Test Bank Fundamentals of Nursing Thinking Doing and Caring 4th Edition Volume 2 Wilkinson Treas by ACADEMIAMILL

Fundamentals of Nursing Thinking Doing and Caring 4th Edition Volume 2 Wilkinson Treas Test Bank Chapter 1. Evolution of Nursing Thought & Action Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse is working in a community health promotion clinic. Which is an example of an illness prevention activity? 1. Encouraging the use of a food diary 2. Joining a cancer support group 3. Administering immunization for human papillomavirus (HPV) 4. Teaching a diabetic patient about his diet 2. A practicing nurse is aware that continuing education courses may be required for license renewal. Which organization can require nurses to obtain a specified amount of continuing education courses? 1. American Nurses Association 2. National League for Nursing 3. Sigma Theta Tau 4. State Board of Nursing 3. An experienced nurse uses knowledge of patient medical conditions and intuition to identify patient problems. The nurse often fulfills the role of a resource for other nurses on the unit. At this point, which stage of proficiency has this nurse achieved? 1. Novice 2. Advanced beginner 3. Competent 4. Expert 4. Which statement best explains the importance of standards of practice in the nursing profession? 1. Nurses have the same standards of practice as other healthcare professionals. 2. Standards of practice are applied exclusively to nurses working in hospital settings. 3. Standards of practice identify the components nurses need to provide safe care. 4. Standards of practice differ among registered nurses, based on the population they serve. 5. The nursing instructor is considering becoming a member of the National League for Nursing (NLN). Which primary goal of the NLN will most strongly impact the nurse’s decision to become a member? 1. Emphasizing the necessity for registered nurses to promote patient safety 2. Establishing and maintaining identified standards for nursing education 3. Supporting global health policies and improving health worldwide 4. Fostering nursing scholarship, leadership, and service to improve health

6. The nurse is providing care for a patient following a debilitating stroke. Which type of care will the nurse recognize as the best choice for this patient? 1. Primary care 2. Secondary care 3. Tertiary care 4. Preventive care 7. The nurse is providing care for an older adult patient in an acute care setting for various agerelated health issues. When planning for discharge, the patient states concern about being able to adequately provide for health maintenance and self-care needs. Which type of facility does the nurse recognize for this patient? 1. Skilled nursing facility 2. Assisted living facility 3. Nursing home facility 4. Independent living facility 8. The nurse understands that the most important reason for the development of a definition for the profession of nursing is that it: 1. Will result in more informed people being recruited as nurses. 2. Is a means for evaluating the degree of role satisfaction in nurses. 3. Helps dispel the stereotypical images about nurses and nursing. 4. Differentiates the nursing role from those of other health professionals. 9. Which activity provides evidence-based support for the contribution made by advanced practice nurses (APNs) within healthcare? 1. Reduced use of diagnostics using advanced technology 2. Decreased number of unnecessary visits to the emergency department 3. Improved patient compliance with prescribed treatments 4. Increased use of complementary and alternative therapies 10. The nurse is providing care for a pediatric patient in an acute care facility. The patient’s parents express concern about the cost of the medical care. The parents state, “We have jobs, but we don’t make a lot of money and have no insurance.” Which medical assistance program does the nurse recognize as being most appropriate for this family? 1. Children’s Health Insurance Program (CHIP) 2. Medicare 3. Medicaid 4. Local charity 11. A nurse working in a rehabilitation facility has a physician’s prescription to contact therapists as required by patient need. A patient has started to have difficulty with bathing and grooming. Which therapist does the nurse contact to assist the patient to regain these skills? 1. Physical therapist 2. Occupational therapist 3. Speech-language pathologist

4. Respiratory therapist 12. An older adult patient is diagnosed with type 1 diabetes mellitus. The patient can perform self-care activities but needs assistance with shopping and meal preparation. As well, assistance is necessary for blood glucose monitoring and insulin administration. Which type of healthcare facility is most appropriate for the patient? 1. Acute care facility 2. Ambulatory care facility 3. Extended care facility 4. Assisted living facility 13. The nurse in the intensive care unit is providing care for only one patient, who was admitted with a diagnosis of septic shock. Based on this information, which care delivery model is this nurse following? 1. Functional 2. Primary 3. Case method 4. Team 14. The nurse is providing care for a patient who needs extensive acute care, which is being rejected by the patient because of financial and family stressors. Which healthcare worker does the nurse consult to counsel this patient? 1. Social worker 2. Occupational therapist 3. Physician’s assistant 4. Technologist 15. Which type of managed care provides patients with the greatest choice of providers, medications, and medical devices? 1. Health maintenance organization 2. Integrated delivery network 3. Preferred provider organization 4. Employment-based private insurance 16. The registered nurse is discharging a patient to an assisted living facility. Which statement by the nurse is most appropriate for the patient? 1. “Therapists will work with you daily to help you regain your functional abilities.” 2. “You will be provided with 24-hour nursing care for the next 6 weeks.” 3. “Assistance with meals and housekeeping tasks is available to you.” 4. “A nurse will come to your home and provide you with nursing care.” 17. Which member of the healthcare team typically serves as the case manager? 1. Social worker 2. Physician 3. Physician’s assistant

4. Registered nurse 18. The nurse works in a public health department. Which nursing function is considered a primary care service? 1. Providing wound care 2. Administering childhood immunizations 3. Providing drug rehabilitation 4. Providing outpatient hernia repair 19. A patient who is 80 years of age is in an acute care facility because of a fractured hip resulting from a fall. Previously, the patient lived at home and managed activities of daily living independently. The patient goal is to return to the previous living style. The patient is to be discharged because of insurance regulations. If the patient cannot walk or provide self-care, to which type of facility will the patient be transferred? 1. Nursing home 2. Rehabilitation center 3. An outpatient therapy center 4. None of these; she should receive home healthcare 20. A health care facility hires new nursing graduates to work on patient care units. The hired nurses come from a variety of accredited nursing programs. Additionally, applicants need to be aware of facility hiring practices based on which specific definition of a nurse? 1. Graduate of a nursing education program, and passed the National Council Licensure Exam (NCLEX) 2. Obtained certification permitting the administration of medications in certain healthcare settings 3. Specifically licensed to practice in either an acute care setting or in a home environment 4. Received advanced education and is licensed to practice under the direct supervision of a physician 21. A nurse who has been practicing for 3 years in an acute care facility is caring for a postsurgical patient. The nurse observes an abnormal change in vital signs and associates these changes with a postoperative bleeding problem. Which level of proficiency is the nurse demonstrating? 1. Advanced beginner 2. Competent 3. Proficient 4. Expert 22. In the United States, each state enacts its own nurse practice acts. Which agency is responsible for nurse practice acts? 1. The American Nurses Association 2. Institute of Medicine 3. State Board of Nursing 4. National League for Nursing

23. A nurse is recently hired at an acute care facility. During orientation, the nurse is given a chart describing each person’s role on the assigned unit. The chart reflects that registered nurses are responsible for all admission and discharge assessments and patient treatments. Licensed practical nurses (LPNs) administer medications, and certified nursing assistants (CNAs) obtain vital signs and perform personal care. Which model of care does the nurse recognize? 1. Case method 2. Team 3. Primary 4. Functional 24. Nurses currently employed are aware of the trends that affect contemporary nursing practice. Which trend is a primary cause for changes in the nursing profession? 1. The expected increase in the number of older adults in society 2. The large amount of medical information that is technically accessible 3. The increasing demands for more medical care from all aspects of society 4. The multiple medical care expectations implemented by the government 25. A patient is preparing to be discharged after total knee replacement. The patient tells the case manager, “I feel pretty good, but I am having a hard time getting in and out of the bathroom.” Which is the most appropriate response by the case manager? 1. “I’ll be sure to teach your family how to help you with this.” 2. “Once you are home for a while, it will get easier.” 3. “I can have a recreational therapist help you take your mind off your concerns.” 4. “An occupational therapist can be ordered to assist you in this area.” 26. An older adult patient is preparing for discharge and tells the case manager, “I don’t know what I am going to do when I get home. I cannot afford the medications the doctor has ordered for me.” Which is the most appropriate response by the case manager? 1. “We can have a social worker see you when you get home.” 2. “Medications are expensive, but you will need to take them.” 3. “I will check if some of the medications can be discontinued.” 4. “The home health nurse will address this when she sees you.” 27. A patient in an ambulatory clinic tells the nurse, “Every visit costs me $10, even though I have insurance.” Which is the most appropriate response by the nurse? 1. “I am not involved in your insurance; you need to contact the insurance company.” 2. “Let’s check if this is a co-payment described by your insurance plan for each visit.” 3. “Healthcare is expensive, and insurance companies can’t pay all of the costs.” 4. “This charge is actually part of the insurance premium that you pay monthly.” 28. The nursing staff on a surgical unit expresses to the manager concerns about not having enough time to complete all wound care and dressing changes. Which is the initial action the manager takes?

1. 2. 3. 4.

Decrease the patient-to-nurse ratio within budget limits Offer an in-service session on time-management strategies Suggest a continuing quality improvement committee to assess the issue Report the concerns to the director of nurses at the next management meeting

Multiple Response Identify one or more choices that best complete the statement or answer the question. 29. Which activities indicate the implementation of direct nursing care? Select all that apply. 1. Bathing a patient 2. Administering a medication 3. Teaching a patient to change a wound dressing 4. Making work assignments for the shift 5. Evaluating patient progression toward goals 30. Which actions by the nurse are considered “skilled nursing care”? Select all that apply. 1. Changing a wound dressing 2. Assisting with bathing and grooming 3. Monitoring intravenous (IV) antibiotic administration 4. Teaching a patient how to use a blood glucose monitor 5. Helping a patient to get dressed 31. To reflect the changes in healthcare and nurses’ expanded roles, the International Council of Nurses revised the definition of nursing. Which statements are consistent with the revised definition of nursing? Select all that apply. 1. Nursing encompasses the autonomous and collaborative care of others. 2. Nursing includes the care of ill, disabled, and dying people. 3. Nursing is involved in shaping health policy and system management. 4. Nursing involves the use of the nursing process to plan care. 5. Nursing requires knowledge regarding the process of nursing education. 32. According to the American Nurses Association (ANA), which statements best describe the characteristics of registered nursing? Select all that apply. 1. Nursing practice is individualized. 2. Nursing practice is similar to medical practice. 3. Caring is central to the practice of the registered nurse. 4. Nurses coordinate care by establishing partnerships. 5. Nurses promote health through political involvement. 33. The field of nursing has struggled to prove that nursing is a profession. Which strategies to improve the status of nursing will promote professionalism? Select all that apply. 1. Standardizing the educational requirements for entry into practice 2. Mandating uniform continuing education requirements for licensure 3. Guaranteeing that all nurses will obtain employment upon graduation

4. Encouraging participation of nurses in professional organizations 5. Educating the public about the true nature of nursing practice 34. Each U.S. state has its own state board of nursing responsible for protecting the health, safety, and welfare of the general public. The state boards of nursing meets these responsibilities by performing which functions? Select all that apply. 1. Advocating for nursing student issues 2. Determining the nurse’s scope of practice 3. Enforcing the rules that govern nursing 4. Writing the laws that regulate nursing 5. Regulating the number of licensed nurses 35. The nurse is preparing a presentation for nursing students about the processes of thinking and implementation that apply to nursing. Which topics will the nurse include? Select all that apply. 1. Critical thinking 2. Pain evaluation 3. Clinical judgment 4. Problem solving 5. Sterile technique Completion Complete each statement. 36.

is a health program, administered by the state and funded by federal and state governments, to provide care for low-income people.

37.

is a federal insurance program designed to fund healthcare for people age 65 years and older, persons with disabilities, and those with end-stage renal disease.

Chapter 1. Evolution of Nursing Thought & Action Answer Section MULTIPLE CHOICE 1. ANS: 3 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Name and recognize the four purposes of nursing care. Page: 19 (V1) Heading: Nursing and Illness Prevention Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate Feedback 1 This is incorrect. Illness prevention activities focus on avoiding a specific disease. Keeping a food diary is a health promotion activity. 2 This is incorrect. Although cancer is a disease, it is assumed that a person joining a support group would already have the disease; therefore, it would be treatment and not disease prevention. 3 This is correct. Administering immunization for HPV is an example of illness prevention. 4 This is incorrect. Teaching a diabetic patient about diet is a treatment for diabetes; the patient already has diabetes, so the teaching cannot prevent diabetes. PTS: 1 CON: Health Promotion 2. ANS: 4 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Explain how nursing practice is regulated. Page: 23 (V1) Heading: Continuing Education Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Professionalism Difficulty: Moderate

Cognitive Level: Application [Applying] Feedback 1 This is incorrect. The American Nurses Association is a professional organization and does not mandate continuing education. However, the organization may offer continuing education units (CEUs) to fulfill education requirements. 2 This is incorrect. The National League for Nursing is a professional organization and does not mandate continuing education. However, the organization may offer continuing education units (CEUs) to fulfill education requirements. 3 This is incorrect. Sigma Theta Tau is a professional organization and does not mandate continuing education. However, the organization may offer continuing education units (CEUs) to fulfill education requirements. 4 This is correct. Continuing education is a professional strategy designed to ensure that nurses remain current in their clinical knowledge. Many states require nurses to engage in a certain number of continuing education requirements to renew their license. Requirements for renewal of a nurse’s license can be found in the state’s nurse practice act (state board of nursing). PTS: 1 CON: Professionalism 3. ANS: 4 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Differentiate among the various forms of nursing education. Page: 13 (V1) Heading: Benner’s Model Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Professionalism Difficulty: Moderate Feedback 1 This is incorrect. The novice nurse is inexperienced and relies on rules and processes. 2 This is incorrect. The advanced beginner focuses on aspects of a situation and is unable to see the comprehensive perspective. 3 This is incorrect. A nurse functioning at the competent level is able to prioritize to meet patient needs but does not fully grasp the total situation. 4 This is correct. The nurse who has reached the expert stage of proficiency has a deep understanding of the clinical situation based on knowledge and experience. The nurse often senses a potential problem in the absence of classic signs and symptoms. PTS:

CON: Professionalism

4. ANS: 3 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Explain how nursing practice is regulated. Page: 24 (V1) Heading: Contemporary Nursing: Education, Regulation, and Practice > Standards of Practice Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Professionalism Difficulty: Moderate Feedback 1 This is incorrect. Nursing standards of practice are exclusive to the profession of nursing; standards of nursing practice are not shared with other healthcare professionals. 2 This is incorrect. The standards of practice for nursing are applicable regardless of the setting in which nursing care is provided. 3 This is correct. Standards of practice are authoritative statements of the duties that all registered nurses, regardless of role, population, or specialty, are expected to perform competently. Standards are derived from several sources, including professional organizations and healthcare facilities’ policies and procedures. 4 This is incorrect. The standards of practice for nursing are applicable regardless of the population receiving nursing care. PTS: 1 CON: Professionalism 5. ANS: 2 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Give four examples of influential nursing organizations. Page: 13 (V1) Heading: Nursing Organization Guidelines Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Professionalism Difficulty: Moderate Feedback 1 This is incorrect. The American Nurses Association (ANA) is the official professional organization for nurses in the United States. Originally, the ANA focused on establishing standards of nursing to promote high-quality care and working toward licensure as a means to ensure adherence to the standards; both these actions focus on patient safety. 2 This is correct. The National League for Nursing (NLN) was founded to

establish and maintain a universal standard of nursing education. The NLN focuses on faculty development in nursing education programs and is the voice for nursing education. This is incorrect. The International Council of Nursing (ICN) represents more than 20 million nurses on a global level. It is composed of a federation of national nursing organizations from more than 130 nations. The ICN aims to ensure quality nursing care for all. This is incorrect. The goal of Sigma Theta Tau International is to foster nursing scholarship, leadership, service, and research to improve health worldwide.

PTS: 1 CON: Professionalism 6. ANS: 3 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Name and recognize the four purposes of nursing care. Page: 19 (V1) Heading: Healthcare Delivery System > How Is Healthcare Categorized? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Health Promotion Difficulty: Difficult Feedback 1 This is incorrect. The six domains of acute care are: (1) trauma care and acute care surgery, (2) emergency care, (3) urgent care, (4) short-term stabilization, (5) prehospital care, and (6) critical care. The goal is to prevent deterioration and restore health. Initially, this patient requires acute care. 2 This is incorrect. Secondary care is available for patients who require support or rehabilitation over a limited period of time. A patient may require secondary care following a joint replacement. 3 This is correct. Tertiary care is required for individuals who need long-term care or for those who are dying. After a debilitating stroke, this patient is most likely to require long-term care. 4 This is incorrect. Preventive care is provided as an effort to prevent disease and illness; following a stroke, the patient is no longer considered for preventive care alone. PTS: 1 CON: Health Promotion 7. ANS: 2 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare. Page: 17 (V1)

Heading: Where Is Care Provided? > Extended Care Facilities Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Difficult Feedback 1 This is incorrect. The question does not include information regarding the patient care needs following discharge; therefore, this option is not a good choice. Skilled care facilities include services of trained professionals who are needed for a limited period of time after an injury or illness (e.g., wound care, intravenous infusions). Services are provided to clients who no longer need 24hour acute care services and who can be expected to improve with treatment. 2 This is correct. An assisted-living facility is designed to bridge the gap between independence and institutionalization for older adults who have a decline in health status and cannot live independently. Residents of these facilities are able to perform self-care activities but require assistance with meals, housekeeping, or medications. Because skilled care is usually not required, nurses have a limited presence at assisted living sites. The patient expresses concern over the ability to provide adequate self-care. 3 This is incorrect. There is no information to support the patient needing nursing home care, which provides custodial care for people who cannot live on their own but are not sick enough to require hospitalization. They may be a permanent home for people who require continual supervision to ensure their safety. Residents are offered a provider to supervise care, recreational activities, and salon services. 4 This is incorrect. Independent living facilities are designed for seniors 55 years or older who (a) are independent in all aspects and (b) want to live in a community with other senior citizens. Services usually include a peer support network that provides socialization opportunities, structured recreational activities, transportation arrangements, fitness centers, pools, and quiet environments. Nurses may provide periodic health screening and health information. The patient’s expressed concern does not support this extended care type.

PTS: 1 CON: Safety 8. ANS: 4 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Define nursing in your own words. Page: 24 (V1) Heading: Contemporary Nursing: Education, Regulation, and Practice > How Is Nursing Defined?

Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Evidence-Based Practice Difficulty: Moderate Feedback 1 This is incorrect. A definition of nursing is not likely to increase the number of informed people recruited into nursing. 2 This is incorrect. A definition of nursing would do little to improve the nurse’s role satisfaction. 3 This is incorrect. Although a definition of nursing might contribute to fighting stereotypes of nursing, other, more powerful influences (e.g., media portrayals), exist to counteract it. 4 This is correct. Nursing organization leaders think it is important to develop a definition of nursing to bring value and understanding to the profession, differentiate nursing activities from those of other healthcare professionals, and help student nurses understand what is expected of them. PTS: 1 CON: Evidence-Based Practice 9. ANS: 3 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Delineate the forces and trends affecting contemporary nursing practice. Page: 27 (V1) Heading: Expanded Career Roles for Nurses > Advanced Practice Nurses (APNs) Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Evidence-Based Practice Difficulty: Moderate Feedback 1 This is incorrect. No well-known, scientific studies support APNs’ effect on the use of advanced technology. 2 This is incorrect. No well-known, scientific studies support APNs’ effect on the frequency of emergency department visits. 3 This is correct. Studies demonstrate that APNs have achieved improved patient outcomes compared with physicians, including increased patient understanding and cooperation with treatments and decreased need for hospitalizations. 4 This is incorrect. No well-known, scientific studies support APNs’ effect on the use of alternative therapies. PTS: 1 10. ANS: 1

CON: Evidence-Based Practice

Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Discuss issues related to healthcare reform. Page: 20 (V1) Heading: How Is Healthcare Financed? > Government (Public) Financing Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is correct. CHIP is a joint venture between the federal government and states. CHIP provides health insurance to millions of children whose family income exceeds Medicaid eligibility criteria but who cannot afford private insurance and are not covered under a parent’s policy. The nurse recognizes this program as the most appropriate one for this family. 2 This is incorrect. Medicare is a federal insurance program created by Title XVIII of the Social Security Act of 1965. This act as designed to provide insurance coverage for persons age 65 years and older and later expanded to include younger people with permanent disabilities, such as end-stage renal disease. 3

This is incorrect. Medicaid was developed under Title XIX of the Social Security Act of 1965 to provide access to healthcare services for people with low incomes and minimal resources. Medicaid offers a fairly comprehensive set of benefits, including prescription drugs, skilled care, and long-term care. This is incorrect. The nurse is aware that charitable organizations are an increasingly important funding source for healthcare. Community agencies that are funded through networks, such as the United Way, Salvation Army, and Red Cross, provide important resources for children, poor families, older adults, and vulnerable populations, such as the homeless, mentally ill, and victims of violence. This is the second-most appropriate program for this family.

PTS: 1 CON: Patient-Centered Care 11. ANS: 2 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare. Page: 19 (V1) Heading: Who Are the Members of the Interprofessional Healthcare Team? Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate

Feedback This is incorrect. Physical therapists focus on the rehabilitation of muscles and bones and helping clients gain optimal functioning in self-care skills for activities of daily living and learn how to use assistive devices. This is correct. Occupational therapists help patients to regain and maintain function and independence with activities of daily living, such as dressing, bathing, and grooming. This is incorrect. Speech-language pathologists provide assistance to clients experiencing swallowing and speech disturbances (e.g., developing speech and language skills after neurological impairment). This is incorrect. Respiratory therapists provide respiratory treatments that have been prescribed by physicians or advance practice nurses (e.g., oxygen therapy, mechanical ventilation).

PTS: 1 CON: Patient-Centered Care 12. ANS: 4 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare. Page: 18 (V1) Heading: Where Is Care Provided? Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Acute care facilities focus on preventing illnesses and treating acute problems. These facilities include physicians’ offices, clinics, and diagnostic centers. 2 This is incorrect. Ambulatory care facilities provide outpatient care. Clients live at home or in nonhospital settings and come to the site for care. Ambulatory care facilities include private health and medical offices, clinics, surgery centers, and outpatient therapy centers. 3 This is incorrect. Extended care facilities typically provide long-term care, rehabilitation, wound care, and ongoing monitoring of patient conditions. 4 This is correct. Assisted living facilities are intended for those who are able to perform self-care activities but require assistance with meals, housekeeping, or medications. PTS:

CON: Patient-Centered Care

13. ANS: 3 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare. Page: 24 (V1) Heading: What Models of Care Are Used to Provide Nursing Care? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. When the functional nursing model is employed, care is compartmentalized, and each task is assigned to a staff member with the appropriate knowledge and skills. 2 This is incorrect. In primary nursing, one nurse plans the care for a group of patients around the clock. The primary nurse assesses the patient and develops the plan of care. When this nurse is working, he or she provides care for those patients for whom he or she is responsible. In the absence of this nurse, the associate nurses deliver care. Although the nurse in this case could possibly be a primary nurse, there are not enough data to confidently infer that. 3 This is correct. The nurse is following the case method model of nursing care. In this model, one nurse cares for one patient during a single shift. 4 This is incorrect. If the team nursing approach is employed, a licensed nurse (registered nurse [RN] or licensed vocational nurse [LVN]) is paired with a nursing assistant. The pair is then assigned to a group of patients. PTS: 1 CON: Patient-Centered Care 14. ANS: 1 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare. Page: 19 (V1) Heading: Who Are the Members of the Interprofessional Healthcare Team? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is correct. The social worker coordinates services and counsels patients about financial, housing, marital, and family issues impacting healthcare.

2 3 4

This is incorrect. The occupational therapist helps patients regain function and independence for activities of daily living. This is incorrect. Physician’s assistants work under the physician’s direction to diagnose certain diseases and injuries. This is incorrect. Technologists provide a variety of specific functions in hospitals, diagnostic centers, and emergency care. For example, laboratory technologists aid in the diagnosis and treatment of patients by examining blood, urine, tissue, and body fluids. Radiology technologists perform x-rays and other diagnostic testing.

PTS: 1 CON: Patient-Centered Care 15. ANS: 3 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare. Page: 22 (V1) Heading: How Have Healthcare Reform Efforts Affected Care? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Health maintenance organizations allow the patient to choose a primary care provider within an organization to coordinate his care. This type of program will only reimburse medical care when the patient has first obtained a referral from the primary provider. 2 This is incorrect. Integrated delivery networks combine providers, healthcare facilities, pharmaceuticals, and services into one system, and the patient must remain within the system to receive care. 3 This is correct. Preferred provider organizations are a form of managed care that allows the patient a greater choice of providers, medications, and medical devices within the designated list. 4 This is incorrect. Employment-based private insurance is not a managed care organization. PTS: 1 CON: Patient-Centered Care 16. ANS: 3 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare. Page: 19 (V1)

Heading: Where Is Care Provided? Integrated Processes: Caring Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Rehabilitation centers have a team of therapists who work with patients to help them achieve their optimal functional status. This can be an inpatient or outpatient service. 2 This is incorrect. Hospitals, skilled nursing units, and other acute care facilities provide 24-hour nursing care. 3 This is correct. Assisted living facilities are designed to bridge the gap between independence and institutionalization for persons who have a decline in health status. The assistance available will vary, based on the facility, but commonly involves meals and housekeeping tasks. 4 This is incorrect. Home care, even with nurse visitations, is not classified as care with assistance. The question states that the patient is being discharged to an assisted living facility. PTS: 1 CON: Patient-Centered Care 17. ANS: 4 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare. Page: 24 (V1) Heading: Who Are the Members of the Interprofessional Healthcare Team? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Easy Feedback 1 This is incorrect. Social workers provide psychosocial support and client services throughout the healthcare system to coordinate continuity of care in a cost-effective manner. 2 This is incorrect. Physicians are considered team leaders for an inpatient, and their primary role is to make a medical diagnosis and outline a treatment plan. Physicians are licensed as medical doctors (MD) or doctors of osteopathy (DO). Their role is to diagnose and treat diseases and illnesses through medical and surgical services. 3 This is incorrect. Physician’s assistants diagnose and treat certain diseases and

injuries. Because they are not independently licensed, they must practice under the supervision of a physician. This is correct. Typically, registered nurses serve as case managers for patients with specific diagnoses. Their role is coordination of care across the healthcare system.

PTS: 1 CON: Patient-Centered Care 18. ANS: 2 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare. Page: 18 (V1) Heading: How Is Healthcare Categorized? Integrated Processes: Caring Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate Feedback 1 This is incorrect. Wound care and drug rehabilitation are examples of tertiary care services. 2 This is correct. Primary care services focus on health promotion and disease prevention; administering childhood immunizations is one such service. 3 This is incorrect. Wound care and drug rehabilitation are examples of tertiary care services. 4 This is incorrect. Outpatient hernia repair surgery is an example of a secondary care service. PTS: 1 CON: Health Promotion 19. ANS: 2 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare. Page: 18 (V1) Heading: Extended Care Facilities Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is incorrect. A nursing home provides custodial care for people who cannot

3 4

live on their own but who are not sick enough to require hospitalization. It provides a room, custodial care, and opportunity for recreation. This is correct. A skilled nursing facility (e.g., a rehabilitation center) primarily provides skilled nursing care for patients who can be expected to improve with treatment. For example, a patient who no longer needs hospitalization may transfer to a skilled nursing facility until able to return home. This is incorrect. This patient cannot ambulate or perform activities of daily living, so outpatient therapy and home care would not be appropriate. This is incorrect. This patient cannot ambulate or perform activities of daily living, so outpatient therapy and home care would not be appropriate.

PTS: 1 CON: Patient-Centered Care 20. ANS: 1 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Define nursing in your own words. Page: 8 (V1) Heading: How Is Nursing Defined? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Professionalism Difficulty: Moderate Feedback 1 This is correct. The best legal description of a nurse is one who has graduated from an accredited nursing education program and has passed the NCLEX exam. 2 This is incorrect. Persons certified to administer medications may be certified medication technicians and not necessarily nurses. 3 This is incorrect. Nurses can practice in a vast variety of settings, and not exclusively in an acute care setting or in home care. 4 This is incorrect. Practicing under the direct supervision of a physician is descriptive of a physician’s assistant or of a nurse practitioner; both positions require advanced education. PTS: 1 CON: Professionalism 21. ANS: 2 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Define nursing in your own words. Page: 12 (V1) Heading: Benner’s Model Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care

Cognitive Level: Comprehension [Understanding] Concept: Professionalism Difficulty: Moderate Feedback 1 This is incorrect. The advanced beginner can distinguish abnormal findings but cannot readily understand their significance. 2 This is correct. The nurse is demonstrating competency (competent) level, as evidenced by associating abnormal changes in vital signs with postoperative bleeding. Additionally, this nurse has been practicing for 3 years, which is within the range needed for the competency proficiency level. 3 This is incorrect. The proficient nurse recognizes problems but will immediately gather resources to initiate treatment; there is no evidence in the scenario that the nurse took any actions. 4 This is incorrect. The expert can often recognize a problem in the absence of signs and symptoms. PTS: 1 CON: Professionalism 22. ANS: 3 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Explain how nursing practice is regulated. Page: 13 (V1) Heading: How Is Nursing Practice Regulated? Integrated Processes: Nursing Process Client Need: Safe and Effective Nursing Care Cognitive Level: Comprehension [Understanding] Concept: Professionalism Difficulty: Easy Feedback 1 This is incorrect. The American Nurses Association is a professional organization responsible for guiding and improving nursing practice, usually by setting standards of practice and establishing a nursing code of ethics. 2 This is incorrect. The Institute of Medicine provides information and advice concerning health and science policy, for example, its involvement in the project Quality and Safety Education for Nurses. 3 This is correct. Each state board of nursing is responsible for enacting and enforcing the nurse practice act of its state. 4 This is incorrect. The National League for Nursing sets standards for all nursing education. PTS: 1 CON: Professionalism 23. ANS: 4 Chapter: Chapter 1 Evolution of Nursing Thought & Action

Objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare. Page: 12 (V1) Heading: What Models of Care Are Used to Provide Nursing Care? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment Cognitive Level: Application [Applying] Concept: Professionalism Difficulty: Moderate

1 2 3

Feedback This is incorrect. In the case method model, one nurse cares for one patient during a single shift. This is incorrect. In the team model, a nurse is paired with an LPN or a CNA. The team is then assigned to a specific group of patients. This is incorrect. Primary nursing is a method where one nurse manages care for a group of patients. The primary nurse assesses the patient and develops a plan of care. In the absence of the primary nurse, associate nurses deliver care and implement the plan developed by the primary nurse. This is correct. The nurse recognizes this practice as the functional model of care in which care is compartmentalized and each employee is assigned specific tasks and roles with the associating knowledge and skill.

PTS: 1 CON: Professionalism 24. ANS: 1 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Delineate the forces and trends affecting contemporary nursing practice. Page: 25 (V1) Heading: What Are Some Trends in Society? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Evidence-Based Practice Difficulty: Difficult

Feedback This is correct. With aging, people experience more acute and chronic illnesses and a greater need for medical and nursing care. In 2017, 49.2 million individuals were 65 years and older. This number is expected to increase to 98.2 million by 2060, with 19.7 million of these individuals age 85 years or older. As the population of older adults grows, little growth is expected in individuals under 20 years of age. The result is fewer younger people who can provide care.

This has significant implications for the healthcare system and the profession of nursing. This is incorrect. It is true that current technology enables vast numbers of people to access medical information. And while the teaching opportunities for nurses expand, this factor alone is not a primary cause for changes in the profession of nursing. This is incorrect. Increase in the demands for medical care from all members of society is not specifically a primary cause for changes in the profession of nursing; all aspects of medical care will be affected. This factor alone is not a primary cause for changes in the profession of nursing. This is incorrect. Government-implemented medical care expectations will impact all aspects of medical care delivery. This factor alone is not a primary cause for changes in the profession of nursing.

PTS: 1 CON: Evidence-Based Practice 25. ANS: 4 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare. Page: 19 (V1) Heading: Who Are the Members of the Interprofessional Healthcare Team? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate

2 3

Feedback This is incorrect. Teaching the family how to assist with toileting is not typically the role of the case manager. Additionally, this does not assist the patient regarding the immediate concern of toileting. This is incorrect. Reassurance is important and positive, but the patient first needs assistance with toileting. This is incorrect. Recreational therapists promote patient physical, social, and emotional well-being through the use of leisure activities. There is no indication that this patient is in need of a recreational therapist. This is correct. The patient is expressing a concern for managing toileting at home. Upon discharge, the therapy that focuses most closely on activities of daily living is occupational therapy.

PTS: 1 26. ANS: 1

CON: Communication and Documentation

Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare. Page: 19 (V1) Heading: Who Are the Members of the Interprofessional Healthcare Team? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate

2 3

Feedback This is correct. Social workers counsel patients on financial, housing, marital, and family issues affecting healthcare. Owing to rising healthcare costs and diminished access to healthcare, particularly for aging populations, social workers are increasingly being used to help move clients through the healthcare system. This is incorrect. Acknowledging the rising costs of medications does not assist the patient in solving the problem of his ability to pay for medications. This is incorrect. The case manager cannot make any assumption that to alleviate the patient’s concerns about affording medications, it might be appropriate to have some medications discontinued. This is incorrect. The home health nurse typically coordinates the care and services but is not typically the healthcare provider addressing financial concerns.

PTS: 1 CON: Patient-Centered Care 27. ANS: 2 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare. Page: 20 (V1) Heading: How Is Healthcare Financed? Integrated Processes: Communication and Documentation Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate

Feedback This is incorrect. Most facilities have access to the patient’s coverage plan and can answer immediate questions until the patient is able to follow up with his or

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her insurance company. This is correct. Those who have insurance or government-financed insurance bear some of the expenses of healthcare through cost sharing. Typical cost sharing can be in the form of co-pays, deductibles, paying a portion of one’s insurance premium, or paying costs above a fixed payment amount. Patients do not always understand cost-sharing methods and may need an explanation at the time of the visit. The best response is for the nurse to explain what a co-payment is. This is incorrect. Stating that healthcare is expensive is merely stating the obvious; it may also be perceived as defensive rather than supportive. This is incorrect. Co-payments are typically not part of an insurance premium and are only collected at the time of a service.

PTS: 1 CON: Patient-Centered Care 28. ANS: 3 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare. Page: 22 (V1) Heading: Nursing Practice: Caring for Clients Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

Feedback This is incorrect. There may be a need to look at nurse–patient ratios, and there may be a need to provide an in-service session on time management. However, these are not known until some assessment is completed and data are obtained. This is not the manager’s initial action. This is incorrect. Total Quality Management (TQM) or Continuous Quality Improvement (CQI) projects assist in looking at all aspects of quality and safe care practices. Offering a session on time management may be useful; however, it is not the initial action taken by the manager. This is correct. The most appropriate action by the nurse manager is to assess the issue through establishing some quality improvement/quality care activities in the form of an appointed committee. Assessment is always the initial action taken when evaluating an issue or concern. This is incorrect. Reporting the concern to the director of nurses may be indicated, but this will not immediately address the concerns of the staff. The initial action is for assessment

PTS:

CON: Patient-Centered Care

MULTIPLE RESPONSE 29. ANS: 1, 2, 3 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare. Page: 19 (V1) Heading: Who Are the Members of the Interprofessional Healthcare Team? Integrated Processes: Caring Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Professionalism Difficulty: Difficult

Feedback This is correct. Direct care involves personal interaction between nurses and clients (e.g., bathing a patient, giving medications, dressing a wound, or teaching a client about medicines or care). This is correct. Direct care involves personal interaction between nurses and clients (e.g., bathing a patient, giving medications, dressing a wound, or teaching a client about medicines or care). This is correct. Direct care involves personal interaction between nurses and clients (e.g., bathing a patient, giving medications, dressing a wound, or teaching a client about medicines or care). This is incorrect. Nurses deliver indirect care when they work on behalf of an individual, group, family, or community to improve their health status (e.g., restocking the code blue cart [an emergency cart], ordering unit supplies, or arranging unit staffing). This is incorrect. Nurses deliver indirect care when they work on behalf of an individual, group, family, or community to improve their health status (e.g., restocking the code blue cart [an emergency cart], ordering unit supplies, evaluating the patient, or arranging unit staffing).

PTS: 1 CON: Professionalism 30. ANS: 1, 3, 4 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare. Page: 8 (V1)

Heading: How Is Nursing Defined? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Professionalism Difficulty: Difficult

2. 3.

Feedback This is correct. Skilled care includes services offered by healthcare professionals who have received the education and are licensed to provide the services. A skilled activity in nursing includes changing a wound dressing. This is incorrect. Assisting with bathing and dressing is characteristic of custodial care that can be done by unlicensed healthcare personnel or the patients themselves. This is correct. Skilled care includes services offered by healthcare professionals who have received the education and are licensed to provide the services. A skilled activity in nursing includes monitoring IV antibiotic administration. This is correct. Skilled care includes services offered by healthcare professionals who have received the education and are licensed to provide the services. A skilled activity in nursing includes patient teaching. This is incorrect. Assisting with bathing and dressing is characteristic of custodial care that can be done by unlicensed healthcare personnel or the patients themselves.

PTS: 1 CON: Professionalism 31. ANS: 1, 2, 3 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Define nursing in your own words. Page: 8 (V1) Heading: How Is Nursing Defined? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Professionalism Difficulty: Difficult

2. 3.

Feedback This is correct. The International Council of Nursing (ICN) definition of nursing includes the autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. This is correct. In addition to caring for ill, disabled, and dying persons, nurses are expected to promote health and prevent illness. This is correct. Key nursing roles include advocacy, education, research, promotion of a safe environment, and participation in shaping health policy and in healthcare

4. 5.

systems management. This is incorrect. The ICN definition does not mention that registered nurses use the nursing process to plan and individualize care. This is incorrect. The ICN definition does not mention that registered nurses use the nursing process to plan and individualize care. The acquisition of knowledge regarding the process of nursing education is also not included.

PTS: 1 CON: Professionalism 32. ANS: 1, 3, 4 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Define nursing in your own words. Page: 8 (V1) Heading: How Is Nursing Defined? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Professionalism Difficulty: Difficult

1. 2. 3. 4. 5.

Feedback This is correct. In 2010, the ANA acknowledged five characteristics of the registered nurse. Nursing practice is individualized. This is incorrect. The ANA does not acknowledge that nursing practice is similar to medical practice. This is correct. In 2010, the ANA acknowledged five characteristics of the registered nurse. Nurses coordinate care by establishing partnerships with others. This is correct. In 2010, the ANA acknowledged five characteristics of the registered nurse. Caring is central to the practice of the registered nurse. This is incorrect. The ANA does not acknowledge that nurses promote health through political involvement.

PTS: 1 CON: Professionalism 33. ANS: 1, 2, 4, 5 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Delineate the forces and trends affecting contemporary nursing practice. Page: 8 (V1) Heading: Is Nursing a Profession, Discipline, or Occupation? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Professionalism Difficulty: Difficult

1. 2. 3.

4. 5.

Feedback This is correct. A suggestion to improve the professional status of nursing includes standardizing educational requirements for entry to practice. This is correct. A suggestion to improve the professional status of nursing includes mandating uniform continuing education requirements. This is incorrect. There are no regulating bodies or professional organizations that equate guaranteeing employment with improving the status of nursing, nor is it likely it would be possible to do that. This is correct. A suggestion to improve the professional status of nursing includes encouraging participation of more nurses in professional organizations. This is correct. A suggestion to improve the professional status of nursing includes educating the public about the true nature of nursing practice.

PTS: 1 CON: Professionalism 34. ANS: 2, 3 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Explain how nursing practice is regulated. Page: 24 (V1) Heading: How Is Nursing Practice Regulated? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Professionalism Difficulty: Difficult

1. 2. 3. 4. 5.

Feedback This is incorrect. State boards of nursing do not advocate for nursing student issues. This is usually addressed through the National Student Nurses Association. This is correct. State boards of nursing are responsible for determining scope of practice and enforcing the rules that govern nursing. This is correct. State boards of nursing are responsible for determining scope of practice and enforcing the rules that govern nursing. This is incorrect. State boards of nursing do not write the laws that regulate nursing; rather, they enforce them. This is incorrect. State boards of nursing do not regulate the number of licensed nurses.

PTS: 1 CON: Professionalism 35. ANS: 1, 3, 4 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Delineate the forces and trends affecting contemporary nursing practice.

Page: 22 (V1) Heading: Application of Knowledge, Skill, and Caring Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Professionalism Difficulty: Difficult

2. 3.

Feedback This is correct. Critical thinking is a reflective thinking process that involves collecting information, analyzing the adequacy and accuracy of the information, and carefully considering options for action. Nurses use critical thinking in every aspect of nursing care. This is incorrect. Pain evaluation is a process of assessment involving critical thinking, clinical judgment, and problem solving. This is correct. Clinical judgment is a process in nursing involves observing, comparing, contrasting, and evaluating the client’s condition to determine whether change has occurred. It also involves careful consideration of the client’s health status in light of what is expected based on the client’s condition, medications, and treatment. These actions are collectively known as the nursing process. This is correct. Problem solving is a process by which nurses consider an issue and attempt to find a satisfactory solution to achieve the best outcomes. Nurses often use problem solving in professional life. The nursing process is one type of problem solving process. This is incorrect. Sterile technique is a nursing skill based on critical thinking, clinical judgment, and problem solving abilities.

