIPLE CHOICE 1. While doing a nutritional assessment of a low-income family, the community health nurse determines the familys diet is inadequate in protein content. The nurse suggests which of the following foods to increase protein content with little increase in the food budget?

Oranges and potatoes

2 3

Potatoes and rice Rice and macaroni

Peas and beans

ANS: 4 For families on limited budgets, substitutes can be used. For example, bean or cheese dishes can often replace meat in a meal. Peas and lentils are also inexpensive food sources of protein. Oranges and potatoes are not high in protein content. Potatoes and rice are sources of carbohydrates, not protein. Rice and macaroni are carbohydrates and are not high in protein. PTS: 1 DIF: A REF: 1087 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 2. A client is suspected of having a fat-soluble vitamin deficiency. To assist the client with this deficiency, the nurse informs the client that:

More exposure to sunlight and drinking milk could solve your nutritional problem

Eating more pork, fish, eggs, and poultry will increase your vitamin B complex intake

Increasing your protein intake will increase your negative nitrogen imbalance Decreasing your triglyceride levels by eating less saturated fats would be a good health intervention for you

ANS: 1 The fat-soluble vitamins are A, D, E, and K. With the exception of vitamin D, which can be obtained through exposure to sunlight, these vitamins are provided through dietary intake, including fortified milk. The B vitamins are not fat-soluble; they are water-soluble vitamins. Increasing protein intake will improve (decrease) a negative nitrogen imbalance, not increase it. Furthermore, increasing protein intake does not address the problem of a fat-soluble vitamin deficiency. PTS: 1 DIF: C REF: 1088 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 3. The client is diagnosed with malabsorption syndrome (celiac disease). In teaching about the gluten-free diet, the nurse informs the client to avoid:

Citrus fruits Vegetables

Red meats

Wheat products

ANS: 4 The treatment of malabsorption syndromes, such as celiac disease, includes a gluten-free diet. Gluten is present in wheat, rye, barley, and oats. Citrus fruits, vegetables, and red meat do not contain gluten. PTS: 1 DIF: A REF: 1126 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 4. The school nurse suspects that a junior high student may have anorexia nervosa. This eating disorder is characterized by:

A lack of control over eating patterns

2 3

Self-imposed starvation Binge-purge cycles

Excessive exercise

ANS: 2 Anorexia nervosa is characterized by self-imposed starvation. Bulimia nervosa is characterized by a lack of control over eating patterns and binge-purge cycles. Clients with bulimia may exercise excessively to prevent weight gain. PTS: 1 DIF: A REF: 1093 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 5. A client is pregnant for the third time. In regard to her nutritional status, she should:

Limit her weight gain to a maximum of about 25 pounds

Approximately double her protein intake

Increase her vitamin A and milk product consumption

Increase her intake of folic acid

ANS: 4 Folic acid intake is particularly important for DNA synthesis and the growth of red blood cells. Inadequate intake may lead to fetal neural tube defects, anencephaly, or maternal megaloblastic anemia. It is now recommended that women planning future pregnancies discuss preconception folic acid supplements. The recommended weight gain for pregnancy is 25 to 35 pounds for the woman of average weight. There is no need for the client to limit her weight gain to a maximum of 25 pounds on the basis of this being her third pregnancy. The client needs to increase her protein intake to 60 g during pregnancy; she does not need to double it. (This is an increase of approximately 20 g of protein.) Prenatal care usually includes vitamin and mineral supplementation to ensure daily intakes. The recommended intake of vitamin A does not increase over the nonpregnant state. Calcium intake increases from 800 mg to 1200 mg during pregnancy. PTS: 1 DIF: A REF: 1094 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 6. The nurse should offer a client who has had throat surgery which of the following?

Chicken noodle soup

2 3

Ginger ale Oatmeal

Hot tea with lemon

ANS: 2 The client who has had throat surgery should first be offered clear liquids. If the client tolerates clear liquids, then he or she may be advanced to a full liquid diet, and then to a mechanical soft diet. Because the client had throat surgery, excoriating liquids such as citrus juices should be avoided. Also, to be able to assess for bleeding, red or dark liquids should be avoided (e.g., apple juice or ginger ale is recommended rather than grape or cranberry juice). The client should begin oral intake with clear liquids. Neither chicken noodle soup nor oatmeal is included on a clear liquid diet. Hot tea with lemon would not be recommended. Liquids should not be hot or contain citrus, which could cause pain or excoriation and possible bleeding at the surgical site. PTS: 1 DIF: A REF: 1106 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 7. The nurse is discussing dietary intake with a client who is human immunodeficiency virus (HIV) positive. The nurse informs the client that the diet will include a:

Restriction of potassium, phosphate, and sodium

Reduction in carbohydrate intake

Decreased protein and increased folic acid intake

Reduction in fat with smaller, more frequent meals

ANS: 4 HIV-infected clients typically experience body wasting and severe weight loss. Restorative care for these clients focuses upon maximizing kilocalories and nutrients. Low-fat diets and small, frequent, nutrient-dense meals may be better tolerated. There is no need to restrict potassium, phosphate, and sodium in the client with HIV infection. The client with HIV infection does not need to reduce carbohydrate or protein or increase folic acid intake. PTS: 1 DIF: A REF: 1110 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort /Nutrition and Oral Hydration

8. Which of the following should the nurse do first when introducing a feeding to a client with an indwelling gavage tube?

1 2 3 4

Irrigate the tube with normal saline solution. Check to see that the tube is properly placed. Place the client in a supine position. Introduce some water before giving the liquid nourishment.

ANS: 2 Before introducing a feeding through an indwelling gavage tube for enteral nutrition, it is essential that the nurse check to see that the tube is properly placed. It is not necessary to irrigate the tube with normal saline. The clients head should be elevated 30 to 45 degrees to help prevent the chance of aspiration. The tube may be flushed with 30 mL of water before initiating the feeding. However, the nurse should first verify correct tube placement. PTS: 1 DIF: C REF: 1113-1116 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 9. The nurse is caring for a client who is receiving parenteral nutrition (PN). Which of the following is an appropriate nursing intervention when administering parenteral nutrition to a client?

Begin the infusion rates at 100 to 150 mL/hour.

Maintain a consistent infusion rate.

Change the infusion tubing once a week. Monitor protein levels daily.

ANS: 2 The infusion should be maintained at a consistent rate. If an infusion falls behind schedule, the nurse should not increase the rate in an attempt to catch up, because this could lead to osmotic diuresis and dehydration. An infusion should not be discontinued abruptly, because it may cause hypoglycemia. An initial rate of 40 to 60 mL/hr is recommended. To avoid infection, the infusion tubing should be changed every 24 hours with lipids and every 48 hours when lipids are not infused. Protein levels do not need to be monitored daily. The client should be weighed daily until maximum administration rate is reached and maintained for 24 hours; then weigh the client 3 times per week. PTS: 1 DIF: C REF: 1121 OBJ: Analysis

TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 10. Before inserting a small-bore nasogastric tube for enteral nutrition, the nurse correctly tells the client:

The tube will feel uncomfortable and may make you gag at times when I am inserting it

We will mark this tube from the end of your nose to your umbilicus to obtain the right length for insertion Please hold your breath when I insert this small tube through your nose down into your stomach

3 4

Please tilt your head back after the tube passes the nasopharynx.

ANS: 1 The procedure should be explained to the client, including how to communicate during intubation by raising his or her index finger to indicate gagging or discomfort. This will help reduce anxiety and help the client to assist in insertion. The length of the tube to be inserted is measured from the tip of the nose, to the earlobe, to the xiphoid process of the sternum. The client should be told to mouth-breathe and swallow during the procedure. The client should not hold his or her breath. The nurse should instruct the client to flex the head toward the chest after the tube has passed the nasopharynx. PTS: 1 DIF: C REF: 1113 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 11. A client is seen in the outpatient clinic for follow-up of a nutritional deficiency. In planning for the clients dietary intake, the nurse includes a complete protein, such as:

Eggs

Oats

Lentils Peanuts

ANS: 1 A complete protein contains all essential amino acids in sufficient quantity to support growth and maintain nitrogen balance. Eggs and meats are examples of complete proteins. Incomplete

proteins lack one or more of the nine essential amino acids and include oats (cereals) and legumes (lentils and peanuts). PTS: 1 DIF: A REF: 1087 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 12. According to the food guide pyramid, vegetables should be included in the average adults diet as:

1 2

1 to 3 servings per day 2 to 4 servings per day

3 to 5 servings per day

6 to 11 servings per day

ANS: 3 According to the food guide pyramid, the average adults diet should include 3 to 5 servings of vegetables per day. According to the food guide pyramid, the average adults diet should include 2 to 4 servings per day of fruit and 2 to 4 servings per day of grains. PTS: 1 DIF: A REF: 1091 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 13. When providing nutritional guidance, the nurse shares with the mother of an 8-year-old client that children of this age need to:

Increase their intake of B vitamins

Significantly increase iron intake

Maintain a sufficient intake of protein and vitamins A and C

Increase carbohydrates to meet increased energy needs

ANS: 3 School-age childrens diets should be carefully assessed for adequate protein and vitamins A and C. School-age children frequently fail to eat a proper breakfast and have unsupervised intake at school. An increase in B complex vitamins is needed to support heightened metabolic activity of the adolescent, and the pregnant woman has a need to significantly increase iron intake. Increased energy needs are expected in the adolescent period.

PTS: 1 DIF: A REF: 1092 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 14. When assisting the client who practices Islam or Judaism with meal planning, the nurse knows that both religions share an avoidance of:

Alcohol

Shellfish

Caffeine

Pork products

ANS: 4 Clients who practice Islam or Judaism share an avoidance of pork in their diet. Clients who practice Islam avoid alcohol and caffeine but will eat shellfish. Clients who practice Judaism do not restrict alcohol or caffeine intake and only eat fish with scales. Seventh-Day Adventists also avoid shellfish. Mormons also avoid caffeine. PTS: 1 DIF: A REF: 1096 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 15. Which of the following would the nurse expect to see offered on a full liquid diet?

Custard

Pureed meats

Soft fresh fruit

Canned soup

ANS: 1 Custard is included in a full liquid diet. Pureed meats are allowed in a pureed diet, not a full liquid diet. Soft fresh fruit is not included in a full liquid diet. Fresh fruit is often part of a highfiber diet. Cooked or canned fruits are allowed on a mechanical soft diet. Canned soup is not part of full liquid diet because it may contain noodles or rice or vegetables. Soups are allowed on a mechanical soft diet. PTS: 1 DIF: A REF: 1111 OBJ: Comprehension TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 16. During an enteral tube feeding, the client complains of abdominal cramping and nausea. The nurse should:

Cool the formula

Remove the tube

Use a more concentrated formula

Decrease the administration rate

ANS: 4 If the client begins to experience abdominal cramping and nausea during an enteral tube feeding, the nurse should decrease the administration rate to increase tolerance. Administration of cold formula may cause abdominal cramping and nausea. The formula is best tolerated at room temperature. The nurse should not remove the tube if the client complains of abdominal cramping and nausea. The formula may need to be diluted if the client is complaining of abdominal cramping and nausea. PTS: 1 DIF: B REF: 1117 OBJ: Application TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 17. A client is diagnosed with a peptic ulcer and has come to the primary health care provider for a follow-up visit. The client asks the nurse what foods are safe to add to his diet. An appropriate response by the nurse is to inform the client that which of the following may be added to the diet?

Citrus juices

Green vegetables

Frequent glasses of milk Unlimited decaffeinated coffee

ANS: 2 The client diagnosed with a peptic ulcer may be allowed to add green vegetables to his diet. The client with a peptic ulcer should avoid foods that increase stomach acidity, such as caffeine, decaffeinated coffee, frequent milk intake, citric acid juices, and certain seasonings (hot chili peppers, chili powder, black pepper). Smoking, alcohol, and aspirin are also discouraged. PTS: 1 DIF: A REF: 1126 OBJ: Comprehension

TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 18. When teaching the parents of a toddler about safe finger foods, the nurse suggests trying which of the following?

Nuts

2 3

Popcorn Cheerios

Hot dogs

ANS: 3 Cheerios are an appropriate finger food for a toddler or preschool child. Nuts, popcorn, and hot dogs have been implicated in choking deaths and should be avoided. If hot dogs are given to this age child, they should be cut up into irregularly shaped pieces, such as long strips. PTS: 1 DIF: A REF: 1092 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 19. Which of the following is accurate nutritional information that the nurse should share with the parents of an adolescent child?

Girls require less protein.

Boys require additional iron.

Vitamin B needs are decreased.

Energy and caloric needs are decreased.

ANS: 2 Adolescent boys require additional iron for muscle development. Daily requirements of protein increase for both adolescent boys and adolescent girls. B complex vitamins are needed to support heightened metabolic activity. Energy and caloric needs are increased to meet greater metabolic demands of growth during the adolescent period. PTS: 1 DIF: A REF: 1093 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

20. The client is assessed by the nurse as having a high risk for aspiration. The nursing diagnosis identified for the client is feeding self-care deficit related to unilateral weakness. An appropriate technique for the nurse to use when assisting the client with feeding is to:

Place food in the unaffected side of the mouth

2 3

Place the client in semi-Fowlers position Have the client use a straw

Use thinner liquids

ANS: 1 If the client has unilateral weakness, the nurse should place food in the stronger side of the mouth. The client should be positioned in an upright, seated position to prevent aspiration.Clients with unilateral weakness often have difficulty using a straw. Thickened liquids are often tolerated better and will help prevent aspiration, because clients with impaired swallowing often choke more with thin liquids. PTS: 1 DIF: A REF: 1110 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 21. A nasogastric tube is inserted in order for the client to receive intermittent tube feedings. An initial chest x-ray examination is done to confirm placement of the tube in the stomach. After the x-ray confirmation, the most reliable method of checking for tube placement is for the nurse to:

Place the end of the tube in water and observing for bubbling

Auscultate while introducing air into the tube

Measure the pH of the secretions aspirated Ask the client to speak

ANS: 3 After the x-ray confirmation, the next best method involves testing the pH of the feeding tube aspirate and observing the appearance of the aspirate. A properly obtained pH of 0 to 4 is a good indication of gastric placement. Placing the end of the tube in water and observing for bubbling is not an accurate method of checking for tube placement. Auscultation is no longer considered a reliable method for verification of tube placement because a tube inadvertently placed in the lungs, pharynx, or esophagus can transmit a sound similar to that of air entering the stomach. Asking the client to speak as a method of checking for tube placement has a high degree of inaccuracy. There have been cases reported in which clients have been able to speak despite placement of feeding tubes in the lung.

PTS: 1 DIF: A REF: 1117 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 22. For the client who is receiving parenteral nutrition via a central venous catheter, the nurse recognizes that a priority is to:

Use sterile technique during the administration of the feedings

Maintain the initial infusion rate at no more than 40 to 60 mL/ hr Complete the administration of the feeding within 12 hours

3 4

Have radiographic confirmation of the placement of the catheter

ANS: 4 After catheter placement, the catheter is flushed with saline or heparin until the position is radiographically confirmed. Aseptic technique, not sterile technique, is used during the administration of feedings. An initial rate of 40 to 60 mL/hr is recommended, and the rate is gradually increased. The rate of administration is not the priority. The nurse must first confirm correct placement of the catheter. A single container of PN should hang no longer than 24 hours; lipids no more than 12 hours. The nurse must first confirm correct placement of the catheter before any infusion is begun. PTS: 1 DIF: C REF: 1123 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 23. A client has been receiving tube feedings and is tolerating them very well. The health care provider determines that the rate of the intermittent tube feedings may be advanced. The nurse prepares to:

Increase the feedings by 50 mL/day

Start an isotonic formula at half strength

Infuse a bolus feeding over 5 to 10 minutes

Begin feedings with 250 to 500 mL at each interval

ANS: 1

When a client is tolerating tube feedings well, the nurse should expect the health care provider to order the feedings to be increased by 50 mL/day to achieve needed volume and calories in six to eight feedings. Formula is started at full strength for isotonic formulas. Intermittent feedings are allowed to infuse over at least 20 to 30 minutes. Feedings should be begun with no more than 150 to 250 mL at one time. PTS: 1 DIF: A REF: 1123 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 24. The nurse is aware that there are medications that are taken that alter the clients taste and may influence the dietary intake. In reviewing the medications taken by the clients on the unit, the nurse will consult with the nutritionist to develop a palatable meal plan for the client taking:

1 2

Ampicillin Morphine

Furosemide

Acetaminophen

ANS: 1 Ampicillin may cause an alteration in taste. Opiates, such as morphine, cause decreased peristalsis and may result in constipation. Decreased drug absorption may occur when diuretics, such as furosemide, are administered with food. Decreased acetaminophen absorption may occur if administered with food. Overdose of acetaminophen is associated with liver failure. Morphine, furosemide, and acetaminophen do not affect the clients sense of taste. PTS: 1 DIF: C REF: 1097 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity Basic Care and Comfort/Nutrition and Oral Hydration 25. Food safety is a concern of a group of adults attending the community health clinic. The participants identify to the nurse that they have seen a lot of reports on television about Escherichia coli and how dangerous it can be. When asked where the bacteria comes from, the nurse responds that a potential source of E. coli is:

Sausage

Soft cheeses

Milk products Ground beef

ANS: 4 E. coli may be contracted from undercooked meat, such as ground beef. Sausage is a potential source of botulism. Soft cheeses are a potential source of listeriosis, and milk products are a potential source of shigellosis. PTS: 1 DIF: A REF: 1109 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 26. A nurse is discussing high-nutrient-density food selections with a client recovering from extensive partial-thickness burns. Which of the following statements by the client reflects the best understanding of this dietary concept?

Ill snack on things like sugar-free pudding and Jello.

Fried chicken and potato salad are my favorite comfort foods. My wife has a wonderful recipe for low-calorie vegetable dip.

3 4

Its a good thing that I really enjoy salads and whole wheat breads.

ANS: 4 High-nutrient-density foods, such as fruits and vegetables, provide a large number of nutrients in relationship to kilocalories. Low-nutrient-density foods, such as alcohol or sugar, are high in kilocalories but are nutrient poor. The remaining options mention low-calorie and comfort food; they are not really discussing high-nutrient-density foods. PTS: 1 DIF: C REF: 1086 OBJ: Nursing Process: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 27. A nurse is discussing high-nutrient-density food selections with a client recovering from extensive partial-thickness burns. Which of the following statements by the nurse reflects the best understanding of this dietary concept?

Do you enjoy fresh fruits and vegetables?

Would you consider replacing soda with milk?

Your body requires lots of energy in order to heal itself, and that energy comes from nutrient-packed foods.

You need a great deal of energy, and youll get that by eating large volumes of food that can be turned into energy.

ANS: 3 High-nutrient-density foods, such as fruits and vegetables, provide a large number of nutrients in relationship to kilocalories. Low-nutrient-density foods, such as alcohol or sugar, are high in kilocalories but are nutrient poor. The remaining options either provide suggestions for food substitutes or provide a less informative explanation. PTS: 1 DIF: C REF: 1086 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 28. The nurse recognizes which of the following clients as being at greatest risk for a negative nitrogen balance?

A 10-year-old with an infected laceration on the left thumb

A 75-year-old who fell and experienced a mild concussion

A 40-year-old who has partial-thickness burns over 15% of his body

A 19-year-old who has lost 70 pounds in 7 months as a result of dieting

ANS: 3 Negative nitrogen balance occurs when the body loses more nitrogen than the body gains, for example, with infection, sepsis, burns, fever, starvation, head injury, and trauma. Although all these clients may be experiencing an increased nitrogen need for body repair, the burn client has the greatest need and so is at greatest risk for a negative nitrogen balance. PTS: 1 DIF: C REF: 1087 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 29. The nurse is discussing food selection with a client who recently experienced a partialthickness burn over 20% of her body. The client expresses a reluctance to ingest a large amount of carbohydrates because she successfully lost 50 pounds and does not want to regain the weight. The most therapeutic response to the clients nutritional needs is:

Dont be concerned about regaining the weight until your burns have healed.

You need a huge amount of calories to heal, so there wont be a weight gain.

You will experience a nitrogen imbalance if there arent enough carbohydrates in your diet. The extra carbohydrates will be utilized for energy so that your protein can be saved for repair of your skin.