PTS:

CON: Professionalism

COMPLETION 36. ANS: Medicaid Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare. Page: 25 (V1) Heading: How Is Healthcare Financed? Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding]

Concept: Health Promotion Difficulty: Moderate Feedback: Medicaid is a health program run by the state and funded by the federal and state governments. It is intended to provide preventive and acute healthcare for individuals, in particular pregnant women and children, who are unable to pay for services. PTS: 1 37. ANS: Medicare

CON: Health Promotion

Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare. Page: 25 (V1) Heading: How Is Healthcare Financed? Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Health Promotion Difficulty: Moderate Feedback: Medicare is a federal insurance program created by Title XVIII of the Social Security Act of 1965. This act was designed to protect people age 65 years and older from the high cost of healthcare. In 1972, the program was expanded to cover workers with disabilities as well as people with end-stage renal disease. PTS:

CON: Health Promotion

Chapter 3. Assessment Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse is collecting data on a new patient at an adult clinic. Which data does the nurse need to validate? 1. The client’s weight is 185 lb (83.9 kg) at the clinic. 2. The client’s liver function test results are elevated. 3. The client states that blood pressure (BP) of 160/94 mm Hg is typical. 4. The client reports eating processed foods on a low-sodium diet. 2. After collecting data on a client, the nurse reviews and sorts the information. Which example includes both objective and subjective data? 1. The client’s blood pressure reading is 132/68 mm Hg, and heart rate is 88 beats/min. 2. The client’s cholesterol is elevated, and he admits to liking and eating fried food. 3. The client reports having trouble sleeping and admits drinking coffee in the evening. 4. The client verbally reports having frequent headaches and taking aspirin for the pain. 3. The nurse manager in an acute care facility is orienting new graduate nurses to a patient care unit. While reviewing The Joint Commission standards, a discussion begins about assessment. Which type of assessment is to be performed on all patients in compliance with The Joint Commission? 1. Nutritional status 2. Pain 3. Cultural 4. Wellness 4. The nurse is providing care for a variety of patients in an acute care facility. Which of the following constitutes an ongoing assessment? 1. Obtaining a patient’s temperature 1 hour after giving acetaminophen 2. Examining a patient’s throat after soreness with swallowing is reported 3. Requesting a patient to rate pain intensity level using a scale of 0 to 10 4. Asking a patient the details of a plan to return to normal exercise activities 5. Each time the nurse comes into contact with a patient, a systematic observation is made. For which reason is this type of assessment performed so frequently? 1. Time constraints support small portions of assessment at a time. 2. Validating an absence of change decreases the need to document. 3. Critical changes are less likely to occur with constant observation. 4. Repetition makes it less likely the nurse will miss an assessment area.

6. The nurse is obtaining the health history of a client. Which question is an example of the nurse using an open-ended question? 1. “Have you had surgery before?” 2. “When was your last menstrual period?” 3. “What happens when you have a headache?” 4. “Do you have a family history of heart disease?” 7. The nurse is interviewing a patient being admitted for gastrointestinal issues. The patient informs the nurse that he has persistent vomiting and diarrhea. Which type of assessment is the nurse performing by asking, “When did you first begin to have the vomiting and diarrhea?”? 1. Comprehensive assessment 2. Ongoing focused assessment 3. Special needs assessment 4. Initial focused assessment 8. The nurse is currently performing the initial assessment on a newly admitted client. The nurse receives notification of another client’s admission to the unit. Which professional standard influences the nurse’s decision about who will be assigned to perform the assessment of the second client? 1. The state board for nursing-assistant testing 2. The American Nurses Association (ANA) 3. The facility policy and procedure committee 4. The bargaining committee for facility nurses 9. The nurse is obtaining information from a newly admitted patient during the initial nursing assessment. Which difference does the nurse recognize between the nursing history and the medical history? 1. A nursing history focuses on the patient’s responses and needs to the health problem. 2. The same information is gathered in both; the difference is in who obtains the information. 3. A nursing history is gathered by using a specific format. 4. A medical history collects more in-depth information. 10. During the initial assessment of a newly admitted client, the nurse asks about use of nutritional and herbal supplements. For which reason is it important for the nurse to obtain this specific information? 1. To determine what type of therapies are acceptable to the client 2. To identify whether the client has a nutrition deficiency 3. To help the nurse understand the client’s cultural and spiritual beliefs 4. To be aware of potential interaction with prescribed medication 11. After completing an initial patient assessment, for which reason does the nurse utilize a nursing assessment model? 1. To sort and cluster assessment data into specific categories

2. To organize assessment data according to body systems 3. To validate the use of the nursing process to collect data 4. To follow the American Nurses Association (ANA) Standards of Care 12. For which reason does the nurse use nondirective interviewing as an assessment technique? 1. Allows the nurse to have control of the interview 2. Is an efficient way to interview a patient 3. Facilitates open communication 4. Helps focus the attention of patients who are anxious 13. A nursing instructor is guiding nursing students on best practices for interviewing patients. Which of the following comments by a student would indicate a need for further instruction? 1. “My patient is a young adult, so I plan to talk to her without her parents in the room.” 2. “Because my patient is old enough to be my grandfather, I will address him with ‘Mr.’” 3. “When reading my patient’s health record, I thought of a few questions to ask.” 4. “When I give my patient his pain medication, I will have time to ask questions.” 14. A patient comes to the urgent care clinic because of injury from stepping on a rusty nail. Which type of assessment does the nurse perform? 1. Comprehensive 2. Ongoing 3. Initial focused 4. Special needs 15. The nurse is providing care to a patient who has left-sided weakness because of a recent stroke. Which type of special needs assessment is most important for the nurse to perform? 1. Family 2. Functional 3. Community 4. Psychosocial 16. The nurse is interviewing a patient with a recent onset of migraine headaches. The patient is very anxious and cannot seem to focus on what the nurse is saying. Which comment by the nurse is best when beginning to gather data about the headaches? 1. “When did your migraines begin?” 2. “Tell me about your family history of migraines.” 3. “What are the things that trigger your headaches?” 4. “Describe for me what your headaches feel like.” 17. The nurse is conducting an assessment interview with a newly admitted client. When asking openended questions, which action by the nurse indicates an active listening behavior? 1. Taking frequent notes 2. Asking for more details

3. Leaning toward the patient 4. Sitting comfortably with legs crossed 18. A nursing instructor asked his nursing students to discuss their experiences with charting assessment data. Which comment by the student indicates the need for further teaching? 1. “I find it difficult to avoid using phrases like ‘the patient tolerated the procedure well.’” 2. “It’s confusing to have to remember which abbreviations this hospital allows.” 3. “I need to work on charting assessments and interventions right after they are done.” 4. “My patient was really quiet and didn’t say much, so I charted that he acted depressed.” 19. The nurse prefers to review patient data on a graphic flow sheet, when possible. Which situation is the best example of the reason a graphic flowsheet is superior to other methods of recording data? 1. Provides easy documentation of routine vital signs 2. Visually reflects the patterns of a patient’s fever 3. Describes symptoms accompanying vital sign changes 4. Enables a quick check for patient tolerance of care 20. The nurse is aware that patient data are often difficult to analyze. Which is the most obvious reason for using a framework for collecting and recording patient data? 1. Prioritizes collection of assessment data 2. Organizes and clusters data efficiently 3. Separates subjective and objective data 4. Identifies both primary and secondary data 21. The nurse is preparing to conduct an admission interview with an adult client who is alert and oriented. The client’s spouse and two children are visiting and are watching television. Which action by the nurse is conducive to a successful interview? 1. Provide enough chairs for the family to sit facing the client. 2. Ask the client’s preference for how to be addressed by the nurse. 3. Ask if the client is willing to answer questions after the family leaves. 4. Give the client the option of having the interview while the family watches television. 22. The nurse obtains information from a patient during admission. The patient is noted to be alert and oriented, be married, have a history of heart disease. Obtaining this information is an example of which process? 1. Collecting data 2. Analyzing data 3. Categorizing data 4. Physical assessment

23. The nurse on a medical-surgical unit receives the third admission over a period of 1.5 hours. A certified nursing assistant (CNA) offers to assist the nurse with the assessment process. Which response by the nurse is the most appropriate? 1. “Thank you. I am having a busy day, and I can use your help.” 2. “I’m sorry, but nurses are responsible for all patient assessments.” 3. “If you start an assessment on the last patient, I will continue it later.” 4. “If you could obtain and record the vital signs, it would be a big help.” 24. During the assessment process, the patient tells the nurse, “I am having numbness and tingling in my right arm.” Which type of data does the nurse recognize on the basis of the patient’s statement? 1. Subjective data 2. Objective data 3. Secondary data 4. Comprehensive data 25. The nurse is performing an initial interview with an older adult patient. Which statement by the patient indicates a need for a special needs assessment by the nurse? 1. “I don’t go to church as much as I used to, but I watch services on TV.” 2. “I have fallen twice at home in the past 6 months, but I have not injured myself.” 3. “I don’t eat much red meat anymore, but I get my protein from other foods.” 4. “I had a toothache recently, so I made an appointment to see the dentist.” 26. A patient comes to the emergency department to be evaluated after feeling ill at home. Which is the first question the nurse asks in the initial nursing interview with the patient? 1. “Do you live alone?” 2. “Are you having any pain?” 3. “What is your past medical history?” 4. “Why did you come to the hospital today?” 27. The patient comes to the emergency department complaining of chest pain. Which question by the nurse will encourage the patient to provide the most details about the pain? 1. “When did your chest pain begin?” 2. “On a scale of 0 to 10, what is your pain level?” 3. “Can you give a description of the pain you are having?” 4. “Have you taken any medication for your pain?” 28. Nurses are aware that documentation is essential in monitoring and validating appropriate patient care. Which statement is the best example of high-quality nursing documentation? 1. “Patient breathing is normal. No pain noted. Urine output is adequate at this time.” 2. “Good strength in both lower extremities. Ambulating with walker in the hall.” 3. “Started on solid foods. Ate 75% of dinner. No complaints of any nausea or vomiting.” 4. “Patient seems upset with visiting spouse. Physical assessment planned at a later time.”

Multiple Response Identify one or more choices that best complete the statement or answer the question. 29. The nurse is conducting an interview with a patient in a clinic setting. Which questions will be effective for obtaining information from the patient? Select all that apply. 1. “How did this happen to you?” 2. “What was your first symptom?” 3. “Why didn’t you seek healthcare earlier?” 4. “When did you start having symptoms?” 5. “Why did you decide to seek help now?” 30. A nurse, with a large caseload of patients, needs to delegate some assessment tasks to other members of the healthcare team. The nurse is unsure which tasks can be delegated to nursing assistive personnel (NAP) and which are appropriate for a licensed practical nurse (LPN) instead of a registered nurse (RN). Which sources does the nurse consult for clarification related to delegation? Select all that apply. 1. Nurse practice act of the nurse’s state 2. American Medical Association (AMA) guidelines 3. Code of Ethics for Nurses 4. American Nurses Association (ANA) Scope and Standards of Practice 5. Facility policy and procedure guidelines 31. Which of the following are cues rather than inferences? Select all that apply. 1. Patient ate 50% of the meal. 2. Patient feels better today. 3. Patient states, “I slept well.” 4. Patient’s white blood cell (WBC) count is 15,000/mm3. 5. Patient does not appear to be in pain. 32. Nurses use the professional standards of nursing assessment when formulating patient care. Which statements regarding professional standards of nursing assessment are true? Select all that apply. 1. Assessment is a professional nursing responsibility. 2. Assessment helps the nurse identify problems and priorities. 3. Assessment helps the nurse formulate the medical diagnosis. 4. Assessment of pain is focused on patients indicating the presence of pain. 5. Assessments can be delegated according to state practice acts and agency policies. 33. The nurse recognizes which examples of objective data? Select all that apply. 1. Blood pressure of 120/80 mm Hg 2. Pain rated as 6 on a pain scale of 0 to 10 3. Moderate amount of yellow drainage from right ear 4. Spouse stating the client is not sleeping well at night 5. Patient reporting the presence of stomach pain

34. The nurse manager is reviewing documentation performed by newly hired nurses. Which of the examples does the nurse manager recognize as high-quality nursing documentation? Select all that apply. 1. Patient states, “I feel dizzy in the morning.” 2. Patient is alert and oriented to person, place, and time. 3. Drainage from midline abdominal incision appears normal. 4. Patient appears angry and is refusing to talk to the spouse. 5. Patient expresses no complaints of pain at this time. 35. The nurse is conducting a patient interview in an acute care setting. Which statements made by the nurse during the interview are appropriate? Select all that apply. 1. “You shouldn’t be smoking cigarettes; you have already had one heart attack.” 2. “Why don’t you take your blood pressure medications? Your blood pressure remains high.” 3. “I can see you are in pain. I will bring pain medication and complete the interview later.” 4. “If it is a good time for you, we can complete your interview now.” 5. “Have you noticed any changes in your ability to sleep or patterns of sleeping?”

Chapter 3. Assessment Answer Section MULTIPLE CHOICE 1. ANS: 4 Chapter: Chapter 3 Assessment Objective: Describe circumstances in which you should validate data. Page: 45 (V1) Heading: Types and Sources of Data Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate

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Feedback This is incorrect. Personal information that patients might be embarrassed about, such as weight, is best validated with a scale. This is incorrect. Validation is not necessary for laboratory data unless the nurse suspects an error has been made in the results. Retesting needs a prescription from the physician. This is incorrect. If data, such as blood pressure, are gathered by using an objective method, validation is not necessary. The patient’s comment does not affect the validity of the data one way or another. This is correct. Validation is done when the client’s statements are inconsistent, as in the client reporting consumption of processed foods on a low-sodium diet.

PTS: 1 CON: Patient-Centered Care 2. ANS: 2 Chapter: Chapter 3 Assessment Objective: Identify the following types of data: subjective, objective, primary source, secondary source. Page: 45 (V1) Heading: Types and Sources of Data Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate Feedback

2 3 4

This is incorrect. Objective data can be observed by someone other than the patient (e.g., from physical assessments or laboratory and diagnostic tests). Subjective data are information given by the client. Blood pressure and heart rate measurements are both objective. This is correct. Elevated cholesterol is objective data, and the patient’s stated food preference is subjective. This is incorrect. When the patient verbally expresses trouble sleeping and the consumption of coffee in the evening, all of the data are subjective. This is incorrect. When the patient verbally reports frequent headaches and of treating the pain with aspirin, all the data are subjective.

PTS: 1 CON: Patient-Centered Care 3. ANS: 2 Chapter: Chapter 3 Assessment Objective: Name three requirements of The Joint Commission regarding patient assessment. Page: 44 (V1) Heading: What Do Professional Standards Say About Assessment? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate

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Feedback This is incorrect. The Joint Commission does not require assessment on nutritional status unless cues indicate there are risk factors. This is correct. The Joint Commission requires that assessments for pain and the risk for falls be performed on all patients. Other special needs assessments should be performed when cues indicate there are risk factors. This is incorrect. The Joint Commission does not require a cultural assessment. This is incorrect. The Joint Commission does not require a wellness assessment.

PTS: 1 CON: Patient-Centered Care 4. ANS: 1 Chapter: Chapter 3 Assessment Objective: Describe and differentiate initial, ongoing, comprehensive, focused, and special needs assessments. Page: 45 (V1) Heading: Types and Sources of Data Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying]

Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is correct. An ongoing assessment occurs when a previously identified problem is being reassessed—for example, taking an hourly temperature when a patient has a fever. 2 This is incorrect. Examining a patient’s throat is a focused assessment to explore the possible source of pain with swallowing. 3 This is incorrect. Asking for a pain rating using a scale of 0 to 10 is a focused assessment. 4 This is incorrect. Asking a patient for details of a plan to return to normal exercise activities is a special needs assessment. There is no way to determine if this assessment will be ongoing. PTS: 1 CON: Patient-Centered Care 5. ANS: 4 Chapter: Chapter 3 Assessment Objective: Describe and differentiate initial, ongoing, comprehensive, focused, and special needs assessments. Page: 46 (V1) Heading: Nursing Assessment Skills Integrated Processes: Nursing Process Client Need: Safe and Effective Nursing Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is incorrect. Systematic observation, like other types of assessment, is not performed in a parameter of time constraints. Complete assessments at the beginning of a shift are a vital tool to identify change. 2 This is incorrect. Systematic observation is a type of assessment focused on patient well-being; it does not influence the need to document. 3 This is incorrect. In itself, systematic observation does not prevent critical changes in a patient’s status; however, the process does alert the nurse to changes in a timely manner. 4 This is correct. By making systematic observations each time the nurse is with a patient, the nurse is less likely to miss an assessment area and/or overlook changes in the patient’s status. PTS: 1 CON: Patient-Centered Care 6. ANS: 3 Chapter: Chapter 3 Assessment

Objective: Compare open-ended and closed questions, including definitions, uses, advantages, and disadvantages. Page: 47 (V1) Heading: Types of Interviews Integrated Processes: Communication and Documentation Client Need: Safe and Effective Nursing Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Communication Difficulty: Moderate Feedback 1 This is incorrect. Questions that require a simple answer, such as a “yes” or a “no,” are considered closed-ended questions. This question would be open ended if the nurse asked, “What surgeries have you had?” 2 This is incorrect. Questions that require a specific answer, such as a date, is considered closed-ended question. This question would be open ended if the nurse asked, “What can you tell me about your menstrual periods?” 3 This is correct. Open-ended questions—for example, “What happens when you have a headache?”—are broadly worded to encourage the patient to elaborate. 4 This is incorrect. Questions that require a simple answer, such as a “yes” or a “no,” are considered closed-ended questions. This question would be open ended if the nurse asked, “Who are your family members with heart disease?” PTS: 1 CON: Communication 7. ANS: 4 Chapter: Chapter 3 Assessment Objective: Describe and differentiate initial, ongoing, comprehensive, focused, and special needs assessments. Page: 46 (V1) Heading: Types of Assessment Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is incorrect. A comprehensive assessment provides the nurse with holistic information about the client’s overall health status; enables identification of client problems and strengths; enhances the nurse’s sensitivity to a patient’s culture, values, beliefs, and economic situation; and uses the nursing skills of observation, physical assessment, and interviewing. 2 This is incorrect. An ongoing focused assessment is used to evaluate the status of existing problems and goals. The nurse performs ongoing focused assessment

periodically throughout the period of providing patient care. This is incorrect. A special needs assessment is a type of focused assessment that provides in-depth information about a particular area of client functioning and often involves using a specially designed form. The nurse will perform a special needs assessment any time assessment cues suggest risk factors or problems for a client, such as nutrition status or pain management. This is correct. An initial focused assessment is used to follow up on clientreported symptoms or unusual findings during the first examination. The nurse is seeking additional information about specific symptoms reported by the patient—in this scenario, vomiting, and diarrhea.

PTS: 1 CON: Patient-Centered Care 8. ANS: 2 Chapter: Chapter 3 Assessment Objective: State the ANA position on delegating assessment. Page: 44 (V1) Heading: What Do Professional Standards Say About Assessment? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Managing Care Cognitive Level: Application [Applying] Concept: Professionalism Difficulty: Moderate Feedback 1 This is incorrect. Most states have a method of testing for nursing assistant personnel, but it is not necessarily the state board of nursing. Nurse aides or other unlicensed assistive personnel (UAP) may collect certain information, such as vital signs, pain reports, and finger stick blood glucose levels. However, it is the professional nurse’s responsibility to assign those tasks, validate the data collected, conduct the interview, and complete the physical assessment. 2 This is correct. The ANA’s Scope and Standards of Practice (2015), which applies to professional nurses (registered nurses [RNs]), identifies assessment as a professional responsibility. The Joint Commission, the National Council of State Boards of Nursing (NCSBN), and nurse practice acts support the ANA standard. 3 This is incorrect. Agency policies/procedures state which caregivers can collect and document specified data within that agency/facility. However, the parameters of professional standards are observed with the development of agency policy/procedures. 4 This is incorrect. Bargaining committees for a facility’s nurses will observe the parameters of professional standards. Not all care facilities will have bargaining committees.

PTS: 1 CON: Professionalism 9. ANS: 1 Chapter: Chapter 3 Assessment Objective: Discuss the relationship between the nursing process and collaborative care. Page: 49 (V1) Heading: Interviewing to Obtain a Nursing Health History Integrated Processes: Nursing Process Client Need: Safe and Effective Nursing Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Moderate

2 3

Feedback This is correct. A nursing history focuses on the patient’s responses to and perception of the illness/injury or health problem, the patient’s coping ability, and the patient’s resources and support. This is incorrect. A medical history focuses on the patient’s current and past medical/surgical problems. This is incorrect. Nursing history formats vary, depending on the patient, the agency, and the patient’s needs. Both nursing and medical histories typically use a specific format. This is incorrect. A medical history does not necessarily contain more in-depth information. A nursing history can be thorough, covering a wide range of topics, including biographical data, reason(s) patient is seeking healthcare, history of present illness, patient’s perception of health status and expectations for care, past medical history, use of complementary modalities, and review of functional ability associated with activities of daily living.

PTS: 1 CON: Patient-Centered Care 10. ANS: 4 Chapter: Chapter 3 Assessment Objective: Identify the following types of data: subjective, objective, primary source, secondary source. Page: 49 (V1) Heading: Interviewing to Obtain a Nursing Health History Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult Feedback

1 2 3

This is incorrect. The information alone does not specifically address the client’s acceptance of certain types of therapy. This is incorrect. Physical assessment and laboratory tests are needed to assess a nutritional deficiency. This is incorrect. To identify the client’s cultural and spiritual beliefs and well as what therapies are acceptable to the client, the nurse would need more than just information about nutritional and herbal supplements. This is correct. Herbs and nutritional supplements can interact with prescription medications, and complementary and alternative treatments can interfere with conventional therapies.

PTS: 1 CON: Patient-Centered Care 11. ANS: 1 Chapter: Chapter 3 Assessment Objective: Use nursing frameworks to organize data. Page: 50 (V1) Heading: How Can I Organize Data? Integrated Processes: Nursing Process Client Need: Safe and Effective Nursing Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Professionalism Difficulty: Difficult

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Feedback This is correct. Nursing assessment models categorize or cluster data into functional health patterns, domains, or categories to make the data easier to use. This is incorrect. None of the nursing assessment models cluster data according to body systems. This is incorrect. Assessment is the first step in the nursing process; however, the nurse does not use the entire nursing process in data collection. This is incorrect. The ANA Standards of Care describe a competent level of clinical nursing practice based on the nursing process; nursing models are not based on the ANA Standards of Care.

PTS: 1 CON: Professionalism 12. ANS: 3 Chapter: Chapter 3 Assessment Objective: Describe the differences between directive and nondirective interviewing. Page: 49 (V1) Heading: Table 3-3: Comparison of Directive and Nondirective Interviews Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care

Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Easy Feedback 1 This is incorrect. With the use of nondirective interviewing, the patient controls the subject matter. 2 This is incorrect. Because nondirective interviewing puts the patient in control of the subject matter, the process can be very time consuming (inefficient) and produce information that is not relevant. 3 This is correct. Nondirective interviewing helps build rapport between the nurse and the patient and facilitates the use of open communication. 4 This is incorrect. Directive interviewing is used to focus the attention of anxious patients. The method focuses on obtaining factual, easily categorized information. The process is especially useful in an emergency situation. PTS: 1 CON: Patient-Centered Care 13. ANS: 4 Chapter: Chapter 3 Assessment Objective: Discuss how to prepare for and conduct an interview. Page: 50 (V1) Heading: Preparing for an Interview Integrated Processes: Communication and Documentation Client Need: Safe and Effective Nursing Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate

1 2

3 4

Feedback This is incorrect. It is appropriate to interview patients without family/friends around; this decision does not require further instruction. This is incorrect. In nearly every culture, addressing a patient with “Mr.” or “Mrs.” shows respect and is, therefore, correct and does not require further instruction. This is incorrect. Reading the patient’s health record is appropriate preparation for an interview. This decision does not require further instruction. This is correct. A patient should be comfortable when interviewing. The pain medication should have time to work before the nurse would consider interviewing the patient, so asking questions when giving the medication is not a good idea. This decision requires further instruction.

PTS: 1 14. ANS: 3

CON: Patient-Centered Care

Chapter: Chapter 3 Assessment Objective: Describe and differentiate initial, ongoing, comprehensive, focused, and special needs assessment. Page: 47 (V1) Heading: Focused Assessments Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. A comprehensive assessment is holistic and is usually done upon the client’s admission to a healthcare facility. 2 This is incorrect. An ongoing assessment is a follow-up procedure after an initial database is completed or a problem is identified. 3 This is correct. An initial focused assessment is performed during a first examination for specific abnormal findings. 4 This is incorrect. A special needs assessment is performed when there are cues that more in-depth assessment is needed. PTS: 1 CON: Patient-Centered Care 15. ANS: 2 Chapter: Chapter 3 Assessment Objective: Describe and differentiate initial, ongoing, comprehensive, focused, and special needs assessments. Page: 48 (V1) Heading: Special Needs Assessments Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. A family assessment is helpful to evaluate the patient’s support systems. This is probably the second-most important special needs assessment for the nurse to make for this patient. 2 This is correct. A functional assessment is the most important assessment because of discharge needs (e.g., self-care ability at home) and patient safety. 3 This is incorrect. A community assessment is helpful to evaluate community services available to assist the patient. However, this is not the most important special needs assessment. 4 This is incorrect. A psychosocial assessment is helpful to evaluate a patient’s

understanding of and coping with the recently diagnosed stroke. However, this is not the most important special needs assessment for the nurse to perform. PTS: 1 CON: Patient-Centered Care 16. ANS: 1 Chapter: Chapter 3 Assessment Objective: Describe the differences between directive and nondirective interviewing. Page: 47 (V1) Heading: Table 3-3: Comparison of Directive and Nondirective Interviews Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is correct. For someone who is anxious, it is best to use closed-ended questions. A closed-ended question can be answered in one or very few words and has a very specific answer. 2 This is incorrect. This statement requires the patient to give a detailed response, which is not suitable for interviewing an anxious patient. 3 This is incorrect. Asking what triggers the patient’s migraine is an open-ended question, which requires a detailed response. This is not suitable for interviewing an anxious patient. 4 This is incorrect. Asking the patient for a description of how the headaches feel requires a detailed response, which is not suitable for interviewing an anxious patient. PTS: 1 CON: Patient-Centered Care 17. ANS: 3 Chapter: Chapter 3 Assessment Objective: Discuss how to prepare for and conduct an interview. Page: 49 (V1) Heading: Interviewing to Obtain a Nursing Health History Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Communication Difficulty: Easy

Feedback This is incorrect. Taking frequent notes makes it difficult for the nurse to maintain eye contact with the client.

2 3

This is incorrect. Asking for more details may seem like idle curiosity to the client. This is correct. The nurse is exhibiting active listening behaviors by leaning toward the client; facing the patient; exhibiting an open, relaxed posture without crossing the arms or legs; and maintaining eye contact. This is incorrect. When the nurse is sitting with legs crossed, it may indicate to the client that the nurse is not receptive to the client.

PTS: 1 CON: Communication 18. ANS: 4 Chapter: Chapter 3 Assessment Objective: Describe circumstances in which you should validate data. Page: 53 (V1) Heading: How Should I Document Data? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Communication Difficulty: Moderate

1 2

3 4

Feedback This is incorrect. Chart specific data, not vague phrases; the student is acknowledging the importance of this. This is incorrect. There are no universally accepted phrases, just agencyapproved abbreviations; the student is acknowledging the need to use agencyapproved abbreviations. This is incorrect. The student is correct that charting should be completed as soon after data collection as possible. This is correct. When charting data, chart only what was observed, not what it meant. Inferences should not be made about a patient’s behavior during data collection (“he acted depressed”), so this response reflects the student’s lack of knowledge and need for teaching.

PTS: 1 CON: Communication 19. ANS: 2 Chapter: Chapter 3 Assessment Objective: Describe circumstances in which you should validate data. Page: 53 (V1) Heading: Tools for Recording Assessment Data Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing]

Concept: Communication Difficulty: Moderate

1 2

3 4

Feedback This is incorrect. Flowsheets can be used to record various types of information, such as routine documentation of vital signs. This is correct. To easily and graphically see trends over time, the graphic flowsheet is superior to other methods of documentation, allowing quick assessment of patient changes in status. The pattern of a patient’s fever is the best example of the superiority of a graphic flowsheet. This is incorrect. A description of the symptoms accompanying changes in vital signs is narrative information for which a graphic flowsheet may not be suitable. This is incorrect. Patient tolerance of care is most likely to be documented in narrative form and not on a graphic flowsheet.

PTS: 1 CON: Communication 20. ANS: 2 Chapter: Chapter 3 Assessment Objective: Use nursing frameworks to organize data. Page: 50 (V1) Heading: How Can I Organize Data? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. During the assessment phase, the nurse is collecting and recording data, not prioritizing data. 2 This is correct. The major concept of a framework is to assist the nurse to organize and cluster data to find patterns. 3 This is incorrect. A framework includes subjective and objective data but does not help the nurse to separate the two types of data. 4 This is incorrect. A framework includes primary and secondary data but does not help the nurse to separate the two types of data. PTS: 1 CON: Patient-Centered Care 21. ANS: 3 Chapter: Chapter 3 Assessment Objective: Discuss how to prepare for and conduct an interview. Page: 50 (V1) Heading: Preparing for an Interview

3 4

Feedback This is incorrect. Family members may offer information that may or may not be pertinent and may distract the client from the interview. The presence of family members may also inhibit full disclosure of information by the client. This is incorrect. The nurse always needs to ask the client’s preference for how they are addressed. However, this action alone does not ensure a successful interview. This is correct. The interview should be done when the client is comfortable and there are no distractions. This is incorrect. The family watching television during the nurse’s interview of the client may be distracting to both the nurse and the client.

PTS: 1 CON: Communication 22. ANS: 1 Chapter: Chapter 3 Assessment Objective: Identify at least four components of a nursing health history. Page: 49 (V1) Heading: Interviewing to Obtain a Nursing Health History Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Easy Feedback 1 This is correct. The nurse is collecting data on this patient; however, the data provided indicate that further data collection is warranted. 2 This is incorrect. Data are analyzed to formulate nursing diagnoses and a plan of care. 3 This is incorrect. After assessment, data are categorized to organize the information and add clarity. 4 This is incorrect. The information in the scenario indicates that a comprehensive physical assessment has not been completed. PTS: 1 CON: Patient-Centered Care 23. ANS: 4 Chapter: Chapter 3 Assessment

Objective: State the ANA position on delegating assessment. Page: 47 (V1) Heading: What Do Professional Standards Say About Assessment? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Professionalism Difficulty: Moderate Feedback 1 This is incorrect. In making decisions about which parts of an assessment can be delegated to the CNA, the nurse must consider agency policies and the regulations of the state board of nursing. 2 This is incorrect. Certain assessment activities, such as vital signs, weighing the client, and maintaining output and intake measures, can be assigned to qualified CNAs. 3 This is incorrect. Nursing regulatory bodies specify that client assessment is the responsibility of the registered nurse. Therefore, the CNA cannot be instructed to start an assessment that will be completed by the nurse. 4 This is correct. In most states, the CNA can obtain vital signs and record them in the patient’s chart; however, the ability to perform this task must first be validated by the nurse. The nurse is also responsible for validating the documentation of the information by the CNA. PTS: 1 CON: Professionalism 24. ANS: 1 Chapter: Chapter 3 Assessment Objective: Identify the following types of data: subjective, objective, primary source, secondary source. Page: 45 (V1) Heading: Types and Sources of Data Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Professionalism Difficulty: Moderate

Feedback This is correct. The patient’s statement about experiencing numbness and tingling down the right arm is an example of subjective data because the statement is in the patient’s own words. This is incorrect. Objective data are overt and gathered by the nurse through physical assessment, laboratory findings, or diagnostic testing results.

3 4

This is incorrect. Secondary data are obtained through a source other than the patient, such as a family member This is incorrect. There is not enough information in the patient’s statement to categorize it as comprehensive data because the nurse would have to complete a physical assessment and obtain all data.

PTS: 1 CON: Professionalism 25. ANS: 2 Chapter: Chapter 3 Assessment Objective: Describe and differentiate initial, ongoing, comprehensive, focused, and special needs assessments. Page: 46 (V1) Heading: Types of Assessment Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This incorrect. The patient verbalizes that he misses church but adds that he is able to view services on television. 2 This is correct. An older adult who has fallen twice in 6 months has a safety risk. There is no indication that a walker has been obtained. Falling and the risk for falls require the nurse to perform a special needs assessment related to functional status. The lack of injury does not diminish the need. 3 This is incorrect. The patient verbalizes eating less red meat but adds that protein is obtained from other sources. The nurse may want to determine what the other protein sources are before performing a special needs assessment. 4 This is incorrect. The client verbalizes a physiological concern regarding a toothache, but the patient has addressed the issue by making an appointment to see the dentist. PTS: 1 CON: Patient-Centered Care 26. ANS: 4 Chapter: Chapter 3 Assessment Objective: Describe the differences between directive and nondirective interviewing. Page: 49 (V1) Heading: Interviewing to Obtain a Nursing Health History Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Professionalism

Difficulty: Moderate Feedback 1 This is incorrect. It is appropriate to ask the patient about the home situation; however, this question can be addressed later when taking the health history and performing the physical assessment. 2 This is incorrect. It is appropriate to ask the patient about pain, but this question can be addressed later when taking the health history and performing the physical assessment or by following the patient’s lead. 3 This is incorrect. It is appropriate to ask the patient about the medical history; however, this question can be addressed later when taking the health history and performing the physical assessment. 4 This is correct. The nurse should first ask in the initial interview why the patient is seeking nursing or medical assistance. This broad question will elicit the most information because it is open ended. PTS: 1 CON: Professionalism 27. ANS: 3 Chapter: Chapter 3 Assessment Objective: Describe the differences between directive and nondirective interviewing. Page: 49 (V1) Heading: Interviewing to Obtain a Nursing Health History Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis [Analyzing] Concept: Professionalism Difficulty: Moderate Feedback 1 This is incorrect. Asking when the patient’s pain began will only elicit a short answer specific to that question. Each question is asked in pain assessment; however, the question that will elicit the most information is the one that asks the patient to tell the nurse more about the pain. 2 This is incorrect. Asking to rate the level of pain on a scale of 0 to 10 will only elicit a short answer; of greater importance is the description of the pain present with chest pain. 3 This is correct. The most information is gained by asking the patient to tell the nurse more about the pain. This is an open-ended question and will give the nurse more information about the pain. 4 This is incorrect. Although asking the patient about medication taken for the pain is appropriate, the question will elicit only a short answer with a limited amount of information about the characteristics of the pain. PTS:

CON: Professionalism

28. ANS: 3 Chapter: Chapter 3 Assessment Objective: Use assessment skills to gather data during a nursing assessment. Page: 53 (V1) Heading: How Should I Document Data? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Communication Difficulty: Moderate Feedback 1 This is incorrect. Noting that patient breathing is normal and urine output is adequate does not give enough information about either function. 2 This is incorrect. “Good strength in both lower extremities” is vague as the word good is subjective. 3 This is correct. “Started on solid foods. Ate 75% of dinner. No complaints of nausea or vomiting” is clear, concrete, and specific. 4 This is incorrect. “Patient seems upset” does not give enough information and involves an assumption by the nurse. Also, the nurse does not document what things have not been done; this action can be used to show inadequate nursing care if litigation is ever initiated. PTS:

CON: Communication

MULTIPLE RESPONSE 29. ANS: 1, 2, 4 Chapter: Chapter 3 Assessment Objective: Discuss how to prepare for and conduct an interview. Page: 50 (V1) Heading: Preparing for an Interview Integrated Processes: Communication and Documentation Client Need: Communication and Documentation Cognitive Level: Analysis [Analyzing] Concept: Communication Difficulty: Difficult

1. 2. 3.

Feedback This is correct. “How,” “what,” and “when” are acceptable lines of questioning. It will be beneficial for the nurse to ascertain how a patient’s issue occurred. This is correct. “How,” “what,” and “when” are acceptable lines of questioning. This is incorrect. Asking “why” can put the patient on the defensive and may suggest

4. 5.

disapproval, limiting the amount of information the patient is willing give. Questioning the patient’s judgment for seeking care is inappropriate. This is correct. “How,” “what,” and “when” are acceptable lines of questioning. This is incorrect. Asking “why” can put the patient on the defensive and may suggest disapproval, limiting the amount of information the patient is willing give. Why the patient decided to seek help at this time is of least importance.

PTS: 1 CON: Communication 30. ANS: 1, 4 Chapter: Chapter 3 Assessment Objective: State the ANA position on delegating assessment. Page: 47 (V1) Heading: What Do Professional Standards Say About Assessment? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Professionalism Difficulty: Difficult

2. 3.

Feedback This is correct. State nurse practice acts specify which portions of the assessment can legally be completed by individuals with different credentials. The practice acts will vary from state board to state board. This is incorrect. The AMA provides guidelines and standards for physicians, not nurses. This is incorrect. The Code of Ethics for Nurses merely states that the nurse should delegate tasks appropriately; it does not speak directly to the specific credentials of personnel. This is correct. The ANA’s Scope and Standards of Practice provides professional guidance for determining who is ultimately responsible and qualified to collect assessment data. This is incorrect. The facility policy and procedure index should reflect the professional nursing standards of practice; however, this is not the best source of validating delegation guidelines.

PTS: 1 CON: Professionalism 31. ANS: 1, 3, 4 Chapter: Chapter 3 Assessment Objective: Use assessment skills to gather data during a nursing assessment. Page: 47 (V1) Heading: Guidelines for Recording Assessment Data Integrated Processes: Nursing Process

Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

1. 2.

3. 4. 5.

Feedback This is correct. Cues are what the client says and what the nurse observes. The nurse can observe the percentage of the meal eaten by the client. This is incorrect. When the nurse states, “The patient feels better,” the nurse is making an inference. What did the nurse observe to validate that the client feels better? Those observations are cues. This is correct. Cues are what the client says and what the nurse observes. When the client states, “I slept well,” it is a verbal fact stated by the client and is a cue. This is correct. A laboratory value is a factual statement and, therefore, a cue. This is incorrect. When the nurse notes that the patient “does not appear to be in pain,” the nurse is making an inference. What validating cues does the nurse recognize?

PTS: 1 CON: Patient-Centered Care 32. ANS: 1, 2, 5 Chapter: Chapter 3 Assessment Objective: Discuss professional standards affecting nursing process (e.g., American Nurses Association, The Joint Commission). Page: 44 (V1) Heading: What Do Professional Standards Say About Assessment? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

1. 2. 3. 4. 5.

Feedback This is correct. Assessment is a professional responsibility as designated by professional standards. This is correct. Assessment is a professional responsibility that assists the nurse to identify problems and prioritize care. This is incorrect. Assessment helps the nurse formulate a nursing diagnosis; a medical diagnosis is not within the nurse’s scope of practice. This is incorrect. All patients are assessed for pain. This is correct. Parts of the assessment may be delegated, depending on state boards of nursing and agency policies.

PTS: 1 CON: Patient-Centered Care 33. ANS: 1, 3 Chapter: Chapter 3 Assessment Objective: Identify the following types of data: subjective, objective, primary source, secondary source. Page: 45 (V1) Heading: Types and Sources of Data Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

1. 2.

3. 4. 5.

Feedback This is correct. A blood pressure reading is an example of objective data. Such data are obtained by the nurse through assessment and can be validated. This is incorrect. Pain that is rated on a scale of 0 to 10 is still considered subjective because it is rated on the patient’s opinion. Objective data about pain includes crying, grimacing, or posturing. This is correct. The presence and description of drainage is an example of objective data. Such data are obtained by the nurse through assessment and can be validated. This is incorrect. The spouse’s statement about the patient’s quality of sleep is indicative of secondary data, which is vague and subjective. This is incorrect. The patient’s report about the presence of stomach pain is subjective. Objective validation would include physical manifestations of pain.

PTS: 1 CON: Patient-Centered Care 34. ANS: 1, 2, 5 Chapter: Chapter 3 Assessment Objective: Use assessment skills to gather data during a nursing assessment. Page: 53 (V1) Heading: How Should I Document Data? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Communication Difficulty: Difficult

1. 2.

Feedback This is correct. Recording the patient’s statement in the patient’s own words is an example of high-quality documentation. The statement is not vague or subjective. This is correct. When the nurse documents validation of orientation and the means of

3. 4. 5.

evaluation, the documentation is an example of high-quality documentation. This is incorrect. The statement regarding the patient’s incision is vague because what is considered normal cannot be measured. This is incorrect. Noting that the patient is angry and refuses to talk with the spouse is subjective and unclear. This is correct. Documentation that includes the patient’s response to an assessment of pain is an example of high-quality documentation.