ANS: 4 Negative nitrogen balance occurs when the body loses more nitrogen than the body gains; for example, with infection, sepsis, burns, fever, starvation, head injury, and trauma. Nutrition during this period needs to provide nutrients to put clients into positive nitrogen balance for healing. Carbohydrates are the main source of energy in the diet. The remaining options concentrate more on the weight gain issue than the energy need. PTS: 1 DIF: C REF: 1087 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 30. A client with a family history of cancer is discussing the effects of free radicals on body cells and tissue. Which of the following responses is the most therapeutic answer to the clients question, What can I do to protect against free radicals?

1 2 3 4

Eat foods like blueberries, oranges, almonds, and carrots; they fight free radicals. I can give you some literature on which foods are highest in free-radical fighters. Research seems to support the positive role vitamins A, C, and E play in neutralizing free radicals. Foods that contain vitamins A, C, and E as well as betacarotene seem to combat the effects of free radicals.

ANS: 4 Certain vitamins are currently of interest in their role as antioxidants. These vitamins neutralize substances called free radicals, which produce oxidative damage to body cells and tissues. Researchers believe that oxidative damage increases a persons risk for various cancers. These vitamins include beta-carotene and vitamins A, C, and E. The remaining options oversimplify the response or give very unspecific information.

PTS: 1 DIF: C REF: 1088 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 31. The nurse is discussing vitamin supplements with a client who is an amateur body builder. Which of the following statements by the nurse shows the greatest understanding concerning the risk for hypervitaminosis?

Vitamins are important to proper body building and repair, but be aware that you can overdose and harm yourself.

Fat-soluble vitamins are stored in the bodys fat reserves, so be careful not to take too much vitamins A, D, E, and K. Water-soluble vitamins are not stored in the body like fatsoluble ones, so its less likely to overdose on vitamin C and the B complex.

I realize vitamin supplements are a factor in your training, but be aware of daily requirements so you dont overdose, especially the fat-soluble vitamins.

ANS: 4 The fat-soluble vitamins (A, D, E, and K) are stored in the fatty compartments of the body. Hypervitaminosis of fat-soluble vitamins results from megadoses (intentional or unintentional) of supplemental vitamins, excessive amounts in fortified food, and large intake of fish oils. The water-soluble vitamins, vitamin C and the B complex (which is eight vitamins), are not stored, so these need to be provided in the daily food intake. Although water-soluble vitamins are not stored, toxicity can still occur. The remaining option is not incorrect but is not as inclusive as the answer. PTS: 1 DIF: C REF: 1088 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 32. Which of the following statements reflects the best understanding of the benefits of breastfeeding related to the infants health and wellness?

My husband and I both have food allergies, but she wont be allergic to my breast milk.

The antibodies she gets will help keep her immunized from many illnesses for up to her first birthday.

I can spend so much more time with her because I have to devote my attention to her while I nurse.

Its so convenient, no formula preparation, no bottles to wash and fill, no packing for outings; its great.

ANS: 1 Breast-feeding benefits include the following: reduced food allergies and intolerances; fewer infant infections; easier digestion; convenient; always correct temperature, available, and fresh; economical, because it is less expensive than formula; and increased time for mother and infant interaction. The other options are not incorrect but do not focus on health benefits for the infant as directly as the answer. PTS: 1 DIF: C REF: 1092 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 33. The nurse and the mother of an infant are discussing the introduction of solid foods into her childs diet. Which of the following statements made by the mother reflects the best understanding of the most appropriate manner to introduce new foods?

Both my husband and I have allergies, so I am very cautious about introducing anything new into her diet.

Im a fussy eater, and so are my other children; but I will offer her a variety of foods so she will have a good appetite. Ill start with nonwheat cereal and then vegetables; one new food a week so I can see if something doesnt agree with her.

3 4

My other children just loved solids and really were a joy to feed; I expect she will be as receptive to new foods as they were.

ANS: 3 Caregivers introduce new foods one at a time, approximately 4 to 7 days apart to identify allergies. The other options are not as directly focused on the possibility of food allergies. PTS: 1 DIF: C REF: 1092 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

34. The mother of a 25-month-old is discussing her concerns regarding her daughters eating habits with the nurse. The most therapeutic response to the mothers statement, She is such a fussy eater; it seems that she will only eat dry cereal and cheese is:

As long as she is eating a little from all the food groups and getting enough fluids, she will be all right

Her weight and height are right on target, so she must be getting what she needs to grow and develop Dont expect her to start liking a variety of foods for several more months; just keep offering her what she likes

3 4

Its very common for toddlers to be picky eaters; try offering her food frequently, and offer high-nutrient-density snacks such as the cheese she likes

ANS: 4 Toddlers exhibit strong food preferences and become picky eaters. Small frequent meals consisting of breakfast, lunch, and dinner with three interspersed high-nutrient-density snacks help improve nutritional intake. The answer provides the most comprehensive response to the mothers statement because it provides both an explanation and a suggestion. PTS: 1 DIF: C REF: 1192 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 35. Which of the following statements by an older adult shows the most need for follow-up regarding the risk for dehydration in this age-group?

I have a glass of water with each meal and whenever Im thirsty.

As long as I drink whenever Im thirsty, I think Ill be well hydrated.

I try not to drink much after dinner so I dont have to get up to urinate at night. I limit my coffee and tea drinking because I dont think they are particularly good for you.

ANS: 2

Thirst sensation diminishes with age, leading to inadequate fluid intake or dehydration. The remaining options deal more with the effects of fluid consumption than with the risk for dehydration. PTS: 1 DIF: C REF: 1094 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 36. The nurse is questioning a newly admitted client regarding his dietary history. Which of the following questions asked by the nurse is most likely to secure additional pertinent information regarding the clients statement, I think Im allergic to peanuts?

What happens when you eat peanuts?

What makes you think you are allergic to peanuts? When did you first notice this sensitivity to peanuts?

3 4

A peanut allergy is very serious; how do you manage to avoid them?

ANS: 1 Asking the client to describe the reactions to a particular food allows for a more thorough discussion than does any of the other options. Some options are more directed at the management rather than securing additional information regarding the reaction itself. PTS: 1 DIF: C REF: 1101 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 37. The nurse is counseling a client undergoing chemotherapy. The client has shared with the nurse that the client does not have much of an appetite and is worried about not getting enough nutrients. Which of the following statements by the nurse addresses the clients concerns?

Let me share information regarding how a high-calorie diet can help prevent you from losing weight.

Let me share information about high-nutrient-density foods to help you make choices.

You need to avoid carbohydrates in your diet. Your body needs a lot of protein right now to prevent muscle loss.

ANS: 2 Foods are sometimes described according to their nutrient density, the proportion of essential nutrients to the number of kilocalories. High-nutrient-density foods, such as fruits and vegetables, provide a large number of nutrients in relationship to kilocalories. The client did not express a concern about weight loss but is asking about nutrition. Protein provides energy, but because of proteins essential role in growth, maintenance, and repair, a diet needs to provide adequate kilocalories from nonprotein sources. Each gram of carbohydrate produces 4 kcal and serves as the main source of fuel (glucose) for the brain, skeletal muscles during exercise, erythrocyte and leukocyte production, and cell function of the renal medulla. When there is sufficient carbohydrate in the diet to meet the energy needs of the body, protein is spared as an energy source. PTS: 1 DIF: B REF: 1111 OBJ: Application TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 38. A 41-year-old female client has been dieting to lose weight. Which of the following statements indicates that the client needs additional teaching regarding a healthy weight-loss plan?

I have based my diet on the food pyramid.

I am planning to lose between 1 and 2 pounds per week. I need to eliminate all fat from my diet.

3 4

I plan to begin an exercise program as soon as I see my health care provider.

ANS: 2 Total fat intake should be between 20% and 35% of total calories with most fats coming from polyunsaturated or monounsaturated fatty acids. The Food Guide Pyramid is a basic guide for buying food and meal preparation. This basic system provides for diets ranging from 1600 to 2800 kcal/day. Losing weight at a slow rate is healthier than taking it off quickly. In general, when energy requirements are completely met by kilocalorie intake in food, weight does not change. When the kilocalories ingested exceed a persons energy demands, the individual gains weight. If the kilocalories ingested fail to meet a persons energy requirements, the individual loses weight. PTS: 1 DIF: B REF: 1109 OBJ: Application TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

39. The nurse is caring for a 5-kg 8-month-old infant admitted to the hospital by the health care provider, who was concerned about the infants low weight. The infants birth weight was 3.5 kg. The nurse knows that on average an infant doubles his or her birth weight at what age?

2 to 3 months

2 3

4 to 5 months 6 to 7 months

8 to 9 months

ANS: 2 The infant usually doubles birth weight at 4 to 5 months and triples it at 1 year. PTS: 1 DIF: C REF: 1087 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 40. The nurse is caring for a 6-kg 4-month-old infant who is hospitalized with a respiratory infection. The nurse knows that an infant this age needs approximately 108 kcal/kg of body weight. The nurse also understands that human breast milk provides approximately 20 kcal/oz. About how much breast milk does the nurse need to feed the infant every 4 hours in order to provide enough to meet the infants nutritional needs?

4.5 ounces

5.5 ounces

6.5 ounces 7.5 ounces

ANS: 2 6 kg x 108 kcal/kg/day = 648 kcal/day; 648 kcal/day 20 kcal/oz = 32.4 oz/day; 32.4 oz/day 24 hr/ day = 1.35 oz/hr; 1.35 oz/hr x 4 hours = 5.4 ounces every 4 hours. PTS: 1 DIF: C REF: 1092 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 41. Which of the following statements by a new mother indicates that the nurse needs to provide additional teaching before the client is discharged home with her infant?

1 2

I will be using infant formula, which will provide all the nutrition that my new baby needs. I can feed my new baby every 3 to 4 hours when I get home.

I will need to sterilize all my babys bottles and nipples to make sure they dont have any germs.

I can put a few drops of honey in my babys formula to make it taste better.

ANS: 4 Honey and corn syrup are potential sources of botulism toxin. Infant formula provides all the nutrition that a newborn infant needs. Newborns need to be fed every 3 to 4 hours, and their bottles and nipples need to be sterilized. PTS: 1 DIF: B REF: 1092 OBJ: Application TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 42. One easy way that parents of teenagers can ensure that they are getting enough iodine in their diets to support the increased thyroid activity during adolescence is to:

Give the child a multivitamin daily

Use iodized table salt

Keep fresh fruit and vegetables on hand for snacks

Serve red meat at least once a week

ANS: 2 Iodine supports increased thyroid activity, and use of iodized table salt ensures availability. PTS: 1 DIF: B REF: 1092 OBJ: Application TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 43. A 68-year-old female client tells the home care nurse that she is worried about her 70-yearold husband because he does not eat as much as he used to when he was younger. Which of the following is the best response from the nurse?

Perhaps your husband needs to have his thyroid level checked.

3 4

Your husband is at an age when his metabolism is slowing down and his energy requirements arent as great as they were when he was younger. Are you fixing the foods that he likes? That should cut down on your grocery bill.

ANS: 2 Adults 65 years and older have a decreased need for energy as metabolic rate slows with age. However, vitamin and mineral requirements remain unchanged from middle adulthood. PTS: 1 DIF: B REF: 1094 OBJ: Application TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 44. The nurse is counseling a 64-year-old client that it is important to eat plenty of fruits and vegetables, but the client should avoid which of the following because it can inhibit the absorption of some drugs?

Oranges

Grapefruit

Pineapple

Asparagus

ANS: 2 Caution older adults to avoid grapefruit and grapefruit juice because these will decrease absorption of many drugs. PTS: 1 DIF: C REF: 1086 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 45. When menu planning for a newly diagnosed diabetic client who practices Judaism, the nurse should avoid which of the following dishes?

Vegetable beef soup

Chicken pot pie

Beef lasagna

Scrambled eggs

ANS: 3 Judaism prohibits the mixing of milk or dairy products with meat dishes, and the beef lasagna has both meat and cheese in it. PTS: 1 DIF: B REF: 1086 OBJ: Application TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 46. The nurse caring for a 55-year-old male client knows that due to his religious beliefs he is most likely a vegetarian. Which of the following religions encourage vegetarianism?

Church of Jesus Christ of Latter-Day Saints

2 3

Seventh-Day Adventist Judaism

Pentecostal

ANS: 2 Vegetarian or ovolactovegetarian diets are encouraged in followers of the Seventh-Day Adventist Church. PTS: 1 DIF: C REF: 1092 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration MULTIPLE RESPONSE 1. The nurse is delegating the feeding of an older adult client to ancillary personnel. Which of the following should the nurse include in the instructions as possible warning signs of dysphagia (difficulty swallowing)? (Select all that apply.)

Delay in swallowing food

Easily triggered gag reflex

3 4

Absence of a gag reflex Uncoordinated speech

Disinterest in eating

Pocketing food

ANS: 1, 2, 3, 4, 6 Signs of dysphagia include the following: cough during eating; change in voice tone or quality after swallowing; abnormal movements of the mouth, tongue, or lips; and slow, weak, imprecise, or uncoordinated speech. Abnormal gag reflex, delayed swallowing, incomplete oral clearance or pocketing, regurgitation, pharyngeal pooling, delayed or absent trigger of swallow, and inability to speak consistently are other signs of dysphagia. PTS: 1 DIF: A REF: 1092 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 2. Which of the following clients has an identified factor that is affecting the clients energy requirements? (Select all that apply.)

1 2

A 27-year-old diagnosed anorexic client A 21-year-old college football quarterback

A 73-year-old recovering from hip surgery

A 39-year-old who is currently menstruating

A 4-year-old with a temperature of 102.2 F rectally

A 50-year-old diagnosed with chronic depression

ANS: 1, 2, 3, 4, 5 Factors such as age, body mass, gender, fever, starvation, menstruation, illness, injury, infection, activity level, or thyroid function affect energy requirements. There is no direct connection between depression and energy requirements. PTS: 1 DIF: C REF: 1092 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 3. Besides being pivotal in the growth, maintenance, and repair of body tissue, protein plays a significant role in the bodys ability to: (Select all that apply.)

Produce T cells

Manage bleeding

Produce carbon dioxide

Maintain blood pressure Manage waste production

Transport drugs systemically

ANS: 1, 2, 4, 6 Proteins provide a source of energy (4 kcal/g), and they are essential for synthesis (building) of body tissue in growth, maintenance, and repair. Collagen, hormones, enzymes, immune cells, DNA, and RNA are all made of protein. In addition, blood clotting, fluid regulation, and acidbase balance require proteins. These proteins transport nutrients and many drugs in the blood. There is not a direct connection between the other options and protein. PTS: 1 DIF: C REF: 1092 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 4. The nurse is discussing breast-feeding with a pregnant mother who is being seen for a routine obstetrical visit. Which of the following should the nurse include as positive effects/outcomes of breast-feeding? (Select all that apply.)

Good source of antibodies

Convenient source of nutrition

3 4

Economical source of nutrients Minimal digestive system upsets

Less risk related to food allergies

Encourages family-infant bonding

ANS: 1, 2, 3, 4, 5 Benefits of breast-feeding include reduced food allergies and intolerances; fewer infant infections; easier digestion; convenient; always correct temperature, available, and fresh; economical, because it is less expensive than formula; and increased time for mother and infant interaction, although it does not contribute to family-infant bonding. PTS: 1 DIF: A REF: 1094 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 5. Which of the following factors are believed to contribute to the prevalence of overweight children seen in America today? (Select all that apply.)

Unavailability of high-nutrient-density foods

Reliance on food as a stress-coping mechanism

Decline in an interest in physically active hobbies

Reliance on fast foods for major portion of daily diet Increased interest in passive, technology-driven activities

5 6

Reduced supervision in the home, especially during afterschool hours

ANS: 2, 3, 4, 5, 6 A combination of factors contributes to the problem, including a diet rich in high-calorie foods, inactivity, genetic predisposition, use of food as a coping mechanism for stress or boredom, and family and social factors. There is not a scarcity of healthy foods in this country. PTS: 1 DIF: C REF: 1094 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 6. Older adults are at an increased risk for dehydration from a variety of risk factors that include a decreased thirst drive. Which of the following should a nurse include in a discussion with members of a senior center regarding the signs of dehydration? (Select all that apply.)

Dry, hot skin

Memory lapses

Dry, cracked lips Weak, slow pulsec

4 5 6

Physical weakness Decreased urination

ANS: 1, 2, 3, 5, 6 Symptoms of dehydration in older adults include confusion; weakness; hot, dry skin; furrowed tongue; rapid pulse; and high urinary sodium level. PTS: 1 DIF: A REF: 1096 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration 7. Which of the following assessment findings in an older adult increases the individuals risk for poor nutrition? (Select all that apply.)

Living on a Social Security income check

Did not graduate from high school Is easily tired by activity

3 4 5

Living in a group home Chronically depressed

Recently widowed

ANS: 1, 2, 3, 5, 6 Malnutrition in older adults has multiple causes, such as income, educational level, physical functioning level to meet activities of daily living (ADLs), loss, dependency, loneliness, and transportation. Living in a managed environment is not a risk factor for poor nutrition. Chapter 46. Urinary Elimination MULTIPLE CHOICE 1. While doing a nutritional assessment of a low-income family, the community health nurse determines the familys diet is inadequate in protein content. The nurse suggests which of the following foods to increase protein content with little increase in the food budget?

Oranges and potatoes

Potatoes and rice

Rice and macaroni

Peas and beans

More exposure to sunlight and drinking milk could solve your nutritional problem

Eating more pork, fish, eggs, and poultry will increase your vitamin B complex intake

Increasing your protein intake will increase your negative nitrogen imbalance Decreasing your triglyceride levels by eating less saturated fats would be a good health intervention for you

Citrus fruits Vegetables

Red meats

Wheat products

A lack of control over eating patterns

2 3

Self-imposed starvation Binge-purge cycles

Excessive exercise

Limit her weight gain to a maximum of about 25 pounds

Approximately double her protein intake

Increase her vitamin A and milk product consumption

Increase her intake of folic acid

Chicken noodle soup

2 3

Ginger ale Oatmeal

Hot tea with lemon

Restriction of potassium, phosphate, and sodium

Reduction in carbohydrate intake

Decreased protein and increased folic acid intake

Reduction in fat with smaller, more frequent meals

8. Which of the following should the nurse do first when introducing a feeding to a client with an indwelling gavage tube?

1 2 3 4

Irrigate the tube with normal saline solution. Check to see that the tube is properly placed. Place the client in a supine position. Introduce some water before giving the liquid nourishment.

Begin the infusion rates at 100 to 150 mL/hour.

Maintain a consistent infusion rate.

Change the infusion tubing once a week. Monitor protein levels daily.

The tube will feel uncomfortable and may make you gag at times when I am inserting it

3 4

Please tilt your head back after the tube passes the nasopharynx.

Eggs

Oats

Lentils Peanuts

ANS: 1 A complete protein contains all essential amino acids in sufficient quantity to support growth and maintain nitrogen balance. Eggs and meats are examples of complete proteins. Incomplete

1 2

1 to 3 servings per day 2 to 4 servings per day

3 to 5 servings per day

6 to 11 servings per day

Increase their intake of B vitamins

Significantly increase iron intake

Maintain a sufficient intake of protein and vitamins A and C

Increase carbohydrates to meet increased energy needs

Alcohol

Shellfish

Caffeine

Pork products

Custard

Pureed meats

Soft fresh fruit

Canned soup

Cool the formula

Remove the tube

Use a more concentrated formula

Decrease the administration rate

Citrus juices

Green vegetables

Frequent glasses of milk Unlimited decaffeinated coffee

Nuts

2 3

Popcorn Cheerios

Hot dogs

Girls require less protein.

Boys require additional iron.

Vitamin B needs are decreased.

Energy and caloric needs are decreased.

Place food in the unaffected side of the mouth

2 3

Place the client in semi-Fowlers position Have the client use a straw

Use thinner liquids

Place the end of the tube in water and observing for bubbling

Auscultate while introducing air into the tube

Measure the pH of the secretions aspirated Ask the client to speak

Use sterile technique during the administration of the feedings

Maintain the initial infusion rate at no more than 40 to 60 mL/ hr Complete the administration of the feeding within 12 hours

3 4

Have radiographic confirmation of the placement of the catheter

Increase the feedings by 50 mL/day

Start an isotonic formula at half strength

Infuse a bolus feeding over 5 to 10 minutes

Begin feedings with 250 to 500 mL at each interval

ANS: 1

1 2

Ampicillin Morphine

Furosemide

Acetaminophen

Sausage

Soft cheeses

Milk products Ground beef

Ill snack on things like sugar-free pudding and Jello.

Fried chicken and potato salad are my favorite comfort foods. My wife has a wonderful recipe for low-calorie vegetable dip.

3 4

Its a good thing that I really enjoy salads and whole wheat breads.

Do you enjoy fresh fruits and vegetables?

Would you consider replacing soda with milk?

Your body requires lots of energy in order to heal itself, and that energy comes from nutrient-packed foods.

You need a great deal of energy, and youll get that by eating large volumes of food that can be turned into energy.

A 10-year-old with an infected laceration on the left thumb

A 75-year-old who fell and experienced a mild concussion

A 40-year-old who has partial-thickness burns over 15% of his body

A 19-year-old who has lost 70 pounds in 7 months as a result of dieting

Dont be concerned about regaining the weight until your burns have healed.

You need a huge amount of calories to heal, so there wont be a weight gain.

1 2 3 4

Vitamins are important to proper body building and repair, but be aware that you can overdose and harm yourself.

I realize vitamin supplements are a factor in your training, but be aware of daily requirements so you dont overdose, especially the fat-soluble vitamins.

My husband and I both have food allergies, but she wont be allergic to my breast milk.

The antibodies she gets will help keep her immunized from many illnesses for up to her first birthday.

I can spend so much more time with her because I have to devote my attention to her while I nurse.

Its so convenient, no formula preparation, no bottles to wash and fill, no packing for outings; its great.

Both my husband and I have allergies, so I am very cautious about introducing anything new into her diet.

3 4

My other children just loved solids and really were a joy to feed; I expect she will be as receptive to new foods as they were.

As long as she is eating a little from all the food groups and getting enough fluids, she will be all right

3 4

Its very common for toddlers to be picky eaters; try offering her food frequently, and offer high-nutrient-density snacks such as the cheese she likes

I have a glass of water with each meal and whenever Im thirsty.

As long as I drink whenever Im thirsty, I think Ill be well hydrated.

I try not to drink much after dinner so I dont have to get up to urinate at night. I limit my coffee and tea drinking because I dont think they are particularly good for you.

ANS: 2

What happens when you eat peanuts?

What makes you think you are allergic to peanuts? When did you first notice this sensitivity to peanuts?

3 4

A peanut allergy is very serious; how do you manage to avoid them?

Let me share information regarding how a high-calorie diet can help prevent you from losing weight.

Let me share information about high-nutrient-density foods to help you make choices.

You need to avoid carbohydrates in your diet. Your body needs a lot of protein right now to prevent muscle loss.

I have based my diet on the food pyramid.

I am planning to lose between 1 and 2 pounds per week. I need to eliminate all fat from my diet.

3 4

I plan to begin an exercise program as soon as I see my health care provider.

2 to 3 months

2 3

4 to 5 months 6 to 7 months

8 to 9 months

4.5 ounces

5.5 ounces

6.5 ounces 7.5 ounces

1 2

I will be using infant formula, which will provide all the nutrition that my new baby needs. I can feed my new baby every 3 to 4 hours when I get home.

I will need to sterilize all my babys bottles and nipples to make sure they dont have any germs.

I can put a few drops of honey in my babys formula to make it taste better.

Give the child a multivitamin daily

Use iodized table salt

Keep fresh fruit and vegetables on hand for snacks

Serve red meat at least once a week

Perhaps your husband needs to have his thyroid level checked.

3 4

Oranges

Grapefruit

Pineapple

Asparagus

Vegetable beef soup

Chicken pot pie

Beef lasagna

Scrambled eggs

Church of Jesus Christ of Latter-Day Saints

2 3

Seventh-Day Adventist Judaism

Pentecostal

Delay in swallowing food

Easily triggered gag reflex

3 4

Absence of a gag reflex Uncoordinated speech

Disinterest in eating

Pocketing food

1 2

A 27-year-old diagnosed anorexic client A 21-year-old college football quarterback

A 73-year-old recovering from hip surgery

A 39-year-old who is currently menstruating

A 4-year-old with a temperature of 102.2 F rectally

A 50-year-old diagnosed with chronic depression

Produce T cells

Manage bleeding

Produce carbon dioxide

Maintain blood pressure Manage waste production

Transport drugs systemically

Good source of antibodies

Convenient source of nutrition

3 4

Economical source of nutrients Minimal digestive system upsets

Less risk related to food allergies

Encourages family-infant bonding

Unavailability of high-nutrient-density foods

Reliance on food as a stress-coping mechanism

Decline in an interest in physically active hobbies

Reliance on fast foods for major portion of daily diet Increased interest in passive, technology-driven activities

5 6

Reduced supervision in the home, especially during afterschool hours

Dry, hot skin

Memory lapses

Dry, cracked lips Weak, slow pulsec

4 5 6

Physical weakness Decreased urination

Living on a Social Security income check

Did not graduate from high school Is easily tired by activity

3 4 5

Living in a group home Chronically depressed

Recently widowed

ANS: 1, 2, 3, 5, 6 Malnutrition in older adults has multiple causes, such as income, educational level, physical functioning level to meet activities of daily living (ADLs), loss, dependency, loneliness, and transportation. Living in a managed environment is not a risk factor for poor nutrition. Chapter 47. Bowel Elimination MULTIPLE CHOICE 1. Which of the following would the nurse expect as a normal change in the bowel elimination as a person ages?

Absorptive processes are increased in the intestinal mucosa.

Esophageal emptying time is increased.

Changes in nerve innervation and sensation cause diarrhea.

Mastication processes are less efficient.

ANS: 4 An expected change in bowel elimination is decreased chewing and decreased salivation, resulting in less efficient mastication. There is decreased nutrient absorption of the small intestine in the older adult. Esophageal emptying slows, as a result of reduced motility, especially in the lower third of the esophagus. With decreased peristalsis and weakened musculature, the older adult is more prone to constipation. Duller nerve sensations may place the older adult at increased risk for fecal incontinence. DIF: A REF: 1177 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/ Elimination 2. An 8-month-old infant is hospitalized with severe diarrhea. The nurse knows that the major problem associated with severe diarrhea is:

Pain in the abdominal area

Electrolyte and fluid loss

Presence of excessive flatus Irritation of the perineal and rectal area

ANS: 2 Excess loss of colonic fluid because of diarrhea can result in serious fluid and electrolyte or acidbase imbalances. Infants and older adults are particularly susceptible to associated complications. Pain from abdominal cramping may occur with diarrhea, but it is not the major problem associated with severe diarrhea. Excessive flatus is not the major problem associated with severe diarrhea. Because repeated passage of diarrhea stools exposes the skin of the perineum and buttocks to irritating intestinal contents, meticulous skin care and containment of fecal drainage are needed to prevent skin breakdown. The greatest danger of severe diarrhea is a fluid and electrolyte or acid-base imbalance. DIF: A REF: 1180 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/ Elimination 3. A 50-year-old male client is having a screening colonoscopy. The nurse instructs the client that:

No special preparation is required Light sedation is normally used

No metallic objects are allowed

Swallowing of an opaque liquid is required

ANS: 2 Light sedation is required for a colonoscopy. Special preparation is required before a colonoscopy. Clear liquids are given the day before and then some form of bowel cleanser, such as GoLytely, is administered. Enemas until clear may also be ordered. There is no restriction of metallic objects for a colonoscopy, not does it require swallowing an opaque liquid. DIF: A REF: 1178 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/ Elimination 4. A client is to have a stool test for occult blood. The nurse is instructing the nursing assistant in the correct procedure for the test. The nursing assistant is correctly informed that:

Sterile technique is used for collection

2 3

Stool should be collected over a 3-day period The specimen should be kept warm

A 1-inch sample of formed stool is needed

ANS: 4 Tests performed by the laboratory for occult blood in the stool and stool cultures require only a small sample. The nurse uses clean technique to collect about 1 inch of formed stool or 15 to 30 mL of liquid stool. Unlike testing for occult blood, tests for measuring the output of fecal fat require a 3- to 5-day collection of stool, and tests that measure for ova and parasites require the stool to be warm. DIF: A REF: 1188 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/ Elimination 5. A client who recently underwent surgery and now has a colostomy is correctly instructed by the nurse that for the next few weeks the clients diet will include foods such as:

Vegetables

Fresh fruit

Whole grain breads

Poached eggs and rice

ANS: 4 During the first weeks after surgery, many health care providers recommend low-fiber diets because the bowel requires time to adapt to the diversion. Low-fiber foods include bread, noodles, rice, cream cheese, eggs (not fried), strained fruit juices, lean meats, fish, and poultry. Poached eggs and rice would be appropriate for this client. After the ostomy heals, the client is allowed to eat whole grains, fruits, and vegetables. High-fiber foods such as fresh fruits and vegetables help ensure a more solid stool needed to achieve success at irrigation. Ostomy clients may benefit from avoiding foods that cause gas and odor, including broccoli, cauliflower, dried beans, and Brussels sprouts. DIF: A REF: 1210 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/ Elimination

6. The client has been admitted to an acute care unit with a diagnosis of biliary disease. The nurse suspects that the feces will appear:

1 2 3 4

Bloody Pus filled Black and tarry White or clay colored

ANS: 4 Stool that is white or clay colored indicates an absence of bile. Bloody feces is not an indication of biliary disease. Pus-filled feces indicate infection. Black or tarry feces may indicate upper gastrointestinal (GI) bleeding or iron ingestion. DIF: A REF: 1188-1190 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/ Elimination 7. The client asks the nurse to recommend bulk-forming foods that may be included in the diet. Which of the following should be recommended by the nurse?

Whole grains

Fruit juice

Rare meats

Milk products

ANS: 1 Bulk-forming foods, such as grains, fruits, and vegetables, absorb fluids and increase stool mass. Fruit juice, rare meats, and milk products are not bulk-forming foods. DIF: A REF: 1177 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/ Elimination 8. The client is taking medications to promote defecation. Which of the following instructions should be included by the nurse in the teaching plan for this client?

Increased laxative use often causes hyperkalemia.

Salt tablets should be taken to increase the solute concentration of the extracellular fluid.

3 4

Emollient solutions may increase the amount of water secreted into the bowel. Bulk-forming additives may turn the urine pink.

ANS: 3 Emollient solutions are stool softeners that may increase the amount of water secreted into the bowel. Laxative overuse can cause serious diarrhea that can lead to dehydration and hypokalemia. Salt tablets should not be taken to increase the solute concentration of extracellular fluid. Bulk-forming additives do not turn the urine pink. Phenolphthalein or danthron stimulant cathartics (e.g., Doxidan, Correctol, Ex-Lax) may cause pink or red urine. DIF: A REF: 1198 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/ Elimination 9. While undergoing a soapsuds enema, the client complains of abdominal cramping. The nurse should:

Immediately stop the infusion

2 3

Lower the height of the enema container Advance the enema tubing 2 to 3 inches

Clamp the tubing

ANS: 2 The nurse should lower the container if the client complains of abdominal cramping. Cramping may prevent the client from retaining all of the fluid, which would alter the effectiveness of the enema. If the nurse stops the infusion, the client will not receive all of the fluid, and the enema will be less effective. The nurse may slow the infusion until the abdominal cramping passes. The enema tubing should not be advanced further. The tubing may be clamped temporarily if fluid escapes around the rectal tube. The instillation should be slowed in the instance of abdominal cramping. DIF: B REF: 1202 OBJ: Application TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/ Elimination 10. A nurse who is caring for postoperative clients on a surgical unit knows that for 24 to 48 hours postoperatively, clients who have undergone general anesthesia may experience:

Colitis

Stomatitis

Paralytic ileus Gastrocolic reflex

ANS: 3 Any surgery that involves direct manipulation of the bowel temporarily stops peristalsis. This condition, called paralytic ileus, usually lasts about 24 to 48 hours. Colitis is inflammation of the colon. Stomatitis is inflammation of the mouth. The gastrocolic reflex is the peristaltic wave in the colon induced by entrance of food into the stomach. Colitis, stomatitis, and gastrocolic reflex are not caused by anesthetic used during surgery. DIF: A REF: 1178 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/ Elimination 11. For clients with hypocalcemia, the nurse should implement measures to prevent:

Gastric upset Malabsorption

Constipation

Fluid secretion

ANS: 3 Disorders of calcium metabolism contribute to difficulty with the passage of stools. The nurse should implement measures to prevent constipation in clients with hypocalcemia. Gastric upset, malabsorption, and fluid secretion are not caused by hypocalcemia. DIF: A REF: 1179 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/ Elimination 12. The client is to receive a Kayexalate enema. The nurse recognizes that this is used to:

Prevent further constipation

Remove excess potassium from the system

Reduce bacteria in the colon before diagnostic testing

Provide direct antidiarrheal medication to the intestine

ANS: 2 Kayexalate is a type of medicated enema used to treat clients with dangerously high serum potassium levels. This drug contains a resin that exchanges sodium ions for potassium ions in the large intestine. Kayexalate enemas are not used to treat or prevent constipation, and Kayexalate is not a diarrheal medication. Neomycin enemas, not Kayexalate enemas, may be used to reduce bacteria in the colon before diagnostic testing. DIF: A REF: 1197 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/ Elimination 13. The appropriate amount of fluid to prepare for an enema to be given to an average-size school-age child is:

1 2

150 to 250 mL 250 to 350 mL

300 to 500 mL

500 to 750 mL

ANS: 3 The appropriate amount of fluid to prepare for an enema to be given to an average-size schoolage child is 300 to 500 mL. An infant should receive 150 to 250 mL, a toddler should receive 250 to 350 mL, and an adolescent should receive 500 to 750 mL. DIF: A REF: 1200 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/ Elimination 14. A client has undergone intestinal surgery and now has an incontinent ostomy. The use of which of the following products by the client indicates that the discharge learning goals have been achieved?

A powder for a yeast infection

Peroxide to toughen the peristomal skin

A commercial deodorant around the stoma

Alcohol to cleanse the stoma

ANS: 1

If a yeast infection occurs, thorough cleansing should be performed, followed by patting the area dry and applying a prescribed topical agent, such as triamcinolone acetonide (Kenalog) spray or nystatin (Mycostatin), to the affected region. The peristomal skin should be cleansed gently with warm tap water using gauze pads or a clean washcloth. An ostomy deodorant may be placed into the pouch, not around the stoma. Alcohol should not be used to clean the stoma. The area may be cleaned with warm tap water. DIF: A REF: 1217 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/ Elimination 15. Which of the following is an appropriate nursing intervention for a client with a nasogastric tube in place?

Tape the tube up and around the ear on the side of insertion.

2 3

Secure the tubing to the bed by the clients head. Mark the tube where it exits the nose.

Change the tubing daily.

ANS: 3 Once placement is confirmed, a mark should be placed, either making a red mark or using tape, on the tube to indicate where the tube exits the nose. The mark or tube length is to be used as a guide to indicate whether displacement may have occurred. The tube should be taped to the nose, not to the ear. The tubing should be secured to the clients gown, not the bed. The tubing should not be changed daily, but it should be irrigated daily. DIF: A REF: 1208 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/ Elimination 16. The nurse instructs the client that before the fecal occult blood test (FOBT) she may eat:

Whole wheat bread

A lean, T-bone steak

Veal

Salmon

ANS: 1

Whole wheat bread may be eaten before a fecal occult blood test. A lean, T-bone steak may cause false-positive results if eaten before a fecal occult blood test. Veal may cause false-positive results if eaten before a fecal occult blood test. Salmon may cause false-positive results if eaten before a fecal occult blood test. DIF: A REF: 1188 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/ Elimination 17. The nurse is discussing arteriosclerosis and the effects it has on the body with an older adult client. Although the most commonly recognized effect is on the cardiovascular system, the nurse should include which of the following statements regarding its effect on the gastrointestinal system to complete the discussion?

1 2 3 4

Circulatory problems make getting to the bathroom easily problematic. The benefit you get from your food is also decreased by this condition. The aging process that causes the vascular problems also causes elimination problems. The problem it creates with blood flow also affects blood flow to the bowels and so affects elimination.

ANS: 4 Systemic changes in the function of digestion and absorption of nutrients result from changes in older clients cardiovascular and neurological systems, rather than their gastrointestinal system. For example, arteriosclerosis causes decreased mesenteric blood flow, thus decreasing absorption from the small intestine. DIF: C REF: 1177 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/ Elimination 18. Which of the following statements made by an older adult reflects the best understanding of the role of fiber regarding bowel patterns?

The more fiber I eat, the fewer problems I have with my bowels.

Whole grain cereal and toast for breakfast keeps my bowels moving regularly. My wife makes whole grain muffins; they are really good and good for me too.

3 4

I use to have trouble with constipation until I started taking a fiber supplement.

ANS: 2 The bowel walls are stretched, creating peristalsis and initiating the defecation reflex. By stimulating peristalsis, bulk foods pass quickly through the intestines, keeping the stool soft. Ingestion of a high-fiber diet improves the likelihood of a normal elimination pattern if other factors are normal. The other options are not as specific about the role of fiber, or they fail to provide an example of a high-fiber food. DIF: C REF: 1177 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/ Elimination 19. Which of the following statements made by an older adult reflects the best understanding of the role of fiber regarding good bowel health?

Fiber is very effective at cleaning out the bowels.

A high-fiber diet results in softer bowel movements.

Passing hard, dry stool is more uncomfortable and harder on the bowels.

The more fiber there is in my diet, the less risk I have of developing polyps.

ANS: 4 When there is no fiber to transport waste matter through the colon, it increases the risk for polyps. Although the other options are not incorrect, they do not address the most important barrier to good bowel health. DIF: C REF: 1177 OBJ: Analysis TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/ Elimination 20. The nurse is discussing food allergies with a group of mothers whose children are allergy prone. Which of the following statements made by the nurse best describes lactose intolerance?

If milk causes diarrhea, cramps, or gas, it might be an intolerance of lactose.

You dont have to be allergic to dairy for it to cause you problems.

Allergies to milk can be very dangerous, even life threatening.

Many children outgrow their intolerance of dairy lactose.

ANS: 1 Food intolerance is not an allergy, but a particular food that causes the body distress within a few hours of ingestion. The result is diarrhea, cramps, or flatulence. For example, people who drink cows milk who have these symptoms are not allergic to milk but lack the enzyme needed to digest the milk sugar lactose; they are lactose intolerant. DIF: C REF: 1177 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/ Elimination 21. The nurse is discussing food allergies with a group of mothers whose children are allergy prone. Which of the following statements made by a mother best describes lactose intolerance?

My child is allergic to milk; it makes her very gassy.

Dairy products require a special enzyme to be digested properly.

Being lactose intolerant means my child cant tolerate dairy products. My child gets diarrhea from dairy products because she cant digest lactose.

ANS: 4 Food intolerance is not an allergy, but a particular food that causes the body distress within a few hours of ingestion. The result is diarrhea, cramps, or flatulence. For example, people who drink cows milk who have these symptoms are not allergic to milk but lack the enzyme needed to digest the milk sugar lactose; they are lactose intolerant. To be lactose intolerant (exhibiting the

signs after ingesting dairy products) does not constitute a dairy allergy. The remaining options are not as specific as the answer. DIF: C REF: 1177 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/ Elimination 22. An adult client reports to the nurse that she has been experiencing constipation recently and is interested in any suggestions regarding dietary changes she might make. Which of the following suggestions provided by the nurse is most likely to minimize the clients complaint?

1 2 3 4

Have you tried foods like prunes and bran? You might find the new flavored bulk laxatives helpful. What have you tried in the past that hasnt been helpful? Increase your fluid intake; have some juice with breakfast.

ANS: 4 Unless there is a medical contraindication, an adult needs to drink six to eight glasses (1500 to 2000 mL) of noncaffeinated fluid daily. An increase in fluid intake with the use of fruit juices softens stool and increases peristalsis. Poor fluid intake increases the risk for constipation because of reabsorption of fluid in the colon, resulting in hard, dry stools. Although some of the options are food related, they are not as direct; a laxative is not a dietary change. DIF: C REF: 1178 OBJ: Analysis TOP: Nursing Process: Physiological Integrity/Basic Care and Comfort/Elimination MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/ Elimination 23. A client who is 2 days postoperative reports feeling constipated to the nurse. The client has good bowel sounds in all four quadrants and has tolerated liquids well. Her pain is being controlled with an opioid analgesic. Which of the following interventions should the nurse try initially?

Let me get you some apple juice.

Ambulating may get your bowels moving.

Ill see about getting a different pain medication.

Your health care provider might prescribe an enema if I call.