PTS: 1 CON: Communication 35. ANS: 3, 4, 5 Chapter: Chapter 3 Assessment Objective: Discuss how to prepare for and conduct an interview. Page: 49 (V1) Heading: Interviewing to Obtain a Nursing Health History Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Communication Difficulty: Difficult

4. 5.

Feedback This is incorrect. Criticizing the patient’s behavior and citing a medical situation diminishes the possibility of establishing a positive rapport between the patient and the nurse. This is incorrect. When the nurse asks a “why” question, it is often offensive to the patient. The nurse needs to use therapeutic communication skills to determine the patient’s noncompliance with medical treatment. This is correct. Observing that the patient is in pain, offering pain medication, and postponing the interview are appropriate when performing the nursing interview. Pain and use of medication will make the interview process more difficult and possibly less accurate. This is correct. Asking the patient about the timing of the interview is appropriate and accommodating. This is correct. Asking the patient about sleeping patterns is appropriate when performing the nursing interview.

PTS:

CON: Communication

Chapter 4. Analysis/Diagnosis Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse is providing care for various patients in an acute care facility. Which patient issue is a problem that nurses can treat independently? 1. Hemorrhage following surgery 2. Nausea after ambulating in the hall 3. Fracture pain following an accident 4. Infection in a wound 2. Which of the following is an example of what the nurse recognizes as a cluster of related cues? 1. Complains of nausea and stomach pain after eating 2. Has a productive cough and states stools are loose 3. Has a daily bowel movement and eats a high-fiber diet 4. Has a respiratory rate of 20 breaths/min, heart rate of 85 beats/min, and blood pressure of 136/84 mm Hg 3. The nurse works in an extended care facility. The residents are primarily older adults with health factors that put them in danger of falling. Which option best describes the type of nursing diagnosis the nurse is likely to use? 1. A risk diagnosis, because it is based on data about the patients 2. A possible diagnosis, because a suspected diagnosis is present 3. A wellness diagnosis, because of the health status and patient environment 4. A syndrome diagnosis, because of the age and physical condition of the patients 4. Which of the following describes the difference between a collaborative problem and a medical diagnosis? 1. A collaborative problem is treated by the nurse; a physician is responsible for the treatment of a medical problem. 2. A collaborative problem is a nursing diagnosis that requires specific orders from a physician; a medical diagnosis directs all nursing care. 3. A collaborative problem has the potential to become an actual nursing diagnosis; a medical diagnosis rarely changes. 4. A collaborative problem requires intervention by the nurse and the physician or other professional; a medical diagnosis requires intervention by a physician. 5. The nurse is aware that which approach is best to validate a clinical inference? 1. Have another nurse evaluate it 2. Have the physician evaluate it 3. Have sufficient supportive data 4. Have the client’s family confirm it

6. The nurse manager notices that a staff nurse writes a nursing diagnosis as “Impaired Physical Mobility, related to laziness and not having appropriate shoes.” Which issue related to the nursing diagnosis will the nurse manager discuss with the staff nurse? 1. The staff nurse is being judgmental. 2. As written, the diagnosis is too complex. 3. The diagnosis is legally questionable. 4. There is deficiency of supportive data. 7. When making a diagnosis using NANDA-I taxonomy, which part of the statement provides support for the diagnostic label you choose? 1. Etiology 2. Related factors 3. Diagnostic label 4. Defining characteristics 8. The nurse is applying the nursing process to the development of a plan of care for a patient. Based on the patient’s problems, the nurse is using Maslow’s Hierarchy of Needs. Which nursing diagnosis does the nurse recognize as having the highest priority? 1. Self-Care Deficit 2. Risk for Aspiration 3. Impaired Physical Mobility 4. Functional Urinary Incontinence 9. A staff nurse states, “I get tired of all the paperwork about nursing diagnosis and plans for patient care.” Which of the following describes the most important purpose for developing a nursing diagnosis? 1. Differentiates the nurse’s role from that of the physician 2. Identifies a body of knowledge unique to nursing 3. Helps nursing develop a more professional image 4. Describes the client’s needs for nursing care 10. The nurse has relocated to a different state and has accepted a position as a staff nurse on an acute care nursing unit. The patient care team consists of both registered nurses (RNs) and licensed practical nurses/licensed vocational nurses (LPNs/LVNs). Which action by the nurse constitutes a possible theoretical error? 1. Assigning an LPN/LVN to formulate a nursing diagnosis 2. Instructing an LPN/LVN to perform a prescribed dressing change 3. Delegating an RN to perform the admitting history on a new client 4. Expecting RNs and LPNs/LVNs to administer medications to assigned clients 11. The nurse is formulating a nursing diagnosis for a patient. Which definition most accurately describes nursing diagnoses? 1. Supports the nurse’s diagnostic reasoning 2. Supports the client’s medical diagnosis 3. Identifies a client’s response to a health problem

4. Identifies a client’s health problem 12. The nurse has gathered information about a client, has sorted the information, and is preparing to identify the diagnostic label, or patient problem. For which purpose are diagnostic labels primarily used? 1. To set client goals 2. To make cue clusters 3. To identify interventions 4. To understand disease etiology 13. Which nursing diagnosis is written in the correct format when using NANDA-I taxonomy? 1. Bowel Obstruction, related to recent abdominal surgery, as manifested by (AMB) nausea, vomiting, and abdominal pain 2. Inability to Ingest Food, related to imbalanced nutrition: less than body requirements, AMB inadequate food intake, weight less than 20% under ideal body weight 3. Impaired Skin Integrity, related to physical immobility, AMB skin tear over sacral area 4. Caregiver Role Strain, related to alienation from family and friends, AMB 24-hour care responsibilities 14. Which nursing diagnosis is written in the correct format? 1. Imbalanced Nutrition: Less than Body Requirements, related to body weight less than 20% under ideal weight 2. Ineffective Airway Clearance, related to increased respiratory rate and irregular rhythm 3. Impaired Swallowing, related to absent gag reflex 4. Excess Fluid Volume, related to 3 lb weight gain in 24 hours 15. The nurse has diagnosed Decisional Conflict related to unclear personal values and beliefs, and the patient shows the necessary defining characteristics. Which essential action does the nurse take to help ensure the accuracy of this diagnosis? 1. Ask a more experienced nurse to confirm it 2. Request a social worker interview the patient 3. Ask for the patient’s confirmation of the diagnosis 4. Read about Decisional Conflict in the NANDA-I handbook 16. A client’s weight is appropriate for the client’s height, and laboratory values and other assessments reflect normal nutritional status. However, the client states, “I probably eat a little too much red meat. And, what is this I hear about needing omega 3 oils in my diet? I don’t like to take supplements, and I think I could really improve my nutrition.” Which nursing diagnoses does the nurse use? 1. Balanced Nutrition 2. Possible Imbalanced Nutrition: Less Than Body Requirements 3. Risk for Imbalanced Nutrition: Less Than Body Requirements

4. Readiness for Enhanced Nutrition 17. A patient verbalizes an overwhelming lack of energy, stating, “I still feel exhausted even after sleeping. I feel guilty when I can’t keep up with my usual daily activities, or I sleep during the day. I’ve been a little depressed lately, too.” The nurse notes the patient’s difficulty concentrating but does not note any apparent physical problems. Which diagnoses best describes the patient’s health status? 1. Fatigue related to depression 2. Fatigue related to difficulty concentrating 3. Guilt related to lack of energy 4. Chronic confusion related to lack of energy 18. The nurse documents in a patient’s progress notes: “Admitted to emergency department accompanied by spouse. Patient is alert and oriented, blood pressure is 120/80 mm Hg, and pulse is 80 beats/min. The patient is anxious and becomes nervous when asked about a smoking history.” Which statement from the nurse’s note is the best example of an inference? 1. The blood pressure reading is 120/80 mm Hg. 2. The patient is accompanied by spouse. 3. The patient has a history of smoking. 4. The patient is anxious. 19. Which statement made by the nurse is an example of stereotyping? 1. “Patients with a Japanese background are always quiet and emotionless.” 2. “Patients with type 1 diabetes do not make insulin and will need to take insulin regularly.” 3. “The patient needs to understand the benefits of getting out of bed and not cry each time.” 4. “I am confused why the client at 2 years of age is having a tantrum; my child never has one.” 20. Which of the following is the best example of a nursing diagnosis statement? 1. Pain related to appendicitis 2. Fractured left leg related to impaired mobility 3. Impaired mobility related to fractured left leg 4. Acute pain related to out of bed activities 21. The nurse is providing care for a patient following abdominal surgery. The nurse created a collaborative diagnosis of “Potential complication of surgery: hemorrhage” During patient assessment, the nurse recognizes the symptoms of serious blood loss. The nurse is aware that which action is now relative to the collaborative diagnosis? 1. The diagnosis is modified to watch for “continued” hemorrhage. 2. The diagnosis is removed because of the development of a medical problem. 3. The nurse collaborates with the physician to formulate a new diagnosis. 4. The nurse documents the effectiveness and value of the initial diagnosis.

22. The nurse completes assessment on a patient and begins to formulate a nursing diagnosis from the collected data. Which action does the nurse take prior to writing the nursing diagnosis statement? 1. Verifies the nursing diagnosis with the patient 2. Validates information with the primary care provider 3. Checks the medical diagnosis for consistency in treatments 4. Reviews the data and the diagnosis with another nurse 23. Which statement related to the nurse prioritizing patient problems is most accurate? 1. Nurses must resolve one problem before addressing another problem. 2. Nurses prioritize problems in the order of problem urgency. 3. Nurses give priority to actual problems instead of risk problems. 4. Nurses give the highest priority to problems most important to the patient. 24. The nurse receives reports on four patients on a medical-surgical unit. Which patient will the nurse attend to first? 1. Gait unsteady, uses walker, needs two-person assist with ambulation 2. Abdominal wound with foul-smelling drainage, incision margins are red, heart rate 100 beats/min 3. Blood pressure 90/50 mm Hg, heart rate 40 beats/min, patient rates chest pain at 8 on a 0-to-10 pain scale 4. Verbalizes history of migraine headaches, eyes closed during assessment interview Multiple Response Identify one or more choices that best complete the statement or answer the question. 25. What are the benefits for nursing practice in using a standardized nursing language when writing nursing diagnoses? Select all that apply. 1. Defines and communicates nursing knowledge 2. Assists the nurse in understanding medical diagnoses 3. Facilitates better understanding of nursing research 4. Helps nurses provide consistent interventions for all patients 5. Promotes medical understanding of nursing functions 26. Which statements regarding nursing diagnoses are accurate? Select all that apply. 1. Provide the basis for nursing interventions 2. Are validated with patient and family, when possible 3. Have historically been well substantiated by research 4. Contain descriptions of pathological disease processes 5. Analyze assessment data by using critical-thinking skills 27. The nurse manager is evaluating the nursing diagnoses written by staff nurses. Which nursing diagnosis statements does the nurse manager identify as being written correctly? Select all that apply. 1. Chronic Pain, related to osteoarthritis, as manifested by (AMB) patient rating pain

2. 3. 4. 5.

at 8 on a 0 to 10 pain scale and having difficulty with ambulation Ineffective Airway Clearance, related to excessive mucus, AMB cough, shortness of breath, change in respiratory rate and rhythm Caregiver Role Strain, related to increasing care needs, AMB wife stating, “He is just getting too heavy for me to lift” Anxiety (moderate), related to cardiac catheterization, AMB crying and yelling at family members Emotional distress, AMB inability to eat related to recent diagnosis of a terminal disease

Completion Complete each statement. 28. Using Maslow’s Hierarchy of Needs, rank the following nursing diagnoses in order of importance, beginning with the highest-priority diagnosis. (Enter using the following format: 1, 2, 3, 4) A. Anxiety B. Risk for infection C. Disturbed body image

D. Sleep deprivation

Chapter 4. Analysis/Diagnosis Answer Section MULTIPLE CHOICE 1. ANS: 2 Chapter: Chapter 4 Analysis/Diagnosis Objective: Explain why an etiology is always an inference. Page: 64 (V1) Heading: Draw Conclusions About Health Status Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate

Feedback This is incorrect. Hemorrhage following surgery is a collaborative problem involving the nurse and the physician. The nurse can address the hemorrhage, but actual treatment is a medical issue. This is correct. A nursing diagnosis (or nursing problem) is a human response to a disease, injury, or other stressor that nurses can identify, prevent, or treat independently. When a patient experiences nausea after walking in the hall, the nurse can treat the patient’s manifestation without seeking medical intervention. This is incorrect. Fracture pain after an accident is expected but is a collaborative problem. The nurse can monitor the pain and provide treatment, as prescribed; however, the medical management of pain is the responsibility of the physician. This is incorrect. Infection in a wound is a collaborative problem, involving at least the nurse and the physician. The nurse can monitor an infection and provide prescribed care; however, the medical management is the responsibility of the physician.

PTS: 1 CON: Patient-Centered Care 2. ANS: 1 Chapter: Chapter 4 Analysis/Diagnosis Objective: Define the following terms: diagnosis, nursing diagnosis, diagnostic reasoning, diagnostic label, defining characteristics, related factors, risk factors, and health problem. Page: 63 (V1) Heading: Analyze and Interpret Data Integrated Processes: Nursing Process

Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

1 2 3 4

Feedback This is correct. A cue is an unhealthy response; a cluster of cues consists of cues related to each other, such as nausea and stomach pain after eating. This is incorrect. Productive cough and loose stools are abnormal findings but are not obviously or usually related to each other. This is incorrect. Daily bowel movement and high-fiber diet are related but normal responses. This is incorrect. The vital signs provided are within normal limits.

PTS: 1 CON: Patient-Centered Care 3. ANS: 1 Chapter: Chapter 4 Analysis/Diagnosis Objective: Explain the differences among actual, risk, possible, syndrome, and wellness nursing diagnoses. Page: 61 (V1) Heading: Types of Nursing Diagnosis Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is correct. A risk diagnosis describes a problem that may develop in a vulnerable client if nursing care is not initiated to prevent it; it is made when risk factors, such as age, health status, and environment, are present in the data. A risk diagnosis becomes an actual diagnosis when symptoms develop. 2 This is incorrect. A possible nursing diagnosis is based on nursing knowledge, intuition, and experience and does not have enough data to support it; it is based on incomplete data. 3 This is incorrect. The nurse’s description of the patient’s health status does not warrant the use of a wellness diagnosis, which indicates absence of a problem. The scenario indicates a danger for falling. 4 This is incorrect. This represents a collection of nursing diagnoses that usually occur together. The scenario states the nurse is concerned about the danger of falling. PTS:

CON: Patient-Centered Care

4. ANS: 4 Chapter: Chapter 4 Analysis/Diagnosis Objective: Differentiate among nursing diagnoses, medical diagnoses, and collaborative problems. Page: 62 (V1) Heading: Table 4-2: Differentiating Problem Types: Medical, Collaborative, and Actual, Risk, Possible, Syndrome, and Wellness Nursing Diagnoses Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is incorrect. A medical diagnosis requires interventions (medications, treatments) by the physician. 2 This is incorrect. Medical diagnoses do not direct all nursing care. 3 This is incorrect. Collaborative problems have the potential to become medical diagnoses, not nursing diagnoses. 4 This is correct. Collaborative problems are physiological complications for which a client may be at risk based on her medical diagnosis, medical treatment, or diagnostic studies. A collaborative problem requires monitoring by a nurse and intervention by a physician. PTS: 1 CON: Patient-Centered Care 5. ANS: 3 Chapter: Chapter 4 Analysis/Diagnosis Objective: Explain why an etiology is always an inference. Page: 64 (V1) Heading: Draw Conclusions About Health Status Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate

1 2 3

Feedback This is incorrect. Although another experienced nurse could evaluate the inference, it still needs to be supported by sound and sufficient data. This is incorrect. Because inferences are nursing diagnoses, it would be inappropriate to have a physician evaluate them. This is correct. All clinical inferences should be well supported by data. The more reliable the data the nurse gathers are, the more certain the nurse can be that the inference is accurate.

This is incorrect. The client’s family, even clients can validate clinical inferences in some situations; however, adequate supporting data are still needed. Keep in mind that the client’s data might or might not be sufficient to “prove” the inference.

PTS: 1 CON: Patient-Centered Care 6. ANS: 1 Chapter: Chapter 4 Analysis/Diagnosis Objective: Use standardized nursing language to write nursing diagnoses. Page: 74 (V1) Heading: Reflecting Critically About Diagnostic Statements Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate

1 2 3 4

Feedback This is correct. “Lazy” implies criticism of the client and, therefore, is judgmental. The nurse manager will discuss this issue with the staff nurse. This is incorrect. There need to be several (certainly more than two) etiological factors for the statement to be complex. This is incorrect. There is no implied blame or resulting harm, so the statement is not legally questionable. This is incorrect. There is no minimum “amount” of supportive data for a diagnosis and the stated etiology related to the nursing diagnosis. In this question, no supportive data are provided in the stem of the question.

PTS: 1 CON: Patient-Centered Care 7. ANS: 4 Chapter: Chapter 4 Analysis/Diagnosis Objective: Use standardized nursing language to write nursing diagnoses. Page: 71 (V1) Heading: Writing Diagnostic Statements Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Moderate

Feedback This is incorrect. The etiology is a cause of or contributing factor to the

2 3 4

problem. This is incorrect. The related factors are causes of or contributing factors to the problem. This is incorrect. The diagnostic label is the name NANDA-I has given for the problem; it is chosen based on the presence of defining characteristics. This is correct. The defining characteristics are the signs and symptoms that must be present to support any given nursing diagnosis.

PTS: 1 CON: Patient-Centered Care 8. ANS: 2 Chapter: Chapter 4 Analysis/Diagnosis Objective: Describe at least two frameworks for prioritizing nursing diagnoses. Page: 65 (V1) Heading: Prioritize Problems Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate

1 2

Feedback This is incorrect. Self-care deficit is not life threatening or possibly destructive to the client; therefore, this diagnosis is not a priority. This is correct. Safety is most basic in Maslow’s hierarchy. Even though Risk for Aspiration is not an actual problem, it poses the most immediate lifethreatening risk to the client. Nursing interventions must be performed to prevent the nursing diagnosis from becoming an actual problem. This is incorrect. Impaired physical mobility is important, but does not represent an immediate life-threatening risk to the client. Therefore, this nursing diagnosis is not a priority. This is incorrect. Functional Urinary Incontinence does not represent an immediate life-threatening risk to the client. Therefore, this nursing diagnosis is not a priority.

PTS: 1 CON: Patient-Centered Care 9. ANS: 4 Chapter: Chapter 4 Analysis/Diagnosis Objective: Explain the relationship between nursing diagnoses and goals/interventions. Page: 62 (V1) Heading: Analysis/Diagnosis: The Second Step of the Nursing Process Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential

Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

Feedback This is incorrect. The benefits to nurses and nursing are that nursing diagnoses differentiate the nurse’s role from that of the physician. However, this is not the most important purpose for developing a nursing diagnosis. This is incorrect. The benefits to nurses and nursing are that nursing diagnoses identify a unique body of nursing knowledge. However, this is not the most important purpose for developing a nursing diagnosis. This is incorrect. The benefits to nurses and nursing are that nursing diagnoses help nursing to develop a more professional image. However, this is not the most important purpose for developing a nursing diagnosis. This is correct. The primary goal of nursing is to serve the good of the patient. Therefore, the most important use of a diagnosis is to specifically identify the client’s needs for quality nursing care.

PTS: 1 CON: Patient-Centered Care 10. ANS: 1 Chapter: Chapter 4 Analysis/Diagnosis Objective: Describe errors of theoretical and self-knowledge that may occur in diagnostic reasoning. Page: 57 (V1) Heading: Theoretical Knowledge: Knowing Why Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

Feedback This is correct. Assigning an LPN/LVN to formulate a nursing diagnosis constitutes a possible theoretical error by the staff nurse. Many nursing activities can be delegated, but not diagnosis. Most state nurse practice acts limit the role of the LPN/LVN to gathering data that will be analyzed by the RN. However, the nurse may have relocated from a state where the state board of nursing standards may have been different. This is incorrect. Instructing an LPN/LVN to perform a prescribed dressing change is not likely to be a theoretical error by the staff nurse. It is probable the task is in the scope of practice for the LPN/LVN. This is incorrect. Delegating an RN to perform the admitting history on a new

client is within the scope of practice for the RN. This is incorrect. Expecting RNs and LPN/LVNs to administer medications to assigned clients is not a likely cause of a theoretical error. Most state boards of nursing have guidelines for this procedure.

PTS: 1 CON: Patient-Centered Care 11. ANS: 3 Chapter: Chapter 4 Analysis/Diagnosis Objective: Define the following terms: diagnosis, nursing diagnosis, diagnostic reasoning, diagnostic label, defining characteristics, related factors, risk factors, and health problem. Page: 57 (V1) Heading: Analysis/Diagnosis: The Second Step of the Nursing Process Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Diagnostic reasoning is used to identify the appropriate nursing diagnosis; it is not meant to “support” the diagnosis. 2 This is incorrect. Nursing diagnoses are not medical diagnoses or meant to support medical diagnoses. 3 This is correct. Nursing diagnoses are statements that nurses use to describe a client’s physical, mental, emotional, spiritual, and social response to disease, injury, or other stressor. 4 This is incorrect. A health problem is a condition that requires intervention to promote wellness or prevent illness; it is sometimes, but not always, a nursing diagnosis. PTS: 1 CON: Patient-Centered Care 12. ANS: 1 Chapter: Chapter 4 Analysis/Diagnosis Objective: Define the following terms: diagnosis, nursing diagnosis, diagnostic reasoning, diagnostic label, defining characteristics, related factors, risk factors, and health problem. Page: 68 (V1) Heading: Standardized Nursing Languages Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate Feedback

2 3 4

This is correct. Diagnostic labels are developed using standardized nursing languages and identifies patient goals specifically based on patient needs/problems. As a general rule, the problem always suggests goals for client outcomes. This is incorrect. Cue clusters are used to support the identification of the correct nursing diagnosis. This is incorrect. Diagnostic labels are used to identify client goals. Interventions are based on client needs. This is incorrect. The etiology is a source for suggestions about interventions.

PTS: 1 CON: Patient-Centered Care 13. ANS: 3 Chapter: Chapter 4 Analysis/Diagnosis Objective: Use standardized nursing language to write nursing diagnoses. Page: 68 (V1) Heading: Standardized Nursing Languages Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Difficult

2 3

Feedback This is incorrect. For “Bowel Obstruction …,” the problem is a medical diagnosis. The cause-and-effect order of “Inability to Ingest Food …” is incorrect; it starts with the etiology. This is incorrect. The diagnostic label is Imbalanced Nutrition, not Inability to Ingest Food. This is correct. The components of NANDA-I nursing diagnosis might include the following four parts: diagnostic label, defining characteristics, related factors, and risk factors. “Impaired Skin Integrity …” has the problem statement, etiology, and symptoms. This is incorrect. The etiology and symptoms (AMB) of “Caregiver Role Strain ...” are reversed (alienation from family and friends are the symptoms that support the diagnosis).

PTS: 1 CON: Patient-Centered Care 14. ANS: 1 Chapter: Chapter 4 Analysis/Diagnosis Objective: Use standardized nursing language to write nursing diagnoses. Page: 68 (V1) Heading: Standardized Nursing Languages

Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

1 2 3 4

Feedback This is correct. The etiology should describe what the problem actually is, such as Less than Body Requirements. This is incorrect. Ineffective Airway Clearance describes the signs of symptoms rather than a cause for the nursing diagnosis. This is incorrect. Impaired Swallowing includes the symptom of the nursing diagnosis and not the cause. This is incorrect. The etiologies for Excess Fluid Volume describe signs or symptoms rather than causal factors.

PTS: 1 CON: Patient-Centered Care 15. ANS: 3 Chapter: Chapter 4 Analysis/Diagnosis Objective: State at least five criteria for judging the quality of a diagnostic statement. Page: 57 (V1) Heading: Analysis/Diagnosis: The Second Step of the Nursing Process Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate

1 2

Feedback This is incorrect. Certainly, the nurse could ask another nurse’s opinion, but this action is not essential. This is incorrect. It would make no sense to have a social worker interview the patient unless the situation remains unclear even after confirming with the client. This is correct. After identifying problems and etiologies (which this nurse has done), the nurse should verify them with the patient to help ensure the nurse’s conclusions are accurate. If the patient does not agree with the diagnosis of Decisional Conflict, the nurse will perform a more in-depth interview to clarify the meaning of the data. This is incorrect. If the nurse did have adequate theoretical knowledge of Decisional Conflict for this patient, the nurse is likely informed by reading the NANDA-I handbook before making the diagnosis. If the patient does not

confirm the diagnosis, and the nurse concludes the diagnosis is in error, the nurse might then reread the NANDA-I guide. PTS: 1 CON: Patient-Centered Care 16. ANS: 4 Chapter: Chapter 4 Analysis/Diagnosis Objective: Explain the differences among actual, risk, possible, syndrome, and wellness nursing diagnoses. Page: 61 (V1) Heading: Types of Nursing Diagnoses Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate

1 2

3 4

Feedback This is incorrect. Balanced Nutrition is not supported by the assessment findings or the client’s statements. This is incorrect. The nurse uses a diagnosis when the nurse has enough data to suspect a problem but needs more data to support a diagnosis. The scenario does not support the client receiving less nutrition than the body requires. This is incorrect. The nurse uses a risk diagnosis when there are risk factors for a problem, which are not noted in this scenario. This is correct. The nurse uses a wellness diagnosis when a client’s present level of wellness is effective, and when the person wants to move to a higher level of wellness—in this case, a higher level of nutrition. The format for a wellness diagnosis is “Readiness for Enhanced ….”

PTS: 1 CON: Patient-Centered Care 17. ANS: 1 Chapter: Chapter 4 Analysis/Diagnosis Objective: Define the following terms: diagnosis, nursing diagnosis, diagnostic reasoning, diagnostic label, defining characteristics, related factors, risk factors, and health problem. Page: 59 (V1) Heading: What Are Health Problems? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Difficult Feedback

3 4

This is correct. The diagnosis that best describes the overall health status is Fatigue. The only cue that might cause Fatigue is depression. You cannot use depression as the problem because it is a medical diagnosis, and it is not a NANDA-I label. These diagnoses would lead the nurse to focus on dealing with guilt and confusion, so the source of Fatigue would not be addressed. This is incorrect. Difficulty concentrating is a symptom of Fatigue, not a cause. This diagnosis will lead the nurse to focus on how to deal with the guilt and confusion, and the source of the true diagnosis, Fatigue, would not be addressed. This is incorrect. Lack of energy is a symptom of Fatigue, not an etiology. Fatigue and the lack of energy are connected; guilt is not a consideration. This is incorrect. Chronic confusion is a symptom of Fatigue, not an etiology. Fatigue and chronic confusion are connected; lack of energy is not connected to chronic confusion.

PTS: 1 CON: Patient-Centered Care 18. ANS: 4 Chapter: Chapter 4 Analysis/Diagnosis Objective: Explain why an etiology is always an inference. Page: 63 (V1) Heading: Analyze and Interpret Data Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

1 2 3 4

Feedback This is incorrect. Blood pressure value is an example of objective data. This is incorrect. The presence of a spouse with the patient is objective data. This is incorrect. When the nurse asks about a smoking history, either a positive answer or a negative answer is considered subjective data. This is correct. The inference in this item is about the patient’s anxiety. The nurse observes that the patient is nervous and shaky and can document these observations. However, the nurse cannot infer that these observations mean the patient has anxiety.

PTS: 1 CON: Patient-Centered Care 19. ANS: 1 Chapter: Chapter 4 Analysis/Diagnosis Objective: Describe errors of theoretical and self-knowledge that may occur in diagnostic reasoning. Page: 67 (V1)

Heading: Reflecting Critically on Your Diagnostic Reasoning Integrated Processes: Nursing Process Client Need: Physical Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is correct. Stereotypes are judgments and expectations about an individual based on the personal beliefs about a specific group. The statement generalizing the traits of patients with a Japanese background is an example of stereotyping. 2 This is incorrect. Patients with type 1 diabetes will need insulin therapy because this is the medical treatment for all patients with diabetes. 3 This is incorrect. The comment about the patient who cries about needing to get out of bed is judgmental. 4 This is incorrect. The example of the 2-year-old demonstrates bias because the nurse is reflecting an opinion based on the nurse’s personal opinion and experience. PTS: 1 CON: Patient-Centered Care 20. ANS: 4 Chapter: Chapter 4 Analysis/Diagnosis Objective: Use standardized nursing language to write nursing diagnoses. Page: 68 (V1) Heading: Standardized Nursing Languages Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate

Feedback This is incorrect. Acute Pain is a nursing diagnosis because it is a human response to a health problem. However, “pain related to appendicitis” is not descriptive of pain, nor is appendicitis a nursing etiology; it is a medical diagnosis. This is incorrect. “Fractured left leg” is a medical diagnosis and cannot be used as a nursing diagnosis. “Impaired mobility” is not appropriate because a medical diagnosis is used in the etiology. This is incorrect. This nursing diagnosis contains a problem and its etiology. A problem describes the human response to a health problem and should be written in the NANDA-I format. The etiology contains factors that cause or contribute to the problem and should direct nursing interventions.

This is correct. The etiology, out-of-bed activities, is an example of a contributing factor that the nurse can direct and for which nursing interventions can be formulated.

PTS: 1 CON: Patient-Centered Care 21. ANS: 2 Chapter: Chapter 4 Analysis/Diagnosis Objective: Use collaborative problem statements appropriately. Page: 69 (V1) Heading: Recognizing Collaborative Problems Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate

Feedback This is incorrect. A collaborative nursing diagnosis is written to direct nursing care in relationship to a medical diagnosis. Once a potential risk becomes actual, there is no reason to modify the initial diagnosis. This is correct. Once a potential problem in a collaborative diagnosis becomes an actual problem, the initial diagnosis is no longer maintained because of the development of a medical problem. This is incorrect. The nurse does not collaborate with the physician to formulate a new nursing diagnosis. The nurse can formulate a collaborative nursing diagnosis based on a medical diagnosis and the associated nursing care. This is incorrect. Documentation about the function of a collaborative nursing diagnosis is not needed; documentation is patient focused.

PTS: 1 CON: Patient-Centered Care 22. ANS: 1 Chapter: Chapter 4 Analysis/Diagnosis Objective: Describe the diagnostic process. Page: 61 (V1) Heading: What Is Diagnostic Reasoning? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Moderate Feedback

This is correct. After identifying problems and etiologies, the nurse must verify them with the patient. A diagnostic statement is an interpretation of the data, and the patient’s interpretation may not be the same as that of the nurse. This is incorrect. Validating information with the primary care provider does not assist the nurse in developing a plan of care based on nursing diagnoses and interventions. This is incorrect. Checking the medical diagnosis for consistency in treatments does not assist the nurse in tailoring the nursing diagnosis to individual patient needs, although when planning care, the nurse does need to be certain that nursing interventions do not conflict with medical therapies. This is incorrect. Reviewing the data and the diagnosis with another nurse may reaffirm the nurse’s conclusions; however, the diagnosis still needs to be verified with the patient.

PTS: 1 CON: Patient-Centered Care 23. ANS: 2 Chapter: Chapter 4 Analysis/Diagnosis Objective: Describe at least two frameworks for prioritizing nursing diagnoses. Page: 65 (V1) Heading: Prioritize Problems Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Moderate

Feedback This is incorrect. Nurses do not need to resolve one problem before attending to another. Actually, in many circumstances, nurses may be assessing and intervening for several problems at the same time. This is correct. Patients often have more than one problem, so the nurse must use nursing judgment to decide which to address first and which can wait. Prioritization assigns a ranking of urgency to patient problems according to the degree of threat they pose to the patient’s life or to the immediacy with which treatment is needed. This is incorrect. The highest priority is always given to life-threatening problems; however, not all patient problems are life threatening. Frequently, nurses encounter risk problems that may earn a higher priority ranking than an actual problem. This is incorrect. Giving priority to problems the patient thinks are most important is appropriate, provided that the decision does not conflict with the basic/survival needs or medical treatments.

PTS: 1 CON: Patient-Centered Care 24. ANS: 3 Chapter: Chapter 4 Analysis/Diagnosis Objective: Describe at least two frameworks for prioritizing nursing diagnoses. Page: 65 (V1) Heading: Prioritize Problems Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate

1 2

Feedback This is incorrect. Although an unsteady gait places a patient at risk for falls, this answer indicates that the patient uses a walker and two-person assist. This is incorrect. The draining wound is infected; however, this can be addressed with medications. Infections do not usually progress rapidly (i.e., compared with chest pain). The wound symptoms are not immediately life threatening. This is correct. Unstable vital signs with chest pain is of the highest priority because these symptoms may be life threatening. These instabilities must be addressed at once. This is incorrect. A patient with a history of migraine headaches is not a priority at this time, although the patient’s pain should be relieved as quickly as possible after dealing with the highest priority problem(s). PTS:

CON: Patient-Centered Care

MULTIPLE RESPONSE 25. ANS: 1, 3 Chapter: Chapter 4 Analysis/Diagnosis Objective: Use standardized nursing language to write nursing diagnoses. Page: 68 (V1) Heading: Standardized Nursing Languages Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

2. 3.

Feedback This is correct. Standardized nursing languages are a comparatively recent attempt to bring clarity to communication of nursing knowledge and nursing thinking. A standardized language can define, communicate, and expand nursing knowledge, increase visibility and awareness of nursing interventions, facilitate research, and improve patient care by providing better communication among nurses and other healthcare providers. This is incorrect. A medical diagnosis describes a disease, illness, or injury. Its purpose is to identify a pathology so that appropriate medical treatment can be given. This is correct. A standardized language can define, communicate, and expand nursing knowledge, increase visibility and awareness of nursing interventions, facilitate research, and improve patient care by providing better communication among nurse and other healthcare providers. This is incorrect. Nurses deliver nursing care and actions in different ways to different patients. All patients do not have the same needs and problems; therefore, care is planned on an individual basis. This is incorrect. The purpose of standardized nursing language is to promote uniformity within nursing, and to aid in determining patient care. Medical understanding of nursing is achieved through other methods of communication.

PTS: 1 CON: Patient-Centered Care 26. ANS: 1, 2, 5 Chapter: Chapter 4 Analysis/Diagnosis Objective: Define the following terms: diagnosis, nursing diagnosis, diagnostic reasoning, diagnostic label, defining characteristics, related factors, risk factors, and health problem. Page: 58 (V1) Heading: Analysis/Diagnosis: The Second Step of the Nursing Process Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

Feedback This is correct. Nursing diagnosis is the second step in the Nursing Process. It is the link between the preceding assessment data and all future phases. The diagnostic statement is written after all data are collected and reflects the nurse’s clinical reasoning in establishing the nursing problem. This is correct. When possible, the nursing diagnosis, as well as all other steps in the Nursing Process, should be validated with the patient. It further provides the basis for planning client-centered goals and interventions. This is incorrect. Many nursing diagnoses have been verified and established

4. 5.

through research; however, this has not been a historical strength of the taxonomy. This continues to be a criticism of nursing diagnoses. This is incorrect. Nursing diagnoses are human responses to health problems, whereas medical diagnoses establish the presence of disease processes. This is correct. Keeping with the professionalism of nursing, formulating nursing diagnosis uses critical-thinking skills to analyze assessment data.

PTS: 1 CON: Patient-Centered Care 27. ANS: 2, 3 Chapter: Chapter 4 Analysis/Diagnosis Objective: Differentiate between nursing diagnoses, medical diagnoses, and collaborative problems. Page: 57 (V1) Heading: What Are Health Problems? Integrated Processes: Communication and Documentation Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Communication Difficulty: Difficult

1. 2.

4. 5.

Feedback This is incorrect. The statement beginning with “Chronic Pain” contains an etiology that is a medical diagnosis and cannot be used by the nurse to act on independently. This is correct. The statements about Ineffective Airway Clearance and Caregiver Role Strain contain all of the components of a correctly written nursing diagnosis statement. The problems are stated in correct NANDA-I format and reflect patient responses to health problems. The connecting “related to” statements reflect etiologies that cause or contribute to the health problem and can direct nursing interventions. The AMBs reflect signs and symptoms that have validated the patient’s response to the health problem. This is correct. The connecting “related to” statements reflect etiologies that cause or contribute to the health problem and can direct nursing interventions. The AMBs reflect signs and symptoms that have validated the patient’s response to the health problem. This is incorrect. The statement about Anxiety contains an etiology that describes a diagnostic procedure and cannot be independently acted on by a nurse. This is incorrect. The diagnosis Emotional Distress is not correctly supported by the AMB or the patient’s response to the health problem.

PTS: COMPLETION

CON: Patient-Centered Care

28. ANS: d, b, a, c Chapter: Chapter 4 Analysis/Diagnosis Objective: Describe at least two frameworks for prioritizing nursing diagnoses. Page: 65 (V1) Heading: Prioritize Problems Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult Feedback: In Maslow’s hierarchy, physiological needs and safety are the highest priority. Sleep is a basic physiological need. Infection can threaten physical health. In this question, infection is not present; therefore, there is only a risk for it. Sleep Deprivation is an immediate problem that affects general physical, mental, and emotional health. Neither Anxiety nor Disturbed Body Image is a physiological or safety need. Anxiety is a more immediate need compared with Disturbed Body Image; therefore, it probably deserves a higher ranking. The ranking would depend on the severity of each problem, which is not known by the labels alone. PTS:

CON: Patient-Centered Care

Chapter 5. Planning Outcomes Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse asks the nurse manager, “What do initial planning, ongoing planning, and discharge planning have in common?” Which information from the nurse manager is correct? 1. They are based on assessment and diagnosis. 2. They focus on the patient’s perception of needs. 3. They require input from a multidisciplinary team. 4. They have specific time lines in which to be completed. 2. The nurse recognizes which client as having the greatest need for comprehensive formal discharge planning? 1. A postpartum patient after the birth to her second child, who lives with her spouse and 18-month-old daughter 2. A patient who is readmitted for exacerbation of chronic obstructive pulmonary disease (COPD) 3. A patient who is 12-years of age being discharged home with a parent after outpatient surgery 4. An adult patient just diagnosed with renal failure who is scheduled to start peritoneal dialysis 3. The nurse is working on a new nursing unit that utilizes preprinted standardized care plans along with comprehensive care plans developed by the nurse. Which is the most important advantage for the use of both types of care plans? 1. Helps ensure that important interventions for the diagnosis are not overlooked 2. May prescribe care for one or more nursing diagnosis or medical conditions 3. Includes nursing interventions along with multidisciplinary interventions 4. Promotes a consistency of care among patients with similar conditions 4. The nurse is planning care for a patient by using a standardized care plan for Impaired Walking, related to left-side weakness. Which activity will the nurse perform when individualizing the plan for the patient? 1. Validating conflicting data with the patient 2. Transcribing medical orders 3. Stating the frequency for ambulation 4. Performing a comprehensive assessment 5. The nurse is working on development of a plan of care for a patient hospitalized for a respiratory infection. Which is the best example of an outcome statement for this patient? 1. Uses the incentive spirometer when awake 2. Walks two times in the hall during day and evening shift 3. Maintains oxygen saturation above 92% while performing activities of daily living

(ADLs) 4. Tolerates 10 sets of range-of-motion exercises with physical therapy 6. The nurse is formulating a plan of care for an older client admitted for dehydration. The nurse develops goals from a standardized care plan and the physician’s medical orders. Which nursesensitive goal is appropriate for this patient? 1. Ask the patient about oral fluid preferences. 2. Maintain a full water pitcher at the patient’s bedside. 3. Ensure patient’s oral intake is 100 mL/hour during the day. 4. Keep the patient on strict intake and output (I&O) monitoring. 7. The nurse is creating a comprehensive patient plan of care. Which information does the nurse include? 1. Methods of performing patient activities of daily living (ADLs) 2. Both medical and nursing interventions 3. Reasons for assigning care personnel 4. Symptoms of patient’s medical diagnosis 8. The nurse is reviewing the goals set on a patient’s plan of care. Which description specifically differentiates short-term goals from long-term goals? Short-term goals: 1. Can be met within a few hours or a few days. 2. Flow from the problem side of the nursing diagnosis. 3. Must have target times with dates. 4. Specify desired patient responses to interventions. 9. The nurse is individualizing a client’s plan of care for the nursing diagnosis Anxiety. For which reason does the nurse write goals/outcomes on the plan of care? 1. To recognize desirable changes related to formulated interventions 2. To monitor specific patient responses to medical interventions 3. To identify specific nursing behaviors to improve a patient’s health 4. To utilize criteria to evaluate the appropriateness of a nursing diagnosis 10. The nurse is updating a patient plan of care. Which outcome statement, written by the nurse, contains the best example of performance criteria? 1. Patient turns self in bed frequently while awake 2. Patient understands how to use crutches by day two 3. Patient states that pain is decreased after being medicated 4. Patient eats 75% of each meal without complaint of nausea 11. The nurse is developing a plan of care for a patient following surgery, and plans to include collaborative interventions. Which definition of goal/outcome is applicable for collaborative problems? 1. Collaborative problems are monitored only by other disciplines. 2. Collaborative problems are usually affected by nursing interventions. 3. Collaborative problems state that a complication will not occur.