ANS: 1

An increase in fluid intake with the use of fruit juices softens stool and increases peristalsis. The remaining interventions are not inappropriate, but they are not the initial intervention for such a complaint. DIF: B REF: 1178 OBJ: Application TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/ Elimination 24. Which of the following statements by a client reporting constipation reflects the most informed understanding of interventions that will aid in assuming proper bowel mobility?

Could it be that I need to get more exercise, even here in the hospital?

Is it true that drinking coffee often helps stimulate the bowels to work?

I guess a little high-fiber cereal might help. Can you get me some from the cafeteria?

May I have a cup of decaffeinated tea in addition to my breakfast juice? That usually helps.

ANS: 4 Unless there is a medical contraindication, an adult needs to drink six to eight glasses (1500 to 2000 mL) of noncaffeinated fluid daily. An increase in fluid intake with the use of fruit juices softens stool and increases peristalsis. Poor fluid intake increases the risk for constipation because of reabsorption of fluid in the colon, resulting in hard, dry stools. Although the other options are not incorrect, the client does not seem to have past experience with these suggestions. DIF: C REF: 1177-1178 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/ Elimination 25. A client is caring for her husband who recently experienced a cerebral vascular accident. She tells the home care nurse that she has been very anxious lately about all the added responsibilities. She adds that she has not been sleeping well and has had several bouts of diarrhea. Which of the following statements by the nurse focuses on the most likely cause of the gastrointestinal problem?

Have you experienced increased gas and cramping in addition to the diarrhea?

You are under a lot of stress; that can affect your bowels and result in diarrhea.

I suggest you get some over-the-counter medication and keep it on hand to manage those bouts. Have you been eating a well-balanced diet since you brought your husband home?

ANS: 2 During emotional stress the digestive process is accelerated, and peristalsis is increased. Side effects of increased peristalsis are diarrhea and gaseous distention. The remaining options are focused on the most likely cause of the problem, or they are focused on treatment, not cause. DIF: C REF: 1178 OBJ: Analysis TOP: Nursing Process: Analysis MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/ Elimination 26. A client is caring for her daughter, who recently suffered multiple fractures in an automobile accident. The client tells the home care nurse that she has been really down since all this happened. She adds that she has been constipated and not really interested in eating. Which of the following statements by the nurse focuses on the most likely cause of the gastrointestinal problem?

1 2 3 4

Actually, how long have you been constipated? Are you eating fiber-rich foods like fruit and whole grains? You may be depressed; emotional depression can cause constipation. I suggest you get some over-the-counter mild laxative and see if that helps.

ANS: 3 If a person becomes depressed, the autonomic nervous system slows impulses, and peristalsis decreases, resulting in constipation. Although the other options are not incorrect, they are not the most likely cause for this particular client. DIF: C REF: 1178 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/ Elimination

27. A 70-year-old client is discussing his recent difficulty with having regular bowel movements while on a cross-country bus tour with a senior citizens group. Which of the following assessment questions is directed toward the most likely cause of the problem?

Did the bus stop frequently so you could get up and walk around? Did you eat enough fiber while you were on the trip? Do you find using public restrooms unsettling?

Do you have any chronic bowel-related problems?

ANS: 3 Attempting to eliminate in a public restroom sometimes results in a temporary inability to defecate. This embarrassment may prompt clients to ignore the urge to defecate, which begins a vicious cycle of constipation and discomfort. Although the remaining options may affect bowel elimination, the situation of the scenario strongly suggests an emotional cause. DIF: C REF: 1178 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/ Elimination 28. The nurse is caring for a 19-year-old male client with a fractured left femur whose leg was pinned 36 hours ago and is now in traction. Which of the following stressors is mostly likely the cause of this clients difficulty related to constipation?

Pain related to the fracture and its repair

Anxiety regarding the serious nature of the injury

The need to defecate in an unfamiliar, awkward position

Poor fluid intake after the accident and ensuing surgery

ANS: 3 For the client immobilized in bed, defecation is often difficult. In a supine position it is impossible to contract the muscles used during defecation. If the clients condition permits, raise the head of the bed; this assists the client to a more normal sitting position on a bedpan, enhancing the ability to defecate. Although the other options may have some effect, the primary cause is most likely the emotional stress of not being able to assume the usual position for defecation. DIF: C REF: 1178 OBJ: Analysis TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/ Elimination 29. A client who was recently diagnosed with anemia and rheumatoid arthritis reports to the nurse that she has noticed that her stool is black, and she is concerned because there is a history of colon cancer in her family. Which of the following assessment questions is most likely to provide information regarding this clients bowel problem?

What medications are you currently on?

When did you have your last colonoscopy?

Does the arthritis severely impair your mobility?

Would you like to have the stool tested for occult blood?

ANS: 1 Ingestion of iron, commonly prescribed for certain types of anemia, causes discoloration of the stool (black), nausea, vomiting, constipation (diarrhea is less commonly reported), and abdominal cramps. The remaining options, although focusing on aspects of function that could result in constipation, are not focused on the most likely cause in this scenario. DIF: C REF: 1190 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/ Elimination 30. Which of the following statements made by a nurse discussing the effect of an antibiotic on the gastrointestinal system reflects the best understanding of the possible occurrence of diarrhea?

The GI tract naturally rids itself of bacterial toxins by increasing peristalsis, and that causes diarrhea.

The antibiotic is responsible for killing off the GI tracts normal bacterial, and diarrhea is the result. For some, antibiotics irritate the mucous lining of the intestines, causing decreased absorption and diarrhea.

3 4

When you are taking an antibiotic, your body is fighting off an infection, and peristalsis is faster and so diarrhea occurs.

ANS: 2 Antibiotics inadvertently produce diarrhea by disrupting the normal bacterial flora in the GI tract. The remaining options are not necessarily true. DIF: A REF: 1179 OBJ: Comprehension

TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/ Elimination 31. A client is reporting that the oral medication she was prescribed for her hypothyroidism does not seem to be helping. The client goes on to report that she has been experiencing tensionrelated headaches and constipation. She has been self-medicating with nonsteroidal antiinflammatory drugs (NSAIDs) and bulk laxatives. Which of the following assessment questions is most likely to provide information regarding this clients concern regarding her thyroid problem?

How long have you taken Synthroid?

What other medications are you currently on?

How long have you been taking a bulk laxative?

Have you developed any other gastrointestinal symptoms?

ANS: 3 Laxatives often influence the efficacy of other medications by altering the transit time (i.e., the time the medication remains in the GI tract and is available for absorption). The remaining options would have little bearing on the effectiveness of the hypothyroid medication unless the medication has not been taken long enough to reach therapeutic levels. DIF: C REF: 1178 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/ Elimination 32. The nurse is assessing a cognitively impaired older adult client and observes a leaking of liquid stool from the rectum. The nurses initial intervention for this client is to:

Determine if the client has been eating sufficiently, especially fiber-rich foods

Determine how long it has been since the client had a normalsize, formed stool

Perform a digital examination of the rectum to determine the presence of stool Call the health care provider to get a prescription for an antidiarrheal medication

ANS: 1

When a continuous oozing of diarrhea stool occurs, suspect impaction. The liquid portion of feces located higher in the colon seeps around the impacted mass. An obvious sign of impaction is the inability to pass a stool for several days, despite the repeated urge to defecate. The digital examination should be performed after it has been determined that the client has been without a normal bowel movement for several days. Although the remaining options are not inappropriate, they would not be the initial intervention. DIF: B REF: 1179 OBJ: Application TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/ Elimination 33. The greatest risk for injury for a client who has fecal incontinence is:

1 2 3 4

Perineal and rectal skin breakdown The contamination of existing wounds Falls resulting from attempts to reach the bathroom Cross-contamination into the upper gastrointestinal tract

ANS: 1 Fecal incontinence is a potentially dangerous condition in terms of contamination and risk for skin ulceration. The greatest risk to the otherwise healthy individual is skin breakdown. Although the other options may be risk factors, they are not as great as that of skin breakdown. DIF: C REF: 1181 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/ Elimination 34. The nurse is providing ancillary personnel with instructions regarding the proper methods to implement when caring for a client with a Clostridium difficile infection. Which of the following practices will have the greatest impact on containment of the bacteria and thus prevention of cross-contamination?

Frequent in-services on transmission modes of C. difficile

Practice of proper hand hygiene by all staff

Appropriate handling of contaminated linen Stool cultures on all suspected carriers

4 ANS: 2

Poor hand hygiene and erratic disinfection practices result in the transmission of C. difficile. Stool cultures are useful in the diagnosis, not the prevention, of C. difficile. Although the other options are appropriate, they do not have the most impact on preventing the spread of these bacteria. DIF: C REF: 1180 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/ Elimination 35. Which of the following clients is at greatest risk for serious complications when using the Valsalva maneuver to expel feces?

1 2

25-year-old pregnant client 66-year-old male with hypertrophied prostate disease

44-year-old male client with glaucoma

53-year-old female with stomach cancer

ANS: 3 Clients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk, such as cardiac irregularities and elevated blood pressure, with this maneuver and need to avoid straining to pass the stool. Although the Valsalva maneuver may contribute to hemorrhoids, this is not as serious as increasing the intraocular pressure of a client with glaucoma. The Valsalva maneuver is not contraindicated in a client with hypertrophied prostate disease or in a client with stomach cancer. DIF: A REF: 1179 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation Physiological Integrity/Basic Care and Comfort/Elimination 36. The mother of an 18-month-old male client shares with the nurse that she is trying to get her child to tell her when he needs to have a bowel movement. Which of the following statements is the most appropriate response from the nurse?

Im sure that you will be glad to have your son out of diapers.

I once heard of a child who was totally potty-trained by the time he was a year old. Development of neuromuscular control of the bowels doesnt normally occur until a child is between 2 and 3 year of age.

3 4

You will have to really be persistent about taking him to the bathroom frequently in order to be successful.

ANS: 3 Developmental changes affecting elimination occur throughout life. The infant is unable to control defecation because of a lack of neuromuscular development. This development usually does not take place until 2 to 3 years of age. DIF: A REF: 1177 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation Physiological Integrity/Basic Care and Comfort/Elimination 37. The 35-year-old pregnant client is concerned about constipation. When weighing the advantages and disadvantages of having a local anesthetic over a general anesthetic for a caesarian section, the nurse shares with the client that the local will cause less risk for constipation following surgery. The best reason that there is less constipation following this surgery is because:

The client will not have to be allowed nothing by mouth (NPO) before surgery

The client will be able to ambulate immediately following surgery

The client will be able to eat following surgery

Local or regional anesthetic often has little or no effect on bowel activity

ANS: 4 The client who receives a local or regional anesthetic is less at risk for elimination alterations because this often affects bowel activity minimally or not at all whereas general anesthetic agents used during surgery cause temporary cessation of peristalsis, which can result in constipation. The client will still need to remain NPO before a scheduled caesarian section in case she would need to receive a general anesthetic. The client will not be able to ambulate immediately after surgery because of loss of feeling in the lower extremities. Clients should be able to eat following nonbowel-related surgery whether or not they have undergone a general anesthetic or a local anesthetic. DIF: A REF: 1178 OBJ: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation Physiological Integrity/Basic Care and Comfort/Elimination 38. A 44-year-old male client was placed on a daily low-dose aspirin regimen by his health care provider following a recent diagnosis of hypertension and periodic atrial fibrillation. The client is currently hospitalized with renal stones. As the nurse is admitting the client, he shares that he has

been very tired. The nurse gathers additional data regarding his bowel habits. The client shares that he has recently had black, tarry stools. The nurse is most concerned that the client may have:

1 2 3 4

Colon cancer A GI bleed from the aspirin therapy Ongoing atrial fibrillation Electrolyte imbalance

ANS: 2 Although the client could have any one of the items mentioned, it is most likely that the aspirin is causing a GI bleed. The loss of blood can cause the client to be fatigued. Aspirin is a prostaglandin inhibitor, which interferes with the formation and production of protective mucus and causes GI bleeding. DIF: C REF: 1179 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation Physiological Integrity/Basic Care and Comfort/Elimination 39. The nurse is counseling a 65-year-old female client on her use of mineral oil as a laxative. One of the most important things that the nurse can share with the client is how mineral oil can cause the decreased absorption of which of the following vitamins?

Vitamin C

Niacin

Vitamin D Riboflavin

ANS: 3 Mineral oil, a common laxative, decreases fat-soluble vitamin absorption. Vitamin D is the only fat soluble vitamin listedthe others are all water-soluble. DIF: A REF: 1178 OBJ: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation Physiological Integrity/Basic Care and Comfort/Elimination 40. An active 25-year-old female client shared with the nurse that ever since she had gone on a high-protein low-carbohydrate diet she had suffered from constipation. The client states that the diet is working for her in terms of weight loss and would like to stay on it. The best response from the nurse is that the client should try:

Consuming more low-carbohydrate fiber-rich foods like broccoli, raspberries, blackberries, and asparagus Taking a laxative when feeling constipated Try a different diet with less tendency to cause constipation

Exercise more

ANS: 1 A low-fiber diet high in animal fats (e.g., meats, dairy products, eggs) can slow peristalsis, leading to constipation. By consuming fiber-rich low-carbohydrate foods, the client can still maintain weight loss while avoiding constipation. The client could develop a dependence on laxatives by using them on a regular basis. The client has expressed a desire to remain on the diet she is currently on, and it seems to be working to help her lose weight. Because client is already active, additional activity is not likely to have a profound effect on relieving the constipation. DIF: A REF: 1177 OBJ: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation Physiological Integrity/Basic Care and Comfort/Elimination 41. The nurse knows that the client receiving enteral feedings is at risk for diarrhea. One of the measures that the nurse can take to minimize the risk for diarrhea in this client is:

Making sure to chill the canned feeding before administering

Using strict sanitation when administering the formula

Not deviating from the prescribed rate of delivery for the formula

Not diluting or changing the strength of the prescribed formula

ANS: 2 Interventions to prevent diarrhea include the following: administer canned formulas at room temperature, follow strict sanitation when preparing the formula, increase the rate slowly, administer the volume at a rate tolerable to your client, or if using a hypertonic solution, give the initial feeding at half strength and gradually increase the volume to allow the client to adjust to a hypertonic solution. Consult a dietitian when diarrhea occurs. DIF: A REF: 1180 OBJ: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation Physiological Integrity/Basic Care and Comfort/Elimination 42. Upon auscultation of the clients abdomen, the nurse hears hyperactive bowel sounds (greater than 35 per minute). The nurse knows that this can indicate which of the following?

Paralytic ileus

2 3

Fecal impaction Small intestine obstruction

Abdominal tumor

ANS: 3 Absent (no auscultated bowel sounds) or hypoactive sounds (less than five sounds per minute) occur with paralytic ileus, such as after abdominal surgery. High-pitched and hyperactive bowel sounds (35 or more sounds per minute) occur with small intestine obstruction and inflammatory disorders. DIF: A REF: 1187 OBJ: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation Physiological Integrity/Basic Care and Comfort/Elimination 43. The health care provider has ordered a stool specimen for ova and parasites from the 43-yearold male client. The nurse knows that when collecting the specimen the stool must be:

Kept on ice

Kept warm

Collected using sterile technique Free from urine

ANS: 2 It is important to avoid delays in sending specimens to the laboratory. Some tests such as measurement for ova and parasites require the stool to be warm. The specimen need not be collected using sterile technique, because the laboratory will not be testing the sample for bacteria, but it should be collected with good sanitation practices. Likewise, a small amount of urine should not alter the test results. Chapter 48. Skin Integrity and Wound Care MULTIPLE CHOICE 1. The nurse determines that the clients wound may be infected. To perform an aerobic wound culture, the nurse should:

Collect the superficial drainage

Collect the culture before cleansing the wound

Obtain a culturette tube and use sterile technique Use the same technique as for collecting an anaerobic culture

ANS: 3 The nurse uses different methods of specimen collection for aerobic or anaerobic organisms. To collect an aerobic wound culture, the nurse uses a sterile swab from a culturette tube and sterile technique. The nurse never collects a wound culture sample from old or superficial drainage. Resident colonies of bacteria from the skin grow in superficial drainage and may not be the true causative organisms of a wound infection. The nurse should clean a wound first with normal saline to remove skin flora before obtaining the culture. DIF: A REF: 1299 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems 2. Pressure ulcers form primarily as a result of:

1 2 3 4

Nitrogen buildup in the underlying tissues Prolonged illness or disease Tissue ischemia Poor nutrition

ANS: 3 Pressure is the major cause of pressure ulcer formation. Prolonged, intense pressure affects cellular metabolism by decreasing or obliterating blood flow, resulting in tissue ischemia and ultimately tissue death. Prolonged illness or disease and poor nutrition may place a client at risk for pressure ulcer development. DIF: A REF: 1280 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems 3. The nurse notes a clients skin is reddened with a small abrasion and serous fluid present. The nurse should classify this stage of ulcer formation as:

Stage I

Stage II

Stage III

Stage IV

ANS: 2

This description is consistent with a stage II pressure ulcer. A stage II pressure ulcer is defined as partial-thickness skin loss involving the epidermis and/or dermis. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. A stage I pressure ulcer is an observable pressure-related alteration of intact skin whose indicators may include changes in one or more of the following: skin temperature, tissue consistency, and/or sensation. A stage III pressure ulcer has full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. A stage IV pressure ulcer has fullthickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. DIF: A REF: 1282 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems 4. The client has rheumatoid arthritis, is prone to skin breakdown, and is also somewhat immobile because of arthritic discomfort. Which of the following is the best intervention for the clients skin integrity?

Having the client sit up in a chair for 4-hour intervals

Keeping the head of the bed in a high-Fowlers position to increase circulation Keeping a written schedule of turning and positioning

3 4

Encouraging the client to perform pelvic muscle training exercises several times a day

ANS: 3 The frequency of repositioning should be individualized for the client; however, clients should be repositioned at least every 2 hours. The Agency for Healthcare Research and Policy (AHRQ) guidelines recommend that a written turning and positioning schedule be used. Clients able to sit in a chair should be limited to sitting for 2 hours or less. Elevating the head of the bed to 30 degrees or less will decrease the chance of pressure ulcer development from shearing forces. Pelvic muscle training may help prevent incontinence, but it is not the best intervention for maintaining the clients skin integrity. DIF: A REF: 1304 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems 5. Upon changing the clients dressing, the nurse notes that the wound appears to be granulating. An appropriate noncytotoxic cleansing agent selected by the nurse is:

Sterile saline

2 3

Hydrogen peroxide Povidone-iodine (Betadine)

Sodium hypochlorite (Dakins solution)

ANS: 1 Pressure ulcers should be cleansed only with wound cleansers that are not cytotoxic, such as normal saline. Normal saline will not damage or kill cells, such as fibroblasts and healing tissue. Hydrogen peroxide, povidone-iodine (Betadine), and sodium hypochlorite (Dakins solution) are cytotoxic and therefore should not be used to clean a wound that is granulating. DIF: A REF: 1307 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems 6. A client requires wound debridement. The nurse is aware that which one of the following statements is correct regarding this procedure?

It allows the healthy tissue to regenerate.

When performed by autolytic means, the wound is irrigated.

Mechanical methods involve direct surgical removal of the eschar layer of the wound.

Enzymatic debridement may be implemented independently by the nurse whenever it is required.

ANS: 2 Removal of necrotic tissue is necessary to rid the ulcer of a source of infection, to enable visualization of the wound bed, and to provide a clean base necessary for healthy tissue to regenerate. Autolytic debridement uses synthetic dressings over a wound to allow the eschar to be self-digested by the action of enzymes that are present in wound fluids. The wound is not irrigated. Mechanical methods include wet-to-dry dressings, wound irrigation, and whirlpool treatments. Surgical debridement involves direct surgical removal of the eschar layer of the wound. Enzymatic debridement requires a health care providers order. DIF: A REF: 1307 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems

7. The nurse prepares to irrigate the clients wound. The primary reason for this procedure is to:

1 2

Decrease scar formation Remove debris from the wound

Improve circulation from the wound

Decrease irritation from wound drainage

ANS: 2 The gentle washing action of the irrigation cleanses a wound of exudate and debris. The primary purpose of wound irrigation is not to improve circulation, decrease scar formation, or decrease irritation from wound drainage, but to remove debris from the wound. DIF: A REF: 1307 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems 8. When turning a client, the nurse notices a reddened area on the coccyx. What skin care interventions should the nurse use on this area?

Clean the area with mild soap, dry, and add a protective moisturizer.

Apply a dilute hydrogen peroxide and water mixture and use a heat lamp to the area.

Soak the area in normal saline solution. Wash the area with an astringent and paint it with povidoneiodine (Betadine).

ANS: 1 The skin should be cleansed and completely dried and a protective moisturizer applied to keep the epidermis well lubricated. Hydrogen peroxide is cytotoxic and should not be used. A heat lamp is not necessary and would increase the clients risk for an accidental burn. The area should not be soaked because this may lead to maceration of the skin. The area should not be cleansed with an astringent and painted with povidone-iodine. An astringent may cause excessive drying of the tissue, and povidone-iodine is cytotoxic. DIF: A REF: 1304 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems

9. A client with a large abdominal wound requires a dressing change every 4 hours. The client will be discharged to the home setting, where the dressing care will be continued. Which of the following is true concerning this clients wound healing process?

An antiseptic agent is best followed with a rinse of sterile saline solution.

A heat lamp should be used every 2 hours to rid the wound area of contaminants. Sterile technique should be emphasized to the client and family.

3 4

A dressing covering will allow the wound area to remain moist.

ANS: 4 A dressing should support a moist wound environment if the wound is healing by secondary intention, such as with a large abdominal wound. A moist wound base facilitates the movement of epithelialization, thus allowing the wound to resurface as quickly as possible. Only mild soap may be used or saline. Antiseptics may be damaging to granulation tissue. A heat lamp should not be used because it will dry out the wound and impair the movement of epithelialization. Clean dressings may be used in the home setting. DIF: A REF: 1312 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems 10. Upon inspection of the clients wound, the nurse notes that it appears infected and has a large amount of exudate. An appropriate dressing for the nurse to select based on the wound assessment is:

Foam

Hydrogel

Hydrocolloid

Transparent film

ANS: 1 A foam dressing absorbs exudate and debris while maintaining a moist environment. Topical agents, such as antibiotic ointment, may also be used with a foam dressing. This would be the most appropriate type of dressing for this wound. A hydrogel dressing provides moisture to a

clean granular wound. A hydrocolloid dressing interacts with the wound fluid to provide a moist environment. Transparent film protects from friction injury and may be left in place up to 7 days. DIF: A REF: 1313 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems 11. A client has a healing abdominal wound. The wound has minimal exudate and collagen formation. The wound is identified by the nurse as being in which phase of healing?

1 2

Primary intention Inflammatory phase

Proliferative phase

Secondary intention

ANS: 3 During the proliferative phase, the wound fills with granulation tissue (including collagen formation), the wound contracts, and the wound is resurfaced by epithelialization. Primary intention is not a phase of wound healing. Wounds that heal by primary intention have minimal tissue loss, such as a surgical wound. The edges are approximated and the risk for infection is low. During the inflammatory phase, platelets gather to stop bleeding, a fibrin matrix forms, and white blood cells reach the wound, clearing it of debris. Secondary intention is not a phase of wound healing. Wounds that heal by secondary intention have loss of tissue, such as a pressure ulcer. The wound is left open until it becomes filled by scar tissue. DIF: A REF: 1286 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems 12. A client comes to the emergency department following an injury. The nurse implements appropriate first aid for the client when:

Removing any penetrating objects

Elevating an affected part that is bleeding

Vigorously cleaning areas of abrasion or laceration

Keeping any puncture wounds from bleeding

ANS: 2

If a client is bleeding, the nurse applies direct pressure and elevates the affected part. When a penetrating object is present, it is not removed. Removal could cause massive, uncontrolled bleeding. Vigorous cleaning can cause bleeding or further injury. Abrasions and minor lacerations should be rinsed with normal saline and lightly covered with a dressing. Puncture wounds are allowed to bleed to remove dirt and other contaminants. DIF: A REF: 1311 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems 13. The nurse is concerned that the clients midsternal wound is at risk for dehiscence. Which of the following is the best intervention to prevent this complication?

Administering antibiotics to prevent infection

Using appropriate sterile technique when changing the dressing

Keeping sterile towels and extra dressing supplies near the clients bed

Placing a pillow over the incision site when the client is deep breathing or coughing

ANS: 4 A strategy to prevent dehiscence is to use a folded thin blanket or pillow placed over an abdominal wound when the client is coughing. This provides a splint to the area, supporting the healing tissue when coughing increases the intraabdominal pressure. A client who has an infection is at risk for poor wound healing and dehiscence. However, prophylactic use of antibiotics is not the best intervention to prevent dehiscence. Using appropriate sterile technique is always important to prevent the development of infection but is not the best intervention to prevent dehiscence. DIF: A REF: 1287 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems 14. Following a head injury, the client has thin drainage coming from the left ear. The nurse describes this drainage as:

Serous

2 3

Purulent Cerebrospinal fluid

Serosanguineous

ANS: 1 Serous drainage is clear, watery plasma. Purulent drainage is thick, yellow, green, tan, or brown. Drainage must be tested to determine if it is cerebrospinal fluid. The nurse should describe the drainage by its appearance (i.e., serous). Serosanguineous drainage is pale, red, and watery, a mixture of clear and red fluid. DIF: A REF: 1287 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems 15. Which nursing entry is most complete in describing a clients wound?

Wound appears to be healing well. Dressing dry and intact.

Wound well approximated with minimal drainage.

Drainage size of quarter; wound pink, 4 4s applied. Incisional edges approximated without redness or drainage; two 4 4s applied.

ANS: 4 This is the most complete description of the clients wound. It describes the wound according to characteristics observed and the dressing that covers it. Wounds should be measured using the metric system, not described as the size of objects. DIF: A REF: 1307 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems 16. The nurse recognizes that skin integrity can be compromised by being exposed to body fluids. The greatest risk exists for the client who has exposure to:

Urine

Purulent exudates

Pancreatic fluids

Serosanguineous drainage

ANS: 3 Exposure to gastric and pancreatic drainage has the highest risk for skin breakdown. Exposure to urine, bile, stool, acetic fluid, and purulent wound exudates carries a moderate risk for skin breakdown. Serosanguineous drainage is not caustic to the skin, and the risk for skin breakdown from exposure to this fluid is low. DIF: A REF: 1287 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems 17. The client is scheduled for a dressing change. When removing the adhesive tape used to secure the dressing, the nurse should lift the edge and hold the tape:

1 2 3 4

At a 45-degree angle to the skin surface while pulling away from the wound At a right angle to the skin surface while pulling toward the wound At a right angle to the skin surface while pulling away from the wound Parallel to the skin surface while pulling toward the wound

ANS: 4 To remove tape safely, the nurse loosens the tape ends and gently pulls the outer end parallel with the skin surface toward the wound. Tape should not be pulled in a direction away from the wound because this may cause the wound edges to separate. Holding the tape at a right angle to the skin surface may pull on the wound bed, causing separation of wound layers, or may damage the underlying skin. DIF: A REF: 1320 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems 18. When cleaning a wound, the nurse should:

Wash over the wound twice and discard that swab

Move from the outer region of the wound toward the center

3 4

Start at the drainage site and move outward with circular motions Use an antiseptic solution followed by a normal saline rinse

ANS: 3 To cleanse the area of an isolated drain site, the nurse cleans around the drain, moving in circular rotations outward from a point closest to the drain. The nurse never uses the same piece of gauze or swab to cleanse across an incision or wound twice. The wound should be cleansed in a direction from the least contaminated area, such as from the wound to the surrounding skin. The wound is cleaned from the center region to the outer region. An antiseptic solution is not used to clean a wound, as it may be cytotoxic. DIF: A REF: 1324 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems 19. The client has a large, deep wound on the sacral region. The nurse correctly packs the wound by:

Filling two thirds of the wound cavity

Leaving saline-soaked folded gauze squares in place

Putting the dressing in very tightly

Extending only to the upper edge of the wound

ANS: 4 The wound should be packed only until the packing material reaches the surface of the wound. Wound packing that overlaps onto the wound edges can cause maceration of the tissue surrounding the wound. It can also impede the proper healing and closing of the wound. The wound should be packed to the upper edge of the wound to prevent dead space and the formation of abscesses. The gauze should be saturated with the prescribed solution, wrung out, unfolded, and lightly packed into the wound. The wound should not be packed too tightly. Overpacking the wound may cause pressure on the tissue in the wound bed. DIF: A REF: 1319 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems 20. The nurse is aware that application of cold is indicated for the client with:

Menstrual cramping

An infected wound

A fractured ankle Degenerative joint disease

ANS: 3 Direct trauma such as fractures or sprains may be treated with cold. The application of cold can initially diminish swelling and pain. Application of heat to reduce muscle tension and reduce pain would be more appropriate for the client with menstrual cramping. The application of cold is not indicated for the client with an infected wound because it reduces the blood flow to the area. This would limit the number of macrophages to clear the area of bacteria and would lessen the nutrient supply to the already impaired tissue. The effects of heat application would be more beneficial to the client with degenerative joint disease. DIF: A REF: 1335 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems 21. The client has a stage IV pressure ulcer. In accordance with the Agency for Healthcare Research and Quality (AHRQ), the nurse recommends that the client should have a(n):

Foam mattress Air-fluidized bed

Rotokinetic bed

Static support surface

ANS: 2 Air-fluidized beds are recommended for clients with burns or multiple stage III or stage IV pressure ulcers. A foam mattress is recommended for pressure reduction in clients at high risk for developing a pressure ulcer. A Rotokinetic bed is recommended for clients who are at risk for or have developed atelectasis and/or pneumonia. A static support surface is not recommended for a client with a stage IV ulcer. It is used for clients at high risk for developing a pressure ulcer. DIF: A REF: 1305 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems 22. The nurse uses the Norton scale in the extended care facility to determine the clients risk for pressure ulcer development. Which one of the following scores, based on this scale, places the client at the highest level of risk?

ANS: 1 According to the Norton scale, a lower score indicates a higher risk for pressure ulcer development. The total score ranges from 5 to 20. The client at highest risk would be the client with a score of 6. DIF: A REF: 1288 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems 23. The client requires support, and an abdominal binder is ordered. The nurse correctly implements the use of a binder by:

Using it as a replacement for underlying dressings

Keeping it loose for client comfort

Having the client sit or stand when it is applied

Making sure the client has adequate ventilatory capacity

ANS: 4 After applying the binder, the nurse should assess the clients ability to ventilate properly, including deep breathing and coughing. Wounds should be entirely covered with dressings; the binder is applied over the dressing. The binder should not be loose, or it will be ineffective in providing support. The client should be lying supine with head slightly elevated and knees slightly flexed for application of the abdominal binder. DIF: A REF: 1328-1329 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems 24. The client is brought into the emergency department with a knife wound. The nurse correctly documents the clients wound as a(n):

Contusion wound

Clean wound

Acute wound

Intentional wound

ANS: 3 A client with a knife wound is an example of an acute wound. An acute wound is caused by trauma from a sharp object. A contusion is a closed wound caused by a blow to the body by a blunt object, resulting in a bruise. A clean wound is a wound that contains no pathogenic organisms, such as a closed surgical wound that does not enter the gastrointestinal, respiratory, or genitourinary system. An intentional wound is a wound resulting from therapy, such as a surgical incision. DIF: A REF: 1294 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems 25. The nurse is planning a program on wound healing and includes information that smoking influences healing by:

Suppressing protein synthesis

Creating increased tissue fragility

Depressing bone marrow function

Reducing functional hemoglobin in the blood

ANS: 4 Smoking reduces the amount of functional hemoglobin in the blood, thus decreasing tissue oxygenation. Antiinflammatory drugs suppress protein synthesis. Radiation creates tissue fragility. Chemotherapeutic drugs can depress bone marrow function. DIF: A REF: 1311 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems 26. To reduce pressure points that may lead to pressure ulcers, the nurse should:

Position the client directly on the trochanter when side-lying

2 3

Use a donut device for the client when sitting up Elevate the head of the bed as little as possible

Massage over the bony prominences

ANS: 3 Elevating the head of the bed to 30 degrees or less will decrease the chance of pressure ulcer development from shearing forces. The client should not be positioned directly on the trochanter because this can create pressure over the bony prominence. Donut-shaped cushions are contraindicated because they reduce blood supply to the area, resulting in wider areas of ischemia. Bony prominences should not be massaged. Massaging reddened areas increases breaks in the capillaries in the underlying tissues and increases the risk for injury to underlying tissue and pressure ulcer formation. DIF: A REF: 1302 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems 27. The client is experiencing low back pain and is to have an aquathermia pad applied. The nurse recognizes that safe application of heat to a clients injury includes:

1 2 3 4

Providing a timer for the client Allowing the client to adjust the temperature for comfort Placing the pad directly onto the area requiring treatment Using the highest temperature that is tolerated by the client

ANS: 1 An application should last only 20 to 30 minutes. Providing a timer for the client will help prevent injury to the tissue. The temperature setting is fixed by inserting a plastic key into the temperature regulator. In many institutions the central supply room sets the regulators to the recommended temperature. The nurse does not place the pad directly on the clients skin. To prevent injury, it should be covered with a thin towel or pillow case. The recommended temperature is 105 to 110 F. The pad should not be used at the highest temperature that is tolerated by the client. DIF: A REF: 1338 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems 28. In reviewing the clients nutritional intake, the nurse wants to recommend intake of foods that will specifically promote collagen synthesis and capillary wall integrity. The nurse suggests that the client eat:

Fish

Eggs

Liver

Citrus fruits

ANS: 4 Citrus fruits contain vitamin C, which is important in collagen synthesis, capillary wall integrity, and fibroblast function. Fish and eggs contain protein and vitamin E. Protein plays a role in neogenesis, collagen formation, and wound remodeling. Liver contains vitamin A, which is important in epithelialization and wound closure. DIF: A REF: 1310-1311 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems 29. A client on the medical unit is taking steroids and also has a wound from a minor injury. To promote wound healing for this client, the nurse recommends that which of the following be specifically added?

Iron

Folic acid

Vitamin A

B complex vitamins

ANS: 3 Vitamin A can reverse steroid effects on skin and delayed healing. Iron does not reverse the effects of steroids. It is important in the transport of oxygen. Folic acid does not reverse the effects of steroids. It is a B complex vitamin needed for DNA synthesis. The B complex vitamins do not reverse the effects of steroids. The B vitamins affect growth and stimulate appetite, lactation, and the gastrointestinal, neurological, and endocrine systems. DIF: A REF: 1310-1311 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems 30. When asked what the role of the skin is in maintaining homeostasis, the answer that reflects the greatest insight is:

Our body needs vitamin D, and without healthy skin we cannot utilize it into a form we can use.

Without skin we would not be able to enjoy the sense of touch that is so important to us as humans.

The skin is a barrier that is really quite good at keeping disease-causing pathogens from getting into our body. It is the pain with its pain receptors that alert us to danger so that we can take appropriate action in order to be safe.

ANS: 3 Although it is a sensory organ for pain, temperature, and touch and synthesizes vitamin D, its primary role is that of a protective barrier against disease-causing organisms. DIF: C REF: 1279 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems 31. The primary reason an older adult client is more likely to develop a pressure ulcer on the elbow as compared to a middle-age adult is:

A reduced skin elasticity is common in the older adult The attachment between the epidermis and dermis is weaker

The older client has less subcutaneous padding on the elbows

Older adults have a poor diet that increases risk for pressure ulcers

ANS: 3 Although all the options are related to causes of skin injury in older adults, the hypodermis decreases in size with age, and so the older client has little subcutaneous padding over bony prominences; thus they are more prone to skin breakdown. DIF: C REF: 1279 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems 32. Which of the following interventions is mostly likely to minimize the cause of a pressure ulcer on the left buttock of a client who is comatose?

Turn and position the client at least every 2 hours.

Use a lift sheet when moving the client up in the bed.

Change wet, soiled clothing as promptly as it is detected.

Keep the head of the clients bed elevated to less than 30 degrees.

ANS: 1 Pressure is the major cause in pressure ulcer formation, and changing the clients position to minimize the time spent in a particular position will be the best intervention to relieve the pressure. DIF: C REF: 1304 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems 33. Which of the following statements made by the nurse shows the greatest insight into the need to manage the risk factors that contribute to the formation of a pressure ulcer?

Her diet needs to include more protein and less sugary foods.

She needs to be moved more gently and with attention to her skin. We need to decrease the time she spends with the weight of her body resting on her hip

3 4

The urinary incontinency makes the risk for developing a pressure ulcer so much greater for her.

ANS: 3 Pressure is the major cause in pressure ulcer formation. Three pressure-related factors contribute to pressure ulcer development: (1) pressure intensity, (2) pressure duration, and (3) tissue tolerance. The remaining options, although related to contributing factors, do not address the primary factor, pressure. DIF: C REF: 1304 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems 34. Which of the following statements made by the nurse shows the most thorough understanding of the therapeutic value of testing a reddened area on the heel of a mobilityimpaired client for blanching?

If it blanches, the problem isnt too bad.

When it stays red, the damage is great.

Nonblanching hyperemia is a poor indictor of healing. Blanching denotes an attempt to deliver blood to the site.

ANS: 4 If the area blanches (turns lighter in color) and the erythema returns when you remove your finger, the hyperemia is transient and is an attempt to overcome the ischemic episode, thus called blanching hyperemia. If, however, the erythemic area does not blanch (nonblanching erythema) when you apply pressure, deep tissue damage is probable. DIF: C REF: 1280 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems 35. Which of the following nursing documentation best reflects the observable assessment of skin breakdown on the heel of an African American client?

2-cm area of scaly, dry skin located on the clients right heel.

2-cm area of nonblanching erythema located on the clients right heel.

2-cm area purplish blue in color surrounded by lighter-colored skin located on right heel.

2-cm area of blanching erythema located on the clients right heel; entire foot warm to the touch.

ANS: 3 In dark-skinned individuals areas of pressure appear darker than surrounding skin and have a purplish/bluish hue; the temperature of the area may be warm or cool to the touch. The remaining options use descriptives not applicable to the dark-skinned individual or less definite indicators. DIF: C REF: 1281 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems 36. When changing the soiled linen on the bed of a client who is comatose, the nurse notices a reddened, blanchable area approximately 2 cm in diameter on her left buttock. The nurses initial skin breakdown intervention is to:

Position the client on her right side

Finish providing fresh, dry linen to the clients bed

Include a 2-hour turning schedule in the clients care plan Measure the area in order to describe it in the nurses notes

ANS: 1 Pressure is the major cause in pressure ulcer formation, and changing the clients position to minimize the time spent in a particular position will be the best intervention to relieve the pressure. The remaining options are appropriate, but none has priority over proper positioning of the client. DIF: C REF: 1304 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems 37. Although all of the following represent poor transfer techniques, which is most likely to result in a shearing injury to the skin of an older adult client?

Only one staff member positioning an immobile client

Allowing the heels to be dragged as the client is being positioned

Failing to lower the head of the bed before moving the client upward

Neglecting to use a lift sheet when moving the client to the head of the bed

ANS: 3 Shear is the force exerted parallel to skin resulting from both gravity pushing down on the body and resistance (friction) between the client and a surface. The remaining options result in friction damage to the clients skin. DIF: C REF: 1281 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems 38. Which of the following clients has the greatest risk for friction-induced skin breakdown?

A client who is obese and is frequently incontinent of both urine and feces

A client who insists she is comfortable only when positioned on her left side

A client who is cognitively impaired and comforts herself by wringing her hands An immobile client who slides down in the recliner where he spends the morning hours

ANS: 3 A friction injury occurs in clients who are restless or in those who have uncontrollable movements or any repetitive skin-against-skin motion. The other options represent friction or moisture factors that contribute to skin breakdown. DIF: C REF: 1281 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems 39. A cognitively impaired client spends hours a day involuntarily wringing her hands. Which of the following interventions is the most therapeutic as a means of minimizing this clients risk for friction damage to her hands?

Placing thin cotton mitts on her hands

Frequently distracting her with conversation

Regularly reminding her to stop wringing her hands

Getting a prescription to minimize the compulsive behavior

ANS: 1 A friction injury occurs in clients who are restless or in those who have uncontrollable movements or any repetitive skin-against-skin motion. The remaining options are not as likely to be effective with a cognitively impaired client. DIF: C REF: 1281 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Potential for Risk Reduction/Potential for Alterations in Body Systems 40. Which of the following assessment findings is most representative of a stage II pressure ulcer?