4. Collaborative problems state only broad performance criteria. 12. In which manner does the nurse understand that NANDA-I problem labels and Nursing Outcome Classification (NOC) outcome labels are alike? 1. Health status is expressed in terms of human responses. 2. Patient response is expressed before interventions are done. 3. Patient responses are always expressed in positive terms. 4. Both methods reveal patterns of related cues. 13. The nurse writes a nursing diagnosis for a patient, which states, “Impaired Memory, related to fluid and electrolyte imbalances, as manifested by (AMB) inability to express knowledge of recent events.” Which essential goal/outcome does the nurse include on the care plan? 1. Current medications are reviewed for mind-altering side effects. 2. Patient demonstrates using techniques to help with memory loss. 3. Oral fluid intake of at a minimum of 1,500 mL of fluid per day. 4. Electrolyte supplements will be taken, as prescribed, with meals. 14. A client arrives in the emergency department and is pale and breathing rapidly. The client immediately becomes unconscious and collapses to the floor. The nurse rapidly assesses the client and decides the first series of actions needed. Which type of planning is the nurse demonstrating? 1. Formal planning 2. Informal planning 3. Ongoing planning 4. Initial planning Multiple Response Identify one or more choices that best complete the statement or answer the question. 15. A nurse is providing care for an older adult patient of Asian heritage. When planning outcomes for this patient, which actions by the nurse would meet the American Nurses Association (ANA) standards for outcomes identification? Select all that apply. 1. Developing culturally appropriate outcomes 2. Using the standardized outcomes on the clinical pathway 3. Choosing the best outcome for the patient, regardless of the cost 4. Involving the patient and family in formulating the outcomes 5. Advocating for the patient regarding unwanted treatment or healthcare 16. The nurse in an acute care facility is preparing to discharge an older client to an extended care facility. Which objectives does the nurse address in preparation for a comprehensive discharge process for this client? Select all that apply. 1. Maintain interagency communication 2. Determine level of family involvement 3. Share information about financial status 4. Activities for maintaining functional ability

5. Current ability for performing self-care needs 17. A nurse is overheard complaining about the time used to develop patients’ plans of care. Which information does the nurse manager share with the nurse about the importance of the process? Select all that apply. 1. Ensures that provided care is complete 2. Supports of continuity of care among nurses and between shifts 3. Promotes the efficient use of nursing efforts and care activities 4. Provides nurses with a guide for assessment and documentation 5. Meets the requirements set by accrediting agencies regarding care 18. Newly hired nurses on an acute care unit are encouraged to utilize computerized care planning in providing patient care. Which advantages exist from this process? Select all that apply. 1. The computer stores nursing diagnoses, medical diagnoses, and individualized interventions. 2. The computer generates a diagnosis and desired outcome after the patient’s assessment is entered. 3. The computer is capable of generating a list of suggested interventions, the nursing diagnosis, and goals. 4. The computer promotes the development and refinement of nursing intuition, insight, or expertise. 5. The computer prompts the nurse to consider a variety of actions and decreases overlooking common and important interventions. 19. The nurse is providing care for a patient following a total-knee replacement. The patient is to remain in acute care for two days. When developing an individualized plan of care for this patient, which goals set by the nurse are considered to be short-term? Select all that apply. 1. Patient will ambulate 10 feet with assistance 5 hours after surgery. 2. Patient will exhibit the ability to use a walker when ambulating. 3. Patient will understand the signs of infection at the surgery site. 4. Patient will experience a pain level of 4 or below on a 0-to-10 scale. 5. Patient will voice understanding of pain management at home. 20. The nurse is providing care for a hospitalized patient after surgery. Which statement is an example for the need of ongoing planning? Select all that apply. 1. Patient completes daily hygiene activities without assistance. 2. Patient consumes 25% of daily diet due to continued reports of nausea. 3. Patient completes dressing change after verbal coaching and assistance. 4. Patient ambulates 10 of the 25 feet anticipated on second postop day. 5. Patient rates pain at a level of 3 on a 0 to 10 scale 1 hour after medicated.

Chapter 5. Planning Outcomes Answer Section MULTIPLE CHOICE 1. ANS: 1 Chapter: Chapter 5 Planning Outcomes Objective: Describe formal, informal, initial, ongoing, and discharge planning. Page: 78 (V1) Heading: How Is Planning Related to Other Steps of the Nursing Process? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Moderate

1 2 3

Feedback This is correct. All planning is based on nursing assessment data and identified nursing diagnoses. This is incorrect. The patient should have input; however, the planning is based on the nursing assessment. This is incorrect. Multidisciplinary input may be used; however, the planning is based on the nursing assessment. Discharge planning often requires a multidisciplinary team, but initial and ongoing planning may not. This is incorrect. The different types of planning are intertwined and may or may not be done at distinct, separate times. Initial planning is usually begun after the first patient contact, but there is no specified time for completion. Ongoing planning is more or less continuous and is done as the need arises. Discharge planning must be done before discharge.

PTS: 1 CON: Patient-Centered Care 2. ANS: 4 Chapter: Chapter 5 Planning Outcomes Objective: Identify patients who need a comprehensive, formal discharge plan. Page: 81 (V1) Heading: What Is Planning? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate

Feedback This is incorrect. A postpartum patient will require discharge planning, but the planning would not be as comprehensive as it would be for someone with a new diagnosis resulting in a complex treatment regimen. Discharge planning is not altered because this is the patient’s second delivery. This is incorrect. A patient readmitted for exacerbation of COPD will require reinforcement of discharge planning. After exacerbation of a disease process, discharge planning will focus on management of the condition. This is incorrect. Anytime a patient has undergone an outpatient procedure, discharge planning is provided. However, although planning is important for this patient, it is not a need greater than that for the patient with a chronic disease and complex needs. This is correct. Comprehensive discharge planning is done for patients who have a newly diagnosed chronic disease (e.g., renal failure) or have complex needs (e.g., peritoneal dialysis).

PTS: 1 CON: Patient-Centered Care 3. ANS: 1 Chapter: Chapter 5 Planning Outcomes Objective: Describe a process for writing an individualized care plan, making use of available standardized care-planning documents. Page: 81 (V1) Heading: Preprinted Standardized Plans Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is correct. All options in this question are correct. However, the most important advantage of using both types of care plans is to ensure that important interventions for a specific diagnosis are not overlooked. 2 This is incorrect. It is true that a combination of standardized and comprehensive care plans can be used to prescribe care for one or more nursing diagnoses or medical conditions. However, the most important advantage is related to ensuring that important interventions are not overlooked. 3 This is incorrect. Standardized care plans include both nursing interventions and multidisciplinary interventions, which serve as a guide for the nurse regarding appropriate multidisciplinary involvement. However, ensuring the patient gets the benefit of important interventions is most important. 4 This is incorrect. The use of both types of care plans does provide a basis for consistency of care among patients with similar conditions; however, the most

important advantage is ensuring that important interventions are not overlooked. Each standardized care plan must still be tailored to the individual patient. PTS: 1 CON: Patient-Centered Care 4. ANS: 3 Chapter: Chapter 5 Planning Outcomes Objective: Describe the information contained in a comprehensive patient care plan. Page: 81 (V1) Heading: Patient Care Plans Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate

1 2 3

Feedback This is incorrect. Validating data ensures the nurse’s assessment data are accurate. This is incorrect. Transcribing orders is a part of developing and implementing the care plan, but not of individualizing the plan. This is correct. Individualizing the care plan means identifying specific problems, outcomes, and interventions, and the frequency of those interventions to meet the patient’s needs. This is incorrect. Performing an assessment is the beginning step in developing a care plan. Assessment helps the nurse identify the ways in which a standardized plan needs to be individualized to the specific patient.

PTS: 1 CON: Patient-Centered Care 5. ANS: 3 Chapter: Chapter 5 Planning Outcomes Objective: Define the following terms: goal, outcome, expected outcome, and nursing-sensitive outcome. Page: 86 (V1) Heading: Planning Patient Goals/Outcomes Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. The incentive spirometer goal should state how many times the incentive spirometer is to be used each hour, as well as the volume.

2 3

This is incorrect. The walking goal should state how far the patient should walk. This is correct. Outcome statements should have specific performance criteria and a target time; “maintain oxygen saturation” is the only one that meets those criteria. This is incorrect. In the range-of-motion goal, tolerate is a vague word and is difficult to measure, and the outcome needs to specify how often.

PTS: 1 CON: Patient-Centered Care 6. ANS: 3 Chapter: Chapter 5 Planning Outcomes Objective: Define the following terms: goal, outcome, expected outcome, and nursing-sensitive outcome. Page: 86 (V1) Heading: Planning Patient Goals/Outcomes Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is incorrect. Asking the patient about oral fluid preferences is an intervention developed to improve the patient’s dehydration. This is not a nursesensitive goal. 2 This is incorrect. Maintaining a full pitcher of water at the patient’s bedside is an intervention aimed at promoting fluid intake. This is not a nurse-sensitive goal. 3 This is correct. The nurse-sensitive goal states a measurable action to be carried out in a specific manner. 4 This is incorrect. Keeping the patient on strict I&O monitoring is a collaborative intervention, and not a nurse-sensitive goal. It is likely the physician will order I&O monitoring for a dehydrated patient, which is maintained by nursing. PTS: 1 CON: Patient-Centered Care 7. ANS: 2 Chapter: Chapter 5 Planning Outcomes Objective: Describe the information contained in a comprehensive patient care plan. Page: 81 (V1) Heading: What Information Does a Comprehensive Patient Care Plan Contain? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Moderate

1 2

3 4

Feedback This is incorrect. A comprehensive patient plan of care does not include methods for performing ADLs. This is correct. When developing a comprehensive patient plan of care, the nurse will include both medical and nursing interventions. An example of a medical intervention carried out by nursing is administration of pain medication. This is incorrect. A comprehensive patient plan of care does not contain reasons for assigning care personnel. This is incorrect. A comprehensive patient plan of care does not specifically include the symptoms of the patient’s medical diagnosis.

PTS: 1 CON: Patient-Centered Care 8. ANS: 1 Chapter: Chapter 5 Planning Outcomes Objective: Differentiate between short-term and long-term goals. Page: 87 (V1) Heading: How Do I Distinguish Between Short-Term and Long-Term Goals? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is correct. Short-term goals may be accomplished in hours or a few days; long-term goals usually are achieved over weeks, months, or even years. 2 This is incorrect. Both short-term and long-term goals flow from the problem side of the nursing diagnosis. 3 This is incorrect. Both short-term and long-term goals must have target times with dates. 4 This is incorrect. Both short-term and long-term goals specify desired patient responses to interventions. PTS: 1 CON: Patient-Centered Care 9. ANS: 1 Chapter: Chapter 5 Planning Outcomes Objective: Differentiate between essential and nonessential goals. Page: 88 (V1) Heading: Planning Patient Goals/Outcomes Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care

Difficulty: Moderate Feedback 1 This is correct. Goals/outcomes are a measure of the effectiveness of nursing care for a specific nursing diagnosis by recognition of desirable changes related to the formulated interventions. 2 This is incorrect. Goals/outcomes describe changes in the patient’s health status in response to nursing interventions, rather than medical interventions. 3 This is incorrect. Goals/outcomes relate to patient behavior, not nursing behaviors. 4 This is incorrect. Goals/outcomes are not used to evaluate the appropriateness of a nursing diagnosis. PTS: 1 CON: Patient-Centered Care 10. ANS: 4 Chapter: Chapter 5 Planning Outcomes Objective: Write appropriate goals for actual, risk, and possible nursing diagnoses. Page: 87 (V1) Heading: Performance Criteria Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Use of the term “frequently” is a vague description and does not accurately reflect the patient’s performance. 2 This is incorrect. It is not possible for the nurse to physically assess a patient’s understanding unless the evaluation is made on actual performance; the option does not support an observation. 3 This is incorrect. “Decreased” is vague; a numerical pain rating would be better. 4 This is correct. Performance criteria should be specific and measurable. “75% of each meal” is specific and measurable. PTS: 1 CON: Patient-Centered Care 11. ANS: 3 Chapter: Chapter 5 Planning Outcomes Objective: Define the following terms: goal, outcome, expected outcome, and nursing-sensitive outcome. Page: 81 (V1) Heading: Goals for Collaborative Problems Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care

Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Other disciplines may be involved in helping to prevent the problem, but nurses still monitor for the complication. 2 This is incorrect. The outcomes to collaborative problems are not affected by nursing interventions alone. 3 This is correct. The goal for a collaborative problem always is that the complication will not occur. 4 This is incorrect. Goals for collaborative problems are specific to the medical condition/treatment. PTS: 1 CON: Patient-Centered Care 12. ANS: 1 Chapter: Chapter 5 Planning Outcomes Objective: Use standardized terminology to state patient goals. Page: 37 (V2) Heading: How Do I Use Standardized Terminology for Outcomes? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is correct. Both NANDA-I and NOC labels are stated as human responses. 2 This is incorrect. A NOC label can be used to describe patient responses both before and after intervention—NANDA-I can be used before an intervention. 3 This is incorrect. NOC statements are neutral to allow for positive, negative, or no change in health status; NANDA-I diagnoses describe both problem responses and positive responses (wellness labels). 4 This is incorrect. NANDA-I labels are based on patterns of related cues; NOC labels are based on (linked to) NANDA-I labels. PTS: 1 CON: Patient-Centered Care 13. ANS: 2 Chapter: Chapter 5 Planning Outcomes Objective: Differentiate between essential and nonessential goals. Page: 88 (V1) Heading: Planning Patient Goals/Outcomes Integrated Processes: Nursing Process Client need: Safe and Effective Care Environment: Management of Care

Cognitive level: Analysis [Analyzing] [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

1 2

3 4

Feedback This is incorrect. The other goals in this question address the etiology (cause) of the diagnosis, such as the effects of medication on memory. This is correct. An essential goal is aimed at the problem response—in this case, Impaired Memory. The essential goal/outcome is “Demonstrates use of techniques to help with memory loss.” This is incorrect. The other goals in this question address the etiology (cause) of the diagnosis, such as the effect of inadequate fluid intake on memory. This is incorrect. The other goals in this question address the etiology (cause) of the diagnosis, such as the administration of supplemental electrolytes to improve memory. The other goals in this question address the etiology (cause) of the diagnosis.

PTS: 1 CON: Patient-Centered Care 14. ANS: 2 Chapter: Chapter 5 Planning Outcomes Objective: Describe formal, informal, initial, ongoing, and discharge planning. Page: 37 (V2) Heading: What Is Planning? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Formal planning results in a holistic plan of care and addresses the client’s unique problems and strengths. 2 This is correct. Informal planning is performed while doing other nursing process steps and is not written; this nurse is forming a plan in her mind. This nurse has no time to create a holistic plan of care. 3 This is incorrect. Ongoing planning refers to changes made in the plan as the nurse evaluates the client’s responses to care; no care has been given at this point. 4 This is incorrect. Initial planning does, indeed, begin with the first client contact. However, it refers to the development of the initial comprehensive plan of care; this nurse does not have enough data for a comprehensive plan or the time to make such a plan at the moment.

PTS:

CON: Patient-Centered Care

MULTIPLE RESPONSE 15. ANS: 1, 4, 5 Chapter: Chapter 5 Planning Outcomes Objective: Describe the information contained in a comprehensive patient care plan. Page: 87 (V1) Heading: BOX 5-1: American Nurses Association Standards of Nursing Practice for Outcomes and Planning Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

1. 2. 3. 4. 5.

Feedback This is correct. The ANA standard states: “Formulates culturally appropriate outcomes ….” for the patient from the diagnosis. This is incorrect. It is acceptable for the nurse to use outcomes on a clinical pathway, but these are not individualized. This is incorrect. The ANA standard states that the nurse should consider “associated risks, benefits, and costs ….” This is correct. ANA standard states: “Involves the healthcare consumer, family …. in formulating expected outcomes ….” This is correct. The nurse will consider culture, values, and ethical considerations according to the ANA standards.

PTS: 1 CON: Patient-Centered Care 16. ANS: 1 Chapter: Chapter 5 Planning Outcomes Objective: Identify patients who need a comprehensive, formal discharge plan. Page: 81 (V1) Heading: Discharge Planning Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

Feedback This is correct. When a client is being discharged to an extended care facility, a

comprehensive discharge plan needs to include interventions for maintaining interagency communication. This is incorrect. When planning a comprehensive discharge plan for a client to an extended care facility, the nurse in acute care does not need to determine the level of family involvement. The extended care facility will make this determination, which is likely to change from the involvement in an acute care setting. This is incorrect. When planning a comprehensive discharge plan for a client to an extended care facility, the nurse in acute care does not share information about the client’s financial status. Financial information will be obtained by the extended care facility. This is incorrect. The extended care facility will conduct a detailed admission assessment to determine the activities needed to maintain the client’s functional ability. This is incorrect. The level of care is different in an extended care facility when compared to an acute care facility. The extended care facility will conduct a detailed admission assessment to determine the client’s self-care needs.

PTS: 1 CON: Patient-Centered Care 17. ANS: 1, 2, 3, 4, 5 Chapter: Chapter 5 Planning Outcomes Objective: Explain the importance of a written plan of care. Page: 78 (V1) Heading: Why Is a Written Patient Care Plan Important? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

1. 2.

Feedback This is correct. A patient’s plan of care is used to ensure the patient is provided complete care based on the patient’s individual and unique needs and/or problems. This is correct. A patient’s plan of care is key in supporting continuity among nurses and between shifts. Without a plan of care, there is a possibility of a patient’s needs and/or problems not being addressed. This is correct. When nurses know what is to be done to meet a patient’s needs and problems, nurses are able to more efficiently apply their efforts and complete the care activities. This is correct. With an existing plan of care, nurses have written guidelines for assessment and documentation. Therefore, provided care is focused on patient needs and problems and validated by the plan of care for documentation. This is correct. In effort to manage the effectiveness and cost for healthcare delivery,

accrediting agencies focus on the process of planning patient care. Therefore, nursing can validate what is done for the patient, the reasons, and the results of the care. PTS: 1 CON: Patient-Centered Care 18. ANS: 3, 5 Chapter: Chapter 5 Planning Outcomes Objective: Discuss the advantages and disadvantages of computerized care planning. Page: 83 (V1) Heading: Computer Plans of Care Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

3. 4.

Feedback This is incorrect. When using computer-generated plans of care, the computer stores standardized plans (e.g., for nursing diagnoses, medical diagnoses, or Medicare Severity Diagnosis Related Groups [MS-DRGs]). However, individualized interventions are not generated. This is incorrect. The computer does not generate a diagnosis and desired outcome after the patient’s assessment is entered. When the nurse enters a diagnosis or a desired outcome, the computer generates a list of suggested interventions. This is correct. The nurse individualizes interventions by choosing from computergenerated checklists or by entering the nurse’s own interventions and strategies. This is incorrect. Previously, nurses felt that because computerized planning required constant use of a step-by-step thinking process (linear thinking), it could stifle nursing intuition, insight, or expertise. Nurses are encouraged to look for creative approaches that might be more effective for a particular individual. This is correct. Computer prompts help ensure that the nurse considers a variety of actions and keeps the nurse from overlooking common and important interventions.

PTS: 1 CON: Patient-Centered Care 19. ANS: 1, 2, 4 Chapter: Chapter 5 Planning Outcomes Objective: Differentiate between short-term and long-term goals. Page: 86 (V1) Heading: How Do I Distinguish Between Short-Term and Long-Term Goals? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing]

Concept: Patient-Centered Care Difficulty: Difficult

1. 2. 3.

4. 5.

Feedback This is correct. A goal that sets ambulation criteria based on distance of 10 feet at a time frame of 5 hours after surgery is a short-term goal. This is correct. A goal which states that the patient will be able to exhibit the use of a walker when ambulating is a short-term goal. This is incorrect. It is unlikely the patient will experience wound infection while in acute care; therefore, the recognition of infection is important after discharge. This is a long-term goal. This is correct. The ability of a patient to express a pain level of 4 or below on a 0to-10 scale is an example of a short-term goal. This is incorrect. When a patient expresses understanding about pain management at home, the feedback involves a long-term goal.

PTS: 1 CON: Patient-Centered Care 20. ANS: 2, 3, 4 Chapter: Chapter 5 Planning Outcomes Objective: Describe formal, informal, initial, ongoing, and discharge planning. Page: 86 (V1) Heading: Initial and Ongoing Planning Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

1. 2.

Feedback This is incorrect. The patient’s ability of completing daily hygiene activities without assistance does not indicate a need for ongoing planning. This is correct. If a patient consumes only 25% of the daily diet because of reports of nausea, ongoing planning is needed. Ongoing planning may include collaborative interventions for nausea management and/or dietary options. This is correct. When a patient is unable to complete a task needed after discharge, ongoing planning is needed. Ongoing planning may include written instructions or the involvement of a family member or home nursing care. This is correct. If a patient is unable to reach a goal of any type, the nurse needs to utilize ongoing planning. If the patient cannot walk 25 feet by the second day, it may be necessary to change the expectation to 10 feet two to three times a day. This is incorrect. The effective management of pain is not an indicator of ongoing planning.

PTS:

CON: Patient-Centered Care

Chapter 6. Planning Interventions Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse works in an acute care setting as a patient educator for patients newly diagnosed with diabetes mellitus. Which nursing intervention by this nurse is an indirect-care intervention? 1. Providing emotional support to patients 2. Conducting classes for teaching diet management 3. Requesting classroom furniture for adult patients 4. Recommending medical care for diabetic ulcers 2. A nurse makes a nursing diagnosis of Acute Pain related to the postoperative abdominal incision. The nurse writes a nursing order to reposition the client in a comfortable position by using pillows to splint or support the painful areas. Which type of nursing intervention did the nurse write? 1. Collaborative 2. Interdependent 3. Dependent 4. Independent 3. The nurse is performing preoperative teaching for a client who is scheduled for surgery in the morning. The client does not at present have any respiratory problems. The nurse’s teaching plan includes coughing and deep-breathing exercises. Which type of nursing intervention is the nurse performing? 1. Health promotion 2. Treatment 3. Prevention 4. Assessment 4. An adult patient returns to the medical-surgical unit after undergoing abdominal surgery for colon cancer. Which is an appropriate, correctly written nursing order for this patient? 1. (Date) Encourage use of the incentive spirometer every hour while the client is awake. (Nurse’s Signature) 2. (Date) Uses incentive spirometer 10 times every hour while awake to 1,000 mL. (Nurse’s Signature) 3. (Date) Incentive spirometer hourly while awake. 4. Offer incentive spirometer to the client. 5. A client newly diagnosed with diabetes mellitus is admitted to the hospital because of poorly controlled glucose levels. Which action by the nurse is an appropriate direct-care intervention for this client during the client’s hospitalization? 1. Consulting the diabetic nurse educator for help with a teaching plan 2. Making arrangements for the client to join a diabetic support group 3. Demonstrating blood glucose monitoring and insulin administration to the client

4. Consulting with the dietician about the client’s dietary concerns 6. The nurse is gathering data on a patient who is admitted. During the admission process, the nurse notices constant throat clearing behaviors by the patient. Which intervention does the nurse implement if viewing the patient’s behavior from a physiological viewpoint? 1. Ask the patient to explain the noted behavior. 2. Seek a prescription for a bedside humidifier. 3. Administer prescribed pain medication. 4. Inquire about the patient’s anxiety level. 7. A client is admitted to the hospital with an acute respiratory problem resulting from lung disease. The nurse makes a diagnosis of Ineffective Breathing Pattern related to inability to maintain adequate rate and depth of respirations. Which nursing intervention should be listed first on the care plan? 1. Determine airway adequacy hourly and as needed. 2. Administer prescribed oxygen therapy, as needed. 3. Monitor and report arterial blood gas values. 4. Place the client in the high Fowler’s position. 8. The nurse is developing a plan of care for a client at an adult wellness clinic. Which primary decision maker does the nurse recognize when caring for healthy adult clients? 1. Provider 2. Family 3. Client 4. Nurse 9. A client is admitted to the hospital with an acute episode of chronic obstructive pulmonary (lung) disease. The nurse makes a diagnosis of Ineffective Breathing Pattern related to inability to maintain adequate rate and depth of respirations and has recorded the diagnosis and appropriate goals on the care plan. When selecting nursing interventions, which nursing action does the nurse do first? 1. Identify several interventions likely to achieve the desired outcomes. 2. Review the problem and etiology of the nursing diagnosis. 3. Choose the best interventions for the patient. 4. Review the goals written by the nurse. 10. The nurse is using electronic care planning. The nurse enters the patient’s nursing diagnosis into the computer, selects desired outcomes, and validates the patient data, diagnosis, and goals. When considering the list of program generated interventions, the nurse identifies none of them fits this patient’s individual needs. Which action does the nurse take? 1. Reject them all, and enter self-generated appropriate interventions. 2. Select the most suitable interventions from the program. 3. Ask another nurse to assess the patient, and give a recommendation. 4. Restart the computer to eliminate the possibility of a program malfunction.

11. The nurse is completing a plan of care for a patient with congestive heart failure. Which direct-care nursing intervention does the nurse perform? 1. Collaborate with the physician for further medication orders. 2. Instruct the patient about low-sodium and low-fat diets. 3. Refer the patient to cardiac rehabilitation for a home-care program. 4. Consult with physical therapist for cardiac rehabilitation exercises. 12. The nurse works in an acute healthcare facility on a unit where patients with chronic health problems frequently return for treatment and management. The nurses are expected to use evidence-based practice (EBP) for the determination of best care. Which action by a nurse reflects understanding about EBP? 1. The nurse submits compiled research to nursing administration. 2. The nurse conducts a systematic review of published research. 3. The nurse informs the patient care is based on research evidence. 4. The nurse only uses research that reflects the patient’s condition. 13. The nurse is providing care for an adult smoker hospitalized on a medical-surgical unit. The patient states, “I’d really like some help in quitting smoking.” As part of the nurse’s intervention plan, a smoking cessation class is included. Which type of intervention is the nurse performing? 1. Wellness 2. Prevention 3. Assessment 4. Treatment 14. Which is the best example of a well-written nursing order? 1. Provide emotional support to patient and family, as needed. 2. Assist with performance of personal hygiene, if necessary. 3. Follow prescribed fluid restriction of 1,500 mL per day. 4. Insert urinary catheter if patient has not voided within 8 hours. 15. The quality assurance team is reviewing nursing documentation for quality and correctness. Which is the best example of a well-written nursing order? 1. Administer pain medication 30 minutes prior to physical therapy exercises. 2. Teach patient how to self-administer insulin injections prior to discharge. 3. The nurse will assess vital signs and report changes, as needed. 4. Consider patient and family cultural preferences in diet order. 16. The nurse is providing care for a patient in the end stages of a terminal disease. Against the patient’s family’s wishes, the patient makes the decision for comfort care only. Medical prescriptions are obtained from the attending physician. Which individualized nursing order represents an appropriate nursing intervention? 1. Prescribed pain medication will be administered, as needed. 2. Printed materials are given to patient’s family about patient rights. 3. Visitors are asked to support the patient’s decisions for the type of care. 4. Pain assessed hourly for levels above patient’s acceptable level of 5.

Multiple Response Identify one or more choices that best complete the statement or answer the question. 17. The nurse recognizes which statement(s) about nursing interventions as being true? Select all that apply. 1. Writing of nursing orders cannot be delegated to the licensed practical nurse/licensed vocational nurse (LPN/LVN). 2. The best nursing interventions are based on traditional care. 3. Nursing interventions are individualized and culturally sensitive. 4. Standardized nursing interventions improve care for a specific client. 5. Evidence-based practice (EBP) must always be used for nursing interventions. 18. The nurse completes the plan of care for a patient with a medical diagnosis of Gall Bladder Disease. Which consideration will the nurse use when selecting nursing interventions to best help the patient achieve desired outcomes? Select all that apply. 1. Age of the patient 2. Patient abilities and preferences 3. Education levels of the nursing staff 4. Medical orders 5. General health status 19. The nurse is selecting nursing interventions for a patient with diabetes mellitus. Which available resources does the nurse use to assist in the selection of interventions? Select all that apply. 1. A computer-generated list of standardized interventions 2. Self-generated interventions based on knowledge and experience 3. Traditional interventions that seem to have worked in the past 4. Only those interventions that agree with patient preferences 5. Suggested interventions from the facility policy and procedures 20. The nurse is aware of which descriptions being best related to the primary goal(s) of evidencebased practice (EBP)? Select all that apply. 1. Presents the most effective treatments 2. Identifies the most cost-effective treatments 3. Includes all patient and family preferences 4. Creates standardized facility clinical pathways 5. Adds more studies to support an intervention 21. The nurse finishes developing the nursing interventions for a patient. Which questions does the nurse ask mentally after the development and before the implementation of nursing interventions? Select all that apply. 1. Do I possess the skills and knowledge to carry out the interventions? 2. Will any of the interventions interfere with medical prescriptions? 3. Have I explained the intervention enough to obtain patient support?

4. Does administration support expenses associated with the intervention? 5. What consequences might occur from performance of this intervention? Completion Complete each statement. 22. Nurses use a five-step process in selecting the best nursing interventions for their patients. Using the five-step process, arrange the option numbers in the correct order of completion. (Enter the number of each step in the proper sequence; do not use commas.) A. Review the desired outcomes/goals. B. Identify several actions or interventions. C. Individualize standardized interventions. D. Review the nursing diagnosis.

E. Choose the best interventions for the patient.

Chapter 6. Planning Interventions Answer Section MULTIPLE CHOICE 1. ANS: 3 Chapter: Chapter 6 Planning Interventions Objective: Define the term nursing intervention. Page: 95 (V1) Heading: What Are Nursing Interventions? Integrated Processes: Nursing Process Client Need: Safe and Effective Care: Environment Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Emotional support provided to patients is an example of a direct-care intervention. 2 This is incorrect. Conducting classes for patient teaching is an example of a direct-care intervention. 3 This is correct. An indirect-care intervention is an activity performed away from the client on behalf of the client. Indirect-care interventions include consulting with other healthcare team members, making referrals, advocating, and managing the environment. 4 This is incorrect. Recommending medical care to a patient is an example of a collaborative care intervention. PTS: 1 CON: Patient-Centered Care 2. ANS: 4 Chapter: Chapter 6 Planning Interventions Objective: Compare and contrast independent, dependent, and interdependent (collaborative) nursing interventions. Page: 95 (V1) Heading: What Are Nursing Interventions? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. A collaborative or interdependent intervention is one that is

2 3

carried out in collaboration with other health team members, such as providing the client with a sodium-restricted diet. This is incorrect. Collaborative and interdependent interventions are one and the same. The terminology is interchangeable. This is incorrect. A dependent intervention is prescribed by a physician or advanced practice nurse, for example, “Administer oxygen at 2 L/min via nasal cannula.” This is correct. Writing an order to reposition the client in a comfortable position is an example of an independent nursing intervention, one that does not require a physician’s order. The nurse is licensed to prescribe, perform, or delegate the intervention based on the nurse’s knowledge and skills.

PTS: 1 CON: Patient-Centered Care 3. ANS: 3 Chapter: Chapter 6 Planning Interventions Objective: Explain how nursing interventions are determined by problem status (i.e., as actual or potential problems). Page: 98 (V1) Heading: How Does Problem Status Influence Nursing Interventions? Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Health promotion interventions promote a client’s efforts to achieve a higher level of wellness. 2 This is incorrect. Treatment interventions treat disorders, relieve symptoms, and carry out medical orders. 3 This is correct. The nurse is teaching the client coughing and deep-breathing exercises, which help prevent postoperative pneumonia. Therefore, the nurse is employing a prevention intervention. Prevention interventions are used to help prevent complications, such as postoperative pneumonia. 4 This is incorrect. Assessment interventions detect changes in the client’s condition and detect potential problems. PTS: 1 CON: Patient-Centered Care 4. ANS: 1 Chapter: Chapter 6 Planning Interventions Objective: Write complete, detailed nursing orders, in the correct format, for patients. Page: 105 (V1) Heading: Reflecting Critically About Nursing Orders

Integrated Processes: Nursing Process Client Need: Physical Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is correct. The option beginning with a date and ending with the registered nurse’s (RN’s) signature contains necessary information. It contains the date the order was written along with specific instructions written in terms of nursing behavior for the nurse. 2 This is incorrect. “Uses incentive spirometer 10 times ….” is an example of an expected outcome. The documentation should have a date and nurse’s signature. 3 This is incorrect. “Incentive spirometer hourly ….” is an example of a medical order. In this case, the nurse’s signature is missing. 4 This is incorrect. “Offer incentive spirometer ….” does not provide the nurse with enough detailed instruction. Therefore, it is a poorly written nursing order. PTS: 1 CON: Patient-Centered Care 5. ANS: 3 Chapter: Chapter 6 Planning Interventions Objective: Define the term nursing intervention. Page: 94 (V1) Heading: What Are Nursing Interventions? Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is incorrect. Indirect-care activities include consulting the diabetic nurse educator. Indirect-care activities are performed away from the client but on behalf of the client. 2 This is incorrect. Making arrangements for the client to join a diabetic support group is an indirect-care activity. Indirect-care activities are performed away from the client but on behalf of the client. 3 This is correct. Demonstrating blood glucose monitoring and insulin administration is an appropriate direct-care intervention for this client. Directcare interventions are performed through intervention with the client and include interventions such as physical care, emotional support, and client teaching. 4 This is incorrect. Consulting with the dietitian about the client’s dietary concerns is an example of an indirect-care activity. Indirect-care activities are performed away from the client but on behalf of the client.

PTS: 1 CON: Patient-Centered Care 6. ANS: 1 Chapter: Chapter 6 Planning Interventions Objective: Explain how theories, research, and evidence-based practice influence the choice of nursing interventions. Page: 96 (V1) Heading: How Do Theories Influence My Choice of Interventions? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate

1 2

3 4

Feedback This is correct. The nurse needs to determine the cause of the patient’s behavior before deciding on a theory appropriate for planning care interventions. This is incorrect. The patient may benefit from the use of a bedside humidifier if the throat clearing is related to dryness or pain. However, the nurse first needs to determine the cause of the patient’s behavior is physiological. This is incorrect. The patient may or may not be experiencing pain. The nurse needs to first determine if the cause of the patient’s behavior is physiological. This is incorrect. Determining the level of the patient’s anxiety is applying a psychological theory; the question specifically asks about the use of physiological theory.

PTS: 1 CON: Patient-Centered Care 7. ANS: 1 Chapter: Chapter 6 Planning Interventions Objective: Explain how nursing interventions are determined by problem status (i.e., as actual or potential problems). Page: 95 (V1) Heading: What Are Nursing Interventions? Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

Feedback This is correct. For any acute respiratory problem, prior to implementing interventions, the nurse would assess the breathing status of the patient by

2 3 4

checking the respiratory rate and depth. When devising a plan of care for the client, nursing interventions should be listed according to priority. Airway always takes precedence because ventilation, oxygenation, and positioning will be ineffective without a patent airway. This is incorrect. Administering oxygen is ineffective without a patient airway. This is incorrect. Monitoring and reporting arterial blood gas values are important, but the priority is the presence of a patent airway. This is incorrect. Positioning is ineffective if the patient’s airway is compromised. However, if the airway is patent, positioning is used to promote effective respiratory function and gas exchange.

PTS: 1 CON: Patient-Centered Care 8. ANS: 3 Chapter: Chapter 6 Planning Interventions Objective: Compare and contrast independent, dependent, and interdependent (collaborative) nursing interventions. Page: 100 (V1) Heading: What Process Can I Use for Generating and Selecting Interventions? Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Easy Feedback 1 This is incorrect. The provider plays a role in health promotion and screening. 2 This is incorrect. The family may give input, but the client is the decision maker. 3 This is correct. The client is the primary decision maker in the care of healthy clients. 4 This is incorrect. The nurse functions as a teacher and health counselor. PTS: 1 CON: Patient-Centered Care 9. ANS: 2 Chapter: Chapter 6 Planning Interventions Objective: Explain how nursing interventions are determined by problem status (i.e., as actual or potential problems). Page: 95 (V1) Heading: What Are Nursing Interventions? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate

2 3 4

Feedback This is incorrect. After reviewing the nursing diagnosis and etiology, the nurse will identify several interventions or actions aimed at achieving the desired outcomes. This is correct. The process of choosing interventions is first to review the nursing diagnosis and etiology; then review the desired outcomes. This is incorrect. The nurse always needs to consider which interventions will meet the needs of unique characteristics of the patient. This is incorrect. Reviewing selected goals is important, but it is not the first action when the nurse is selecting nursing interventions.

PTS: 1 CON: Patient-Centered Care 10. ANS: 1 Chapter: Chapter 6 Planning Interventions Objective: Explain how theories, research, and evidence-based practice influence the choice of nursing interventions. Page: 100 (V1) Heading: What Process Can I Use for Generating and Selecting Interventions? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

Feedback This is correct. The nurse can reject all the suggested computer-generated interventions if patient needs are not addressed. Nearly all computer programs have an option allowing the nurse to self-generate interventions and nursing orders. This is incorrect. It is the nurse’s responsibility to select computer-generated interventions if appropriate, or reject them if necessary. The nurse has already validated the data, nursing diagnosis, and goals, and should feel reasonably certain there is nothing wrong with the plan to that point. This is incorrect. Although consultation with other nurses may be a wise and prudent step to take at times, the nurse caring for the patient would likely have the most familiarity with the patient’s healthcare needs and is in a better position to make sound judgments than another nurse who does not know the patient. This is incorrect. Unless there is an identifiable problem with the computer program, it is not an efficient decision to restart the computer for a possibility of program malfunction. PTS:

CON: Patient-Centered Care

11. ANS: 2 Chapter: Chapter 6 Planning Interventions Objective: Define the term nursing intervention. Page: 95 (V1) Heading: What Are Nursing Interventions? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. An indirect-care intervention is an activity performed away from the client on behalf of the client. Indirect-care interventions include consulting and collaborating with other healthcare team members. 2 This is correct. Direct-care interventions are performed through interactions by the nurse with the client. Examples are physical care, emotional support, and teaching. 3 This is incorrect. An indirect-care intervention is an activity performed away from the client on behalf of the client. Indirect-care interventions include making referrals, and advocating for the patient. 4 This is incorrect. An indirect-care intervention is an activity performed away from the client on behalf of the client. Indirect-care interventions include managing the environment. PTS: 1 CON: Patient-Centered Care 12. ANS: 2 Chapter: Chapter 6 Planning Interventions Objective: Explain how theories, research, and evidence-based practice influence the choice of nursing interventions. Page: 97 (V1) Heading: What Is Evidence-Based Practice? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is incorrect. The nurse may or may not submit compiled research to nursing administration; this is an important action if EBP research supports a change in nursing policy and/or procedures. There is not enough information in the scenario to make this determination. 2 This is correct. Whenever EBP is used, the nurse conducts a systematic review

of published research. The research may cover a broad topic or a narrow topic of specific concern. This is incorrect. The nurse may make a decision to implement EBP interventions for the patient’s care; however, the patient retains the right to participate in care decisions. Informing the patient about the use of EBP is not necessarily needed. This is incorrect. The nurse may or may not only use research that reflects the patient’s condition. The determination about the spectrum of research is driven by the scope of the question; some are very specific, and some are very broad.

PTS: 1 CON: Patient-Centered Care 13. ANS: 1 Chapter: Chapter 6 Planning Interventions Objective: Give one example of a standardized wellness (health promotion) intervention and one individualized nursing order for performing that intervention. Page: 104 (V1) Heading: Wellness Interventions Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Moderate

2 3 4

Feedback This is correct. A smoking cessation class is an example of a health promotion or wellness intervention to promote a patient’s efforts to achieve a higher level of wellness. This is incorrect. Prevention interventions are used to prevent disorders or complications. This is incorrect. Assessment interventions detect changes in the client’s condition and detect potential problems. This is incorrect. Treatment interventions treat disorders, relieve symptoms, and carry out medical orders.