A blister

Undermining

Nonblanchable redness Visible subcutaneous fat

ANS: 1 Stage II ulcers have partial-thickness skin loss involving the epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. The remaining options describe elements of stage I and stage III ulcers. Chapter 49. Sensory Alterations MULTIPLE CHOICE 1. During a community screening, the nurse informs a 50-year-old African American client about the frequency of eye examinations. It is recommended that individuals in this age-group have eye examinations:

Every 3 to 4 months

Every 6 months

Every 1 to 2 years

Every 4 years

ANS: 3 Clients between the ages of 40 and 64 should have an eye examination every 1 to 2 years if there is a family history of glaucoma or if the client is of African ancestry. DIF: A REF: 1355 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 2. With advancing age, which of the following normal physiological changes in sensory function occurs?

Decreased sensitivity to glare

2 3

Increased number of taste buds Difficulty discriminating vowel sounds

Decreased sensitivity to pain

ANS: 4

Older adults experience tactile changes, including declining sensitivity to pain, pressure, and temperature. Older adults have an increased sensitivity to glare. Older adults have a decreased number of taste buds. Older adults have difficulty discriminating the consonants (z, t, f, g) and high-frequency sounds (s, sh, ph, k). DIF: A REF: 1346 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 3. The nurse teaches a client that prolonged use of the antibiotic streptomycin may result in:

Damage to the auditory nerve

Alteration in perception

Optic irritation

Loss of taste

ANS: 1 Some antibiotics, such as streptomycin, gentamicin, and tobramycin, are ototoxic and can permanently damage the auditory nerve. Narcotic analgesics, sedatives, and antidepressant medications can alter the perception of stimuli. Chloramphenicol can irritate the optic nerve. DIF: A REF: 1351 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 4. Which of the following occupations poses the least risk for sensory alterations?

Waiter

Welder

Computer programmer

Construction worker

ANS: 1 The waiter is at least risk for sensory alterations. A welder is at risk for visual alterations. A computer programmer is at risk for peripheral nerve injury. A construction worker is at risk for hearing alterations. DIF: A REF: 1356 OBJ: Comprehension TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 5. The nurse is working with a client with a moderate hearing impairment. To promote communication with this client, the nurse should:

Use a louder tone of voice than normal

Use visual aids such as the hands and eyes when speaking

Approach a client quietly from behind before speaking

Select a public area to have a conversation

ANS: 2 To promote communication with the client who has a hearing impairment, the nurse should use visible expressions, such as speaking with the hands, face, or eyes. A normal tone of voice and inflections of speech should be used when communicating with a client with a hearing impairment. The nurse should get the clients attention and not startle the client when entering a room. The nurse should not approach a client from behind. It is best to select a quiet environment without background noise to facilitate communication when a client is hearing impaired. DIF: A REF: 1358 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 6. The client has hyperesthesia apparently associated with a neurological trauma. Which of the following is an appropriate nursing intervention in regard to the clients sense of touch?

Reminding the client of the need to have frequent tactile contact

Keeping the client loosely covered with sheets and blankets

Allowing the client to lie motionless Using touch as a form of therapy

ANS: 2 If a client is overly sensitive to tactile stimuli (hyperesthesia), the nurse must minimize irritating stimuli. Keeping bed linens loose to minimize direct contact with the client and protecting the skin from exposure to irritants are helpful measures. Frequent tactile contact is not an appropriate intervention for the client with hyperesthesia. Allowing the client to lie motionless is not an appropriate intervention for the client with hyperesthesia. Using touch as a form of therapy would not be an appropriate nursing intervention for the client with hyperesthesia.

DIF: A REF: 1357 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 7. The client has experienced a cerebral vascular accident (stroke) with resultant expressive aphasia. The nurse promotes communication with this client by:

Speaking very loudly and slowly

Speaking to the client on the unaffected side

Using a picture chart for the clients responses

Using hand gestures to convey information to the client

ANS: 3 For the client with aphasia, the nurse can communicate using a picture chart or communication board for the clients responses. The nurse should not speak loudly and slowly to the client with expressive aphasia. The client is able to understand; this may seem patronizing to the client. The nurse should not speak to the client on the unaffected side, as this will not improve communication. Using hand gestures to convey information to the client may be helpful for the client with receptive aphasia, not expressive aphasia. DIF: A REF: 1350 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 8. The client was working in the kitchen and was splashed in the face with a caustic cleaning agent. His eyes were affected, and he was brought to the hospital for treatment. After cleansing and evaluation, his eyes were bandaged. When assisting this client, who has temporary visual loss, to eat the nurse should:

Feed the client the entire meal

Allow the client to experiment with foods

Orient the client to the location of the foods on the plate Assign ancillary personnel to feed the client

ANS: 3 A meal tray can be set up as a clock. The visually impaired client can easily become oriented to the items after the nurse or family member explains each items location. This enables the client to perform self-care (feeding), which is essential for self-esteem. The client should be allowed to feed himself to maintain self-esteem. Allowing the client to experiment with foods is not

assisting the client in performing self-care. The client should be allowed to feed himself to maintain self-esteem. DIF: A REF: 1361 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 9. The nurse completes a safety assessment during a home visit to an older adult client. Of the following observations made by the nurse, the one that is of greatest concern for this client who has evidence of sensory impairment is:

1 2 3 4

Low-pile carpeting throughout the home A handrail on the stairs that extends the full length Higher wattage incandescent lighting in all the rooms The gray/black settings on the stove handles

ANS: 4 Sometimes settings on electrical appliances and equipment are only highlighted in black and white or shades of gray. Color contrasts help to distinguish settings. The greatest concern for safety for the client with sensory impairment is the gray/black setting on the stove handles. Lowpile carpeting helps to prevent falls. A handrail on the stairs that extends the full length is beneficial for preventing falls. Higher wattage incandescent lighting helps prevent glare and is an appropriate adaptation for visual loss. DIF: C REF: 1356 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 10. A client is legally blind in both eyes. Which of the following is the most appropriate statement for the nurse to make to the client regarding providing the client with assistance?

I will walk in front of you, and you can hold onto my belt.

I know that you must need me to be your sighted guide to get around in this facility. I will warn you of upcoming curbs or stairs.

3 4

ANS: 3

I will get you a wheelchair so that I can move you around safely.

To assist the client who is legally blind, the nurse should warn the client when approaching doorways or narrow spaces, including upcoming curbs or stairs. To assist the client who is legally blind, the nurse should walk one-half step ahead and slightly to the side of the visually impaired person. The client can place his or her hand on the nurses forearm. Often sensorially impaired clients can help themselves, and it is essential that they do so for self-esteem. The client who is able should be encouraged to ambulate. DIF: A REF: 1360 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 11. A 79-year-old client drives his car in the local areas near his home. The most appropriate driving tip for the nurse to give this client is:

Go very, very slow so you will have some chance of reacting

2 3

Take your time on long road trips when you are by yourself Remember to keep your car maintained with regular checkups

To avoid sun glare, you should drive at night

ANS: 3 A safety tip the nurse can share with this client is to keep the car in good working condition. The nurse should advise the client to go slow, but not too slow, for safety. The nurse can offer the driving tip to drive in familiar areas, not on long road trips by himself or herself. The client should be advised to avoid driving at dusk or at night. DIF: A REF: 1356 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 12. An older adult client in a nursing home has visual and hearing losses. The nurse is alert to which of the following signs that represents the effects of sensory deprivation?

Diminished anxiety

Improved task completion

Altered spatial perception

Decreased need for physical stimulation

ANS: 3

Altered spatial perception, increased anxiety, poor task performance, and an increased need for physical stimulation are all signs of sensory deprivation. DIF: A REF: 1345 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 13. During a home safety assessment, the nurse identifies that there are a number of hazards present. Of the following hazards that are noted by the nurse, which one represents the greatest risk for this client with diabetic peripheral neuropathy?

1 2 3 4

Improper water heater settings Absence of smoke detectors Cluttered walkways Lack of bathroom grab bars

ANS: 1 Clients with impaired tactile sensation, as the client with diabetic neuropathy, should be cautioned to have the setting on the water heater no higher than 120 F. The greatest risk for the client with diabetic peripheral neuropathy is an improper water heater setting, because the client would not be able to feel a setting that is too hot and could therefore experience injury. An absence of smoke detectors is not the greatest risk for the client with diabetic peripheral neuropathy. It would be of greater risk for the client who has an olfactory impairment. Although a lack of bathroom grab bars may place a client at risk for falls, it is not the greatest risk for the client with diabetic peripheral neuropathy. DIF: C REF: 1358 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 14. The nurse in the pediatric clinic is checking the basic visual acuity of a 4-year-old child. The nurse should have the child:

Use the standard Snellen chart

Read a few lines from a childrens book

Follow the peripheral movement of an object

Identify crayon colors

ANS: 4

To assess basic visual acuity, the nurse should ask the client to identify crayon colors. The Snellen chart may be used for the adult client but would be less appropriate for the 4-year-old child. DIF: A REF: 1350 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 15. For a client with receptive aphasia, which one of the following nursing interventions is the most effective?

Providing the client with a letter chart to use to answer complex questions

Using a system of simple gestures and repeated behaviors to communicate

Offering the client a notepad to write questions and concerns

Obtaining a referral for a speech therapist

ANS: 2 If the client has problems with comprehension, as in receptive aphasia, the nurse should use simple short questions, facial gestures, and repeated behaviors to communicate. Providing a client with a letter chart would be more appropriate for the client with expressive aphasia. Questions should be simple, not complex, to aid comprehension. A notepad would be appropriate for the client with expressive aphasia, not receptive aphasia. Clients with expressive aphasia often require a speech therapist, not a client with receptive aphasia. DIF: C REF: 1350 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 16. The nurse recommends follow-up auditory testing for a child who was exposed in utero to:

Excessive oxygen

Diabetes

Respiratory tract infection

Rubella

ANS: 4

Children at risk for hearing impairment include those who were exposed to rubella in utero. Children at risk for visual impairment include those who received excessive oxygen as a newborn. DIF: A REF: 1356 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 17. The family of an older client asks the nurse how the stairways and hallways in the home may be enhanced to promote safety. In addition to extra lighting, the nurse recommends the use of paint and decorations that are:

Red and yellow

2 3

Black and white Brown and green

Blue and purple

ANS: 1 Brighter colors such as red, orange, and yellow are easier for the older adult to see. Black and white colors are not the best recommendation for promoting safety in the older adult. Perception of the colors blue, violet, and green usually declines with age. DIF: A REF: 1356 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 18. The nurse is working with older adult clients in an extended care facility. To enhance the clients gustatory sense, the nurse should:

Mix foods together

Assist with oral hygiene

Provide foods of similar texture and consistency

Make sure foods are extremely spicy

ANS: 2 Good oral hygiene keeps the taste buds well hydrated and will enhance the clients gustatory sense. Taste perception is heightened if foods are eaten separately, are different textured, and are well seasoned.

DIF: A REF: 1350 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 19. A home safety measure specific for a client with diminished olfaction is the use of:

Smoke detectors on all levels

2 3

Extra lighting in hallways Amplified telephone receivers

Mild water heater temperatures

ANS: 1 A reduced sensitivity to odors means that the client may be unable to smell a smoldering fire. The client should use smoke detectors as a safety measure. A home safety measure specific for a client with diminished vision is the use of extra lighting in hallways. A home safety measure specific for a client with diminished hearing is the use of amplified telephone receivers. A home safety measure specific for a client with reduced tactile sensation is having mild water heater temperatures. DIF: A REF: 1358 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 20. The nurse has completed the admission assessment for a client admitted to the hospitals subacute care unit. Of the following nursing diagnoses identified by the nurse, the one that takes the highest priority is:

Social isolation

Risk for injury

Risk-prone health behavior

Impaired verbal communication

ANS: 2 Safety is always a top priority. DIF: C REF: 1352 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

21. While participating in a community auditory screening, the nurse is alert to the population that has the greatest prevalence of problems. The nurse is aware that hearing impairment is more common for:

Whites

2 3

Asian Americans African Americans

Native Americans

ANS: 1 Whites have more hearing impairment problems than African Americans and Asian Americans. African Americans are at greater risk for glaucoma, not for hearing impairment. Otitis media is more prevalent among Native Americans than among whites. DIF: A REF: 1346 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 22. The nurse is visiting the day care center for routine assessment of the children. After spending time with the children in one of the playrooms, the nurse suspects that a child has a visual deficit as a result of observing:

Poor balance and gait

An increase in weight

Sitting and rocking back and forth A failure to respond when touched

ANS: 3 Behaviors of children indicating a possible visual deficit include self-stimulation such as eye rubbing, body rocking, sniffing or smelling, and arm twirling. Poor balance and gait may indicate an impairment of position sense in the adult. A weight change may indicate a deficit in taste in the adult. Failure to respond to touch may indicate a touch deficit in the adult. DIF: A REF: 1350 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 23. A client has been in the intensive care unit for 4 days and has begun to show signs of restlessness and anxiety even though the client has been reassured that his or her condition is

improving and discharge to the unit will be occurring soon. The cause of the clients emotional state is a result of:

1 2 3 4

Fear of death Social isolation Sensory overload Anxiety disorder

ANS: 3 The acutely ill client easily falls victim to sensory overload. The client in constant pain or who undergoes frequent monitoring of vital signs or who has irritation from drainage tubes is at risk. DIF: A REF: 1345 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 24. A client has been in the intensive care unit for 4 days and has begun to show signs of restlessness and anxiety, and the nurse believes the client is experiencing sensory overload. Which of the following interventions will be most therapeutic in assisting the client?

Limiting interaction with the client to the safe minimum

Moving the client to a space furthest from the nursing station

Keeping the clients lights dimmed and curtains partially drawn

Asking the clients health care provider to consider early discharge to the unit

ANS: 3 Constant reorientation and control of excessive stimuli becomes an important part of the clients care. Although the remaining options may have value, they are not the most therapeutic because external stimulation is the most likely cause of the problem. DIF: C REF: 1345 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 25. The wife of a 70-year-old client who is recuperating at home from hip replacement surgery expresses a concern to the nurse that He must be getting depressed. He just doesnt interact with people like he used to. Which of the following is the nurses most therapeutic response?

Are there any other signs of depressions?

Does he usually enjoy interacting with visitors?

Do you think he may be having difficulty hearing what people are saying to him?

Well he could be. Do you want me to see if his health care provider will order an antidepressant?

ANS: 3 A concern with normal age-related sensory changes is that older adults with a deficit are sometimes inappropriately diagnosed with dementia or depression. The remaining options assume that depression may be the cause of his personality change. DIF: C REF: 1345 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 26. A 54-year-old client expresses concern about her weakening sense of smell to the nurse during an admission interview. The nurses most therapeutic response is:

I dont think it is anything to worry about, but you could mention it to your health care provider

That is really a fairly common complaint of people your age; I dont think there is anything to worry about As long as you can smell things like smoke if there is a fire, I think it is something you need to get used to

3 4

As long as you can smell things like smoke if there is a fire, I think it is something you need to get used to

ANS: 4 Gustatory and olfactory changes begin around age 50 and include a decrease in the number of taste buds and a decrease in the number of sensory cells in the nasal lining. Reduced taste discrimination and reduced sensitivity to odors are common. The remaining options do not provide the most likely cause of the sensory deficit. DIF: C REF: 1345-1346 OBJ: Analysis TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 27. The daughter of a client recently admitted to a skilled nursing facility shares with the nurse that she is concerned about how disinterested her mother seems in everyone and everything around her. The most therapeutic response by the nurse is:

Bring something from home for her to display in her room

It is most likely just her way of adjusting to leaving her home

Many of the residents have this problem when they first come here

Just give her time to adjust; shell get more involved in a few days

ANS: 1 Meaningful stimuli reduce the incidence of sensory deprivation. The presence or absence of meaningful stimuli influences alertness and the ability to participate in care. The remaining options simply attempt to explain away the behavior. DIF: C REF: 1346 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 28. The nurse is discussing vision and hearing health with a group of senior citizens. Which of the following individuals should be given special encouragement to have regular eye screenings for the presence of glaucoma?

An African American with hypertension

An Asian with osteoarthritis in the hands

A white with peripheral vascular disease A Hispanic with type 2 diabetes

ANS: 1 Glaucoma is almost 3 times as common in African Americans as in white Americans. The remaining options represent ethnic groups with eye-related risk factors but not necessarily for glaucoma. DIF: C REF: 1346 OBJ: Analysis TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 29. Which of the following statements made by a client diagnosed with diabetes shows the most informed understanding of the effect of the disease on optic health?

1 2 3 4

The scariest part about having diabetes is the increased possibility of losing my eyesight. I have my eyes checked yearly to be aware of any retinopathy that may be developing. If I do a good job of keeping my blood sugars in line, I wont run such a risk for eye problems. I try to keep my A1C below 7 so I can minimize the bad effects of hyperglycemia on my eyes.

ANS: 2 Hispanic Americans have an increased incidence of diabetic retinopathy. Although the remaining options reflect a general understanding, they are not as specific nor do they mention the specific self-care measures related to vision. DIF: C REF: 1346 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 30. The nurse and a 69-year-old client are discussing the clients report of Not hearing as well as I used to; I must be getting old. Which of the following nursing responses is most therapeutic regarding the clients assumption of the cause of the diminished hearing?

What makes you think you dont hear as well as you used to?

Well, hearing loss does seem to be more of a problem as we age. You may be right, but I suggest you see an otolaryngologist just to be sure.

3 4

Do you turn the television up louder, or is it difficult to hear on the telephone?

ANS: 3 Be careful to not automatically assume that a clients sensory problem is related to advancing age. The suggestion to see a otolaryngologist is the most therapeutic because it provides a means to

rule out more serious conditions. The remaining options either attempt to further identify the symptoms of the clients problems or simply agree with the theory of aging. DIF: C REF: 1345 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 31. The nurse and a 62-year-old client are discussing the clients sense of hearing. Which of the following assessment questions is most likely to launch a conversation concerning the clients ability to hear effectively?

Do you think you have a hearing problem?

Do you hear as well as you did 5 years ago?

Would you rate your hearing as excellent, good, fair, poor, or bad?

Can you tell me when you believe you started to experience a hearing loss?

ANS: 3 During the history, it is useful to assess the clients self-rating for a sensory deficit. You can simply say, Rate your hearing as excellent, good, fair, poor, or bad. Then, based on the clients self-rating, explore the clients perception of a sensory loss more fully. The remaining options are either closed-ended questions (which do not encourage communication) or an assumption of hearing loss. DIF: C REF: 1348 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 32. The primary safety issue related to the presence of a taste deficit in a young child is there will most likely be:

Little incentive to hydrate

No social connection to food

Limited food experimentation

Little discretion for ill-tasting substances

ANS: 4 The inability to taste ill-flavored substances may well lead to accidental poisoning.

DIF: C REF: 1350 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 33. It has been determined that a vision problem has contributed to a clients ability to provide self-care regarding bathing, dressing, and toileting. The initial nursing responsibility regarding these deficits is to:

Educate the clients family regarding the existing limitations so as to secure their support in meeting needs regarding activities of daily living (ADLs)

Arrange for in-home services to facilitate the clients ability to remain as independent as possible regarding ADLs

Provide the in-home care provider with sufficient information regarding the clients sensory deficits regarding ADLs

Provide sufficient client education regarding the in-home services available to help with ADL needs once discharge has occurred

ANS: 2 If a sensory alteration impairs a clients functional ability, providing resources within the home is a necessary part of discharge planning. Although the other options are not inappropriate, they are not the initial priority. DIF: C REF: 1349 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 34. The nurse is discussing eye safety with a group of adults who regularly work around power tools. Which of the following questions should be the initial follow-up to the nurses inquiry, Do you own safety glasses?

Are they in good working order?

How long have you been using them?

Do you wear them each time you use your tools? What do you think the advantage is to wearing them?

ANS: 3 Although all the options are relevant to the issue of eye safety, the initial follow-up should relate to the clients habit of actually wearing the safety device. DIF: C REF: 1349 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 35. The nurse is preparing a 70-year-old visually impaired male client for home discharge. Which of the following nursing actions will have the greatest impact on the clients safety related to medication administration?

Evaluate the clients ability to read the frequency and dosage information on his medication bottles.

Watch the client demonstrate the appropriate method for splitting his morning medication in half.

Observe the client open and pour out the appropriate number of pills required for his morning medications.

Have the client restate the administration schedule and prescribed dosage of each of his home medications.

ANS: 1 Ask the client to read a label to determine if the client is able to read the dosage and frequency. Although the other options are appropriate interventions, the primary concern is the ability to read the instructions in light of the visual impairment. DIF: C REF: 1349 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 36. The nurse is caring for a newly admitted client who is aphasic. The nurse most therapeutically addresses the communication issue by:

Evaluating the clients ability to express his or her needs by writing

Asking the client how he or she wants to communicate with the staff Giving the client a pad and a pencil with which to communicate

Providing the client with an orientation to the use of the call bell

ANS: 2 Determine whether the client has developed a sign language system or symbols to communicate needs. Every client should be oriented to the proper use of the call bell, and the remaining options assume that writing will be the clients preferred method of communication. DIF: C REF: 1351 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 37. Which of the following statements made by the nurse shows the greatest insight into the possible causes of a hearing-impaired clients irritability?

I know he doesnt hear well, but I wonder if his increased lack of patience today has to do with being in pain.

Not being able to hear us properly appears to be making him irritable today. See if he has his hearing aid turned off.

His hearing aids must need new batteries; he is just so irritable and impatient today. He is certainly irritable today, but maybe it doesnt have to do with his poor hearing.

ANS: 1 Always remember that factors other than sensory deprivation or overload cause impaired perception and emotional irritation (e.g., medications or pain). Although one of the options presents a general suspicion that the cause of the problem may not be his hearing impairment, the remaining options assume that it is the cause of his irritation. DIF: C REF: 1351 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 38. The nurse notes that the 43-year-old male blind client who has had a stroke is not having difficulty recognizing an object by touch. This sense is known as:

Stereognosis

Auditory

Gustatory

Olfactory

ANS: 1 Stereognosis is a sense that allows a person to recognize an objects size, shape, and texture. The auditory sense is the sense of hearing. The gustatory sense is the sense of tasting. The olfactory sense is the sense of smelling DIF: C REF: 1350 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 39. The 25-year-old male client who has been in the trauma intensive care unit (ICU) for 3 weeks is confused and agitated. The nurse knows that this can happen to clients in an ICU setting due to:

Boredom

2 3

Sensory overload Pain

A lack of stimulation

ANS: 2 When a person receives multiple sensory stimuli and cannot perceptually disregard or selectively ignore some stimuli, sensory overload occurs. Excessive sensory stimulation prevents the brain from appropriately responding to or ignoring certain stimuli. Because of the multitude of stimuli leading to overload, the person no longer perceives the environment in a way that makes sense DIF: A REF: 1349 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 40. The 85-year-old female client has moved to an assisted living apartment so that she can remain independent yet have some limited assistance with her ADLs. Which of the following suggestions should the nurse make that would be most appropriate to reduce sensory deprivation?

Provide pictures of the clients family.

Purchase all-new furnishings.

Suggest that the client take all her meals in her apartment until she gets the chance to know her neighbors better.

Ask family and friends to wait a few days to visit until the client has an opportunity to settle in.

ANS: 1 Meaningful stimuli reduce the incidence of sensory deprivation. In the home, meaningful stimuli include pets, music, television, pictures of family members, and a calendar and clock Keeping as many of her own furnishings as possible may help make her new environment more like home. The presence of others offers positive stimulation. The ability to discuss concerns with loved ones is an important coping mechanism for most people. Therefore the absence of meaningful conversation will result in feelings of isolation, loneliness, anxiety, and depression for the client. Often, this is not apparent until behavioral changes occur. DIF: A REF: 1343 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 41. A 47-year-old male client has come in to his primary health care providers office for his annual checkup. The client shares with the nurse that his wife thinks he is suffering from hearing loss. Which of the following responses by the nurse would be most appropriate?

1 2 3 4

You are approaching an age when it is common to start having some hearing loss. Do you work in a noisy environment? You dont seem to have hearing problems to me. Has anyone else noticed that you are having hearing problems?

ANS: 2 In the case of sensory alterations you need to integrate knowledge of the pathophysiology of sensory deficits, factors that affect sensory function, and therapeutic communication principles. A persons occupation places him or her at risk for hearing, visual, and peripheral nerve alterations. Individuals who have occupations involving exposure to high noise levels (e.g., factory or airport workers) are at risk for noise-induced hearing loss and need to be screened for hearing impairments. Hazardous noise is common in work settings as well as recreational activities. Be careful to not automatically assume that a clients sensory problem is related to advancing age. For example, adult sensorineural hearing loss is often due to exposure to excess and prolonged noise or metabolic, vascular, and other systemic alterations. Collect a history that

also assesses the clients current sensory status and the degree to which a sensory deficit affects the clients lifestyle, psychosocial adjustment, developmental status, self-care ability, health promotion habits, and safety. DIF: A REF: 1345 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 42. Which of the following safety measures is most important for the nurse to implement for a hospitalized client with a visual impairment?

Orient the client to the room.

Open the window blinds to let in light.

Keep the clients door to the room open so that he or she can be visualized.

Keep all four side rails up to remind the client not to get up on his or her own.

ANS: 1 Clients with serious visual impairment need to feel comfortable in knowing the boundaries of the immediate environment. Normally we see physical boundaries within a room. The blind or severely visually impaired often touch the boundaries or objects to gain a sense of their surroundings. The client needs to walk through a room and feel the walls to establish a sense of direction. Help clients by explaining objects within the room, such as furniture or equipment. It takes time for the client to absorb a rooms arrangement. The client often needs to reorient again, with your explaining the location of key items. Glare from the window may actually cause more visual problems. The client may prefer to have the door to the room closed for privacy. Putting all four side rails up on the bed increases the risk for falls. DIF: B REF: 1344-1345 OBJ: Application TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 43. Following a brain attack, the 45-year-old female client was very confused She was having difficulty responding appropriately to the nurse and to her family members. The clients daughter was concerned that her mother was suffering from a mental breakdown, even though she had no history of mental illness. The best information that the nurse can share with the clients daughter is:

Your mother appears to have aphasia as a result of her stroke.

Your mother will be just fine in no time.

Your mother has been through a lot as a result of her stroke. We can have a psychiatric workup done if you would like.

ANS: 1 The most common language disorder following a stroke is aphasia. As a result of a disruption in blood flow to the brain, the speech center becomes damaged, altering a persons ability to either use or understand spoken words. Depending on the type of aphasia, the inability to communicate is often frustrating and frightening. Initially you need to establish very basic communication and recognize that aphasia does not indicate intellectual impairment or degeneration of personality. Explain situations and treatments that are pertinent to the client because he or she is able to understand the speakers words. Because a stroke often causes partial or complete paralysis of one side of the clients body, an aphasic client will need special assistive devices. There are communication boards that have been developed for several levels of disability. Sensitive pressure switches, activated by the touch of an ear, nose, or chin, control electronic communication boards. Clients who have had a stroke usually acquire referrals to speech therapists to develop appropriate rehabilitation plans. DIF: C REF: 1349 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems MULTIPLE RESPONSE 1. The nurse is discussing vision changes that normally occur with aging with a group of older adults. Which of the following conditions should be included in the discussion? (Select all that apply.)

Poor night vision Increased optical floaters

Reduced peripheral vision

Reduced depth perception

Increased sensitivity to glare

Diminished color perception

ANS: 1, 3, 4, 5, 6 Normal visual changes associated with aging include reduced visual fields, increased glare sensitivity, impaired night vision, reduced depth perception, and color discrimination. Floaters are not age related.

DIF: C REF: 1359 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 2. Which of the following physical assessments are essential when attempting to determine the presence of sensory deficits in an older adult client? (Select all that apply.)

Vision

Hearing Smell

3 4 5

Taste Touch

Gait

ANS: 1, 2, 3, 4, 5 To identify sensory deficits and their severity, assess vision, hearing, olfaction, taste, and the ability to discriminate light touch, temperature, pain, and position. Although gait may be affected by a sensory deficit, it is not considered a sensory deficit by itself. Chapter 50. Perioperative Nursing Care MULTIPLE CHOICE 1. A 43-year-old client is scheduled to have a gastrectomy. Which of the following is a major preoperative concern?

1 2 3 4

The clients brother had a tonsillectomy at age 11. The client smokes a pack of cigarettes a day. The client has an intravenous (IV) infusion. The client has a history of employment as a computer programmer.

ANS: 2 The client who smokes is at greater risk for postoperative pulmonary complications than a client who does not. An IV should be in place for surgery so access is available to administer medications, fluids, or blood products if necessary. Keeping the client well hydrated will help prevent postoperative thrombophlebitis. DIF: A REF: 1373 OBJ: Comprehension TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 2. An appendectomy is appropriately documented by the nurse as:

1 2

Diagnostic surgery Palliative surgery

Ablative surgery

Reconstructive surgery

ANS: 3 Ablative surgery is the excision or removal of a diseased body part, such as an appendectomy. Diagnostic surgery is surgical exploration that allows the health care provider to confirm a diagnosis. This type of surgery may involve removal of tissue for further diagnostic testing. An example would be a breast mass biopsy. Palliative surgery relieves or reduces the intensity of disease symptoms. It will not produce a cure. An example is resection of nerve roots. Reconstructive surgery restores function or appearance to traumatized or malfunctioning tissues. An example is internal fixation of a hip fracture. DIF: A REF: 1367 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 3. An obese client is admitted for abdominal surgery. The nurse recognizes that this client is more susceptible to the postoperative complication of:

Anemia

Seizures

Protein loss Dehiscence

ANS: 4 An obese client is susceptible to poor wound healing and wound infection because of the structure of fatty tissue, which contains a poor blood supply. This increases the risk for dehiscence. A client who is malnourished is more susceptible to being anemic. A client with liver disease may have altered protein metabolism. DIF: C REF: 1372 OBJ: Analysis TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 4. The nurse is working in a postoperative care unit in an ambulatory surgery center. Of the following clients that have come to have surgery, the client at the greatest risk during surgery is a:

78-year-old taking an analgesic agent

2 3

43-year-old taking an antihypertensive agent 27-year-old taking an anticoagulant agent

10-year-old taking an antibiotic agent

ANS: 3 Anticoagulants alter normal clotting factors and thus increase the risk for hemorrhaging during surgery. Aminoglycosides (a type of antibiotic) may cause mild respiratory depression from depressed neuromuscular transmission; however, the client who has been taking anticoagulants is at greater risk during surgery. DIF: C REF: 1373 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 5. A 92-year-old client is scheduled for a colectomy. Which normal physiological change that accompanies the aging process increases this clients risk for surgery?

An increased tactile sensation

An increased metabolic rate

A relaxation of arterial walls Reduced glomerular filtration rate

ANS: 4 An older adult is likely to have a reduced glomerular filtration rate. This limits the bodys ability to eliminate drugs or toxic substances. An older adult has reduced tactile sense, which decreases the clients ability to respond to early warning signs of surgical complications, including sensing pressure over bony prominences. An older adult has a lower basal metabolic rate, reducing total oxygen consumption. The nurse should ensure the client obtains adequate nutritional intake when diet is resumed, but the client should avoid intake of excess calories. DIF: A REF: 1369 OBJ: Comprehension TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 6. The nurse is completing the preoperative checklist for an adult female client who is scheduled for an operative procedure later in the morning. Which of the following preoperative assessment findings for this client indicates a need to contact the surgeon?

Hemoglobin (Hgb) 14 g/100 mL

2 3

Blood urea nitrogen (BUN) 15 mg/100 mL Platelets 300,000/mm3

Serum creatinine 3.2 mg/100 mL

ANS: 4 The normal serum creatinine in women is 0.5 to 1.1 mg/100 mL. A serum creatinine of 3.2 mg/ 100 mL should be reported to the health care provider, because it can be an indication of renal failure. A Hgb of 14 g/100 mL is within the normal limits of 12 to 16 g/100 mL for women. A BUN of 15 mg/100 mL is within the normal limits of 10 to 20 mg/100 mL. A platelet count of 300,000/mm3 is within the normal limits of 150,000 to 400,000/mm3. DIF: C REF: 1376 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 7. The nurse is evaluating the outcome Client describes surgical procedures and postoperative treatment and determines that the client has not achieved this outcome. The nurse should:

Obtain the consent, because this is expected with preoperative anxiety

Teach the client all about the procedure

Ask the unit manager to assist with a teaching plan

Inform the surgeon so that information can be provided

ANS: 4 When the client has little or no understanding about the surgery, the health care provider will need to be notified to reinform the client. If the client does not understand the surgical procedure, the client would not be giving informed consent. It is the surgeons responsibility to explain the procedure and obtain the informed consent. The nurse can augment the health care providers explanations, but it is the health care providers responsibility to teach the client about the procedure. This teaching includes the need for the procedure, steps involved, risks, expected results, and alternative treatments.

DIF: A REF: 1378 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 8. Which of the following statements most accurately reflects nursing accountability in the intraoperative phase?

I would like to see the client have a regional anesthetic rather than a general anesthetic.

2 3

There seems to be a missing sponge, so a recount should be done of all the sponges that have been removed. Did the client receive the medications and sign the consent?

The client looks to be reactive and stable.

ANS: 2 The scrub nurse counts the sponges and instruments, and the circulating nurse verifies the counts. This statement by the nurse reflects accountability in the intraoperative phase. DIF: C REF: 1390-1391 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 9. The client will have an incision in the lower left abdomen. Which of the following measures by the nurse will help decrease discomfort in the incisional area when the client coughs postoperatively?

Applying a splint directly over the lower abdomen

Keeping the client flat with her feet flexed

Turning the client onto the right side Applying pressure above and below the incision

ANS: 1 Deep-breathing and coughing exercises place additional stress on the suture line and cause discomfort. Splinting the incision with hands or a pillow provides firm support and reduces incisional pulling. Keeping the client flat will not decrease discomfort in the incisional area when the client coughs. Having the knees bent slightly will aid in relaxing the abdominal muscles, causing less discomfort. Turning the client onto the right side will not decrease discomfort in the incisional area when the client coughs. The client should turn from side to side at least every 2

hours and may splint the incision to decrease discomfort when doing so. Splinting should be done directly over the incision to provide firm support and reduce incisional pulling as the client coughs postoperatively. DIF: A REF: 1400-1401 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 10. The nurse is evaluating the client in the hospitals postanesthesia care unit (PACU) and determines that the Aldrete score is 8. Based on this assessment, the nurse anticipates that the client will:

Be sent to the intensive care unit

2 3

Be discharged back to his or her room on the nursing unit Remain in the PACU until the score improves

Return to the operating room for surgical evaluation

ANS: 2 The client must receive a composite Aldrete score of 8 to 10 before being discharged from the PACU. The nurse may anticipate that the client with an Aldrete score of 8 will be discharged back to his or her room on the nursing unit. If the clients condition is still poor 2 to 3 hours after surgery (an Aldrete score below 8), the health care provider may transfer the client to an intensive care unit. If the clients condition is still poor 2 to 3 hours after surgery (an Aldrete score below 8), the health care provider may lengthen the clients stay in the PACU until the score improves. A client with an Aldrete score of 8 is unlikely to return to the operating room for surgical evaluation. DIF: A REF: 1394 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 11. A client is in the postanesthesia care unit (PACU) recovering from a vagotomy and pyloroplasty. Which of the following is a normal expectation of the client in this stage of recovery?

Returned normal bowel sounds on auscultation

Pain that is relieved with noninvasive comfort measures

Voluntary bladder control and function

A subdued level of consciousness and neurological function

ANS: 4 In the PACU the client is often drowsy. The effects of anesthetic agents subdue the clients level of consciousness and neurological function. Normally during the immediate recovery phase in the PACU, faint or absent bowel sounds are auscultated in all four quadrants. Clients who have had abdominal surgery may develop paralytic ileus, with a return of bowel sounds 24 to 48 hours later. The acute incisional pain experienced in this stage of recovery is usually not relieved with noninvasive comfort measures but will require pharmacological measures of pain relief. Depending on the surgery, a client may not regain voluntary control over urinary function for 6 to 8 hours after anesthesia. DIF: A REF: 1397 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 12. The client is scheduled for abdominal surgery and has just received the preoperative medications. The nurse should:

Keep the client quiet

2 3

Obtain the consent Prepare the skin at the surgical site

Place the side rails up on the bed or stretcher

ANS: 4 After administering preoperative medications, the nurse should raise the side rails on the bed or stretcher and keep the bed or stretcher in low position. Preanesthetic medications will help reduce the clients anxiety. Consent must be obtained before preoperative medications are administered or the consent is invalid. Preparing the skin at the surgical site is often done in the operating room. DIF: A REF: 1391 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 13. The nurse is completing the preoperative checklist for an adult client who is scheduled for an operative procedure later in the morning. Which of the following preoperative assessment findings for this client indicates a need to contact the anesthesiologist?

Temperature is 100 F.

Pulse is 90 beats per minute.

Respiratory rate is 20 breaths per minute.

Blood pressure is 130/74 mm Hg.

ANS: 1 An elevated temperature before surgery is a cause for concern. If the client has an underlying infection, the surgeon may choose to postpone surgery until the infection has been treated. An elevated body temperature increases the risk for fluid and electrolyte imbalance after surgery. Anxiety and fear commonly cause elevations in heart rate and blood pressure. A pulse rate of 90 beats per minute is not a concern. A respiratory rate of 20 breaths per minute is normal for an adult. A blood pressure of 130/74 mm Hg is not excessively elevated. DIF: A REF: 1388 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 14. In the postoperative period, the nurse recognizes that an early sign of malignant hyperthermia is:

Fever

Tachycardia

Muscle relaxation

Skin pallor

ANS: 2 Malignant hyperthermia should be suspected when there is unexpected tachycardia and tachypnea; jaw muscle rigidity; body rigidity of limbs, abdomen, and chest; or hyperkalemia. Temperature elevation is a late sign of malignant hyperthermia. Muscle rigidity, not relaxation, is an early sign of malignant hyperthermia. Skin pallor is not an early sign of malignant hyperthermia. Skin pallor may be seen in the immediate postoperative period, because the body is cool. DIF: A REF: 1397 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 15. The client tells the nurse that blowing into this tube thing (incentive spirometer) is a ridiculous waste of time. The nurse explains that the specific purpose of the therapy is to:

Directly remove excess secretions from the lungs

Increase pulmonary circulation

Promote lung expansion Stimulate the cough reflex

ANS: 3 The primary purpose of using an incentive spirometer is to promote lung expansion. Coughing exercises are used to remove excess secretions from the lungs. Ambulation helps increase pulmonary circulation as the respiratory rate increases. The primary purpose of incentive spirometry is not to stimulate the cough reflex, but to promote lung expansion. DIF: A REF: 1401 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 16. The female client on the surgical unit is being prepared for abdominal surgery with general anesthesia. In preparing this client for surgery, the nurse should:

Leave all of her jewelry intact Provide her with sips of water for a dry mouth

Remove her makeup and nail polish

Remove her hearing aid before transport to the operating room

ANS: 3 All makeup, including nail polish, should be removed to expose normal skin and nail color to determine the clients level of oxygenation and circulation during and after surgery. Jewelry and other valuables should be given to family members or secured for safekeeping. A wedding band can be taped in place unless there is a risk that the client will experience swelling of the hand or fingers. For safety, metal items, such as for pierced areas, should be removed. The client should be allowed nothing by mouth (NPO) before surgery to prevent vomiting and aspiration with general anesthesia. Clients may be allowed to keep personal items such as a hearing aid until they reach the preoperative area. DIF: A REF: 1387 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 17. The client asks the nurse the purpose of having medications (Demerol and Vistaril) given before surgery. The nurse should inform the client that these particular medications:

Reduce preoperative fear

2 3

Promote emptying of the stomach Reduce body secretions

Ease the induction of the anesthesia

ANS: 4 Preoperative medications such as Demerol and Vistaril help reduce the clients anxiety, the amount of general anesthesia required, the risk for nausea and vomiting and resulting aspiration, and the amount of respiratory secretions. They may also help the client feel drowsy and lessen his or her anxiety associated with fear. Vistaril (hydroxyzine pamoate) is often given to control nausea and vomiting by suppressing the central nervous system (CNS). Vistaril will have an anticholinergic effect, reducing body secretions. These medications given together will ease the induction of anesthesia. DIF: A REF: 1392 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 18. A client who receives general or regional anesthesia in an ambulatory surgery center:

Has to meet identified criteria in order to be discharged home

Will remain in the phase I recovery area longer than a hospitalized client

Is allowed to ambulate as soon as being admitted to the recovery area Is immediately given liberal amounts of fluid to promote the excretion of the anesthesia

ANS: 1 Ambulatory surgical clients are discharged to home when they meet certain criteria. With new anesthetic agents and techniques, many ambulatory surgery clients are able to bypass phase I. However, if the client is in need of close monitoring, the client is assessed and cared for in the same fashion as inpatient clients in phase I. Whether the client will be able to ambulate as soon as being admitted to the recovery area depends upon the ambulatory clients condition, type of surgery, and anesthesia. This is not a true statement for all ambulatory surgery clients. The administration of fluids is dependent upon the clients condition and type of surgery. The excretion of anesthetic depends on many factors, including the route of administration (e.g., fluids will not promote the excretion of anesthetic gases). Oral fluids cannot be given until it is

determined the client has a gag reflex and bowel sounds. Fluids are often given to prevent circulatory complications. DIF: A REF: 1395 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 19. Following abdominal surgery, the nurse suspects that the client may be having internal bleeding. Which of the following findings is indicative of this complication?