PTS: 1 CON: Patient-Centered Care 14. ANS: 4 Chapter: Chapter 6 Planning Interventions Objective: Write complete, detailed nursing orders, in the correct format, for patients. Page: 103 (V1) Heading: How Can I Use Standardized Language to Plan Interventions? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care

Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. The provision of emotional support to patient and family, as needed, does not provide enough direction and information for the nurse because it is vague and nonspecific. 2 This is incorrect. Directions to assist with the performance of personal hygiene, if necessary, do not provide enough direction and information for the nurse. It is vague and nonspecific. 3 This is incorrect. Instructions to follow prescribed fluid restrictions of 1500 mL per day do not provide enough direction and information for the nurse; it is vague and nonspecific. Fluid restrictions need to include guidelines about allotted fluid amounts throughout the day. 4 This is correct. A well-written nursing order includes date, subject, action verb, time and limits, and a signature. The best example is the nursing order to insert a urinary catheter if the patient has not voided in 8 hours. PTS: 1 CON: Patient-Centered Care 15. ANS: 1 Chapter: Chapter 6 Planning Interventions Objective: Write complete, detailed nursing orders, in correct format, for patients. Page: 103 (V1) Heading: How Can I Use Standardized Language to Plan Interventions? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is correct. A well-written nursing order includes date, subject, action verb, time frame, limits, and a signature. The best example is the nursing order to administer pain medications within 30 minutes prior to physical therapy. This example provides the most information and direction for the nurse as it contains the subject, action verb, time frame, and limits. The remaining options do not provide enough direction and information for the nurse as they are vague and nonspecific. 2 This is incorrect. This nursing order does not provide enough direction and information for the nurse because it is vague and nonspecific. 3 This is incorrect. This is not the best nursing order because it is vague and nonspecific. 4 This is incorrect. Considering a patient’s and family’s cultural preferences in

diet order does not contain specific information; this is a poorly written nursing order due to a lack of clear and specific information. PTS: 1 CON: Patient-Centered Care 16. ANS: 4 Chapter: Chapter 6 Planning Interventions Objective: Give one example of a standardized spirituality intervention and one individualized nursing order for performing that intervention. Page: 100 (V1) Heading: What Process Can I Use for Generating and Selecting Interventions? Integrated Processes: Culture and Spirituality Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate

1 2

3 4

Feedback This is incorrect. Administering prescribed medication, as needed, is a collaborative intervention. In addition, a specific timeframe is not included. This is incorrect. The patient’s family may or may not need printed materials about patient rights. The more appropriate nursing intervention is patient centered. This is incorrect. Developing a nursing intervention about how the nurse is to interact or manage visitors is neither appropriate nor necessary. This is correct. The nursing intervention covers the criteria for an appropriate nursing intervention. The intervention is patient based and utilizes the patient’s specific wishes of being medicated for pain level above 5. There is a specific action of assessment with a specific timeframe of hourly assessment. PTS:

CON: Patient-Centered Care

MULTIPLE RESPONSE 17. ANS: 1, 3 Chapter: Chapter 6 Planning Interventions Objective: Define the term nursing intervention. Page: 100 (V1) Heading: What Process Can I Use for Generating and Selecting Interventions? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care

Difficulty: Difficult

2. 3. 4. 5.

Feedback This is correct. Some nursing interventions and activities can be delegated to the LPN/LVN or nursing assistive personnel (NAP); however, writing nursing orders is the responsibility of the registered nurse. This is incorrect. Whenever possible, nursing interventions should be based on scientific evidence, not tradition. This is correct. Nursing interventions should always be individualized and culturally sensitive. This is incorrect. Standardized interventions are not customized to improve care for a specific client. This is incorrect. Whenever necessary or possible, EBP can be used in the development of nursing interventions; however, it is not mandated in every incidence.

PTS: 1 CON: Patient-Centered Care 18. ANS: 1, 2, 3, 4, 5 Chapter: Chapter 6 Planning Interventions Objective: Explain how nursing interventions are determined by problem status (i.e., as actual or potential problems). Page: 96 (V1) Heading: How Do I Decide Which Interventions to Use? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

Feedback This is correct. The age of the patient is important when considering nursing interventions. Younger patients may respond to an illness and treatment completely different than an older patient. Also, age will impact the patient’s willingness and/or ability to tolerate treatment. Nursing interventions are formulated to assist the patient in achieving the desired goals. In doing so, the nurse must consider patient abilities and preferences, the education, experience, and capabilities of the nursing staff, the resources available, medical orders, and institutional policies and procedures. Therefore, all options are applicable. This is correct. A patient’s abilities and preferences strongly impact the selection of nursing interventions. A patient is not likely to be cooperative or compliant with nursing interventions that are too difficult or not acceptable to the patient. This is correct. The selection of nursing interventions is influenced by both

educational level and nursing experiences of the nursing staff. It is expected for novice nurses to seek the input from experienced nursing staff. This is correct. Nursing interventions can be dependent on or reflective of medical orders. The development of nursing interventions may involve a collaborative effort between the nurse and the physician. This is correct. The general health status of a patient will directly impact the development of nursing interventions. A debilitated patient is not likely able to respond to nursing interventions in the same manner as a healthy patient.

PTS: 1 CON: Patient-Centered Care 19. ANS: 1, 2 Chapter: Chapter 6 Planning Interventions Objective: Explain how nursing interventions are determined by problem status (i.e., as actual or potential problems). Page: 96 (V1) Heading: How Do I Decide Which Interventions to Use? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

Feedback This is correct. In selecting nursing interventions, a nurse has many resources available. One can select from a standardized list, such as the Nursing Interventions Classification (NIC), standardized care plans, agency protocols, nursing texts, journals, and other professional nurses. The nurse can also use computer-generated interventions, when available. This is correct. The nurse can self-generate a list of interventions based on the nurse’s knowledge base and experience. When possible, it is always best to select interventions based on research and scientific principle. This is incorrect. Traditional interventions can be used, but they should be interventions that are supported by research as opposed to those “seeming” to have worked. This is incorrect. Patient preferences and directions are always considered when possible; however, the nurse cannot use only those interventions based on patient direction and preference. This is incorrect. It is unlikely the facility’s policy and procedures will contain suggestions for nursing care interventions.

PTS: 1 20. ANS: 1, 2

CON: Patient-Centered Care

Chapter: Chapter 6 Planning Interventions Objective: Explain how theories, research, and evidence-based practice influence the choice of nursing interventions. Page: 97 (V1) Heading: What Is Evidence-Based Practice? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

2. 3. 4. 5.

Feedback This is correct. EBP is an approach that uses firm scientific data, rather than anecdote, tradition, intuition, or folklore, in making decisions about medical and nursing practice. In nursing, it includes blending clinical judgment and expertise with the best available research evidence and patient characteristics and preferences. This is correct. The goal of EBP is to identify the most effective and cost-effective treatments for a particular disease, condition, or problem. This is incorrect. In using EBP, the nurse considers patient preferences; however, this is not the goal of EBP. This is incorrect. The primary goal of EBP is not create facility standardized clinical pathways. This is incorrect. Implementation of EBP does not contribute studies to support an intervention. EBP is implemented through organized research.

PTS: 1 CON: Patient-Centered Care 21. ANS: 1, 2, 5 Chapter: Chapter 6 Planning Interventions Objective: Give examples of some questions for reflecting critically about nursing orders you have written. Page: 106 (V1) Heading: Reflecting Skeptically Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

Feedback This is correct. The nurse needs to ascertain if the nurse possesses the knowledge and skills needed for the intervention, or if the nurse needs to consult with someone more qualified in this area.

This is correct. The nurse needs to determine if the nursing intervention will interact with medical prescriptions. For example, the nursing intervention cannot include ambulation parameters if the physician orders bedrest for the patient. This is incorrect. While it is important to include patient wishes when creating nursing interventions, patient support is not always required. The focus of nursing interventions is to positively impact the patient. This is incorrect. The nurse always has the responsibility to determine if a nursing intervention feasible. However, administrative support of intervention expenses is not specifically a consideration when developing nursing interventions. This is correct. It is appropriate for the nurse to mentally ask about consequences associated with an intervention. The nurse also needs to determine if any potential ill effects are possible and how they will be handled.

PTS:

CON: Patient-Centered Care

COMPLETION 22. ANS: DAB E C Chapter: Chapter 6 Planning Interventions Objective: Define the term nursing intervention. Page: 100 (V1) Heading: What Process Can I Use for Generating and Selecting Interventions? Integrated Processes: Nursing Process Client Need: Patient-Centered Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate Feedback: The nursing profession uses a specific process for the development of nursing interventions. The following five-step process assists the nurse in selecting the best interventions: Review the nursing diagnosis; review the desired outcomes/goals, identify several actions or interventions; choose the best interventions for the patient; and finally, individualize standardized interventions. PTS:

CON: Patient-Centered Care

Chapter 7. Implementation & Evaluation Multiple Choice Identify the choice that best completes the statement or answers the question. 1. A psychiatrist prescribes oral aripiprazole 10 mg daily for a client with schizophrenia. This medication is unfamiliar to the nurse, who cannot find it in the hospital formulary or other references. In which manner does the nurse proceed? 1. Administer the medication as ordered. 2. Hold the medication and notify the prescriber. 3. Consult with a pharmacist before administering it. 4. Ask the patient’s registered nurse (RN) for information about the medication. 2. The nurse is providing care to a client admitted with pressure injuries. The nurse develops a plan of care focusing on healing measures and prevention of further injury. Which task does the nurse delegate to the nursing assistive personnel (NAP)? 1. Turn and reposition the patient every 2 hours. 2. Assess the patient’s skin condition. 3. Change pressure injury dressings every shift. 4. Apply hydrocolloid dressing to the pressure injury. 3. A physician prescribes an indwelling urinary catheter for a client who is mildly confused and combative. In which manner does the nurse proceed? 1. Ask a colleague for help because the nurse cannot safely perform the procedure alone. 2. Gather and prepare the equipment before informing the client about the procedure. 3. Obtain a prescription to restrain the client before inserting the urinary catheter. 4. Inform the physician the nurse cannot perform the procedure because the client is confused. 4. Before inserting a nasogastric tube, the nurse reassures the client. Reassuring the client requires which type of nursing skill? 1. Psychomotor 2. Interpersonal 3. Cognitive 4. Critical thinking 5. The nurse is providing care for a client newly diagnosed with type 2 diabetes mellitus. Which intervention by the nurse best promotes client cooperation with the treatment plan? 1. Teaching the client that weight must be lost to control blood glucose 2. Informing the client it is necessary to exercise at least three times per week 3. Explaining to the client attendance is mandatory at the diabetic clinic weekly 4. Determining the client’s main concerns about the diagnosis of diabetes

6. The nurse works in an acute care facility, which implements team nursing with each team consisting of members from various levels of healthcare provision. Which statement accurately describes delegation in the nurse’s work environment? 1. Transferring authority to perform a task to a qualified person in a selected situation 2. Collaborating with other caregivers to make decisions and plan patient care 3. Scheduling treatments and activities by coordinating with other departments 4. Implementing an appropriate planned intervention from a critical pathway 7. Which statement by the registered nurse (RN) best demonstrates clear communication to nursing assistive personnel (NAP) about a delegated task? 1. “Record the patient’s intake and output of fluids throughout the shift, please.” 2. “Take the patient’s temperature, pulse, respirations, and blood pressure every 2 hours today.” 3. “Take the patient’s temperature every 4 hours; notify me if it is greater than 100.5°F (38.1°C).” 4. “Assist the patient with all meals so that the patient’s intake of calories will increase.” 8. The nurse is delegating patient care to a nursing assistive personnel (NAP) with whom the nurse has worked before. The nurse provides exact details of which patient, what tasks, what time period, and what feedback is expected; the NAP has no questions. Which responsibility does the nurse retain after completing the delegation assignment? 1. The nurse will determine and evaluate completion of the assignment. 2. The nurse will check the NAP’s progress on the assignment every hour. 3. The nurse will immediately document the assigned tasks as being delegated. 4. The nurse periodically checks the accuracy of the NAP’s documentation. 9. The nurse is assigned to participate in a structure evaluation for an acute care facility. Which response on the nurse’s structure evaluation form indicates the nurse understood the criteria related to the task? 1. “Staff refrains from sharing computer passwords.” 2. “Healthcare provider washes hands with each client contact.” 3. “A defibrillator is present in each client care area.” 4. “Nurses verify client identification before initiating care.” 10. Which client outcome criterion does the nurse use when evaluating client behaviors that affect the client’s health status? 1. Central venous catheter site infection does not occur in 90% of cases. 2. Client will sit in the bedside chair for 20 minutes three times per day. 3. Postoperative phlebitis does not occur in 95% of surgical patients. 4. Falls in the facility will be reduced by 2% at the end of the year. 11. The nurse creates a plan of care for a patient diagnosed with severe dehydration. One nursing goal reads, “Patient will maintain urine output of at least 30 mL/hour.” Which time frame will the nurse use to collect evaluation data for this expected outcome?

1. 2. 3. 4.

At the end of the shift Every 24 hours Every 4 hours Every hour

12. The nurse receives a postsurgical patient who is prescribed to have vital signs taken every 15 minutes for 2 hours. Which type of client-centered evaluation does the nurse recognize? 1. Intermittent 2. Ongoing 3. Terminal 4. Process 13. The nurse is providing care for a patient after joint replacement surgery. The standardized care plan states, “Patient will ambulate 50 feet in the hall with a walker before discharge.” Which patient variable affecting this goal is the nurse unable to control? 1. Confusion and lethargy related to pain medication 2. Compromised respiratory function due to severe chronic obstructive pulmonary disease (COPD) 3. Reluctance to ambulate due to pain at level 7 4. Presence of a spouse who pushes the patient to rest 14. The nurse works with the respiratory therapist to administer a patient’s breathing treatments. The therapist reports the patient’s breathing status and tolerance of the treatment to the primary care provider. The nurse then discusses with the patient the options for further treatment. Which type of implementation process is being used? 1. Delegation 2. Collaboration 3. Coordination of care 4. Supervision of care 15. The nurse reviews a patient’s chart and sees a physician’s prescription for a new medication. The nurse is able to clearly read the medication name, but the dose is not legible. Which is the best action by the nurse? 1. Contact the physician for clarification. 2. Ask another nurse to read the order. 3. Ask the unit secretary to read the order. 4. Contact the pharmacist to read the order. 16. A second-year nursing student is in a clinical rotation on a medical-surgical unit. Which is the most appropriate strategy for the student to use to assist with organizing and prioritizing patient care for the day? 1. Ask the nurse what tasks need to be completed for the day. 2. Make a time-sequenced “to-do” list for care activities for the day. 3. Ask the instructor what needs to be completed for the day. 4. Ask the patient what needs to be completed for the day.

17. The nurse is providing care for a patient in an acute care facility. The nurse plans to evaluate the effectiveness of the plan of care. Which action does the nurse need to take to achieve a valid evaluation? 1. Read the documentation by the previous nurse. 2. Collect reassessment data on the patient. 3. Look at the physician’s progression notes. 4. Ask the patient’s view about each nursing goal. 18. The nurse reviews a nursing order for a patient who is 4 days postoperative after hip surgery, which reads: Assist patient in bathing each morning. The nurse assesses the patient and notes the patient demonstrates the ability to bathe independently. Which action does the nurse do next? 1. Assist with the bath, as ordered. 2. Delegate the bath to the nursing assistant. 3. Discontinue the nursing order on the plan of care. 4. Collaborate with the nurse who originally wrote the order. 19. After gathering and analyzing data and identifying patient needs, the nurse begins the implementation phase of developing a plan of care. Which is the best example of the implementation phase of the nursing process? 1. Patient verbalizes pain is reduced from 8 to 3 after receiving pain medication. 2. Nurse observes that patient has a small, quarter-sized skin tear over coccyx area. 3. Nurse writes in the care plan: Patient requires two-person assist with ambulation to bathroom. 4. Nurse inserts urinary catheter after reporting to physician the patient’s inability to void. 20. The certified nursing assistant (CNA) is feeding a patient and notices that the patient is having difficulty swallowing. The CNA reports the observation to the primary registered nurse. Which action does the nurse take first? 1. Assign the task to a more experienced can. 2. Continue patient feeding by the nurse. 3. Assess the patient, and place the patient on NPO (nothing by mouth) status. 4. Call the primary care provider. 21. Which nursing activity is most reflective of the evaluation phase of the nursing process? 1. Administering pain medication prior to changing a complex wound dressing 2. Obtaining patient’s blood pressure (BP) 30 minutes after administering BP medication 3. Reporting there have been three patient falls in the past month on the nursing unit 4. Teaching the patient how to perform daily finger-sticks for blood glucose readings Multiple Response Identify one or more choices that best complete the statement or answer the question.

22. The nurse and the nursing assistive personnel (NAP) are providing care for various clients on a medical-surgical unit. For which clients can the nurse delegate to the NAP the task of bathing? Select all that apply. 1. A 75-year-old client who is newly admitted with a diagnosis of dehydration 2. A 65-year-old client diagnosed with a stroke, whose BP is currently 189/90 mm Hg 3. A 92-year-old client with stable vital signs admitted with a urinary tract infection 4. A 56-year-old client with chronic renal failure, whose vital signs remain stable 5. An 80-year-old client who is 2 days postoperative after repair of a hernia 23. The nurse is providing care for various patients with the assistance of a licensed practical nurse/licensed vocational nurse (LPN/LVN). Which tasks does the nurse delegate to the LPN/LVN? Select all that apply. 1. Administer oral pain medications. 2. Insert an indwelling urinary catheter. 3. Perform an admission assessment on a patient. 4. Establish a new teaching plan for a patient with diabetes. 5. Call a patient’s physician to validate a new prescription. 24. The nurse is providing care for a patient after abdominal surgery and has just completed a prescribed dressing change. Which activities does the nurse perform soon after this task completed? Select all that apply. 1. Assess the patient’s response to the procedure. 2. Provide patient teaching about the procedure. 3. Document the procedure in the nursing progress notes. 4. Ask if the patient is interested in helping with the next dressing change. 5. Provide a handout about the dressing changes after discharge.

Chapter 7. Implementation & Evaluation Answer Section MULTIPLE CHOICE 1. ANS: 3 Chapter: Chapter 7 Implementation & Evaluation Objective: Describe what nurses do in the implementation phase of the nursing process. Page: 110 (V1) Heading: Check Your Knowledge and Abilities Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. Administering the medication as ordered, without knowing its expected actions and side effects, prevents adequate reassessment, and is dangerous. 2 This is incorrect. Nurse unfamiliarity with the medication is not a reason for holding the medication and delaying patient treatment. Holding the medication and notifying the prescriber prevents the client from receiving timely treatment —many drugs are less effective if a consistent schedule is not maintained. 3 This is correct. The nurse must recognize a lack of knowledge or skill needed to implement an order. It is wisest for the nurse to first consult with the pharmacist for information before administering the medication in order to ensure safe practice. 4 This is incorrect. Asking another nurse about information for a medication is also unsafe because the nurse cannot assume the other nurse has the correct knowledge. In addition, the nurse caring for the client must assess for adverse reactions to the medication. PTS: 1 CON: Patient-Centered Care 2. ANS: 1 Chapter: Chapter 7 Implementation & Evaluation Objective: Define implementation, including a description of the three broad phases (doing, delegating, recording). Page: 115 (V1) Heading: What Should I Know About Delegation and Supervision? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying]

Concept: Patient-Centered Care Difficulty: Moderate

1 2

3 4

Feedback This is correct. The nurse can delegate turning the client every 2 hours to the NAP. This is incorrect. Assessing the client’s skin condition is an intervention which requires nursing knowledge and judgment. This task cannot be delegated to the NAP. This is incorrect. Changing pressure ulcer dressings is not within the NAP’s scope of practice. This task cannot be delegated to the NAP. This is incorrect. Applying a hydrocolloid dressing to a pressure ulcer is an intervention that requires nursing knowledge and judgment. This task cannot be delegated to the NAP.

PTS: 1 CON: Patient-Centered Care 3. ANS: 1 Chapter: Chapter 7 Implementation & Evaluation Objective: List the variables that may influence the effectiveness of a nursing intervention; state which ones the nurse can or cannot control. Page: 111 (V1) Heading: Check Your Knowledge and Abilities Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Moderate Feedback 1 This is correct. Before beginning a procedure, the nurse should review the plan of care and critically evaluate the prescribed care. Because the client is confused, the nurse will ask a colleague to assist with the procedure to promote safety and prevent undue stress for the client and the nurse. 2 This is incorrect. The client should be informed about the procedure before the nurse gathers the equipment. Gathering the equipment and bringing it into the room before explaining the procedure might cause the client anxiety. 3 This is incorrect. Restraining the client should be done only as a last resort and to prevent client injury. 4 This is incorrect. Informing the physician that the procedure cannot be performed because the client is confused is inappropriate because the procedure can be performed with assistance. PTS:

CON: Safety

4. ANS: 2 Chapter: Chapter 7 Implementation & Evaluation Objective: Describe what nurses do in the implementation phase of the nursing process. Page: 112 (V1) Heading: What Knowledge and Skills Do I Need? Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Inserting the nasogastric tube requires psychomotor skills. 2 This is correct. Reassuring the client prior to a procedure is an example of interpersonal skill. 3 This is incorrect. Checking catheter placement after insertion requires cognitive and psychomotor skills. 4 This is incorrect. Assessing whether there is an indication for the nasogastric tube requires critical thinking skills. PTS: 1 CON: Patient-Centered Care 5. ANS: 4 Chapter: Chapter 7 Implementation & Evaluation Objective: List the variables that may influence the effectiveness of a nursing intervention; state which ones the nurse can or cannot control. Page: 112 (V1) Heading: How Can I Promote Client Participation and Adherence? Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate

Feedback This is incorrect. Although it is often important for a diabetic client to lose weight to control blood glucose levels, the client must want to do the suggested activity; weight is not lost simply because the client is told to do so. This is incorrect. It is often important for a diabetic client to exercise to help control blood glucose levels; however, the client will not exercise simply because the client is told to do so. Remember that knowledge does not necessarily change behavior. This is incorrect. The nurse must assess the client’s support systems and resources, not merely tell him he must come to the diabetic clinic weekly. Some

clients do not have access to transportation and, therefore, cannot come to the clinic without social service intervention. Remember that knowledge does not necessarily change behavior. This is correct. Determining the client’s main concerns promotes cooperation with the treatment regimen. For example, if the client is concerned about paying for diabetic monitoring equipment, the client may disregard any teaching about the procedure.

PTS: 1 CON: Patient-Centered Care 6. ANS: 1 Chapter: Chapter 7 Implementation & Evaluation Objective: Compare and contrast the terms delegation and supervision. Page: 114 (vol 1 ) Heading: Implementing the Plan: Doing or Delegating Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Managing Care Cognitive Level: Analyze [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is correct. Delegation is the transfer to another person of the authority to perform a task in a selected situation—the person delegating retains accountability for the outcome of the activity. 2 This is incorrect. Collaboration is described as working with other caregivers to plan, make decisions, and perform interventions. 3 This is incorrect. Coordination of care involves scheduling treatments and activities with other departments. 4 This is incorrect. Implementation is the process of performing planned interventions, which may be from a critical pathway. PTS: 1 CON: Patient-Centered Care 7. ANS: 3 Chapter: Chapter 7 Implementation & Evaluation Objective: Identify and describe the “five rights” of delegation. Page: 115 (V1) Heading: Use UAPs Appropriately Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Managing Care Cognitive Level: Analysis [Analyzing] Concept: Professionalism Difficulty: Moderate Feedback

1 2 3

This is incorrect. This option does not provide guidelines for reporting to the RN, even though the task is appropriate and has a definite timeline. This is incorrect. This option gives exact directions and a timeline; however, there are no guidelines for reporting to the RN. This is correct. Clear communication about a task (such as “Take the patient’s temperature …”) tells the NAP exactly what the task is, the specific time at which it needs to be done, and the method for reporting the results to the RN. This is incorrect. “Assisting” is a vague term with a variety of meanings, from setting up the patient’s tray to actually feeding the patient.

PTS: 1 CON: Professionalism 8. ANS: 1 Chapter: Chapter 7 Implementation & Evaluation Objective: Define implementation, including a description of the three broad phases (doing, delegating, recording). Page: 115 (V1) Heading: What Should I Know About Delegation and Supervision? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate

1 2

Feedback This is correct. Whenever the nurse delegates patient care, the nurse retains the responsibility for determining and evaluating the completion of the assignment. This is incorrect. It is likely that the nurse and NAP will communicate during the shift regarding the NAP’s assignment. However, the nurse does not need to check the progress of the NAP’s assignment hourly. If any part of the assignment has a specific timeline, it is prudent for the nurse and the NAP to acknowledge the timeline being met. This is incorrect. There is no reason for the nurse to immediately document the tasks assigned to the NAP. Correct documentation will contain information about the NAP’s provision of patient care, validated by the nurse. This is incorrect. Most facilities do not permit or expect NAPs to document information about patient care. However, the NAP may document certain information on specific flow sheets.

PTS: 1 CON: Patient-Centered Care 9. ANS: 3 Chapter: Chapter 7 Implementation & Evaluation Objective: Explain how structure, process, and outcomes evaluation are related.

Page:119 (V1) Heading: Evaluation of Structures, Processes, and Outcomes Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. “Refrains from sharing computer passwords” is a criterion associated with process evaluation. 2 This is incorrect. “Washes hands before each client contact” is a criterion associated with process evaluation. 3 This is correct. The criterion “A defibrillator is present on each client care area” is associated with structure evaluation. 4 This is incorrect. “Verifies client identification before initiating care” is a criterion associated with process evaluation. PTS: 1 CON: Safety 10. ANS: 2 Chapter: Chapter 7 Implementation & Evaluation Objective: Explain how structure, process, and outcomes evaluation are related. Page: 119 (V1) Heading: Outcomes Evaluation Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate

Feedback This is incorrect. This is an example of an organizational criterion used to evaluate the quality of care throughout an institution. The criterion also states the percentage of clients expected to have the outcome when care is satisfactory, such as maintaining infections for central venous catheters to 10% or less of the cases. This is correct. A client outcome criterion states the client health status or behaviors one wishes to achieve. “Client will sit out of bed …” is a client outcome criterion. This is incorrect. This is an example of an organizational criterion used to evaluate the quality of care throughout an institution. The criterion also states the percentage of clients expected to have the outcome when care is satisfactory, such as maintaining postoperative phlebitis to 5% or less of the surgical patients.

This is incorrect. “Decreasing the number of falls by 2% over a year” is an evaluation of quality of care in an organization. The criterion will state a percentage for measurement of the outcome.

PTS: 1 CON: Patient-Centered Care 11. ANS: 4 Chapter: Chapter 7 Implementation & Evaluation Objective: Describe a process for evaluating the effectiveness of the nursing care plan. Page: 118 (V1) Heading: How Are Standards and Criteria Used in Evaluation? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Easy Feedback 1 This is incorrect. Checking urinary output at the end of the shift does not reflect the goal of an hourly output goal. 2 This is incorrect. It is not possible to evaluate if 30 mL of urine output is present every hour by maintaining a 24-hour output. 3 This is incorrect. The amount of urine produced in a 4-hour period does not specifically address the goal of 30 mL of urine each hour. 4 This is correct. The nurse should collect evaluation data as defined in the expected outcome. For instance, in this case, the nurse would check the patient’s urine output every hour because the goal statement specifies an hourly rate (30 mL/hr). The unit of measurement in the goal guides how often the nurse would reassess the patient. PTS: 1 CON: Patient-Centered Care 12. ANS: 1 Chapter: Chapter 7 Implementation & Evaluation Objective: Distinguish among ongoing, intermittent, and terminal evaluations. Page: 119 (V1) Heading: Ongoing, Intermittent and Terminal Evaluation Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Easy Feedback 1 This is correct. Intermittent evaluation is performed at specific times; it enables the nurse to judge the progress toward goal achievement and to modify the plan

3 4

of care, as needed. This is incorrect. Ongoing evaluation is performed during implementation, immediately after an intervention, or with each client contact; these are not necessarily scheduled events. This is incorrect. Terminal evaluation is performed at the time of discharge. It describes the client’s health status and progress toward goals at that time. This is incorrect. Process evaluation focuses on the manner in which care is given. It may be performed at specific times, but it is not considered a clientcentered evaluation.

PTS: 1 CON: Patient-Centered Care 13. ANS: 2 Chapter: Chapter 7 Implementation & Evaluation Objective: List the variables that may influence the effectiveness of a nursing intervention; state which ones the nurse can or cannot control. Page: 121 (V1) Heading: Relate Outcomes to Interventions Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

Feedback This is incorrect. When confusion and lethargy from pain medication interferes with the patient’s ability to meet a plan of care goal, the nurse can take steps to correct the problem. The nurse can time ambulation part way through the peak effectiveness of the medication, or contact the physician for a medication change. This is correct. This client has a medical history with a diagnosis of severe COPD, which has a strong possibility of interfering with the patient’s ability to meet the stated goal for ambulation. The nurse has no control over improving the patient’s ability to breathe. The physician needs to be consulted for a possible change in the discharge expectation. This is incorrect. If the patient expresses reluctance to ambulate due to pain at level 7, the nurse can medicate the patient prior to walking. The nurse will need to consider the onset, peak, and duration of the pain medication for safety and the best results. This is incorrect. When a spouse is present who interferes with the patient’s recovery goals, the nurse can provide the spouse and the patient with the rationales for the goal. The nurse may also involve the spouse in the process of helping the patient reach discharge goals.

PTS: 1 CON: Patient-Centered Care 14. ANS: 2 Chapter: Chapter 7 Implementation & Evaluation Objective: Describe what nurses do in the implementation phase of the nursing process. Page: 114 (V1) Heading: What Should I Know About Collaborating and Coordinating Care? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Delegation is the transfer to another person of the authority to perform a task in a selected situation. 2 This is correct. Collaboration means working with other caregivers to plan, make decisions, and perform interventions. 3 This is incorrect. Coordination of care involves scheduling treatments and activities with other departments, putting together all the patient data to obtain “the big picture.” 4 This is incorrect. Supervision is the process of directing, guiding, and influencing the outcome of an individual’s performance of an activity or task. PTS: 1 CON: Patient-Centered Care 15. ANS: 1 Chapter: Chapter 7 Implementation & Evaluation Objective: Describe what nurses do in the implementation phase of the nursing process. Page: 111 (V1) Heading: Preparing for Implementation Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Comprehension [Understanding] Concept: Safety Difficulty: Easy Feedback 1 This is correct. The nurse is obligated ethically and legally to clarify or question prescriptions that are unclear, incorrect, or inappropriate. In this case, the nurse should contact the physician to clarify the prescription because it is not legible. 2 This is incorrect. The nurse does not rely on another nurse’s ability to read the prescription; the only action of certainty is to contact the physician. 3 This is incorrect. The nurse does not rely on the unit secretary’s ability to read the physician’s prescription; the physician has the responsibility to keep

prescriptions legible. This is incorrect. The nurse does not contact the pharmacist to read the physician’s prescription. The nurse must contact the physician for clarification.

PTS: 1 CON: Patient-Centered Care 16. ANS: 2 Chapter: Chapter 7 Implementation & Evaluation Objective: Describe what nurses do in the implementation phase of the nursing process. Page: 111 (V1) Heading: Organize Your Work Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate

Feedback This is incorrect. Nurses provide care for more than one patient on each shift, and most nurses recognize the importance of making a time-sequenced work plan or work sheet to prioritize patient care for the day. However, asking the nurse does not assist the student in developing a personal strategy for the future or in staying organized throughout the day. This is correct. Many institutions have forms that can be used or one may need to write one’s own list of “things to do” in the order of need of completion. This is the best strategy this student can use. This is incorrect. Asking the instructor what patient care for the day needs to be completed does not assist the student in developing a personal strategy for staying organized throughout the day. This is incorrect. The patient is not a reliable source because not every patient is aware of what needs to be “completed” for the day.

PTS: 1 CON: Patient-Centered Care 17. ANS: 2 Chapter: Chapter 7 Implementation & Evaluation Objective: Describe a process for evaluating client health status (outcomes) after interventions. Page: 120 (V1) Heading: How Do I Evaluate Patient Progress? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate

Feedback This is incorrect. Reading the previous nurse’s documentation about the patient does not give the present nurse information that will provide a valid evaluation about the effectiveness of the patient’s plan of care. This is correct. The most valid evaluation about the effectiveness of a patient’s plan of care is for the nurse to collect reassessment data on the patient. The reassessment information can then be compared with where the patient started and intervention goals. This is incorrect. The physician’s progress notes are focused on the patient’s medical condition and will not provide the nurse with information to evaluate the effectiveness of the patient’s plan of care. This is incorrect. The patient’s view about the effectiveness of the interventions implemented to meet the goals on the plan of care are likely to be opinions, and not valid evaluation.

PTS: 1 CON: Patient-Centered Care 18. ANS: 3 Chapter: Chapter 7 Implementation & Evaluation Objective: Describe a process for evaluating client health status (outcomes) after interventions. Page: 120 (V1) Heading: Evaluating and Revising the Care Plan Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate

1 2

Feedback This is incorrect. The existence of a nursing order does not mandate that the order be maintained if the patient no longer needs assistance. This is incorrect. There is no reason for the nurse to delegate bathing the patient to a nursing assistant. The nursing order is no longer applicable to the patient’s care. This is correct. After assessing and evaluating patient progress, the nurse will draw conclusions about goal achievement to decide whether to continue, modify, or discontinue the nursing order on the plan of care. In this item, the nurse has assessed patient independence and can discontinue this nursing order from the plan of care. This is incorrect. A patient’s plan of care and interventions is an ongoing process within nursing; there is no reason for the nurse to collaborate with the nurse who originally wrote the nursing order.

PTS: 1 CON: Patient-Centered Care 19. ANS: 4 Chapter: Chapter 7 Implementation & Evaluation Objective: Define implementation, including a description of the three broad phases (doing, delegating, recording). Page: 109 (V1) Heading: Implementation: The Action Phase of the Nursing Process Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate

1 2 3 4

Feedback This is incorrect. A patient verbalizing that pain is reduced after receiving pain medication is part of the evaluation phase. This is incorrect. Observing or noticing a skin tear relates to assessment and evaluation of skin condition. This is incorrect. Writing on the care plan of a patient requiring assistance to the bathroom is an example of assessment and planning. This is correct. Implementation is the action phase of the nursing process. It involves thinking, but the emphasis is on doing. During implementation, the nurse will perform or delegate planned interventions. In short, implementation is doing, delegating, and documenting.

PTS: 1 CON: Patient-Centered Care 20. ANS: 3 Chapter: Chapter 7 Implementation & Evaluation Objective: List the variables that may influence the effectiveness of a nursing intervention; state which ones the nurse can or cannot control. Page: 116 (V1) Heading: Reflecting Critically About Implementation Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Difficulty: Moderate

Feedback This is incorrect. Feeding a patient is a delegable task that a CNA can perform. This circumstance is then no longer delegable for any CNA regardless of experience. This is incorrect. However, once it is reported to the registered nurse that the

3 4

patient is having difficulty swallowing, this becomes a safety issue that the registered nurse must address. This is correct. The first action by the nurse is to assess the patient and place the patient on NPO status until a primary provider is notified for further orders. This is incorrect. The nurse will call the primary care provider; however, the patient must first be assessed and then placed on NPO status for safety.

PTS: 1 CON: Patient-Centered Care 21. ANS: 2 Chapter: Chapter 7 Implementation & Evaluation Objective: Describe a process for evaluating client health status (outcomes) after interventions. Page: 118 ( vol 1) Heading: Why Is Evaluation Essential to Full-Spectrum Nursing? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Administering pain medication prior to performing a dressing change is an intervention. 2 This is correct. Evaluation is the final step of the nursing process. It is a planned, ongoing, systematic activity in which a nurse will make judgments about patient progress toward desired health outcomes, effectiveness of the nursing care plan, and the quality of nursing care in the healthcare setting. Evaluation data are collected after interventions are performed to determine whether patient goals were achieved. In this item, obtaining a patient’s blood pressure after administering blood pressure medications evaluates the patient’s response to the medication. 3 This is incorrect. Reporting patient falls is part of the assessment process. 4 This is incorrect. Teaching a patient how to perform daily finger-sticks for blood glucose readings is an intervention. PTS:

CON: Patient-Centered Care

MULTIPLE RESPONSE 22. ANS: 1, 3, 4, 5 Chapter: Chapter 7 Implementation & Evaluation Objective: Identify and describe the “five rights” of delegation. Page: 114 ( Vol 1) Heading: What Should I Know About Delegation and Supervision?

Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

3. 4. 5.

Feedback This is correct. The nurse can safely delegate the care of stable clients, such as the client admitted with dehydration. Any client who is very ill or who requires complex decision making should be cared for by a registered nurse. This is incorrect. The nurse should not delegate bathing of a client newly diagnosed with a stroke whose blood pressure is unstable or otherwise abnormal. This client requires the keen assessment and critical thinking skills of a registered nurse. This is correct. The NAP can be assigned to bathe the client admitted with a urinary tract infection. The client’s age is not an issue. This is correct. The NAP can be assigned to bathe the client admitted with chronic renal failure; chronic illnesses do not necessarily indicate the client is unstable. This is correct. The client who is 2 days postoperative after an inguinal hernia repair can be bathed by the NAP. There is no information stating the client is unstable.

PTS: 1 CON: Patient-Centered Care 23. ANS: 1, 2 Chapter: Chapter 7 Implementation & Evaluation Objective: Identify and describe the “five rights” of delegation. Page: 115 (V1) Heading: What Should I Know About Delegation and Supervision? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

Feedback This is correct. The LPN/LVN can administer oral medications. LPNs/LVNs can usually provide care to medically stable patients according to an established plan of care; they can give the nurse feedback about patient responses. Tasks the registered nurse can assign to an LPN/LVN usually include administering oral medications and some medications by other routes. In some instances, starting an intravenous (IV) infusion and administering plain IV solutions is within the scope of practice for the LPN/LVN. This is correct. The LPN/LVN can insert an indwelling urinary catheter within the previously stated parameters above.

4. 5.

This is incorrect. Performing an admission assessment on a newly admitted patient is the responsibility of the registered nurse because these tasks require professional nursing judgment and critical thinking. This is incorrect. Creating or modifying nursing care plans and establishing a teaching plan is not within the scope of practice for an LPN/LVN. This is incorrect. It is not the responsibility of an LPN/LVN to call the physician to validate a new prescription; the registered nurse is responsible for communications with the physician.

PTS: 1 CON: Patient-Centered Care 24. ANS: 1, 3 Chapter: Chapter 7 Implementation & Evaluation Objective: Describe a process for evaluating client health status (outcomes) after interventions. Page: 117 (V1) Heading: How Are Standards and Criteria Used in Evaluation? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

2. 3.

Feedback This is correct. After giving care, the nurse needs to assess and record the nursing activities and the patient’s responses. This is the final step in the implementation process. This is incorrect. Teaching the patient about the procedure may or may not be performed, depending on the patient and the procedure. This is correct. Documentation is a mode of communication among the members of the health team, so it needs to be done soon after finishing the procedure. It provides the information the nurse needs to evaluate the patient’s health status and nursing care plan. This is incorrect. Asking the patient about interest in helping with the next dressing may or may not be appropriate. The complexity of the dressing change and the ability of the patient to participate are important before making this suggestion. This is incorrect. Providing the patient with a handout about dressing changes after discharge may or may not be appropriate. The nurse would not necessarily plan this activity until later when determination is made about the specific patient needs.

PTS:

CON: Patient-Centered Care

Chapter 8. Theory, Research, & Evidence-Based Practice Multiple Choice Identify the choice that best completes the statement or answers the question. 1. Professional nurses value the importance and application of nursing theory and research. Which commonly accepted practice came out of the Framingham study? 1. Mammography in breast cancer screening 2. Colonoscopy in colon cancer screening 3. Papanicolaou (Pap) testing in cervical cancer screening 4. Digital rectal examination in prostate cancer screening 2. Which theorist developed the nursing theory known as the Science of Human Caring? 1. Florence Nightingale 2. Patricia Benner 3. Jean Watson 4. Nola Pender 3. A patient experiences pain after undergoing surgery. The nurse forms a mental image of pain based on the nurse’s own experiences with pain. Which term describes this mental image? 1. Phenomenon 2. Concept 3. Assumption 4. Definition 4. The nurse and other hospital personnel strive to keep the patient care area clean. The theory of which nursing theorist most directly illustrates these ideas? 1. Virginia Henderson 2. Imogene Rigdon 3. Katherine Kolcaba 4. Florence Nightingale 5. The nurse is providing care for a patient originating from a country in the Middle East. The patient has a nasogastric (NG) tube for stomach decompression for a blocked bowel. Which statement by the nurse indicates use of the theory developed by Madeline Leininger when the patient asks if a family member can bring in garlic to be administered through the NG tube? 1. “I think the administration of garlic will cause gastric upset.” 2. “I am sure the physician would not be in favor of allowing this.” 3. “Let’s give the physician’s medical treatment a chance to work first.” 4. “Please explain the association between garlic and your condition.” 6. A nurse researcher is designing a research project. After identifying and stating the problem, the nurse researcher clarifies the purpose of the study. Which step in the research process does the researcher complete next?

1. 2. 3. 4.

Perform a literature review. Develop a conceptual framework. Formulate the hypothesis. Define the study variables.

7. The parent of a child who is participating in a research study using high-dose steroids wishes to withdraw the child from the study. Despite reassurance that adverse reactions to steroids in children are uncommon, the parent does not have a change of mind. Which right is the parent exercising by withdrawing the child from the study? 1. Not to be harmed 2. To self-determination 3. To full disclosure 4. Of confidentiality 8. The nurse uses the non-nursing theory of Maslow’s Hierarchy of Needs when providing care. Which patient intervention does the nurse develop to address physiological needs? 1. Patient is placed on fall precautions due to physical limitations. 2. Patient will begin cardiac rehabilitation to promote complete recovery. 3. Patient will use recognition from others as a motive to improve health. 4. Patient will fulfill cognitive needs effectively through patient education. 9. The nurse works in an extended care facility on the dementia unit. The nurse embraces the validation theory for communication with the clients on the unit. For which reason is the application of this theory most effective? 1. Prevents the client from experiencing painful memories 2. Helps the client to gradually accept the realities of their lives 3. Gives the nurse an accepted method of orienting the client 4. Aids the client to create whatever reality the client desires 10. The PICO question reads, “Is transcutaneous electrical nerve stimulation (TENS) effective in the management of chronic low-back pain in adults?” Which part of this question comes from the “I” in PICO? 1. Adults 2. Management 3. Pain 4. TENS 11. While reading a journal article, the nurse mentally asks these questions: “What is this about overall? Is it true in whole or in part? Does it matter to my practice?” Which process is this nurse demonstrating? 1. Reading the article analytically 2. Performing a literature review 3. Formulating a searchable question 4. Determining the soundness of the article

12. The nurse is planning to initiate a research project that involves adult patients as participants. The nurse accepts moral and legal responsibility to protect research participants from physical or emotional harm. Which mechanism will the nurse utilize for participant protection? 1. The research facility Board of Directors 2. The research facility Board of Medical Advisors 3. The Institutional Review Board (IRB) at the research facility 4. The U.S. Department of Health and Human Services 13. The nurse researcher is conducting a research study. In preparation for the study, the nurse will develop a method for participants’ identification while maintaining privacy and confidentiality. Which method is best for the researcher to use for participant identification? 1. Use a code number for each participant. 2. Use participant initials only. 3. Use gender and age only. 4. Use participant surname only. 14. The new nurse working on a surgical unit observes some patients developing a low-grade fever of 99°F (37.2°C) a few hours after surgery. Which action is appropriate for the nurse to take to gain some insight into the observation? 1. Explore previous patient records for additional data. 2. Talk to the nurse manager about starting a research study. 3. Formulate a searchable question, and research the literature. 4. Speak to the surgeon whose patients are exhibiting symptoms. 15. The nurse is providing care to a patient who is nauseous, vomiting, experiencing abdominal pain, and has no bowel sounds. The nurse concludes the patient’s symptoms may be associated with a paralytic ileus. Which type of thinking is the nurse using to arrive at this conclusion? 1. Inductive reasoning 2. Deductive reasoning 3. Guesswork 4. Diagnostics 16. The nurse researcher is conducting a research study on the association between aging male populations and the development of prostate cancer. The nurse uses a sample of 50 males older than 80 years of age. The quantitative research finds that many of the participants developed cancer after age 80 years. Which is the flaw in this research if the nurse reports all males over 80 years of age will most likely develop prostate cancer? 1. The problem statement does not provide enough information. 2. Sample size is too small to make a generalization. 3. The research is only valuable to those working with aging males. 4. The research design is most likely inappropriate for the type of study. 17. The nurse understands the term “paradigm” is the worldview of a discipline. Which paradigm relates to nursing? 1. Focuses on an in-depth look at parts of a person

2. Involves a broader perspective on the entire person 3. Includes the purpose of providing legal equality 4. Represents the theories used to define society 18. The nurse in a clinical setting states, “I keep up with the latest nursing trends on the Internet.” Which factor causes another nurse to question the statement? 1. The Internet provides rapid and ongoing updates. 2. Publishing on the Internet is strictly monitored. 3. It may be difficult to do a research appraisal on the material. 4. There is no reason for concern because Web sites are reliable sources. 19. A newly graduated nurse is working on a medical-surgical unit and appears to have difficulty identifying what needs to be done, as well as selection of interventions and setting goals. Which advice from the nurse manager is most helpful? 1. Follow an experienced nurse for a week. 2. Contact a former instructor for help and guidance. 3. Discuss each shift’s responsibility with the nurse manager. 4. Review and discuss the use of clinical practice theories. Multiple Response Identify one or more choices that best complete the statement or answer the question. 20. The nurse educator in the local hospital is developing a plan to implement research into nursing care practices. Which are some of the barriers the nurse educator may encounter in the implementation process? Select all that apply. 1. Not enough nursing research has been published. 2. There is a negative attitude toward research. 3. There is a lack of support from the employing hospital. 4. Most nursing research is not relevant to hospital practice. 5. Nurses are extremely reluctant to change nursing practice. 21. Which statements best describe the phases of nursing research? Select all that apply. 1. Selection and definition of the problem 2. Formulation of a research question 3. Selection of individual participants 4. Molding data to the research question 5. Reporting the research findings 22. The American Nurses Association (ANA) has set standards for registered nurses (RNs) in utilizing evidence-based interventions and treatments in practice. According to the ANA, which statements best describe the ANA standards? Select all that apply. 1. The RN uses current evidence-based nursing knowledge to guide practice decisions. 2. The RN critically analyzes evidence-based practice and research findings for

application to practice. 3. The RN shares research activities and findings with healthcare peers and others. 4. The RN uses specific competencies in conducting and integrating research. 5. The RN Incorporates evidence when initiating changes in nursing practice. Completion Complete each statement. 23. The unit committee in the intensive care unit is designing a research study to see whether the spiritual needs of patients are being met. The study will involve patient interviews after discharge. After the interview process, the staff will examine patient statements for recurring themes. The unit committee is conducting research.

24. A 56-year-old patient diagnosed with an acute myocardial infarction (heart attack) makes inappropriate sexual comments to the licensed practical nurse/licensed vocational nurse (LPN/LVN). The LPN/LVN is visibly upset. The registered nurse (RN) assigned to the patient informs the patient that the behavior is unacceptable and will not be tolerated. Is the RN demonstrating holistic nursing or mechanistic nursing?

Chapter 8. Theory, Research, & Evidence-Based Practice Answer Section MULTIPLE CHOICE 1. ANS: 1 Chapter: Chapter 8 Theory, Research, & Evidence-Based Practice Objective: List the four essential concepts in a nursing theory. Page: 126 (V1) Heading: The Importance of Nursing Theory and Research Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Evidence-Based Practice Difficulty: Moderate Feedback 1 This is correct. One commonly accepted practice that came out of the Framingham study is the link between mammography and breast cancer. Before the Framingham study, mammography was considered an unreliable tool in breast cancer screening. 2 This is incorrect. Colonoscopy for colon cancer screening is not related to the Framingham study. 3 This is incorrect. Pap testing for cervical cancer screening is not related to the Framingham study. 4 This is incorrect. Digital rectal examination for prostate cancer screening is not related to the Framingham study. PTS: 1 CON: Evidence-Based Practice 2. ANS: 3 Chapter: Chapter 8 Theory, Research, & Evidence-Based Practice Objective: Name the two prominent nurses who proposed theories of caring. Page: 126 (V1) Heading: The Importance of Nursing Theory and Research Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Knowledge [Remembering] Concept: Evidence-Based Practice

Difficulty: Easy Feedback 1 This is incorrect. Florence Nightingale developed the theory that stated that a clean environment would improve the health of patients. By changing the care environment, she dramatically reduced the death rate of soldiers. 2 This is incorrect. Dr. Patricia Benner’s theory described the progression of a beginning nurse who learns to be an expert nurse. 3 This is correct. Dr. Jean Watson developed the nursing theory known as the Science of Human Caring. Her theory describes caring from a nursing perspective. 4 This is incorrect. Nola Pender’s theory on health promotion became the basis for most health promotion teaching done by nurses. PTS: 1 CON: Evidence-Based Practice 3. ANS: 2 Chapter: Chapter 8 Theory, Research, & Evidence-Based Practice Objective: Define nursing theory. Page: 127 (V1) Heading: What Are the Components of a Theory? Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Evidence-Based Practice Difficulty: Moderate Feedback 1 This is incorrect. Phenomena are the subject matter of a discipline. They mark the boundaries of a discipline. 2 This is correct. A concept is a mental image of a phenomenon, an aspect of reality that you can observe and experience. In the scenario above, the nurse forms a mental image of pain because of the nurse’s past experiences with pain. 3 This is incorrect. An assumption is an idea that is taken for granted. In a theory, the assumption is the idea that the researcher presumes to be true and does not intend to test with research. 4 This is incorrect. A definition is a statement of the meaning of a term or concept that sets forth the concept’s characteristics or indicators. PTS: 1 CON: Evidence-Based Practice 4. ANS: 4 Chapter: Chapter 8 Theory, Research, & Evidence-Based Practice Objective: Name the two prominent nurses who proposed theories of caring. Page: 130 (V1) Heading: How Do Nurses Use Theories?

Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Evidence-Based Practice Difficulty: Moderate Feedback 1 This is incorrect. Virginia Henderson identified 14 basic needs that are addressed by nursing care. 2 This is incorrect. Imogene Rigdon developed a theory about bereavement in older women after noticing that older women handle grief differently than do men and younger women. 3 This is incorrect. Katherine Kolcaba developed a theory of holistic comfort in nursing. 4 This is correct. Florence Nightingale was instrumental in identifying the importance of a clean patient care environment. During the Crimean War, Nightingale dramatically reduced the death rate of soldiers by changing the healthcare environment. PTS: 1 CON: Evidence-Based Practice 5. ANS: 4 Chapter: Chapter 8 Theory, Research, & Evidence-Based Practice Objective: Name the two prominent nurses who proposed theories of caring. Page: 128 (V1) Heading: Who Are Some Important Nurse Theorists? Integrated Processes: Culture and Spirituality Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Evidence-Based Practice Difficulty: Difficult Feedback 1 This is incorrect. The nurse is expressing a personal belief to avoid participating in the patient’s cultural belief. 2 This is incorrect. The nurse is discounting the patient’s cultural belief by using an assumption that the physician would not support the action. 3 This is incorrect. The nurse is being disrespectful to the patient’s cultural practices by suggesting the physician’s medical treatment is the priority or superior care. 4 This is correct. The nurse is using the theory developed by Madeline Leininger. Leininger’s theory focuses on the values of cultural diversity. According to her theory, the nurse must make cultural accommodations for the health benefit of the patient. The nurse’s statement explores the patient’s cultural beliefs/practices.

PTS: 1 CON: Evidence-Based Practice 6. ANS: 1 Chapter: Chapter 8 Theory, Research, & Evidence-Based Practice Objective: Explain how the four building blocks (components) are used in developing a theory. Page: 141 (V1) Heading: What Are the Phases of the Research Process? Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Evidence-Based Practice Difficulty: Moderate Feedback 1 This is correct. After identifying and stating the problem, the nurse researcher should clarify the purpose of the study. Next, the researcher should perform a literature search to find out what is already known about the problem. 2 This is incorrect. After the literature search, the researcher selects a conceptual framework to guide the research. 3 This is incorrect. After the literature search, the researcher formulates the hypothesis or research question on which the study will focus. 4 This is incorrect. After the literature search, the researcher will define the specific variables for the planned study. PTS: 1 CON: Evidence-Based Practice 7. ANS: 2 Chapter: Chapter 8 Theory, Research, & Evidence-Based Practice Objective: Name the three priorities in the process of protecting research participants. Page: 142 (V1) Heading: What Are the Rights of Research Participants? Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Evidence-Based Practice Difficulty: Moderate Feedback 1 This is incorrect. The right not to be harmed outlines the safety protocols of the study. 2 This is correct. The parent is exercising the right to self-determination. This refers to the right of the participant (or parent, in the case of a minor) to withdraw from a research study at any time and for any reason. 3 This is incorrect. All research participants also have the right to full disclosure. This guarantees the participants answers to questions, such as the purpose of the

research study, the risks and benefits, and what happens if the patient feels worse as a result of the study. This is incorrect. Participants have the right to confidentiality. Typically, that right is preserved by giving participants an identification code rather than associating them by name.

PTS: 1 CON: Evidence-Based Practice 8. ANS: 2 Chapter: Chapter 8 Theory, Research, & Evidence-Based Practice Objective: Describe the three non-nursing theories and their contributions to nursing. Page: 136 (V1) Heading: Maslow’s Hierarchy of Basic Human Needs Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Evidence-Based Practice Difficulty: Difficult Feedback 1 This is incorrect. Placing a patient on fall precautions due to physical limitations is aimed at meeting the patient’s safety needs. 2 This is correct. Cardiac rehabilitation most directly addresses the patient’s physiological need for physical activity as well as for health and healing. 3 This is incorrect. When a patient uses recognition from others to improve health, the patient’s self-esteem needs are being met. 4 This is incorrect. Maslow identifies two different needs to achieve selfactualization; one of them is to fulfill cognitive needs. For the patient, this is accomplished effectively through patient education. PTS: 1 CON: Evidence-Based Practice 9. ANS: 1 Chapter: Chapter 8 Theory, Research, & Evidence-Based Practice Objective: Describe the three non-nursing theories and their contributions to nursing. Page: 133 (V1) Heading: How Do Nurses Use Theories From Other Disciplines? Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Evidence-Based Practice Difficulty: Difficult Feedback 1 This is correct. Validation theory arises from social work and provides for a way to communicate with older people with dementia. The theory asks the caregiver

2 3 4

to go where the client with dementia is in their own mind. Wrongful thinking is not corrected to prevent the client from experiencing painful memories repeatedly. This is incorrect. Validation theory is not based on helping a demented client to accept the realities of their lives. This is incorrect. Validation theory does not give the nurse an accepted method of orienting the client with dementia. This is incorrect. Validation is not based on aiding the client to create whatever reality the client desires.

PTS: 1 CON: Evidence-Based Practice 10. ANS: 4 Chapter: Chapter 8 Theory, Research, & Evidence-Based Practice Objective: Use the PICOT method to formulate a question for guiding a literature search. Page: 143 (V1) Heading: Formulate a Searchable Question Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Evidence-Based Practice Difficulty: Difficult Feedback 1 This is incorrect. “Adults” comes from Patient (P). There is no comparison intervention (C) in this PICO question. 2 This is incorrect. “Management” comes from Outcome (O). 3 This is incorrect. As in this example, a research question may not always need a (C) and sometimes not a (T). “C” indicates Comparison intervention; “T” represents Times. 4 This is correct. The “I” in PICOT represents the intervention part of a research question. In this example, “TENS” is the intervention (I) in the PICO system. PTS: 1 CON: Evidence-Based Practice 11. ANS: 1 Chapter: Chapter 8 Theory, Research, & Evidence-Based Practice Objective: Discuss the process of analytic reading, and explain its significance to the appraisal of research. Page: 144 (V1) Heading: Evaluate the Quality of the Research Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Evidence-Based Practice

Difficulty: Moderate Feedback 1 This is correct. Analytical reading involves questioning the article to be sure of the nurse’s understanding and to determine whether it is applicable to the nurse’s practice. Such reading asks these questions: “What is this about as a whole? Is it true in whole or in part? Does it matter to my practice?” 2 This is incorrect. A literature review is performed by searching indexes and databases, and reading more than one article. 3 This is incorrect. Formulating a searchable question involves creating a PICOtype statement to guide a search of the literature. 4 This is incorrect. The nurse determines whether the article is a research report by looking for the individual parts of the article to see if they were present in the form of research (e.g., title, problem, hypothesis, purpose, methods, data, data analysis, conclusions). PTS: 1 CON: Evidence-Based Practice 12. ANS: 3 Chapter: Chapter 8 Theory, Research, & Evidence-Based Practice Objective: Name the three priorities in the process of protecting research participants. Page: 142 (V1) Heading: What Are the Rights of Research Participants? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Evidence-Based Practice Difficulty: Moderate Feedback 1 This is incorrect. The Board of Directors at the nurse’s selected facility may permit or not permit research at the facility; however, the decision is not likely to be specifically based on participant protection. 2 This is incorrect. A facility’s Board of Medical Advisors is not likely to have the authority to assure participant protection during a research project. 3 This is correct. Every hospital, university, and other healthcare facility where federal funds are involved has an IRB. It consists of healthcare professionals and people from the community who are willing to review and critique research proposals. The two main responsibilities of the IRB are to (1) protect the research participants from harm and (2) ensure that the research is of value. 4 This is incorrect. The United States government, through the Department of Health and Human Services (DHHS), has a complex set of standards that all researchers must follow. The mechanism for overseeing the ethical standards established by the DHHS is the IRB.

PTS: 1 CON: Evidence-Based Practice 13. ANS: 1 Chapter: Chapter 8 Theory, Research, & Evidence-Based Practice Objective: Name the three priorities in the process of protecting research participants. Page: 142 (V1) Heading: What Are the Rights of Research Participants? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Evidence-Based Practice Difficulty: Moderate Feedback 1 This is correct. All research participants have the right to have their identification protected. Generally, participants are given a code number rather than being identified by name. Once the study is completed and the data are analyzed, the researcher is responsible for protecting the raw data (such as those from questionnaires and taped interviews). 2 This is incorrect. The use of initials for the identification of research participants is not effective because of the possibility of the same initials being applicable to multiple participants. 3 This is incorrect. The use of gender and age for the identification of research participants is not effective; many participants may share the same factors. 4 This is incorrect. The use of surnames for research participants does not provide fail-safe identification. Multiple numbers of people share the same surname, which can lead to a breach of confidentiality or wrong identification. PTS: 1 CON: Evidence-Based Practice 14. ANS: 3 Chapter: Chapter 8 Theory, Research, & Evidence-Based Practice Objective: Discuss how you might integrate nursing research into your nursing practice. Page: 138 (V1) Heading: Nursing Research Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Evidence-Based Practice Difficulty: Moderate Feedback 1 This is incorrect. Exploring previous patient records for additional data may or may not be needed. The scope of the research question will determine the use of previous records or current records. 2 This is incorrect. Asking the nurse manager about starting a research study is a

matter of professional courtesy. In addition, the nurse manager may be more receptive if the nurse can present some preliminary data and a reason for the study. This is correct. When the nurse finds a topic of interest, the first step is to state it in the form of a question to help narrow a search. A question stated too broadly may yield overwhelming and irrelevant results. A question stated too narrowly may yield no results. This is incorrect. Speaking to the surgeon whose patients are exhibiting the elevated temperature is unnecessary and definitely premature. This action can trigger a defensive attitude, especially if the observation is not validated.

PTS: 1 CON: Evidence-Based Practice 15. ANS: 1 Chapter: Chapter 8 Theory, Research, & Evidence-Based Practice Objective: Discuss how you might integrate nursing research into your nursing practice. Page: 129 (V1) Heading: How Are Theories Developed? Integrated Processes: Nursing Process Client Need: Physical Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Difficulty: Moderate Feedback 1 This is correct. Inductive reasoning is often used in the nursing process. Induction moves from the specific to the general. The nurse gathers separate pieces of information, recognizes a pattern, and forms a generalization or conclusion. In this item, the nurse uses inductive reasoning based on observations and assessment of this patient and concludes that the symptoms are associated with a paralytic ileus. 2 This is incorrect. Deductive reasoning starts with a general premise and moves to a specific deduction. 3 This is incorrect. This is not guesswork because the nurse is using her observation, assessment skills, and knowledge to draw a conclusion. 4 This is incorrect. The nurse is not diagnosing this patient because this is within the scope of practice of a medical doctor. The nurse is, however, making an association between signs and symptoms and a disease process. PTS: 1 CON: Evidence-Based Practice 16. ANS: 2 Chapter: Chapter 8 Theory, Research, & Evidence-Based Practice Objective: Compare and contrast quantitative and qualitative nursing research. Page: 140 (V1) Heading: What Are the Two Approaches to Research?

Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Evidence-Based Practice Difficulty: Difficult Feedback 1 This is incorrect. The problem statement provides enough information to form an idea of what this study is about. 2 This is correct. The sample size of 50 males is too small to make the generalization that all males over age 80 years will develop prostate cancer. 3 This is incorrect. This research is valuable to nurses working with these patients and is valuable to the medical community and healthcare consumers. 4 This is incorrect. The quantitative research design is appropriate for this type of study because it is the design for gathering data from enough subjects to be able to generalize the results to a similar population. PTS: 1 CON: Evidence-Based Practice 17. ANS: 2 Chapter: Chapter 8 Theory, Research, & Evidence-Based Practice Objective: Explain how the four building blocks (components) are used in developing a theory. Page: 144 (V1) Heading: Paradigm, Framework, Model, or Theory? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Evidence-Based Practice Difficulty: Moderate Feedback 1 This is incorrect. The medical paradigm views a person through a lens that focuses on identifying and treating disease. This lens causes the observer to look in depth at the “parts” (e.g., cells, organs) of a person. 2 This is correct. The nursing paradigm views the person through a lens with a broader perspective on the entire person and how the person responds to isolated changes in physical, psychological, social, and spiritual health. 3 This is incorrect. A paradigm is the worldview or ideology of a discipline. It is the broadest, most global conceptual framework of a discipline. It includes and guides the values, philosophy, knowledge, theories, and research processes of the discipline. The paradigm that includes the purpose of providing legal equality may be related to law or lawyers. 4 This is incorrect. Paradigms are not theories; they are just “how we see things.” PTS:

CON: Evidence-Based Practice

18. ANS: 3 Chapter: Chapter 8 Theory, Research, & Evidence-Based Practice Objective: Discuss the process of analytic reading, and explain its significance to the appraisal of research. Page: 144 (V1) Heading: Journals Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Evidence-Based Practice Difficulty: Moderate

Feedback This is incorrect. Information on the Internet is updated at the discretion of the author of the material. The ability for rapid and ongoing updating exists but may be used rarely, if at all. This is incorrect. Publishing on the Internet is not strictly monitored. In fact, anyone can publish/post any material they wish. Some publications on online professional sites are reliable. This is correct. It may be difficult to do a research appraisal on the material found on the Internet. Not all research is good research. Some published studies contain serious flaws, and nurses need to be able to recognize them. An effective strategy for conducting a research appraisal is to use “analytical reading.” This is incorrect. It is important to remember that Web sites are not necessarily reliable. A good practice is to use sites with names that end with .edu and .gov.

PTS: 1 CON: Evidence-Based Practice 19. ANS: 4 Chapter: Chapter 8 Theory, Research, & Evidence-Based Practice Objective: List the three ways in which you can use nursing theory. Page: 131 (V1) Heading: How Do Nurses Use Theories? Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Evidence-Based Practice Difficulty: Moderate Feedback 1 This is incorrect. The new nurse may or may not gain helpful information and/or experience by following an experienced nurse for a week. The new nurse needs a basis on which to build clinical thinking and management. 2 This is incorrect. The new nurse is no longer dependent on former nursing

instructors for help and guidance. This is incorrect. Discussing each shift’s responsibilities with the nurse manager may or may not be helpful. The new nurse needs a basis on which to build clinical thinking and management. This is correct. The best advice for the new nurse is to find or revisit clinical practice theories. Nursing theories serve as a guide for assessment, problem identification, and choice of nursing interventions. They help nurses communicate to other members of the healthcare team and identifies what it is that makes nurses unique and important to the interdisciplinary team. Clinical practice theories very specifically guide what the nurse does each day.

PTS:

CON: Evidence-Based Practice

MULTIPLE RESPONSE 20. ANS: 2, 3, 5 Chapter: Chapter 8 Theory, Research, & Evidence-Based Practice Objective: Discuss how you might integrate nursing research into your nursing practice. Page: 146 (V1) Heading: Box 8-5: Barriers to Using Research Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environments: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Evidence-Based Practice Difficulty: Difficult

1. 2. 3. 4. 5.

Feedback This is incorrect. There is an abundance of nursing research and evidence-based nursing research providing sound evidence on which to base nursing care. This is correct. The nurse researcher is likely to find a negative attitude toward research, hindering the implementation process. This is correct. The nurse researcher is likely to find a lack of support from the employing institutions, which is a barrier to implementation. This is incorrect. Most nursing research is relevant to hospital practice, so this is not seen as an implementation barrier. This is correct. Nurses are extremely reluctant to change nursing practice because a recognized barrier, which identifies that many study findings are not ready for the clinical environment.

PTS: 1 CON: Evidence-Based Practice 21. ANS: 1, 2, 5 Chapter: Chapter 8 Theory, Research, & Evidence-Based Practice

Objective: List the three components of the research process, and explain their importance. Page: 141 (V1) Heading: What Are the Phases of the Research Process? Integrated Processes: Nursing Process Client Needs: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Evidence-Based Practice Difficulty: Difficult

1. 2. 3. 4. 5.

Feedback This is correct. All research begins with the selection and definition of the problem to be studied. This is correct. After the problem is defined and information is gathered on the topic, the nurse formulates a research question, hypothesis, or problem statement. This is incorrect. In research, individual participants are not selected for the study. A random group or specified population are used as research participants. This is incorrect. Data are not molded to the research question; data are analyzed and conclusions are drawn that either support or do not support the research question. This is correct. The final phase of research is the reporting of the findings. Without this phase, the research serves no specific purpose.

PTS: 1 CON: Evidence-Based Practice 22. ANS: 1, 2, 3, 5 Chapter: Chapter 8 Theory, Research, & Evidence-Based Practice Objective: Discuss how you might integrate nursing research into your nursing practice. Page: 138 (V1) Heading: ANA Standards Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Evidence-Based Practice Difficulty: Difficult

Feedback This is correct. According to the ANA Standards of Professional Performance, the registered nurse uses current evidence-based nursing knowledge, including research findings, to guide practice decisions. This is correct. The ANA Standards of Professional Performance supports the registered nurse to critically analyze evidence-based practice and research findings for application to nursing practice. This is correct. The registered nurse participates in the development of evidencebased practice through research activities, and shares research activities and/or

findings with peers and others. This is incorrect. Competencies related to research are stated by Quality and Safety Education for Nurses under its educational competencies and are not part of the ANA standards. This is correct. The RN incorporates evidence when initiating changes in nursing practice instead of randomly initiating changes that may or may not be safe, efficient, and effective.

PTS:

CON: Evidence-Based Practice

COMPLETION 23. ANS: qualitative Chapter: Chapter 8 Theory, Research, & Evidence-Based Practice Objective: Compare and contrast quantitative and qualitative nursing research. Page: 131 (V1) Heading: What Are the Two Approaches to Research? Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Evidence-Based Practice Difficulty: Moderate Feedback: The unit council is conducting qualitative research, which focuses on the lived experiences of people. PTS: 1 24. ANS: mechanistic

CON: Evidence-Based Practice

Chapter: Chapter 8 Theory, Research, & Evidence-Based Practice Objective: List the three ways in which you can use nursing theory. Page: 125 (V1) Heading: Meet Your Patient Integrated Processes: Teaching and Learning Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Evidence-Based Practice Difficulty: Moderate

Feedback: The nurse is demonstrating the mechanistic nursing approach, which focuses on getting the task done. PTS:

CON: Evidence-Based Practice

Chapter 9. Life Span: Infancy Through Middle Adulthood Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse is providing prenatal counseling for a couple who is trying to become pregnant. The priority for the nurse is to include which information? 1. Stages of growth and development of the fetus 2. Recommended schedule of visits to her healthcare provider 3. Recommended average weight gain during pregnancy 4. Healthy eating habits before and during pregnancy 2. According to Erikson, which behavior demonstrates an important psychosocial task for a toddler to exhibit? 1. Acting defiantly by refusing to hold a parent’s hand while crossing the street 2. Recognizing that it is wrong to take a toy away from someone else 3. Displaying an ability to understand the concept of time in hours 4. Expressing to parents and playmates when something is disliked 3. A parent comes to the clinic with a 1-week-old infant for a newborn checkup. The parent tells the nurse, “My baby looks yellow to me.” Which is the nurse’s best response? 1. “What type of detergent are you using to wash the baby’s clothes?” 2. “Is there a possibility you had hepatitis during your pregnancy?” 3. “The color is from the breakdown of maternal red blood cells.” 4. “There is a cream you can use to reduce the yellowing.” 4. A parent brings a toddler to the clinic for well-child care. Which is most important for the nurse to assess? 1. How successful the child is with potty training 2. How the child acts when you enter the room 3. Whether the child is using eating utensils 4. Whether the home is childproofed 5. The nurse is performing physical assessment on a female client who is in her early 50s. Which comment made by the client is a cue indicating the need for further assessment for a problem? 1. “My skin is so dry I need to use lotion every day after I bathe.” 2. “I have episodes when I feel really hot even when others are not.” 3. “It’s getting harder to lift those big bags of dog food.” 4. “I have to write myself notes because I’m getting so forgetful.” 6. The nurse is instructing a group of parents about common adolescent behavior. Which comment by a parent indicates an urgent need for further discussion? 1. “I guess my daughter won’t be asking my opinion very much.” 2. “I’m really going to watch my daughter’s eating habits.”

3. “We are really going to have to think about rules we want to enforce after he gets his driver’s license.” 4. “We don’t keep alcohol in the house, so that’s at least one thing we don’t need to worry about.” 7. Which consideration does the nurse recognize as being a typical priority for an adolescent? 1. Importance of being a good student 2. Conflict about being sexually active 3. Being picked to be on the soccer team 4. The ability to function independently 8. The nurse is interviewing a middle-aged adult. Which comment by the client does the nurse recognize as being representative of Erikson’s theory of psychosocial development? 1. “I look in the mirror and just see an old person.” 2. “The best part of life is over, and my years are numbered.” 3. “I take pride in all that I have accomplished during life.” 4. “Finally, I feel I have a relationship that will last forever.” 9. The nurse teaches the parent of a preschool-age child about expected development. Which comment by the parent indicates understanding of the information? 1. “She understands that the monsters in books are not real.” 2. “When I mention her birthday is in a week, she understands.” 3. “I am saving to buy her the roller skates she’s been asking for.” 4. “I can’t expect her to understand why a friend doesn’t agree with her.” 10. A parent brings an 8-month-old infant to the healthcare clinic for a well-child appointment. Which consideration does the nurse use to compare the child’s physical development with age-appropriate norms? 1. If the child walks while holding onto furniture 2. If the child crawls on hands and knees 3. If the child picks up food with fingers 4. If the child sits up without support 11. A parent brings a 5-year-old male child to the healthcare clinic for a regular health visit prior to kindergarten admission. Which comment by the parent indicates the need for follow-up questions by the nurse? 1. “He is not a good child like my firstborn.” 2. “I’ve had to do lice treatments a couple of times.” 3. “He has an imaginary friend called Buddy.” 4. “He is so funny when imitating his father.” 12. Which behavior by the parent does the nurse recognize as having the most impact on an infant developing trust? 1. Talking to the infant 2. Breastfeeding instead of bottle feeding

3. Responding promptly to the infant’s crying 4. Having the infant sleep in the same room as the parents 13. The nurse is presenting material to a class of 9- to 11-year-old children. Which is the most important topic for the nurse to present for this age group? 1. Safe sex practices 2. Healthy food choices 3. Use of seat belts and safety equipment 4. The importance of getting enough sleep 14. A 38-year-old client comes into the clinic for a health examination. The nurse is aware of the psychosocial development tasks and common health problems for this age group. Which question is most important for the nurse to ask? 1. Whether the client has episodes of feeling depressed 2. Whether the client practices safe sex 3. About the client’s exercise habits 4. About the health history of the client’s parents 15. A mother watches the nurse perform an assessment on her newborn and asks the nurse why the nurse is doing things like stroking the bottom of the newborn’s feet. Which response by the nurse is correct? 1. “Just checking the blood flow to your baby’s feet to make sure it’s normal.” 2. “Testing to see if your baby’s neuromuscular system is fully developed.” 3. “Evaluating to see if your baby has the reflex responses we anticipate.” 4. “Determining if your baby has normal sensation in his feet.” 16. The nurse conducts a class on health promotion for a group of young male adults. Which comment indicates to the nurse the teaching is effective? 1. “I need to get screened for colon cancer.” 2. “I am going to continue doing testicular self-exams.” 3. “I will request a prostate check at my annual exam.” 4. “I have no need to do breast self-exams until I am 40.” 17. Which action is an example of a school-aged child meeting a psychosocial development task? 1. Wants to show off the latest mastered bicycle trick 2. Becomes interested in friendships with the opposite sex 3. Starts to see the value of making good decisions 4. Wants to buy the same jacket bought by a friend 18. The nurse works in a pediatric emergency department. During the nurse’s shift, a 6-year-old child arrives with a parent. The nurse notices bruises on the child, and the parent avoids answering any questions about them. Which is the most appropriate action by the nurse? 1. Contact a child abuse hotline. 2. Notify the physician. 3. Contact the nurse’s supervisor.

4. Continue to ask the mother more questions. 19. The nurse in a pediatric clinic is performing a developmental assessment on a toddler who is a regular client. Over a period of months, the nurse notices the toddler’s inability to walk without holding on to something and poor pincer grasp. The parent states, “There is nothing wrong with my child. We just need to give him more time.” Which developmental principle does the nurse convey to the parent using Havighurst’s Developmental Task Theory? 1. Many infants and toddlers will lag behind in physical development. 2. Failure to master a task leads to difficulty mastering future tasks. 3. Young children often require additional time for developmental tasks. 4. Concerns about early cognitive and physiological tasks are unfounded. 20. The nurse is interviewing the parents of an infant. One parent states, “I was not raised in a family of faith, and I don’t know how to give that to my child.” Using James Fowler’s Spiritual Development Theory, which information does the nurse provide? 1. The stages of faith development are closely associated with evolving cognitive abilities. 2. Faith, for a child, requires the ability to use logic and hypothetical thinking. 3. In a family of faith, a child reaches high levels of faith refinement in adolescence. 4. Parents without a personal understanding of faith will need professional assistance. 21. An adolescent, single mother of a 2-month-old infant comes to the clinic and tells the nurse, “Sometimes no matter what I do, my baby won’t stop crying, and I hold him up in the air and shake him until he stops.” Based on these statements by the mother, which is the first action by the nurse? 1. Teach the mother about the dangers of shaking a baby. 2. Report child abuse to the appropriate authorities. 3. Teach the mother other methods to stop the baby from crying. 4. Encourage the mother to obtain more support from a significant other. 22. The nurse is beginning a routine assessment on a client who is 3 years of age. Which is the most appropriate action by the nurse to gain trust and cooperation from the child? 1. Explain to the child what is going to be done at the visit. 2. Allow the child to control the pace of the assessment. 3. Encourage the parents to leave the room during the assessment. 4. Play a game of ball with the child. 23. A 30-year-old female comes to the emergency department with visible bruises to her face and arms. She tells the nurse: “My husband has been hitting me.” Which is the most appropriate response by the nurse? 1. “Would you like me to contact our domestic violence advocate for you?” 2. “These issues are between you and your husband, but a social worker may be helpful.” 3. “Is this the first time this has happened, or is this an ongoing issue?” 4. “The doctor will need to check you before we go any further.”

24. A 52-year-old female comes to the office for her routine yearly physical examination. As part of the nurse’s assessment, which physical change in women of this age group is most expected? 1. Graying hair 2. Breast cancer 3. Menopause 4. Mood swings 25. A 16-year-old male tells the nurse, “For weeks now, I am just not interested in doing anything, and I’ve stopped all my sports activities. I just feel sad all the time, and I just don’t want to go on.” The nurse completes an assessment and begins to develop a plan of care. What is the most appropriate nursing intervention at this time? 1. Inform the patient you will be contacting his parents. 2. Inform the patient you are completing a mental health referral. 3. Teach the patient about coping strategies. 4. Contact the patient’s teachers for further information. Multiple Response Identify one or more choices that best complete the statement or answer the question. 26. The parents of an adolescent client ask about strategies to use to aid in obesity prevention. Which strategies does the nurse present to the parents? Select all that apply. 1. Maintain a well-balanced diet, but eat smaller portions. 2. Teach the adolescent how to recognize healthier snacks. 3. Do not eat fast foods or drink sodas. 4. Try to have 30 minutes of outdoor activity every day. 5. Follow a popular diet trend (e.g., low-carbohydrate diet). 27. A sexually active high school student is asking about contraceptive devices. Which comment by the student indicates to the nurse that the student understands the information provided? Select all that apply. 1. “Condoms are a foolproof method of preventing sexually transmitted infections (STIs) and HIV/AIDS.” 2. “Oral sex does not put me at risk for STIs, so condoms are not needed.” 3. “STIs are major health consequences especially with unprotected sexual activity.” 4. “Consistent and effective use of condoms can help prevent pregnancy.” 5. “Avoiding vaginal sex is an effective way to prevent STIs and HIV/AIDS.” 28. The pediatric nurse is presenting information about teeth brushing to a preschooler class. Prior to the start of class, the nurse spends some time meeting and talking with the students. Which statement(s) by the preschoolers indicates normal development for this group? Select all that apply. 1. “I am going to read my book. I love my book.” 2. “You should never steal anything from anyone.” 3. “Water and ice are really not the same.”