1 2

Increased blood pressure Incisional pain

Abdominal distention

Increased urinary output

ANS: 3 Signs of internal bleeding following abdominal surgery may include abdominal distention; swelling or bruising around the incision; increased pain; a drop in blood pressure; elevated heart and respiratory rates; thready pulse; cool, clammy, pale skin; and restlessness. The client who is hemorrhaging will have a decreased blood pressure. Incisional pain may occur as a result of surgery. A continuous increase in pain in conjunction with other symptoms of bleeding may indicate internal hemorrhaging. A client who is bleeding will have a decreased urinary output. DIF: A REF: 1397 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 20. After discharge from the postanesthesia care unit (PACU), the client returned to the surgical nursing unit at 10:00 AM. It is now 11:30 AM, and the client is not experiencing any complications or difficulties. The nurse will plan to measure the clients vital signs:

Every 15 minutes

Every 30 minutes

Every 1 hour

Every 4 hours

ANS: 3 Vital sign monitoring on the postoperative nursing unit should initially be hourly for 4 hours and then every 4 hours. As the clients condition stabilizes, the frequency of assessment will usually

decrease to once a shift until discharge. Upon the clients arrival to recovery, the nurse repeats measurement of vital signs every 15 minutes, not for the client who is stable on the surgical nursing unit. The client who is not experiencing any complications or difficulties does not require vital sign measurement every 30 minutes. After the clients vital signs are obtained hourly for 4 hours and remain stable, the client may have his or her vital signs measured every 4 hours. DIF: A REF: 1396 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 21. The client had surgery in the morning that involved the right femoral artery. To assess the clients circulation status to the right leg, the nurse will make sure to check the pulse at the:

1 2 3 4

Radial artery Ulnar artery Brachial artery Dorsalis pedis artery

ANS: 4 The nurse should assess peripheral pulses and capillary refill distal to the site of surgery. After surgery to the femoral artery, the nurse assesses posterior tibial and dorsalis pedis pulses. The nurse also compares pulses in the affected extremity with those in the nonaffected extremity. DIF: A REF: 1397 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 22. Upon admission to the postanesthesia care unit (PACU), the client who has no orthopedic or neurological restrictions is positioned with the:

Bed flat and the clients arms to the sides

Clients neck flexed and body positioned laterally

Head of the bed slightly elevated with the clients head to the side Clients arms crossed over the chest and the bed in highFowlers position

ANS: 3

To promote a patent airway, the head of the bed may be slightly elevated and the clients neck slightly extended, with the clients head turned to the side. The clients head should not be flexed as this may occlude the airway. The clients arms should never be positioned over or across the chest, because this reduces maximal chest expansion. DIF: A REF: 1393 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 23. A client who is scheduled for surgery is found to have thrombocytopenia. A specific postoperative concern for the nurse for this client is:

Hemorrhage

2 3

Wound infection Fluid imbalance

Respiratory depression

ANS: 1 A client with thrombocytopenia is at risk for hemorrhaging during and after surgery. Clients with immunological disorders or diabetes mellitus have an increased risk for wound infection after surgery. A client who has a fever is at risk for fluid imbalance. A client who has chronic respiratory disease may be at increased risk for respiratory depression, not the client with thrombocytopenia. DIF: A REF: 1370 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 24. A prostate biopsy is an acceptable procedure to be performed as an ambulatory surgery on an otherwise healthy adult male because the American Society of Anesthesiologists (ASA) considers that a:

Physical status class 1

Physical status class 2

Physical status class 4

Physical status class 5

ANS: 1

ASA physical status classes 1 and 2 and also stable class 3 are now acceptable for ambulatory surgery. Classes 4 and 5 require inpatient surgery. DIF: A REF: 1367 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 25. Which of the following statements made by a nurse reflects the greatest insight into the responsibility an ambulatory care nurse has to the clients family?

A clients family deserves the attention of the nursing staff.

Family is important to my client, and so family is important to me.

I consider myself as having several clients: the surgical client and all the family thats present.

I am responsible for keeping the family informed of the status of their loved one both during and after the procedure.

ANS: 3 Family members attempt to provide support through their presence but face many of the same stressors as the client. You need to effectively communicate with the client and family; they are clients as well. DIF: C REF: 1386 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 26. Which of the following statements made by a nurse reflects the greatest insight into the planning needs of a same-day surgical experience?

Time is a precious resource in same-day surgery units; being organized allows for the best utilization of time.

Everything must be checked and verified as being ready before the client is admitted into the surgical area. With only a few hours from time of admission to the beginning of the procedure, things have to be effectively organized.

I take the time to review the clients preadmission and preoperative data in order to formulate the most individualized plan of care possible.

ANS: 4 Ambulatory and same-day surgical programs offer challenges in gathering a complete assessment in a limited time. Clients are admitted only hours before the surgical event, so it is important for you to organize and verify data obtained preoperatively and implement a perioperative plan of care. Although the remaining options are not incorrect, they do not stress the importance of effective organization of the clients plan of care. DIF: C REF: 1378 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 27. The perioperative nurse realizes that the most effective means of evaluating the clients understanding of previous teaching is to:

Provide written material on the subject to be reviewed after discharge

Reinforce the material with family as the procedure is being performed

Discuss it with the client and family in the immediate preoperative period Offer to answer any questions that the client or family have just before discharge

ANS: 3 In the immediate preoperative period, assess the clients understanding of previous teaching. The other options are not truly evaluations of the clients knowledge. DIF: C REF: 1386 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 28. Which of the following preoperative assessment findings would most likely delay a planned procedure requiring general anesthetic?

A cough and low-grade fever

The pulse oximetry reading of 97% on room air

A blood pressure that is 10 systolic points higher than baseline The clients report of being so nervous about this procedure

ANS: 1 Preoperative assessment occasionally reveals an abnormality that delays or cancels surgery. A client who presents with a cough and low-grade fever on admission would require the nurse to notify the surgeon immediately. The other options do not necessarily warrant delay or cancellation of a procedure. DIF: C REF: 1388 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 29. A 74-year-old is accompanied by his daughter to the ambulatory surgery department for the surgical removal of a suspicious skin lesion. The client has experienced dysphasia since a cerebral vascular accident 3 years ago. The most effective way for the nurse to secure the necessary preoperative interview information is to:

Question the clients daughter Review the clients past medical records

Present the questions in a simple format

Rely on the clients preadmission survey

ANS: 1 If a client is unable to relate all of the necessary information, rely on family members as resources. The remaining options are not reliable, effective methods of securing information regarding this client. DIF: C REF: 1377 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 30. A client who has type 2 diabetes is scheduled for the removal of a skin lesion on his right shoulder at an ambulatory surgery unit. The nursing diagnosis the client is at greatest risk for postoperatively is:

Risk for injury

Risk for infection

Impaired wound healing

Imbalanced nutrition: less than body requirements

ANS: 3 Diabetes increases susceptibility to infection and impairs wound healing from altered glucose metabolism and associated circulatory impairment. The stress of surgery often causes increases in blood glucose levels. Although all the options present with possible nursing diagnoses, the remaining options are not of primary concern because steps can be taken (e.g., antibiotic, intravenous fluids) to minimize the risk. Impaired wound healing is not as easily managed. DIF: C REF: 1370 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 31. A client with a history of sleep apnea has had a same-day surgery procedure that will require the administration of morphine postoperatively to manage pain. This client will be assessed most appropriately by the perioperative nurse for the risk for respiratory complications by frequently:

Listening to breath sounds

2 3

Monitoring pulse oximetry Evaluating spirometer use

Counting respirations per minute

ANS: 1 Administration of opioids increases risk for airway obstruction postoperatively. Clients will desaturate as revealed by a drop in oxygen saturation by pulse oximetry. The remaining options are not as specific for this particular clients risk. DIF: C REF: 1372 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 32. A client scheduled for an ambulatory surgery procedure requiring anesthetics arrives with a low-grade fever and a productive sough. The postponement of the procedure is most likely a result of the:

Clients increased risk for a respiratory tract infection

Possibility of a respiratory complication during anesthesia

Increased risk for the clients infecting staff and other clients

Clients impaired resistance as a result of a respiratory tract infection

ANS: 2 Cough and low-grade fever increases the risk for respiratory complications during anesthesia (e.g., pneumonia and spasm of laryngeal muscles). Although the other options are not incorrect, they do not represent the most likely risk factor that would result in the cancellation of the procedure. DIF: C REF: 1388 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 33. Which of the following goals is most appropriate for a preoperative client with a nursing diagnosis of deficient knowledge regarding preoperative requirements related to lack of exposure to information?

Client will understand the need for scheduled surgery before leaving the providers office.

Client will understand the preoperative routines of surgical care before leaving providers office.

Client will present for drawing of preoperative laboratory blood at least 48 hours before scheduled surgery. Client will be able to successfully accomplish the preoperative bowel preparation by morning of scheduled surgery.

ANS: 2 Understanding the need for the surgery is not as directly related to preoperative requirements as is the understanding of preoperative routines. The remaining options are client outcomes. DIF: C REF: 1380 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 34. Which of the following client outcomes is most therapeutic for a preoperative client with a nursing diagnosis of deficient knowledge regarding preoperative requirements related to lack of exposure to information?

Client will share the preoperative routines of surgical care with family to facilitate compliance.

Client will understand the preoperative routines of surgical care before leaving providers office. Client will call laboratory to schedule appointment for preoperative blood draw for required testing.

3 4

Client will present for drawing of preoperative laboratory blood at least 48 hours before scheduled surgery.

ANS: 4 The answer provides for behavior that is measurable and pertinent to the preoperative goals. Sharing the information and calling for the appointment are appropriate outcomes, but they are not the most therapeutic because they not related to actual compliance with the preoperative routine. The remaining option is a client goal. DIF: C REF: 1376-1377 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 35. Which of the following client evaluations is most reflective of compliance for a preoperative client with a nursing diagnosis of deficient knowledge regarding preoperative requirements related to lack of exposure to information?

Client will present for scheduled blood laboratory work 48 hours before surgery.

Clients preoperative blood laboratory work results are present on preoperative chart. Client will share the preoperative routines of surgical care with family to facilitate compliance.

3 4

Client will understand the preoperative routines of surgical care before leaving providers office.

ANS: 2 The answer shows proof of the clients compliance, whereas the remaining options are either goals or outcomes. DIF: C REF: 1376-1377 OBJ: Analysis

TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 36. Which of the following best describes the primary nursing role regarding a clients consent to surgery immediately before surgery?

1 2

Explaining the procedure to the client in a fashion that is easily understood Placing the signed consent in the clients medical record

Ensuring that the client understands the possible risks of the procedure before signing the consent

Reviewing the clients surgical consent as a part of the routine preoperative checklist

ANS: 4 It is the surgeons responsibility to explain the procedure and obtain the informed consent. After the client completes the consent form, place it in the medical record. The record goes to the operating room with the client after the nurse confirms all required information has been included. DIF: C REF: 1378 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 37. The initial client educationrelated nursing action by the preadmission nurse is to:

Respond to questions presented by the family regarding the clients surgery

Call the client before the surgery to restate presurgery routine

Provide the client with a list of preoperative requirements Arrange a time for presurgical blood work to be drawn

ANS: 2 Preadmission nurses call clients up to 1 week before surgery to clarify questions and reinforce explanations. The remaining options are directed toward either facilitating compliance with preoperative requirements or addressing the needs of the clients family. DIF: C REF: 1380 OBJ: Analysis TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 38. Which of the following statements made by the nurse shows the most informed understanding of the role of family in the clients postoperative recovery?

The family will be the ones you will be dealing with regarding postoperative needs.

When the family is more relaxed about caring for the client, the client is more relaxed.

The more the family understands what to expect during recovery, the more comfortable they are in caring for the client.

Teaching the family what they need to know before the surgery will maximize their effectiveness regarding the clients postoperative care.

ANS: 4 Often a family member is the caregiver when the client recovers from surgery. Perioperative preparation of family members before surgery helps to maximize effective caregiving while minimizing anxiety and misunderstanding. DIF: C REF: 1380 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 39. The nurse recognizes which of the following as the greatest barrier to meeting a preoperative clients nursing diagnosis of deficient knowledge regarding surgical procedure?

Effects of preoperative medication

Complicated nature of the information

Fear or anxiety regarding the procedure Emotional denial regarding surgical outcomes

ANS: 3 Anxiety and fear are barriers to learning, and both emotions heighten as surgery approaches. Education should be provided before any preoperative sedation is administered; the information should be introduced in terms that the client can understand. The presence of denial is an assumption that is not necessarily correct.

DIF: C REF: 1386 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 40. The nurse knows that the client is most likely going to arrive for the surgical procedure having adhered to the required bowel preparation if:

The client understands the need for the laxative

2 3

The laxative ordered is pleasant tasting The bowel preparation is an uncomplicated process

The client has the appropriate support at home

ANS: 1 Given a rationale for preoperative and postoperative procedures, the client is better prepared to participate in care. The remaining options may have an effect on compliance but not to the degree that understanding the need and purpose of the bowel preparation. DIF: C REF: 1380 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Reduction of Risk Potential/Monitoring Conscious Sedation/Potential for Complications From Surgical Procedures and Health Alterations 41. Which surgical classification would be the most appropriate for a cardiac catheterization scheduled on a 44-year-old male client who is in the hospital with chest pain?

Major

Minor

Ablative Elective

ANS: 1 Major surgery involves extensive reconstruction or alteration in body parts and poses great risks to well-being. Minor surgery involves minimal alteration in body parts, is often designed to correct deformities, and involves minimal risks compared with major procedures. Ablative surgery is the excision or removal of a diseased body part. Elective surgery is performed on the basis of clients choice, is not essential, and is not always necessary for health. DIF: B REF: 1366 OBJ: Application TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 42. A 36-year-old female diabetic client is having an elective breast augmentation procedure done. Which of the following tests must be done on the day of surgery?

Complete blood count (CBC)

Blood glucose

Serum electrolytes

Coagulation studies

ANS: 2 Blood glucose level can be obtained by either a finger stick or peripheral blood sample. Clients often require treatment of low or high levels preoperatively and postoperatively. DIF: A REF: 1367 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 43. A 48-year-old male client with a history of chronic obstructive pulmonary disease (COPD) is scheduled for an inguinal hernia repair. The nurse instructs that client that he can expect the health care provider to order which of the following tests before surgery?

Human immunodeficiency virus (HIV) antibody

Prolactin level

Pulmonary function test

Glucose tolerance test

ANS: 3 Pulmonary function testing and occasionally arterial blood gas analysis are often performed before surgery on clients with preexisting lung disease. An HIV-antibody test diagnoses HIV. It is not a test that is normally ordered before surgery. Prolactin levels are used to diagnose and monitor prolactin-secreting pituitary adenomas. A glucose tolerance test is used to assist in the diagnosis of diabetes mellitus and is also used in the evaluation of hypoglycemia. It is not a test that is normally ordered before surgery. DIF: A REF: 1377 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

44. A 64-year-old male client has been scheduled to undergo surgery for a total knee replacement. The client would like to be able to use his own blood for the surgery, if needed. The nurse explains that there are several advantages to the clients having an autologous infusion, but there are some drawbacks as well. Which of the following would be considered a drawback to an autologous infusion?

The client has a decreased risk for contracting HIV.

There is an decreased risk for infection. The client has less risk for a transfusion reaction.

3 4

The client may have a decreased hemoglobin and hematocrit level on the day of surgery.

ANS: 4 The client must plan ahead in plenty of time in order to be able to donate his own blood. In addition, the client who does self-donation sometimes exhibits a lower hemoglobin and hematocrit level on the day of surgery. Autologous infusions are an option for some clients who choose to donate their own blood before surgery to reduce the risk for transfusion-related infections. The client is at less risk for a transfusion reaction because it is his own blood. There is a lowered risk for infection because the blood is from the client. DIF: A REF: 1377 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 45. A 24-year-old male client has been scheduled to undergo surgery for an ACL repair of his right knee. The client states that he is confused about what the surgeon will be doing. The best response from the nurse is:

The surgeon went over this procedure with you in his office

Let me get the surgeon to talk with you before we proceed so that you fully understand what will be happening To share with the client what he can expect in regard to the procedure

3 4

This is just a simple procedureyou should feel much better afterwards

ANS: 2 The surgeon is responsible for making sure that the client completely understands the procedure before the client gives informed consent. The client may not remember the conversation that the

surgeon had with him regarding the procedure due to anxiety. The nurse should not discount the clients concerns. DIF: A REF: 1378 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 46. A 47-year-old female client has been scheduled to undergo surgery for removal of her gallbladder. Preoperatively the nurse is teaching the client what to expect when she wakes up in the postanesthesia care center. The nurse tells the client that her vision may be blurry due to which of the following reasons?

1 2

The clients blood pressure may be high from the postoperative pain. The client may be slow to arouse from the anesthesia, causing her vision to be blurred upon waking.

The anesthesia provider applies ointment to clients eyes to prevent corneal damage.

The lighting in the postanesthesia area will be subdued, causing the client to have blurred vision upon waking.

ANS: 3 The anesthesia provider applies ointment to clients eyes to prevent corneal damage. Warning clients about sensations of blurred vision will reduce their anxiety on awakening from surgery. The clients pain should be under control and therefore will not cause her blood pressure to be raised. The more subdued lighting in the postanesthesia care area should help the clients vision to focus upon coming out from under the anesthesia. DIF: A REF: 1380 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 47. Given a rationale for preoperative and postoperative procedures, the client is better prepared to participate in care. For which of the following should the nurse provide instruction and rationale?

Incentive spirometry

Specific details regarding the progression of diet

Working the call button for the nurse

Using the patient-controlled analgesia (PCA) pump

ANS: 1 Given a rationale for preoperative and postoperative procedures, the client is better prepared to participate in care. The diet progression should be discussed with the client by the unit nurse as the postsurgical diet progresses. The call light may be specific to the unit the client is on and is best taught to the client once he or she is on the unit so that the client can demonstrate to the nurse that he or she understands how to use it. The PCA pump is best taught to the client once he or she is on the unit so that the client can demonstrate to the nurse that he or she understands how to use it. DIF: A REF: 1380 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems 48. The nurse is very busy and needs to delegate some tasks to the nursing assistive personnel (NAP). Which of the following would be the most appropriate task to delegate?

Postoperative client teaching

Demonstrating postoperative exercises

Transporting the preoperative client from the unit to the holding area Reviewing the preoperative assessment to make sure that the clients vital signs have been documented

ANS: 3 In many hospitals a nursing orderly or transporter brings a stretcher for transporting the client. The transporter checks the clients identification bracelet for two identifiers against the clients chart to be sure that the right person is going to surgery. DIF: B REF: 1380 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems MULTIPLE RESPONSE 1. When discussing the details of having a procedure done in a facilitys ambulatory surgery department, the nurse includes which of the following as advantages? (Select all that apply.)

Facilitates faster postsurgical recovery

Reduces hospital-oriented expenses

Allows for more one-on-one attention by staff

4 5

Cuts preparation time for surgical procedures Minimizes risk for acquiring a nosocomial infection

The anesthetic drugs used result in faster wake-up time

ANS: 1, 2, 5, 6 There are distinct benefits for the client who has ambulatory surgery. Anesthetic drugs that metabolize rapidly with few after-effects allow shorter operative times and faster recovery time. Ambulatory surgery also offers cost savings by eliminating the need for hospital stays. This reduces the possibility of acquiring health careassociated infections, which occur when normal skin flora changes from hospitalization and clients become colonized with bacteria found in the hospital setting. Preparation time and staff attention are not necessarily affected.