4. “I can count to 20 without any help.” 5. “I already know how to brush my teeth.” 29. A 12-year-old child diagnosed with cancer is hospitalized for the first time. Considering many children in this age group have a fear of hospitals, which strategies will the nurse use to help the child during hospitalization? Select all that apply. 1. Encourage visits from friends. 2. Ask the parents to bring in personal items from home. 3. Maintain a strict daily routine to keep the child focused. 4. Limit parental responsibilities for the child’s care. 5. Provide medical equipment for pretend activities. 30. The nurse is providing information to a parent group of adolescent children about body piercings and tattoos. Which information is most important for the nurse to include in the teaching? Select all that apply. 1. Body piercing and tattooing often indicate low self-esteem. 2. Tattoos and piercings can be a source of hepatitis. 3. Tattoos and piercings carry a high risk of skin infections. 4. Body piercings and tattoos are indications of drug abuse. 5. Body piercings and tattoos indicate psychosocial problems. 31. The nurse from the local high school is giving a presentation to 16-year-olds on the risks associated with driving. Which information does the nurse include in the presentation as high-risk activities for causing motor vehicle crashes? Select all that apply. 1. Listening to the radio 2. Talking with passengers 3. Texting 4. Drinking alcohol 5. Eating snacks 32. The nurse is preparing a health promotion class for middle-aged males. As part of the teaching plan, the nurse will provide information on which common health problems associated with this age group? Select all that apply. 1. Cardiovascular disease 2. Cancer 3. Alcoholism 4. Obesity 5. Sports injuries

Chapter 9. Life Span: Infancy Through Middle Adulthood Answer Section MULTIPLE CHOICE 1. ANS: 4 Chapter: Chapter 9 Life Span: Infancy Through Middle Adulthood Objective: Discuss the principles of growth and development. Page: 156 (V1) Heading: Effects of Maternal Nutrition Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Growth and Development Difficulty: Moderate Feedback 1 This is incorrect. “Stages of growth and development of the fetus” is information the nurse will share after conception, but this information does not have an immediate impact on fetal health and is not a priority. 2 This is incorrect. “Recommended schedule of visits to the female’s healthcare provider” is important information, but this does not have an immediate impact on fetal health and is not the priority. 3 This is incorrect. “Recommended average weight gain during pregnancy” is information that will be shared by the nurse after conception, but this information does not have an immediate impact on fetal health and is not a priority. 4 This is correct. Maternal nutrition is vital to the healthy growth of the fetus. Poor maternal nutrition leads to an undergrown placenta. A small, poorly functioning placenta and smaller-than-normal umbilical cord are the causes of small-for-gestational age (otherwise known as small-for-date) babies. PTS: 1 CON: Growth and Development 2. ANS: 1 Chapter: Chapter 9 Life Span: Infancy Through Middle Adulthood Objective: Compare and contrast developmental task theory, psychoanalytic theory, cognitive theory, and the psychosocial theory of growth and development. Page: 154 (V1) Heading: Psychosocial Development Theory Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Growth and Development

Difficulty: Moderate Feedback 1 This is correct. The primary task during Erikson’s stage 2, Autonomy Versus Shame and Doubt, is establishing an identity as separate from the parent/caregiver. A child age between 18 months and 3 years typically tests the boundaries as part of exercising the will to control the environment. “No” is a declaration of independence and a bid for increased autonomy. Acts of independence and autonomy (e.g., refusing to hold the parent’s hand) are normal during this developmental stage. 2 This is incorrect. Recognizing that it is wrong to take a toy away from someone else is a task accomplished during the preschool stage. 3 This is incorrect. Displaying an ability to understand the concept of time in hours is a task commonly accomplished during the preschool stage of development. 4 This is incorrect. Expressing to parents and playmates when something is disliked is a developmental task that is likely to be accomplished during the preschool stage. PTS: 1 CON: Growth and Development 3. ANS: 3 Chapter: Chapter 9 Life Span: Infancy Through Middle Adulthood Objective: Identify common health problems seen in each stage of development. Page: 160 (V1) Heading: Physical Development of the Neonate Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Growth and Development Difficulty: Difficult Feedback 1 This is incorrect. If detergent caused a reaction, the reaction would commonly present as a rash. 2 This is incorrect. Although hepatitis B virus may pass through the placenta to the fetus, the infant does not typically show signs at week 1 of life. 3 This is correct. Jaundice results from the breakdown of the maternal red blood cells that are in the baby’s system after birth, which elevates the bilirubin in serum. 4 This is incorrect. If treatment becomes necessary, the infant would receive phototherapy; there is no cream to reduce the yellow appearance related to newborn jaundice. PTS:

CON: Growth and Development

4. ANS: 4 Chapter: Chapter 9 Life Span: Infancy Through Middle Adulthood Objective: Describe special assessments unique to each age group. Page: 169 (V1) Heading: Interventions (Toddlerhood) Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Analysis [Analyzing] Concept: Growth and Development Difficulty: Moderate Feedback 1 This is incorrect. Potty training is typically accomplished between 18 months and 3 years of age but is not a safety concern. 2 This is incorrect. It would be normal for a child at this age to be afraid of strangers. 3 This is incorrect. The child should be using utensils for most foods, but, again, it is not a safety concern. 4 This is correct. Although all of these areas address important developmental tasks during the toddler period, safety is the highest priority at this age because the child has increased dexterity, mobility, and determination and is becoming more independent. PTS: 1 CON: Growth and Development 5. ANS: 4 Chapter: Chapter 9 Life Span: Infancy Through Middle Adulthood Objective: Identify common health problems seen in each stage of development. Page: 186 (V1) Heading: Common Health Problems of Middle Adults Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Growth and Development Difficulty: Moderate Feedback 1 This is incorrect. There is a normal decrease in skin moisture and muscle tone in middle adulthood. 2 This is incorrect. The perimenopausal period occurs during this time, hallmarked by hot flashes and night sweats. 3 This is incorrect. A decrease in physical strength is not unexpected for the middle adult; the presence of pain or weakness not associated with activity would prompt further assessment. 4 This is correct. Memory in middle adulthood should remain intact, and the nurse

will perform additional assessment to determine if the client’s memory loss is normal or abnormal. PTS: 1 CON: Growth and Development 6. ANS: 4 Chapter: Chapter 9 Life Span: Infancy Through Middle Adulthood Objective: Discuss the cognitive and psychosocial challenges for each age group, infant through middle age. Page: 182 (V1) Heading: Interventions (Adolescents) Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Growth and Development Difficulty: Moderate Feedback 1 This is incorrect. During the teen years, the relationships among peers strengthen and strongly influence adolescent behavior. Although the parents typically still maintain influence on the core values in the home, teens seek peers’ opinions for matters about social life or concerns of everyday living. 2 This is incorrect. As teens are developmentally concerned with appearance and social relationships, there can be an overemphasis on body image, leading to obesity and eating disorders. 3 This is incorrect. Motor vehicle accidents are a leading cause of death among teenagers, typically because of distractibility, inattention, impulsiveness, and inexperience in various driving situations. 4 This is correct. Concerns about alcohol intake during adolescence are the highest priority, whether or not alcohol is kept in the house. Alcohol-related injuries and death are risks that should be avoided in every circumstance. Not having alcohol in the house does not guarantee that the teenager will not consume it with friends. PTS: 1 CON: Growth and Development 7. ANS: 3 Chapter: Chapter 9 Life Span: Infancy Through Middle Adulthood Objective: Discuss the cognitive and psychosocial challenges for each age group, infant through middle age. Page: 181 (V1) Heading: Assessment (Adolescents) Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing]

Concept: Growth and Development Difficulty: Moderate Feedback 1 This is incorrect. School-age children need to receive positive reinforcement for accomplishments and desired behavior, such as being good students. However, this may not be the priority concern for the adolescent. 2 This is incorrect. Although a small number of preadolescents are sexually active, it is not the major focus for this age; however, sexual activity increases with the age of the adolescent. 3 This is correct. The developmental task during adolescence is to establish personal identity. Socially, preteens and teens are driven by the need to belong to a group (e.g., be on the soccer team). 4 This is incorrect. Adolescents may desire and seek some level of independence; however, functioning independently is primarily a task for the young adult. PTS: 1 CON: Growth and Development 8. ANS: 3 Chapter: Chapter 9 Life Span: Infancy Through Middle Adulthood Objective: Discuss the cognitive and psychosocial challenges for each age group, infant through middle age. Page: 153 (V1) Heading: Psychosocial Development Theory Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Growth and Development Difficulty: Moderate Feedback 1 This is incorrect. During the middle years, many adults are realistic and insightful about age-related physical and emotional changes. Others experience difficulty coping with passing youth and advancing age. 2 This is incorrect. Accepting death as part of the continuum of life is a task for the older adult. 3 This is correct. Generativity versus stagnation is the stage Erikson describes for the middle-aged adult. During this stage, a mature adult wishes to make a contribution. The middle-aged adult either continues to gain skills, be productive, and pass on his or her knowledge to the next generation or stagnates. 4 This is incorrect. Developing meaningful relationships is a task most characteristic of the young adult. PTS: 1 9. ANS: 3

CON: Growth and Development

Chapter: Chapter 9 Life Span: Infancy Through Middle Adulthood Objective: Discuss the cognitive and psychosocial challenges for each age group, infant through middle age. Page: 169 (V1) Heading: Preschool Age: Ages 4 and 5 Years Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Growth and Development Difficulty: Moderate Feedback 1 This is incorrect. The imagination of a preschool-age child is typically active, whereby they have fears of mythical figures, such as monsters. 2 This is incorrect. Preschool-age children have a limited ability to understand the concept of time or to tell time. 3 This is correct. Preschoolers’ eye–hand coordination develops markedly during this period. They can hop on one foot, skip, and begin to learn to skate. 4 This is incorrect. A preschooler has the ability to consider simple viewpoints of other people. PTS: 1 CON: Growth and Development 10. ANS: 4 Chapter: Chapter 9 Life Span: Infancy Through Middle Adulthood Objective: Describe special assessments unique to each age group. Page: 163 (V1) Heading: Assessment (Infant) Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Growth and Development Difficulty: Moderate Feedback 1 This is incorrect. Cruising usually occurs around 8 to 12 months. This development may or may not be present. 2 This is incorrect. At about 7 to 10 months, a child begins to crawl. This development may or may not be present. 3 This is incorrect. Infants develop a pincer grasp around 10 months. It is not expected for the infant to have this development. 4 This is correct. At 7 months, most children can sit up by themselves. This is an assessment for a definite development skill. PTS:

CON: Growth and Development

11. ANS: 1 Chapter: Chapter 9 Life Span: Infancy Through Middle Adulthood Objective: Describe special assessments unique to each age group. Page: 163 (V1) Heading: EXAMPLE PROBLEM: Abuse, Neglect, and Violence Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Growth and Development Difficulty: Difficult

3 4

Feedback This is correct. Negative comments or comparisons with another child can be an indicator of or potential for child abuse. The nurse needs to determine whether this is an actual problem. This is incorrect. Head lice are a common health problem among children of this age group because of close physical contact during play. The parent seems to have a healthy attitude about the infestations and to be knowledgeable about the treatment. This is incorrect. Imaginary play, magical thinking, and belief in mythical figures are normal at age 5 years. This is incorrect. A child this age will normally imitate adults, especially the same-sex parent.

PTS: 1 CON: Growth and Development 12. ANS: 3 Chapter: Chapter 9 Life Span: Infancy Through Middle Adulthood Objective: Compare and contrast developmental task theory, psychoanalytic theory, cognitive theory, and the psychosocial theory of growth and development. Page: 153 (V1) Heading: Psychosocial Development Theory Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Growth and Development Difficulty: Moderate

1 2

Feedback This is incorrect. Mother–infant attachment is complex and involves all senses —not simply hearing the mother talk to him. This is incorrect. There are physical and emotional benefits to breastfeeding, but it is not necessary for mother–infant attachment.

This is correct. Because the infant is totally dependent on the parents, quickly responding to cries promotes attachment and trust. Although all options may promote attachment, they are not absolutely necessary for bonding to occur. This is incorrect. Sleeping in the same room may help the parent respond more quickly to the infant’s needs but is not the basis for attachment.

PTS: 1 CON: Growth and Development 13. ANS: 3 Chapter: Chapter 9 Life Span: Infancy Through Middle Adulthood Objective: Identify common health problems seen in each stage of development. Page: 172 (V1) Heading: School-Age: Ages 6 to 12 Years Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Growth and Development Difficulty: Moderate Feedback 1 This is incorrect. The identified group of children may be just starting puberty, so sexual activity is still not usual. This is not the most important topic for the nurse to present. 2 This is incorrect. The discussion of appropriate food choices should be conducted periodically throughout the child’s developmental stages; it is not specific or limited to age 10 to 12 years. 3 This is correct. All are important topics to discuss with school-age children, but children of this age are very active, and injuries are common. Motor vehicle accidents are a common cause of injury. 4 This is incorrect. The preteen years are particularly important for adequate sleep and rest primarily because of the physical changes, active social lives, and increasingly complex demands on their lives. However, this is not the most important topic for the nurse to present. PTS: 1 CON: Growth and Development 14. ANS: 1 Chapter: Chapter 9 Life Span: Infancy Through Middle Adulthood Objective: Describe special assessments unique to each age group. Page: 184 (V1) Heading: Young Adulthood: Ages 19 to 40 Years Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Growth and Development

Difficulty: Difficult Feedback 1 This is correct. Striving to be self-sufficient and successful and to establish a career and family are the tasks for this age. These tasks are demanding and can be emotionally difficult and potentially cause depression. Untreated depression is a leading cause of death among young adults. 2 This is incorrect. Sexually transmitted infections are a risk for this age group but are not as severe a threat as is depression. 3 This is incorrect. Exercise is important to overall health but is not a source of stress; however, it is not the most important question to ask. 4 This is incorrect. There are genetic health problems that can impact the client, but the question is asking about psychosocial development and common health problems. PTS: 1 CON: Growth and Development 15. ANS: 3 Chapter: Chapter 9 Life Span: Infancy Through Middle Adulthood Objective: Describe special assessments unique to each age group. Page: 158 (V1) Heading: The Neonatal Period: Birth to 28 Days Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Growth and Development Difficulty: Moderate Feedback 1 This is incorrect. Stroking the bottom of the foot is not an assessment of circulation to the feet. 2 This is incorrect. The neuromuscular system is not fully developed at birth, but reflexes are present. 3 This is correct. The Babinski reflex is elicited by stroking upward on the side of the sole of the foot. This is one of several reflexes that should be present at birth. 4 This is incorrect. Because an infant is not able to report sensation, which is a subjective finding, this is not the purpose of the nurse’s action. PTS: 1 CON: Growth and Development 16. ANS: 2 Chapter: Chapter 9 Life Span: Infancy Through Middle Adulthood Objective: Describe special assessments unique to each age group. Page: 185 (V1) Heading: Assessment (Young Adults) Integrated Processes: Nursing Process

Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Growth and Development Difficulty: Moderate Feedback 1 This is incorrect. Colon cancer screening starts at age 50 years or older for both males and females. 2 This is correct. Testicular self-exam can be introduced in early adolescence, due to risk of testicular cancer after puberty. Men need to perform monthly testicular exams until they are 40 years old or older. 3 This is incorrect. Prostate exams are part of an annual health exam for middle adults; there is no definitive reason to begin this screening for young adults. 4 This is incorrect. Even young adults should perform breast self-examination (although some practitioners question recommending it routinely). Whatever screening method is chosen, young adults, both male and female, do develop breast cancer; it is not a problem only for those past age 40. PTS: 1 CON: Growth and Development 17. ANS: 4 Chapter: Chapter 9 Life Span: Infancy Through Middle Adulthood Objective: Discuss the cognitive and psychosocial challenges for each age group, infant through middle age. Page: 173 (V1) Heading: Psychosocial Development of the School-Age Child Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Growth and Development Difficulty: Moderate Feedback 1 This is incorrect. Pride in showing off new skills and possessions is normal for all stages of development, particularly during the preschool period. 2 This is incorrect. Friendships are typically between those the same sex at this age. 3 This is incorrect. A value system does not start to develop until adolescence. 4 This is correct. Peers are increasingly more important to the school-age child. The child wants to have what his friends have. PTS: 1 CON: Growth and Development 18. ANS: 3 Chapter: Chapter 9 Life Span: Infancy Through Middle Adulthood Objective: Identify common health problems seen in each stage of development.

Page: 173 (V1) Heading: School-Age: Ages 6 to 12 Years Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Growth and Development Difficulty: Moderate Feedback 1 This is incorrect. If a nurse suspect child abuse, the nurse is legally responsible for reporting the observations; in this setting, suspicions will be reported to the nurse’s supervisor. 2 This is incorrect. The nurse can notify the physician, who is also obligated to report suspected abuse; however, it is not incorrect for the nurse to report to the supervisor. 3 This is correct. If the nurse suspects child abuse, the nurse is legally responsible for reporting any observations that support the suspicion. The nurse contacts the nurse’s supervisor and does not report the suspected abuse directly. 4 This is incorrect. The nurse does not continue to question the parent, which may cause the parent to become angry and leave the facility. This action places the child at greater risk. PTS: 1 CON: Growth and Development 19. ANS: 2 Chapter: Chapter 9 Life Span: Infancy Through Middle Adulthood Objective: Incorporate developmental principles into nursing care. Page: 162 (V1) Heading: Table 9-1: Havighurst’s Developmental Task Theory Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Growth and Development Difficulty: Difficult Feedback 1 This is incorrect. Havighurst does not support the idea that many infants and toddlers will lag behind in physical development. Instead, the theory supports a person moving through six life stages, each associated with a number of tasks that must be learned. 2 This is correct. Havighurst’s theory states failure to master a task leads to difficulty mastering future tasks and interacting with others. This is the information the nurse needs to convey to the parent of a toddler who is not meeting developmental expectations. 3 This is incorrect. Some young children may require additional time for

developmental tasks, such as, children who are born prematurely or experience serious illnesses or conditions. However, the scenario does not cite either of these causes. This is incorrect. The inability to meet developmental tasks is a matter of concern. Havighurst’s theory is based on the concept of a developmental task being “midway between an individual need and societal demand. It assumes an active learner interacting with an active social environment.”

PTS: 1 CON: Growth and Development 20. ANS: 1 Chapter: Chapter 9 Life Span: Infancy Through Middle Adulthood Objective: Outline the major principles involved in moral and spiritual development. Page: 154 (V1) Heading: Spiritual Development Theory Integrated Processes: Nursing Process Client Need: Psychological Integrity Cognitive Level: Analysis [Analyzing] Concept: Growth and Development Difficulty: Difficult Feedback 1 This is correct. Fowler’s Spiritual Development Theory recognizes six stages. Stages 0, 1, and 2 are closely associated with evolving cognitive abilities. In these stages, faith depends largely on the views expressed by parents, caregivers, and those who have significant influence in the life of the person. This is the information the nurse needs to share. 2 This is incorrect. Fowler’s stage 3 coincides with the ability to use logic and hypothetical thinking to construct and evaluate ideas. At this point, faith is largely a collection of conventional, unexamined beliefs. Fowler’s studies demonstrated that approximately one-fourth of all adults function at this level or lower. This principle is not applicable to children alone. 3 This is incorrect. Fowler’s stages 4, 5, and 6 represent increasing levels of refinement of faith. With each increase in level, there is decreasing likelihood that an individual can attain this stage of development. Fowler found that very few people achieve stage 6; it is not expected to be obtained by adolescence. 4 This is incorrect. The statement that parents without a personal understanding of faith will need professional assistance, is not part of Fowler’s Spiritual Development Theory. PTS: 1 CON: Growth and Development 21. ANS: 1 Chapter: Chapter 9 Life Span: Infancy Through Middle Adulthood

Objective: Discuss the cognitive and psychosocial challenges for each age group, infant through middle age. Page: 180 (V1) Heading: Adolescent Pregnancy Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Growth and Development Difficulty: Difficult Feedback 1 This is correct. In this item, safety is the first concern. The mother needs education about the dangers of shaking the baby. Abusive head trauma (AHT), formerly known as “shaken-baby syndrome,” is a form of child abuse that causes severe brain injury. However, in this item, it appears that the mother is open and honest about her concerns and does not know the dangers of shaking the baby. 2 This is incorrect. Further assessment and questioning are indicated prior to reporting child abuse. 3 This is incorrect. It is most important to first teach the mother the dangers of shaking the baby; then, the nurse can proceed with offering suggestions on managing a crying baby. 4 This is incorrect. In incidences of adolescent pregnancy and parenthood, the presence of a significant other is commonly missing. The nurse needs to concentrate on teaching the mother safe and effective parenting skills. PTS: 1 CON: Growth and Development 22. ANS: 4 Chapter: Chapter 9 Life Span: Infancy Through Middle Adulthood Objective: Incorporate developmental principles into nursing care. Page: 169 (V1) Heading: Assessment (Toddlerhood) Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Growth and Development Difficulty: Moderate Feedback 1 This is incorrect. Toddlers are too young to understand verbal explanations about the physical examination. 2 This is incorrect. Toddlers are attempting to exercise some level of independence and cannot be expected to control the pace of the examination. The nurse needs to complete assessment tasks in a timely manner while

promoting calmness in the toddler. This is incorrect. Parents are encouraged to relieve their child’s stress and anxiety by holding the child during the examination and speaking to the child in a calm and reassuring voice. Asking the parents to leave the examination room will intensify the child’s anxiety and decrease cooperation. This is correct. When performing an assessment on a toddler, the nurse must be sensitive to the fact that children of this age are generally fearful of strangers. Thus, before beginning an assessment, the nurse needs to establish a rapport with the child. To do so, the nurse might engage in play, for example, playing catch with a ball.

PTS: 1 CON: Growth and Development 23. ANS: 1 Chapter: Chapter 9 Life Span: Infancy Through Middle Adulthood Objective: Discuss the cognitive and psychosocial challenges for each age group, infant through middle age. Page: 154 (V1) Heading: Moral Development Theory: Gilligan Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Growth and Development Difficulty: Moderate Feedback 1 This is correct. Suspected child abuse and elder abuse must be reported to the appropriate agency, according to federal and state laws. Reporting spousal abuse may be mandatory, depending on the state law. The Joint Commission requires that all cases of possible abuse or neglect be immediately reported in the hospital. If a patient discloses domestic violence, act immediately. Ask the patient whether she would like you to contact the agency’s domestic violence advocate (if there is one). If not, provide contact information for community domestic violence programs. 2 This is incorrect. When the nurse states that the issues are between the client and the spouse, the nurse essentially indicates that abuse is a personal problem that is not a concern of the nurse. Offering the services of a social worker may or may not be useful. 3 This is incorrect. Initially, the time frame of abuse is not the most important information; the client needs someone who can offer safety measures. 4 This is incorrect. It is true that the client may need to be examined by the physician for injuries; however, the nurse needs to obtain a support person for the client first.

PTS: 1 CON: Growth and Development 24. ANS: 3 Chapter: Chapter 9 Life Span: Infancy Through Middle Adulthood Objective: Discuss the principles of growth and development. Page: 185 (V1) Heading: Physical Development of Middle Adults Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Growth and Development Difficulty: Easy Feedback 1 This is incorrect. Graying hair, decreasing muscle tone, decreasing bone mass, and decreasing elasticity of blood vessels are physiological changes in this age group; however, the principal change in a woman in this age group is menopause. 2 This is incorrect. Breast cancer is a common health problem but not an expected or principal change in this age group. 3 This is correct. One of the principal changes that middle-aged women experience is menopause, the cessation of menstrual periods for at least 12 months. Some symptoms include hot flashes, a decrease in breast size, nighttime awakenings, and mood swings. However, each patient is different and experiences different symptoms. 4 This is incorrect. Mood swings may be related to menopause; however, this manifestation is not a principal change. PTS: 1 CON: Growth and Development 25. ANS: 2 Chapter: Chapter 9 Life Span: Infancy Through Middle Adulthood Objective: Discuss age-appropriate interventions for each age group. Page: 176 (V1) Heading: Psychosocial Development of Adolescents Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Growth and Development Difficulty: Difficult Feedback 1 This is incorrect. Confidentiality is important in this age group; however, if there is concern about suicide, explain to the adolescent that you are required to share this information with others, including mental health specialists and his parents. Contacting the parents is important, but the first action is to make a mental

health referral. This is correct. Depression affects up to 8.3% of adolescents in the United States, and the percentage may be even higher. Adolescents who report feeling sad or hopeless almost every day for more than 2 weeks usually stop doing some activities they used to consider fun. Additionally, they may have difficulty identifying and describing their emotional or mood states. In this item, the male is expressing how he feels. He is also describing a severe depressive state by stating, “I do not want to go on.” The nurse must be alert to this and immediately intervene by making a mental health referral, as this male is at high risk for suicide. This is incorrect. The information in this scenario indicates the adolescent is beyond the stage of learning about coping strategies. The nurse needs to recognize the risk of suicide and initiate interventions to protect the adolescent and others. This is incorrect. Contacting the adolescent’s teachers is unnecessary and can be considered a breach in confidentiality.

PTS:

CON: Growth and Development

MULTIPLE RESPONSE 26. ANS: 1, 2, 4 Chapter: Chapter 9 Life Span: Infancy Through Middle Adulthood Objective: Identify common health problems seen in each stage of development. Page: 177 (V1) Heading: Common Health Problems of Adolescents Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Growth and Development Difficulty: Difficult

1. 2. 3.

Feedback This is correct. Appropriate teaching topics to prevent obesity in adolescents include eating smaller portions and maintaining a well-balanced diet. This is correct. Appropriate teaching topics is aimed at teaching the adolescent to identify and select healthier snacks. This is incorrect. During a development stage in which adolescents strive for independence, avoid highly restrictive diets that forbid favorite foods (e.g., fast foods, sodas). This is correct. Appropriate teaching topics to prevent obesity in adolescents include avoiding sedentary lifestyles by adhering to an exercise program.

This is incorrect. Following diet trends may be effective for short-term weight loss but does not lead to sustained weight maintenance.

PTS: 1 CON: Growth and Development 27. ANS: 3, 4 Chapter: Chapter 9 Life Span: Infancy Through Middle Adulthood Objective: Identify common health problems seen in each stage of development. Page: 177 (V1) Heading: Common Health Problems of Adolescents Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Growth and Development Difficulty: Difficult

1. 2. 3.

Feedback This is incorrect. Condoms alone are not a fail-proof method of avoiding pregnancy or STIs. This is incorrect. STIs can be transmitted orally; oral sex still requires the use of a condom. This is correct. Sexual experimentation is common among teenagers. STIs, including HIV/AIDS, and pregnancy are major health consequences associated with sexual activity, especially with unprotected sexual activity. This is correct. Use of condoms and safe sex practices are essential in preventing the unwanted consequences of sexual activity. However, condoms are not 100% effective in preventing either STIs or pregnancy. This is incorrect. STIs can be transmitted during oral or anal sex.

PTS: 1 CON: Growth and Development 28. ANS: 1, 2, 4, 5 Chapter: Chapter 9 Life Span: Infancy Through Middle Adulthood Objective: Discuss age-appropriate interventions for each age group. Page: 170 (V1) Heading: Psychosocial Development of Preschoolers Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Growth and Development Difficulty: Difficult

Feedback This is correct. Verbal skills of a preschooler expands dramatically, and they are

2. 3.

4. 5.

increasingly interested in books and reading. This is correct. Psychosocially, the child at this age develops a conscience and readily recognizes right from wrong. This is incorrect. Preschoolers do lack the ability to reason formally and are unable to understand that two objects that appear different may, in fact, be the same, for example, ice and water. This is correct. Preschoolers are interested in counting and are willing to readily share information about their accomplishments and independence. This is correct. Preschoolers age 4 to 5 years become increasingly verbal and independent but are also interested in learning.

PTS: 1 CON: Growth and Development 29. ANS: 1, 2 Chapter: Chapter 9 Life Span: Infancy Through Middle Adulthood Objective: Discuss age-appropriate interventions for each age group. Page: 175 (V1) Heading: Helping the Hospitalized Child Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Analysis [Analyzing] Concept: Growth and Development Difficulty: Difficult

3. 4. 5.

Feedback This is correct. School-age children are bothered by separations from family and friends and by the loss of control over their personal needs. Hospitalized children may fear the unknown, the strange environment, and strange professionals. The nurse can help by maximizing their contact with friends and school. This is correct. They report missing the comforts of home, their mother’s cooking, their own room, and so on. Encourage parents to bring familiar items from home to personalize their space. This is incorrect. Offer children choices, when possible, to restore some sense of control. For example, allow them to express meal preferences or times for bathing. This is incorrect. Involve parents in their care as much as possible, and provide the parents with accurate information so that they can relieve the child’s anxieties. This is incorrect. Pretend play is an effective way to decrease anxiety in preschoolage children. The school-age child would not likely to be interested in this intervention.

PTS: 1 CON: Growth and Development 30. ANS: 2, 3 Chapter: Chapter 9 Life Span: Infancy Through Middle Adulthood

Objective: Discuss the cognitive and psychosocial challenges for each age group, infant through middle age. Page: 176 (V1) Heading: Psychosocial Development of Adolescents Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Growth and Development Difficulty: Difficult

2. 3. 4.

Feedback This is incorrect. One of the strongest needs for teens is to feel accepted within a group of their own choosing. Acceptance on a sports team, in a club, or in a clique increases the teen’s sense of self-esteem. Additionally, adolescents may engage in the trend of body art and piercings for a number of reasons, including a desire for social bonding, desire to look like their peers, and the wish to commemorate a friend or loved one. Therefore, tattoos and piercings are not necessarily an indication of low self-esteem. This is correct. Tattoos and piercings can be a source of blood-borne diseases, such as HIV and hepatitis, and parents and teens should be educated about this. This is correct. Tattoos and piercings can cause skin infections, and parents and teens should be educated about this. This is incorrect. Although studies have reported a significant relationship between piercing and substance abuse, leading some to speculate that body piercing may serve as a marker of an at-risk teen, most teens who have tattoos and piercings do not have a substance abuse problem. This is incorrect. The decision to obtain body piercing and/or tattoos is not necessarily an indication of psychosocial problems.

PTS: 1 CON: Growth and Development 31. ANS: 3, 4 Chapter: Chapter 9 Life Span: Infancy Through Middle Adulthood Objective: Discuss the cognitive and psychosocial challenges for each age group, infant through middle age. Page: 183 (V1) Heading: Other Health Promotion Activities Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Growth and Development Difficulty: Difficult

4. 5.

Feedback This is incorrect. Listening to the radio can be a distraction while driving, but not to the same degree of high risk as texting and drinking. Changing channels while driving is a greater risk because it involves taking eyes off the road. This is incorrect. Talking to other people in the car while driving is commonly not a distraction, provided the conversation is low key and does not include “horsing around.” Texting and drinking pose a higher degree of risk. This is correct. In the United States, 77% of all deaths among young people age 10 to 25 years result from four causes; motor vehicle crashes are responsible for 30% of these. Texting while driving poses a high risk for accidents. This is correct. Many adolescents engage in behaviors that increase the risk for and likelihood of death or injury, including driving and drinking. This is incorrect. Eating snacks while driving may or may not be a cause of accidents. The type of snacks is a consideration. Nonmessy finger foods may not be a problem, but eating messy foods can definitely contribute to accidents. Texting and drinking are the higher-risk activities.

PTS: 1 CON: Growth and Development 32. ANS: 1, 2, 4 Chapter: Chapter 9 Life Span: Infancy Through Middle Adulthood Objective: Identify common health problems seen in each stage of development. Page: 186 (V1) Heading: Common Health Problems of Middle Adults Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Difficulty: Difficult

3. 4.

Feedback This is correct. Obesity, diabetes mellitus, hypertension all increase the incidence of cardiovascular disease. Health promotion and health screenings should be conducted in all these areas. This is correct. In middle adulthood, chronic diseases emerge as a major health problem. One of the most common is cancer, especially cancers of the lung, breast, colon, and prostate. Health promotion and health screenings should be conducted in all these areas. This is incorrect. Alcoholism is a health problem in many age groups, but it is not classified as a major health problem among middle-aged adults. This is correct. Obesity becomes a higher risk to the health of the middle-aged adult because of a likelihood of decreased physical activity, along with some physiological changes, such as arthritis. This is incorrect. Sports injuries are not classified as a major health problem among

middle-aged adults; playing competitive and contact sports is not common in this age group. PTS:

CON: Growth and Development

Chapter 10. Life Span: Older Adults Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse works at a geriatric clinic. The nurse recognizes which situation as the most common major challenge for older adults? 1. Dealing with the needs of their children 2. Chronic health problems causing loss of independence 3. Loss of the ability to reminisce about the past 4. Decline of intellectual abilities 2. The nurse is interviewing an older adult client who verbally expresses a personal dilemma about staying in the client’s own home or seeking residence in an age-friendly residence. Which information does the nurse seek to determine if the client is suited to this type of change? 1. The financial status of the client to relocate 2. The support available from the client’s family 3. The client’s ability to live closely with others 4. The current level of the client’s independence 3. Which factor reflects the nurse’s understanding of the characteristics of older adults? 1. Fewer than 5% of all older adults live in nursing homes. 2. Average life expectancy at birth has declined slightly during the past 10 years. 3. In general, males tend to live longer than do females. 4. Black men have the lowest life expectancy, but the gap decreases as a person ages. 4. A white female patient who is 75 years of age states, “I’ve heard that women live to an older age than men. My husband and I are the same age, so I am afraid I will have to spend some years without him. This really worries me.” Which answer by the nurse is based on correct information? 1. “That is a realistic concern as women do have a longer life expectancy than men. But many things can happen to change that.” 2. “You need not worry because both you and your husband are white. That statistic is true only for black men and women.” 3. “It is true that women have a longer life expectancy at birth. However, life expectancy measured at age 65 is almost the same for both sexes. You are both well past 65.” 4. “That is true only in certain geographical areas, such as those with a high population of newly retired persons.” 5. The home care nurse suspects physical and emotional abuse of an adult client identified as middleold. Which is the primary nursing intervention for an older adult who is a victim of abuse? 1. Assess the scope of the problem. 2. Analyze the family dynamics. 3. Ensure the safety of the victim.

4. Teach the victim coping skills. 6. Which nursing intervention is most helpful for an older adult client with dementia who exhibits moderate to severe cognitive impairment? 1. Attempt the application of humor to elevate the client’s mood. 2. Explore reasons for the client’s altered cognitive function. 3. Increase environmental stimuli to redirect the client’s attention. 4. Use reminiscence so the client recalls memories and maintains social interaction. 7. A couple who is considered middle-old adults is moving out of state to be closer to family members. Which residence is considered most appropriate for this couple? 1. Second story apartment with safety bars in the bathrooms 2. Small two-bedroom home close to a shopping center and a church 3. One-level living area condominium with good lighting inside and outside 4. Two-level living area condominium close to family members 8. The nurse is preparing a presentation for older adults regarding alternative living options. Which best describes an assisted living facility (ALF)? 1. Residence that provides 24-hour supervision and assistance with scheduled and unscheduled activities 2. An aging-in-place residence that provides services to meet the increasing needs of the resident 3. A facility that provides skilled and nonskilled nursing services to residents with disabilities 4. Residence that accepts only Medicare and Medicaid for persons 65 years and older 9. The nurse is planning a teaching workshop at the local community center for a group of men and women who are considered young-old. Which information is most important for the nurse to include at the workshop? 1. A booklet on heart disease and diabetes 2. Planning leisure activities and exercise 3. How to stay connected with family members 4. A list of doctors in the community 10. A healthy client who is 80 years of age sees the nurse practitioner at the doctor’s office. The client states, “I sit around a lot, and now I notice my legs seem to get tired when I walk.” Which is the most appropriate response by the nurse? 1. “This indicates you don’t have as good circulation as you did when you were younger.” 2. “How do you feel about joining a regular exercise program at the senior center?” 3. “You will need to speak to the doctor about this; your age may cause health problems.” 4. “Have you thought about using a cane or a walker to help you get around better?”

11. The adult child of a patient who is 82 years of age tells the nurse, “When I ask my dad to do something, it takes him a long time to respond to me. But he does do what I ask.” Which is the most appropriate response by the nurse? 1. “At this age, your dad does not have the same intelligence he had when he was younger.” 2. “He may be embarrassed because it is difficult for him to learn new things at this age.” 3. “Reaction time slows in older adults, so it takes him more time to process your requests.” 4. “It is likely that some dementia is developing because this is a normal occurrence in his age group.” 12. The nurse in the local nursing home is planning a memory activity for the older adult residents. Which is the most effective activity the nurse might use to enhance memory? 1. Reading a book 2. Reading the newspaper 3. Baking a cake 4. Doing a crossword puzzle 13. The home health nurse is seeing a patient who is 80 years of age for the first time. In developing a home plan of care, which is the nurse’s highest priority for this visit? 1. Assessing the proximity of family members 2. Planning for provision of a nutritious diet 3. Planning activities for functional status 4. Assessing the home for environment safety 14. A patient who is 85 years of age is admitted through the emergency department for confusion and disorientation. The family states, “We don’t know what is wrong. He has been fine at home. This confusion just started 2 days ago and seems like it is getting worse.” What is the most appropriate first response for the nurse to make? 1. “We will have to place him in temporary restraints for safety purposes.” 2. “Can you tell me about his home medications and other illnesses he has?” 3. “Sometimes older people become more confused when they are away from home.” 4. “He is 85 years old, and this is the age when Alzheimer’s disease begins.” 15. The nurse is providing care for a 75-year-old patient on the medical-surgical unit. The patient states, “I hope I can go home soon. I want to get back to the gym. I like to do a little walking on the treadmill and lift some light weights.” Which response by the nurse demonstrates the use of ageism? 1. “That’s great. I should go to the gym more often myself.” 2. “Exercising is important, but concentrate on your illness for now.” 3. “At your age, you need to be careful with exercise and avoid injuries.” 4. “Follow up with your doctor on how much activity you can do when you get home.”

16. The nurse is interviewing a new client at the community geriatric clinic. The client is in the youngold age range but seems to have multiple issues with pain and physical functioning. The client states, “I have always been active and athletic. Now I hardly feel like doing anything because of pain.” Which theory of aging is the nurse likely to apply to the client? 1. Genetic theories 2. Wear and tear theory 3. Cellular malfunction 4. Autoimmune reaction Multiple Response Identify one or more choices that best complete the statement or answer the question. 17. A client is concerned about the age-related changes of the client’s mother, who is 80 years old. Which statements made by the client likely represent a normal change of aging? Select all that apply. 1. “My mother seems to get cold very easily.” 2. “My mother complains of her mouth being dry.” 3. “My mother goes around the house turning on all the lights.” 4. “My mother complains of urine leaking when she coughs.” 5. “My mother will only eat the food she personally prepares.” 18. A client who lives alone is very weak, stays in bed most of the time, and becomes fatigued after taking only two or three steps with a walker. The client’s personal hygiene is poor. The client moves very slowly even during performance of small tasks, such as eating a meal. Which are appropriate interventions for this patient? Select all that apply. 1. Arrange for a home aide to assist with activities of daily living. 2. Refer the client to a senior center for an adapted physical activity program. 3. Assess the patient for symptoms of depression and memory loss. 4. Arrange for nutritious meals to be delivered to the patient’s home. 5. Make arrangements for admission into an assisted care facility. 19. The nurse works in a geriatric clinic where Havighurst’s activity theory is applied to the clientele. The nurse recognizes which as the physical, cognitive, and social developmental tasks of older adults? Select all that apply. 1. Older adults and society gradually and mutually withdraw or disengage from each other. 2. The older adult accepts that life has had meaning and death is part of the continuum of life. 3. Older adults need to focus on adjusting to their decreasing physical strength and health. 4. The older adult accepts the need for establishing satisfactory physical living arrangements. 5. Older adults will need to adjust to retirement and the impact of a lower income on

living. 20. The nurse works as a home visiting nurse for older adult client. Which risk factors for physical abuse of this population does the nurse recognize? Select all that apply. 1. Socioeconomic status below the poverty level 2. Residence in low-income housing 3. Physical and mental impairment 4. Frequent visits to respite care 5. Deterioration as a young-old person 21. Many older adults suffer from chronic health problems. Which are the most common and costly chronic problems in the older adult? Select all that apply. 1. Heart disease 2. Diabetes 3. Alzheimer’s disease 4. Pneumonia 5. Obesity 22. The nurse is preparing to teach an older woman strategies to reduce the risk of osteoporosis. Which interventions does the nurse include as part of the teaching plan? Select all that apply. 1. Begin a daily walking regimen. 2. Take supplemental hormones. 3. Avoid cigarette smoking. 4. Increase calcium in the diet. 5. Start non–weight-bearing exercises. 23. The nurse practitioner is performing an annual physical examination on a female client who is 86 years old. Which assessments are most important for the nurse to include in the client’s examination? Select all that apply. 1. Height and weight 2. Papanicolaou (Pap) test 3. Colon cancer screening 4. Gait and balance 5. Screening mammogram 24. The nurse is aware that health promotion activities for all older adults include teaching about and facilitating for which immunizations? Select all that apply. 1. Pneumonia 2. Measles and mumps 3. Influenza 4. Herpes zoster 5. Varicella

25. The nurse suspects that an older adult patient may have difficulty hearing. Prior to validating a hearing problem, which strategies does the nurse use in communicating with this patient? Select all that apply. 1. Look directly at the patient when speaking. 2. Pace speech more slowly than usual. 3. Speak loudly toward the patient’s ears. 4. Allow some extra time for the patient to respond. 5. Rely on body language more than usual. 26. The home health nurse is developing a plan of care for a client who is 76 years of age. Which primary nursing goals does the nurse include in the plan of care? Select all that apply. 1. Maintain the patient’s independent functioning as much and for as long as possible. 2. Teach the patient and caregivers how and when to call for professional help. 3. Arrange for appropriate care and equipment that is needed in the home. 4. Teach the patient and family strategies to reduce caregiver role strain. 5. Provide information about community activities of interest to the older adult.

Chapter 10. Life Span: Older Adults Answer Section MULTIPLE CHOICE 1. ANS: 2 Chapter: Chapter 10 Life Span: Older Adults Objective: Discuss the developmental challenges for each older adult age group. Page: 197 (V1) Heading: Common Health Problems of Older Adults Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. During the older adult years, children often provide care for their aging parents. 2 This is correct. Older adults have many losses to deal with, including the development of chronic health concerns and loss of independence. 3 This is incorrect. Loss of short-term memory is more common than recollection of events involving long-term memory. Older adults have vivid memories of past events. 4 This is incorrect. Intellectual abilities do not become impaired with age; shortterm memory and reaction time decline. PTS: 1 CON: Patient-Centered Care 2. ANS: 4 Chapter: Chapter 10 Life Span: Older Adults Objective: Discuss the relationship of life expectancy and livable communities. Page: 192 (V1) Heading: Age-Friendly Residences Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Seeking information about the client’s financial status regarding relocation is not a nursing function. 2 This is incorrect. Whether or not the client has support from family is not information that impacts the client’s consideration about relocating to an age-

friendly residence. This is incorrect. Age-friendly residences may or may not require that the client live in close proximity with other residents. This information is not necessary for the nurse to acquire. This is correct. Age-friendly residences are designed to promote client safety and an environment in which the client can function most easily. The important information for the nurse to acquire is the level of the client’s independence. An inability to live independently may impact the type of residence the client considers.

PTS: 1 CON: Patient-Centered Care 3. ANS: 1 Chapter: Chapter 10 Life Span: Older Adults Objective: Identify common health problems seen in each group and for all older adults. Page: 190 (V1) Heading: Life Expectancy Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is correct. Only 3.3% of people aged 65 years and older live in nursing homes; this rises to 15% for those older than 85 years. 2 This is incorrect. In the United States, life expectancy at birth has risen dramatically: In 1900, average life expectancy was 49.2 years; in 2005, average life expectancy was 77.8 years. 3 This is incorrect. At age 65, white women led life expectancy with 20 additional years, followed closely by black women at 18.7 and white men at 17.2 years. Black men at age 65 had the lowest life expectancy at 15.2 years. 4 This is incorrect. The disparity in death rates for people of different races is less for older adults than younger ones. PTS: 1 CON: Patient-Centered Care 4. ANS: 3 Chapter: Chapter 10 Life Span: Older Adults Objective: Discuss the relationship of life expectancy and livable communities. Page: 190 (V1) Heading: Life Expectancy Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying]

Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is incorrect. The answer “That is a realistic concern ….” is only partially true. Women do have a longer life expectancy at birth, but that tends to almost disappear after men reach age 65, and it continues to lessen as they continue to age. 2 This is incorrect. The statistics are true for white people as well as black people. 3 This is correct. For infants born in 2005, the average total life expectancy for females is 80.4 years. Life expectancy measured at age 65 was nearly the same for men and women in 1900; however, women had a lead of about 3 years over men in 2005, narrowing the gap as men age. So the longer men live, the longer they will live. 4 This is incorrect. In-migration and out-migration have nothing to do with gender differences in life expectancy, although they do affect the population distribution within a state, for example. PTS: 1 CON: Patient-Centered Care 5. ANS: 3 Chapter: Chapter 10 Life Span: Older Adults Objective: Identify common health problems seen in each group and for all older adults. Page: 202 (V1) Heading: Elder Abuse Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Assessing the scope of the problem is an important and appropriate intervention, but the priority intervention is to assure the client is safe and cared for. 2 This is incorrect. Family dynamics are often involved in cases of elder abuse; however the nurse priority intervention is to assure the client’s safety and a level of appropriate care. 3 This is correct. Safety is a priority consideration for the clients who are experiencing abuse. 4 This is incorrect. The nurse understands the victim of abuse needs physical and psychological support and protection; coping skills are inappropriate when abuse is occurring. PTS:

CON: Patient-Centered Care

6. ANS: 4 Chapter: Chapter 10 Life Span: Older Adults Objective: Incorporate developmental principles of aging into nursing care. Page: 202 (V1) Heading: Table 10-2: Distinguishing the Changes of Typical Aging From Dementia Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. The client with dementia may not respond positively to the use of humor in an effort to elevate the client’s mood. 2 This is incorrect. The reasons for the client’s cognitive functioning are directly related to the diagnosis of dementia. Sudden dementia can be caused by dehydration, medications, and illness; however, the scenario does not mention these factors. 3 This is incorrect. Increasing environmental stimuli may increase the level of the client’s dementia. The client will most likely function best in a calm and quieter environment. 4 This is correct. For older clients with dementia, encouraging the act of reminiscence can be highly beneficial to their cognitive function and their interpersonal skills. Reminiscence involves exchanging memories with the caregivers and professionals and passing on information, wisdom, and skills. It aids the person with dementia in maintaining a sense of value, importance, and belonging. PTS: 1 CON: Patient-Centered Care 7. ANS: 3 Chapter: Chapter 10 Life Span: Older Adults Objective: Discuss the relationship of life expectancy and livable communities. Page: 191 (V1) Heading: Aging In Place and Alternatives Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. A second story apartment, even with safety bars in the bathroom, may or may not be the best residence for a middle-old couple. One exception may be the presence of an elevator, which is not mentioned in the

option. This is incorrect. A small two-bedroom home close to a shopping center and a church may or may not be the best residence choice. The scenario presented by this option does not provide enough specific information about the residence. This is correct. Elder-friendly residences should be safe and allow for daily interaction within a living environment for persons with normal changes in aging. However, the focus is on safety first. Features included in elder-friendly residences include ground-level entry or no-step entry, one-level living area, wide doorways, adequate lighting inside and outside, and grab bars, shower seats, and elevated toilets in the bathroom. The choice that is most appropriate for this couple is the one-level-living condominium with good lighting inside and out. This is incorrect. A two-level-living condominium close to family members has both positive and negative aspect. Thought having family members nearby is a positive aspect, two-level living is not best for a middle old couple because of safety.

PTS: 1 CON: Patient-Centered Care 8. ANS: 1 Chapter: Chapter 10 Life Span: Older Adults Objective: Discuss the relationship of life expectancy and livable communities. Page: 191 (V1) Heading: Aging in Place and Alternatives Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is correct. Assisted living facilities (ALFs) are congregate residential settings that provide or coordinate personal services, 24-hour supervision and assistance (scheduled and unscheduled), activities, and health-related services. 2 This is incorrect. ALFs are not aging-in-place environments. 3 This is incorrect. Nursing care facilities, or nursing homes, provide skilled and unskilled nursing care for older adults and adults with disabilities. 4 This is incorrect. Medicaid and Medicare are major sources of payment for nursing homes, with long-term care and private insurances supplementing the costs. PTS: 1 CON: Patient-Centered Care 9. ANS: 2 Chapter: Chapter 10 Life Span: Older Adults

Objective: Discuss age-appropriate interventions for older adults and for each group. Page: 194 (V1) Heading: Young-Old: Age 65 to 74 years Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is incorrect. By the time they reach age 65, young-old persons are already experiencing the effects of chronic illness that began in middle adulthood. Providing them with a pamphlet on heart disease and diabetes alone does not address other chronic illnesses prevalent in this age group. 2 This is correct. Persons 66 years old are in the young-old stage of older adulthood. Physical and psychological adaptations to retirement are paramount in this age group. One key indicator of well-being is use of leisure time. On an average day, young-old persons spend most of their time (57%) watching television, 18% in solitary activities, and 3% participating in sports, exercise, and recreation. 3 This is incorrect. Maintaining connections with family members is important, as is providing a list of doctors in the area; however, the most important focus for this specific age group is leisure time in retirement. 4 This is incorrect. A list of available doctors in the area may or may not be helpful to the young-old clients; however, this information is less important to the entire group than information about the importance of sports, exercise, and recreation. PTS: 1 CON: Patient-Centered Care 10. ANS: 2 Chapter: Chapter 10 Life Span: Older Adults Objective: Identify common health problems seen in each group and for all older adults. Page: 195 (V1) Heading: Middle-Old: Age 75 to 84 years Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is incorrect. Adapted Physical Activity (APA) programs are group exercise programs designed for persons with chronic illnesses; however, senior centers are beginning to offer APA programs as they update their programming and

3 4

prepare for the active “baby boomer” generation. Some health and fitness facilities may also offer senior health programs. This is correct. The most appropriate response by the nurse in this item is to address the fact that weakness is most likely the result of a sedentary lifestyle. The developmental challenge of middle-old persons is an increasingly solitary, sedentary lifestyle. This age group spends one-fourth of their leisure time in solitary activities, such as reading, relaxing, and thinking. They spend only 3% of their time participating in sports, exercise, and recreation. This is incorrect. Responding to this client with a comment regarding his age is ageism. This is incorrect. A cane or a walker may not be indicated if the client can begin an exercise program because this item is suggesting a problem with sedentary lifestyle.

PTS: 1 CON: Patient-Centered Care 11. ANS: 3 Chapter: Chapter 10 Life Span: Older Adults Objective: Identify common health problems seen in each group and for all older adults. Page: 195 (V1) Heading: Middle-Old: Age 75 to 84 years Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Older adults can learn new material, although more slowly. However, there is no loss of intelligence as a person ages. 2 This is incorrect. There is no indication in the scenario that indicates a need to learn something new. Older adults do possess the ability to learn. 3 This is correct. Reaction time slows in older adults, and short-term memory declines; it takes longer to respond to a stimulus, and it takes more time to process incoming information. 4 This is incorrect. Mentioning that dementia is likely to be developing because of age is an example of ageism and is inappropriate. PTS: 1 CON: Patient-Centered Care 12. ANS: 4 Chapter: Chapter 10 Life Span: Older Adults Objective: Incorporate developmental principles of aging into nursing care. Page: 200 (V1) Heading: Example Problem: Dementia

Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Reading a book is a leisure activity and may stimulate the brain, but it may not enhance memory. 2 This is incorrect. Reading the newspaper is a leisure activity and may stimulate the brain, but it may not enhance memory. 3 This is incorrect. Following a recipe for baking a cake may stimulate the brain, but following the steps in a recipe may not enhance thinking or memory. 4 This is correct. There are many factors that impact memory in the older adult. Research indicates that an active social life with complete engagement and participation in the community delays memory loss with aging. Regular mental exercise, such as doing crossword puzzles and engaging in conversation, appear to stimulate the brain and enhance memory. PTS: 1 CON: Patient-Centered Care 13. ANS: 4 Chapter: Chapter 10 Life Span: Older Adults Objective: Describe any special assessments unique to each group of older adults. Page: 206 (V1) Heading: Interventions for All Older Adults Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. It is important for the nurse to assess for the proximity of family members, or other support persons. The highest priority, however, is safety of the home. 2 This is incorrect. The nurse needs to assess the patient’s nutritional status and evaluate how the patient manages nutritional needs. The nurse may need to plan the provision of nutritious meals. However, the highest priority is safety of the home. 3 This is incorrect. Planning activities aimed at maintaining functional status is important; however, the highest priority is safety of the home. 4 This is correct. “Aging in place” means that as people age, they continue to live in their own residences and receive supportive services for their changing needs, rather than moving to another location or type of housing. Housing should be

elder friendly. The goal is a safe environment with accommodations to meet the normal changes of aging. The nurse’s highest priority is safety of the home. PTS: 1 CON: Patient-Centered Care 14. ANS: 2 Chapter: Chapter 10 Life Span: Older Adults Objective: Describe any special assessments unique to each group of older adults. Page: 199 (V1) Heading: Polypharmacy Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is incorrect. The use of restraints draws scrutiny from many accrediting bodies and should be used only with proper documentation to support the need and only after other methods have been exhausted or proved not useful. 2 This is correct. Polypharmacy is a risk factor for acute confusion, delirium, and depression in older adults, and there is growing research in the area of pharmacogenomics. In this item, the first and most appropriate response by the nurse is to ask about medications and other health issues that could be causing or contributing to the confusion. 3 This is incorrect. There are many factors, such as medication toxicity, sensory deficits, and some physiological problems, that contribute to confusion, delirium, and dementia in the older adult. Many of these factors are treatable once assessed and recognized. 4 This is incorrect. Alzheimer’s disease is not a condition exclusive to older adults, who are more likely to experience dementia. PTS: 1 CON: Patient-Centered Care 15. ANS: 3 Chapter: Chapter 10 Life Span: Older Adults Objective: Incorporate developmental principles of aging into nursing care. Page: 202 (V1) Heading: Ageism Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback

1 2

This is incorrect. Praising a patient for exercising is positive and supportive. This is incorrect. The reminder by the nurse to concentrate on getting well before concentrating on exercise is a neutral comment; it is neither negative nor positive. This is correct. Ageism is age-based discrimination. Negative expectations for older adults can cloud nursing assessments, planning, and interventions. The response in this item that is most indicative of ageism is use of the phrase “at your age.” This is a negative response by the nurse. This is incorrect. It is appropriate to tell a patient to check with the doctor for activity resumption upon discharge.

PTS: 1 CON: Patient-Centered Care 16. ANS: 2 Chapter: Chapter 10 Life Span: Older Adults Objective: Describe any special assessments unique to each group of older adults. Page: 194 (V1) Heading: Theories of Aging Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is incorrect. Genetic theories of aging propose that cells have a preprogrammed, finite number of cell divisions. Therefore, the time of death is determined at birth. The genetic messages within the various body cells specify how many times the cell can reproduce, thus defining the life of that cell. 2 This is correct. The wear and tear theory proposes that repeated insults and the accumulation of metabolic wastes eventually cause cells to wear out and cease functioning. The client is most likely to have pain and issues of physical functioning from being an athlete and being physically active. 3 This is incorrect. Cellular malfunction hypothesizes that a malfunction in the cell causes changes in cellular DNA, leading to problems with cell replication. The cellular malfunction can be the result of a chemical reaction with the DNA (cross-linking theory); an abundance of free radicals that damage cells and impair their ability to function normally (free radical theory); or, a buildup of toxins over time that causes cell death (toxin theory). 4 This is incorrect. Autoimmune reaction hypothesizes that cells change with age. Over time, the changes result in the immune system’s perceiving some cells as foreign substances and triggering an immune response to destroy the cells. PTS:

CON: Patient-Centered Care

MULTIPLE RESPONSE 17. ANS: 1, 2, 3 Chapter: Chapter 10 Life Span: Older Adults Objective: Discuss the developmental challenges for each older adult age group. Page: 195 (V1) Heading: Developmental Changes of Older Adults Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

3. 4. 5.

Feedback This is correct. The thinning of the layers of skin causes older adults to feel cold; however, this is a normal part of aging. With aging, the brown fat layer, which contributes to generating and maintaining body temperature, becomes thinner as well. This is not the same type of fat as adipose, which is a white fat layer. Additionally, older adults who are sedentary often feel cooler. This is correct. The elderly normally experience a decrease in saliva production, so although this is also a symptom of dehydration; dry mouth is a normal change of aging. This is correct. Visual acuity decreases with age, but this, too, is a normal part of aging. Brighter lighting helps with this problem. This is incorrect. Incontinence is not a normal part of aging and should be explored further. This is incorrect. Aging does not include a reluctance to eat food prepared by others; this behavior warrants exploration.

PTS: 1 CON: Patient-Centered Care 18. ANS: 1, 3, 4 Chapter: Chapter 10 Life Span: Older Adults Objective: Incorporate developmental principles of aging into nursing care. Page: 203 (V1) Heading: Assessing Functional Tasks Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

3. 4. 5.

Feedback This is correct. This client has the characteristics of frailty: low physical activity, muscle weakness, fatigue, and slowed performance. Clearly, the client is not able to perform activities of daily living (ADLs) adequately; therefore, a home aide is needed. This is incorrect. Adapted Physical Activity (APA) programs are designed for adults in better physical health, not for frail elders. The client would be unlikely to benefit from an APA program and probably could not even participate in such a group activity. This is correct. Depression and impaired mental abilities tend to accompany frailty, so it is important to assess those for this client. This is correct. Nutrition is essential to slow the progression of frailty, so having meals delivered is both appropriate and important. This is incorrect. The nurse needs to implement measures to improve the client’s condition and living needs. At some point, admission into an assisted care facility may need to be discussed; however, it is not appropriate for the nurse to independently begin the process.

PTS: 1 CON: Patient-Centered Care 19. ANS: 3, 4, 5 Chapter: Chapter 10 Life Span: Older Adults Objective: Discuss the developmental challenges for each older adult age group. Page: 197 (V1) Heading: Psychosocial Development of Older Adults Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

3. 4.

Feedback This is incorrect. The gradual and mutual withdrawal or disengagement of older adults and society is part of the disengagement theory developed by Cumming and Henry. This is incorrect. Erikson’s developmental theory identifies ego integrity versus despair as the task of the older adult. This stage of development has as its cornerstone the acceptance that one’s life has had meaning and that death is a part of the continuum of life. This is correct. Havighurst’s activity theory states that older adults need to adjust to decreasing levels of physical strength and health. This is correct. According to Havighurst’s activity theory, the older adult accepts the need for establishing satisfactory physical living arrangements.

This is correct. Older adults will need to adjust to retirement and the impact of a lower living income, according to Havighurst’s activity theory.

PTS: 1 CON: Patient-Centered Care 20. ANS: 1, 2, 3 Chapter: Chapter 10 Life Span: Older Adults Objective: Describe any special assessments unique to each group of older adults. Page: 202 (V1) Heading: Elder Abuse Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Moderate

1. 2. 3.

4. 5.

Feedback This is correct. Elder abuse is seen in all cultures and socioeconomic groups, but risk for physical abuse increases in clients who are of low income status. This is correct. Older adults who live in inadequate or unsafe housing are at greater risk for physical abuse. This is correct. Older adults who have physical, functional, or cognitive impairment, who experience mental illness, alcoholism, or drug abuse (in either the client or caregiver), or who are dependent on others are at greater risk for physical abuse. This is incorrect. Frequent visits to respite care do not increase the risk for physical abuse and, in fact, may be a determent. This is incorrect. Deterioration as a young-old person does not necessarily place the client at greater risk for physical abuse.

PTS: 1 CON: Patient-Centered Care 21. ANS: 1, 2 Chapter: Chapter 10 Life Span: Older Adults Objective: Identify common health problems seen in each group and for all older adults. Page: 197 (V1) Heading: Common Health Problems of Older Adults Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

Feedback This is correct. There are 10 leading causes of death among older Americans. Six of

3. 4.

the seven leading causes of death among older adults are chronic diseases; of these, heart disease, cancer, stroke, and diabetes are the most costly health conditions. This is correct. Diabetes is a common and costly health condition in older adults. The condition can be prevented or modified with therapeutic lifestyle changes. However, the cumulative effects of condition over time can be severely damaging. This is incorrect. Alzheimer’s disease is, unfortunately, most common in younger or young-old clients. Older clients are more likely to develop age-related dementia. This is incorrect. Pneumonia is a diagnosis that is not exclusive to the older client. Children and adults with chronic obstructive pulmonary disease (COPD) are prone to pneumonia. This is incorrect. Obesity is a condition found across the life span and is not exclusive to the older adult. However, obesity can be a precursor to other diseases and conditions that can worsen over time.

PTS: 1 CON: Patient-Centered Care 22. ANS: 1, 3, 4 Chapter: Chapter 10 Life Span: Older Adults Objective: Identify common health problems seen in each group and for all older adults. Page: 197 (V1) Heading: Common Health Problems of Older Adults Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

2. 3. 4.

Feedback This is correct. The risk for osteoporosis increases with age and is much greater for women, in part because of their decreased bone density compared with that of men. Weight-bearing activity, such as walking, will stimulate bone density. This is incorrect. There is some controversy around the use and overuse of hormone supplements, and their use is not necessarily recommended. This is correct. Cigarette smoking increases the risk for osteoporosis, and women need to become nonsmokers early in adult life to decrease the risk. This is correct. An adequate dietary intake of calcium is an important way to decrease the risk of osteoporosis; however, women should take calcium supplements in addition to dietary calcium early in adult life. This is incorrect. Non–weight-bearing exercises are not helpful for reducing the risk of osteoporosis. It is the bone stimulation from weight-bearing activities that increases bone density.

PTS:

CON: Patient-Centered Care

23. ANS: 1, 4 Chapter: Chapter 10 Life Span: Older Adults Objective: Discuss age-appropriate interventions for older adults and for each group. Page: 202 (V1) Heading: Assessment for All Older Adults Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

2. 3.

4. 5.

Feedback This is correct. It is recommended that all older adults have an annual physical examination. The exam for the oldest-old adult should include the same categories as in middle adulthood, as well as screening for mood, cognition, and ability to perform ADLs. Height and weight are measured to screen for osteoporosis, chronic illness, diet, and appetite. This is incorrect. At this time, a Pap test is not generally recommended for women past 65 years old. This is incorrect. The U.S. Preventive Services Task Force (USPSTF) recommends screening for colorectal cancer beginning at age 50 years and continuing until age 75 years. This is correct. Gait and balance are assessed for functional status such as ability to perform ADLs and safety. This is incorrect. Screening mammograms are not recommended for a woman of 86 years of age. However, if pain, lumps, or nipple discharge occurs, a diagnostic test is warranted.

PTS: 1 CON: Patient-Centered Care 24. ANS: 1, 3, 4, 5 Chapter: Chapter 10 Life Span: Older Adults Objective: Discuss age-appropriate interventions for older adults and for each group. Page: 207 (V1) Heading: Illness Prevention Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

Feedback This is correct. Health promotion activities for all older adults include teaching and

3. 4.

facilitating immunizations for pneumonia. The vaccine is a two-step process required only once in a lifetime. This is incorrect. Immunizations against measles and mumps is not recommended or required for older adults; these immunizations are most likely to be given in childhood. This is correct. It is recommended that older adults receive a yearly immunization against influenza. Influenza can be fatal in both the older and younger populations. This is correct. It is recommended that older adults receive a two-step immunization for herpes zoster (shingles). Shingles is most common in older adults and is restricted to those who had chicken pox. The previous one-step immunization is determined to be less effective. This is correct. It is recommended that older adults who never had varicella (chicken pox) receive the varicella immunization to prevent the disease. A history of varicella puts the older adult at risk for developing herpes zoster later.

PTS: 1 CON: Patient-Centered Care 25. ANS: 1, 2, 4, 5 Chapter: Chapter 10 Life Span: Older Adults Objective: Incorporate developmental principles of aging into nursing care. Page: 207 (V1) Heading: Communicating With Older Adults Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

2. 3.

Feedback This is correct. Many normal changes of aging affect communication with older adults. However, do not assume that all older adults are deaf or that they do not understand the meaning of your communication. Check for sensory deficits at the beginning of your interaction. Until you know there is no hearing deficit, look at the patient as you speak to allow for lip reading. This is correct. Older adults tend to process information more slowly, so speak slowly and clearly. This is incorrect. Speaking loudly into the older adult’s ears may or may not be helpful. When an older adult has hearing issues, it is more effective to use a deeper tone at a normal volume. This is correct. Older adults may or may not have hearing problems, but they may process information more slowly. The nurse needs to give the older adult more time to process and form an answer. This is correct. If the nurse suspects a hearing deficit, it is helpful for the nurse to

rely on body language more than usual. PTS: 1 CON: Patient-Centered Care 26. ANS: 1, 2, 3 Chapter: Chapter 10 Life Span: Older Adults Objective: Discuss age-appropriate interventions for older adults and for each group. Page: 205 (V1) Heading: Outcomes/Evaluations (All Older Adults) Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

1. 2.

3. 4.

Feedback This is correct. Nursing goals for all older adults should be to maintain the person’s ability to function as independently as possible for as long as possible. This is correct. A nursing goal for all older adults needs to include information about when clients and caregivers need to call for professional help and how they can reach the appropriate professional. This is correct. A nursing goal for all older adults is to arrange for appropriate care and equipment, as needed. This is incorrect. One cannot assume that there will be caregiver role strain or that the patient needs home care. Additionally, this is not a nursing goal for all older adults. This is incorrect. Providing information about community activities of interest to the older adult is not an appropriate nursing goal and may not be appropriate for all older adults.

PTS:

CON: Patient-Centered Care

Chapter 11. Experiencing Health & Illness Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse is aware the client’s risk of breast cancer is dramatically increased because both her sister and her mother had breast cancer. Which of the multidimensional aspects of health does this scenario illustrate? 1. Personal relationships 2. Biological factors 3. Lifestyle choices 4. Environmental factors 2. The nurse uses the concept of the wellness–illness continuum for developing a nursing plan of care. Which plan for a chronically ill patient does the nurse select? 1. Educate the patient about every possible complication associated with the specific illness. 2. Encourage positive health characteristics within the limits of the specific illness. 3. Limit activities because of the progressive deterioration associated with chronic illnesses. 4. Recommend activity beyond the scope of tolerance to prevent early deterioration. 3. The nurse works at a busy trauma center and needs to establish a relationship of caring, respect, and understanding with clients during a time of extreme physical and emotional stress. Which behavior from the nurse is most likely to convey a sense of compassion? 1. Extend kindness to the client and family. 2. Display competency during procedures. 3. Provide a healing presence. 4. Remain professionally aloof. 4. The nurse is providing care for client who is 76 years of age and experiencing chronic illness related to genetic-linked anemia. The client does not eat a balanced diet and admits preferring sweets to meat and vegetables. Which dimension of health is the nurse most likely to influence with teaching and counseling? 1. Age-related changes 2. Genetic anemia 3. Eating habits 4. Gender-related issues 5. The nurse recognizes which type of loss as being most common among patients who are hospitalized for complex health conditions? 1. Privacy 2. Dignity 3. Functional

4. Identity 6. The nurse is admitting a 62-year-old patient with a diagnosis of hypertension to the hospital. Which question by the nurse is most important when performing the initial assessment interview? 1. “What medications do you take at home?” 2. “Do you have any environmental, food, or drug allergies?” 3. “Do you have an advance directive?” 4. “What greatest concern you are dealing with today?” 7. The nurse is providing care for a 55-year-old client with severe respiratory disease. Using Neuman’s Continuum as a resource, which stage of illness is the nurse most likely to identify as being applicable to this client? 1. Moderate energy related to resiliency of age 2. High energy related to available treatment 3. Low energy related to compromised breathing 4. Extremely low energy due to impending death 8. The nurse is providing care for a client who has been hospitalized for 6 weeks. Which nursing intervention is specifically focused on helping the patient cope with the emotional responses to prolonged hospitalization? 1. Providing skin care every shift to prevent skin breakdown 2. Encouraging the patient to get up in a chair to eat meals 3. Assisting the patient to ambulate in the hallway for several minutes each day 4. Designating a corner of the patient’s room to display personal mementos 9. The nurse is providing care for a patient with a terminal illness. Which is particularly valuable in helping a patient with a terminal illness maintain a sense of self? 1. Family relationships 2. Spirituality 3. Nutrition 4. Sleep and rest 10. The nurse is providing care to a client with a history of schizophrenia who is diagnosed with a urinary tract infection. Which is the most significant barrier the nurse recognizes as this patient facing? 1. Chronic urinary incontinence 2. Stigma associated with mental illness 3. Risk for recurring infections 4. Auditory hallucinations (“hearing things”) 11. The nurse is attending to a 76-year-old patient who is being admitted for an acute myocardial infarction (heart attack). The doctor tells the patient that an angioplasty is necessary, and the patient agrees and signs the informed consent form. Which stage of illness behavior does the nurse identify the patient experiencing? 1. Sick-role behavior

2. Seeking professional care 3. Experiencing symptoms 4. Dependence on others 12. Many healthcare providers define illness as pathology; however, people experience, rather than define, illness. In which manner do most people experience illness? 1. “Feeling lousy,” a true sense of not being all right 2. A change in the way they feel or a disruption in their typical life 3. Something to be dreaded and avoided, if at all possible 4. An experience that offers a potential for learning and spiritual growth 13. Dunn believes that an individual’s state of health should be evaluated in the context of the person’s environment. Which is an approach that illustrates Dunn’s belief? 1. An unhealthy physical environment, characterized by poor living conditions, always has a negative effect on an individual’s health. 2. Adequate income, food, and shelter create a healthful environment and always improve physical health status. 3. Physical environment, family, and social support may help or hinder the health status of an individual. 4. The environment that should always be assessed is the client’s immediate surroundings; extended boundaries do not apply in an ill state. 14. Some people readily become ill when under stress, while others are able to deal with tremendous stress and remain physically and mentally healthy. This disparity is affected by a person’s level of hardiness. In which manner does the nurse apply this knowledge to nursing care? 1. The nurse cannot use the presented information. People are innately hardy or not, a state that the nurse must merely recognize. 2. Nurses need to encourage all people to develop some level of hardiness to help them get through difficult physical and emotional times. 3. Nurses need to assess for their own level of hardiness. If nurses are hardy, they will be better nurses; if not, nurses can learn more about hardiness. 4. Nurses assess for hardiness in patients and can encourage hardy patients to learn about their illness as a means for them to be more comfortable. 15. The new graduate nurse is working with another nurse who is functioning as a mentor to the new graduate. Which advice from the mentor is best suited when the new graduate is preparing to interact with the first patient? 1. Be maximally attentive to the patient at all times. 2. Take a few moments to settle in to the situation. 3. Accept the patient regardless of background. 4. Create a broad attitude of enjoyment of the patient. 16. When transferring a patient from a hospital to a long-term care facility, which action by the nurse is most helpful in facilitating the patient’s planning and emotional adjustment? 1. Notify the patient and family as much in advance of the transfer as possible.

2. Send a complete copy of the patient’s medical records to the new facility. 3. Carefully coordinate the transfer with the long-term facility to keep it smooth. 4. Help arrange for transportation and accompany the patient to the transport vehicle. 17. A parent of three small children has had nausea, vomiting, and extreme fatigue for the past 2 days and calls the children’s grandmother for assistance with caring for the children. Which illness behavior is the parent experiencing? 1. Sick-role behavior 2. Dependence on others 3. Seeking professional care 4. Experiencing symptoms 18. The nurse assigns a nursing assistant the task of ambulating a group of patients on the medicalsurgical unit. Later in the morning, the nursing assistant tells the nurse, “Some of my patients feel very sick but want to get out of bed. Others say they feel well but don’t want to get out of bed. What should I do?” Which is the most appropriate response by the nurse? 1. “All patients are supposed to be out of bed today, so do the best you can with them.” 2. “This is not uncommon. Sometimes you have to push some patients more than others.” 3. “All patients may respond to illness differently. Explain that they must be out of bed today. 4. “Get the patients up if they want to get up, and help the others to ambulate later in the day.” 19. A patient who is 80 years old arrives in the emergency department experiencing a severe heart attack. The patient’s condition is deteriorating and the physician informs the spouse that the patient is not expected to survive. The spouse becomes distraught and tells the nurse, “We have been married for 60 years. What am I going to do?” Which is the most appropriate response by the nurse? 1. “You had a good life together. You just need to understand that death is part of life, too.” 2. “I understand how you feel, but living to 80 years of age is a good long life.” 3. “I will get a social worker to see you for some help you may need at home.” 4. “I understand that this is an incredible and unexpected loss for you.” 20. Living in a healthy family is an important dimension of wellness. Which condition most accurately describes a characteristic of healthy families? 1. A family in which individual members live a health-promoting lifestyle 2. A family that responds to its members’ needs only during serious illness 3. A family who may avoid or withhold the truth to prevent hurting someone’s feelings 4. A family that understands a family member is powerless when experiencing severe illness

21. The home care nurse is providing care for a patient. After several visits and review of the plan of care, the nurse notices the patient does not follow the prescribed diet and exercise regimen. Which is the most appropriate action by the nurse? 1. Discharge the patient from home care because of noncompliance to the medical regimen. 2. Continue to teach and reinforce the importance of the diet and exercise regimen. 3. Notify the healthcare provider of the patient’s refusal to follow the diet and exercise regimen. 4. Identify why the patient is not following the plan, and revise the plan in collaboration with the patient. 22. The nurse is admitting to the medical floor a patient who does not speak English. The patient does not appear to understand the nurse’s questions or instructions. Which is the most appropriate action by the nurse? 1. Contact a family member, and defer the admission assessment until someone arrives. 2. Use hand gesturing and facial expressions to communicate with the patient. 3. See if a staff member who speaks the patient’s language is available to help translate. 4. Activate the hospital’s translating system, and obtain an available translator. 23. The nurse is admitting a patient with heart disease to the cardiac unit. When answering questions related to health history, the patient’s responses are lengthy and time consuming. Which is the most appropriate action by the nurse? 1. Recognize that the patient may be lonely and just wants to talk to someone. 2. Set a time limit, and inform the patient of your time frame to complete the assessment. 3. Anticipate the patient’s answers, and quickly go on to the next question. 4. Be attentive, focus on what the patient has to say, and respond accordingly. 24. A patient who is 30 years of age has been experiencing joint pain for several months and is diagnosed with rheumatoid arthritis. The patient tells the nurse, “This can’t be happening to me. I don’t understand this.” Which statement best describes the nurse’s primary understanding of the patient comments? 1. The patient is too young to possess the ability to cope with this diagnosis. 2. The patient exhibiting the stage of denial related to the illness diagnosis. 3. The patient’s developmental stage affects the ability to cope with stressors. 4. The patient’s statements indicate an inability to accept an ongoing illness. 25. Which situation is most reflective of a life change for managing chronic illness? 1. Beginning self-injection of insulin for diabetes mellitus 2. Taking an antibiotic for a streptococcal throat infection 3. Going to the gym and participating in an exercise program 4. Taking prescribed pain medication after a tooth extraction

Multiple Response Identify one or more choices that best complete the statement or answer the question. 26. The nurse in a retirement complex is intrigued by the time and energy residents spend on favorite activities, which they refer to as their “work.” Which definitions best describe what can be identified as “meaningful work”? Select all that apply. 1. Volunteering in the children’s ward at the local hospital 2. Starting a garden club in the living community 3. Reaching a desired salary after 10 years of employment 4. Playing an instrument in a rock-and-roll band 5. Deciding to return to work because of boredom 27. The nurse is aware that patients may fail to comply with a proposed healthcare regimen and be perceived as being noncompliant. For which common reason(s) does a nurse identify as causing a patient to be noncompliant with a plan of care? Select all that apply. 1. There patient lacks a support system. 2. The patient does not understand the plan. 3. The plan of care is inconvenient. 4. The patient is stubborn by nature. 5. The plan is financially inhibitive. 28. The nurse is aware that which situations can lead to family caregiver’s feeling(s) of “burnout”? Select all that apply. 1. Caring for an infant during eruption of a first tooth 2. Caring for an adolescent child with schizophrenia 3. Caring for child being treated for a broken leg 4. Caring for a spouse with Alzheimer’s disease 5. Caring for grandchildren once a week, as needed 29. A newly hired nurse is working with an experienced nurse on the oncology unit. The newly hired nurse expresses interest in helping patients and making their hospital stay a better experience. Which is the most appropriate response for the experienced nurse to make? Select all that apply. 1. “This takes time. Once you have worked on the unit for a while, it will become clear to you.” 2. “Find your best approach to patient care, and then use this approach with every patient.” 3. “One of the very best ways is to listen to your patient and be attentive to their needs.” 4. “It is helpful to consider your strengths and weaknesses and how you cope with illness.” 5. “Just remember to apply all your nursing knowledge when you interact with a patient.”

True/False Indicate whether the statement is true or false. 30. Health is defined as the absence of illness related to mind, body, and spirit.

31. Having someone physically present during times of illness removes the sense of aloneness during the illness.

Chapter 11. Experiencing Health & Illness Answer Section MULTIPLE CHOICE 1. ANS: 2 Chapter: Chapter 11 Experiencing Health & Illness Objective: Describe the various ways that people experience health and illness. Page: 213 (V1) Heading: How Do People Experience Health and Illness? Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Nurses respond to the physical, emotional, mental, and spiritual dimensions of health. Personal relationships are more psychosocial in nature; for example, family relationships can facilitate coping. 2 This is correct. Biological factors include genetic makeup, gender, age, and developmental stage. The risk of breast cancer increases dramatically in women who have a family history of a mother, sister, or daughter with breast cancer. Recently, a genetic marker for this type of breast cancer was discovered. This is an example of biological factors. 3 This is incorrect. Lifestyle choices involve such health behaviors as choosing not to use tobacco and other substances. 4 This is incorrect. Environmental factors involve, for example, environmental pollutants or the psychosocial environment (a quiet versus a noisy hospital room). PTS: 1 CON: Patient-Centered Care 2. ANS: 2 Chapter: Chapter 11 Experiencing Health & Illness Objective: Differentiate between acute and chronic illnesses. Page: 213 (V1) Heading: How Do People Experience Health and Illness? Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Patient-Centered Care

Difficulty: Moderate Feedback 1 This is incorrect. Education about every possible complication does not promote optimal functioning at the point on the health–illness continuum where the chronically ill patient is located. 2 This is correct. The health–illness continuum defines health and illness as a graduated spectrum that cannot be divided into parts. Encouraging positive health characteristics within the limits of the specific illness will promote maintenance of a personal state of health for the individual patient. 3 This is incorrect. An appropriate plan of care for a chronically ill patient will constantly change with the patient’s condition. Physiological changes, lifestyle choices, and the results of various choices will impact where the patient falls on the continuum; however, activities are limited only by the patient’s ability. 4 This is incorrect. Recommending activity beyond the scope of tolerance to prevent early deterioration is not a part of planning care related to the patient’s position on the health–illness continuum. PTS: 1 CON: Patient-Centered Care 3. ANS: 3 Chapter: Chapter 11 Experiencing Health & Illness Objective: Identify factors that influence individuals’ responses to illness. Page: 224 (V1) Heading: Establish Trust at Your First Patient Contact Integrated Processes: Caring Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is incorrect. Extending kindness to the client and the client’s family is an important way to demonstrate caring and respect. 2 This is incorrect. Merely performing procedures, administering medications, or providing solutions to the patient does not allow you to support the patient transition from health to illness. 3 This is correct. Part of what a nurse does when displaying a healing presence will never show up in a written care plan. However, the nurse’s healing presence may be the most important aspect of care nurses have to offer. 4 This is incorrect. When the nurse remains professionally aloof, the concepts of caring and trust cannot be established. PTS: 1 4. ANS: 3

CON: Patient-Centered Care

Chapter: Chapter 11 Experiencing Health & Illness Objective: Identify factors that influence individuals’ responses to illness. Page: 213 (V1) Heading: How Do People Experience Health and Illness? Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Although people consider biological factors when they describe themselves as well or ill, these factors are not entirely within their control. Age is one of the biological factors for this client. 2 This is incorrect. The biological factor of genetic makeup is not changeable through teaching; however, management is possible. 3 This is correct. The nurse is most likely to influence the patient’s eating habits because those are the dimensions over which the client has the most control. Therefore, those dimensions have the most potential for change. 4 This is incorrect. Gender is a biological factor and is not changeable through teaching. PTS: 1 CON: Patient-Centered Care 5. ANS: 2 Chapter: Chapter 11 Experiencing Health & Illness Objective: Apply the concepts presented in this chapter to a variety of patient care situations. Page: 220 (V1) Heading: The Intensity, Duration, and Multiplicity of the Disruption Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Healthcare providers have a duty to protect the privacy and confidentiality of patients, even though it is certainly threatened by some situations during hospitalization. 2 This is correct. Hospitalized patients commonly experience the loss of dignity. Wearing a hospital gown, having their body exposed, invasive procedures, loss of control over body functions—all of these contribute to loss of dignity, and all are very common among hospitalized patients. 3 This is incorrect. Some patients lose functioning during hospitalization, but this is not a common occurrence.

This is incorrect. Patients may be at risk for losing identity during hospitalization; however, the risk is reduced when healthcare providers use patient-centered communication.

PTS: 1 CON: Patient-Centered Care 6. ANS: 4 Chapter: Chapter 11 Experiencing Health & Illness Objective: Explain what the concepts in this chapter mean to you as you work toward becoming a full-spectrum nurse. Page: 213 (V1) Heading: Nurses Understand Health and Illness as Individual Experiences Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is incorrect. Asking about medications is a routine question by the nurse during the admission process. It is important for the nurse to ask about medications, but it does not take priority over asking about the patient’s greatest concern. 2 This is incorrect. It is part of the routine admission process to ask the patient about any allergies. However, of the presented options, this is not the priority question for the nurse to ask. 3 This is incorrect. It is common for the nurse to ask a patient about an advance directive during the admission process. However, it is not more important than asking about the patient’s greatest concern. 4 This is correct. It is most important for the nurse to ask the patient about the patient’s greatest concerns. The answer to this question will be helpful in identifying any contributing factors to the patient’s admitting diagnosis. Patient concerns need to be incorporated into the plan of care, making sure patient needs are met. PTS: 1 CON: Patient-Centered Care 7. ANS: 3 Chapter: Chapter 11 Experiencing Health & Illness Objective: Apply the concepts presented in this chapter to a variety of patient care situations. Page: 212 (V1) Heading: Nurses Use Conceptual Models to Understand Health and Illness Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing]

Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is incorrect. Nursing theorist Betty Neuman (2002) views health as an expression of living energy available to an individual. The energy is displayed as a continuum with high energy (wellness) at one end and low energy (illness) at the opposite end. In the absence of a medical condition, age can be a contributing factor to where a client falls on Neuman’s Continuum. 2 This is incorrect. With the client’s condition being described as serious, it is unlikely the client will be placed in the moderate area of Neuman’s Continuum. 3 This is correct. Neuman’s Continuum states when more energy is expended than is generated, there is illness and possibly death. Because the client is diagnosed with severe respiratory disease, it is likely the client spends more energy breathing than the energy created. 4 This is incorrect. Newman’s Continuum states that when more energy is expended than is generated, there is illness—and possibly death. However, the scenario does not provide information that supports impending death. PTS: 1 CON: Patient-Centered Care 8. ANS: 4 Chapter: Chapter 11 Experiencing Health & Illness Objective: Explain what the concepts in this chapter mean to you as you work toward becoming a full-spectrum nurse. Page: 216 (V1) Heading: Environmental Factors Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Providing skin care is a physiological nursing intervention and does not address the patient’s emotional status. 2 This is incorrect. Encouraging the patient to get up into a chair for meals is a physiological nursing intervention, which may help the patient’s sense of wellbeing. However, it is not totally focused on the patient’s emotional status. 3 This is incorrect. Assisting the patient to ambulate daily in the hall is a physiological nursing intervention, and while it may increase the patient’s sense of well-being, it does not specifically meet the patient’s emotional needs. 4 This is correct. The patient’s environment can help nourish wellness. Helping the patient designate a corner of the room to display personal mementos can be healing and help the patient to cope with the prolonged hospitalization.

PTS: 1 CON: Patient-Centered Care 9. ANS: 2 Chapter: Chapter 11 Experiencing Health & Illness Objective: Identify factors that influence individuals’ responses to illness. Page: 216 (V1) Heading: Religion and Spirituality Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is incorrect. Family relationships can provide a loving, supportive source of comfort and reassurance, but sometimes cause the patient pain and a feeling of loneliness when faced with a terminal illness. Nutrition, sleep, and rest are healing but usually not as helpful to a patient with terminal illness as is spirituality. 2 This is correct. When patients are faced with a terminal illness, spirituality can help the patient maintain a sense of self. 3 This is incorrect. Nutrition is healing, but not helpful to the patient in maintaining a sense of self. 4 This is incorrect. Sleep and rest can be healing but do not help the patient to maintain a sense of self like spirituality. PTS: 1 CON: Patient-Centered Care 10. ANS: 2 Chapter: Chapter 11 Experiencing Health & Illness Objective: Identify factors that disrupt health. Page: 216 (V1) Heading: What Factors Disrupt Health? Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Chronic urinary incontinence is not commonly associated with urinary tract infection, and nothing in the scenario suggests that the patient is incontinent. 2 This is correct. Mental illness is associated with a stigma that is usually a barrier, and even considered a debilitating handicap. Mental illness carries with

3 4

it a stigma that may be diminishing slowly but is highly visible to those who suffer from its effects. This is incorrect. The patient is at risk for recurring urinary tract infections, but this is not considered a debilitating handicap. This is incorrect. Auditory hallucinations are associated with schizophrenia but have not been described as the most debilitating handicap.

PTS: 1 CON: Patient-Centered Care 11. ANS: 4 Chapter: Chapter 11 Experiencing Health & Illness Objective: Describe the five stages of illness behavior. Page: 219 (V1) Heading: Stages of Illness Behavior Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. The patient entered the sick-role behavior phase when the patient admitted to family that he was experiencing chest pain. 2 This is incorrect. When the patient decided to go to the emergency department for healthcare intervention, the patient entered the “seeking professional care” stage of illness. 3 This is incorrect. The patient entered the “experiencing symptoms” stage when the patient began having chest pain at home. 4 This is correct. This patient is experiencing the “dependence on others” stage of illness behavior; the patient has accepted the diagnosis and treatment of the healthcare provider. PTS: 1 CON: Patient-Centered Care 12. ANS: 2 Chapter: Chapter 11 Experiencing Health & Illness Objective: Describe the various ways that people experience health and illness. Page: 211 (V1) Heading: Nurses Understand Health and Illness as Individual Experiences Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Moderate

2 3

Feedback This is incorrect. “Feeling lousy” is inappropriate, as many people do not feel “lousy” when they are ill. For example, hypertension is an illness that may have no symptoms. Similarly, patients may have chronic disease that is well managed and therefore does not make them feel ill. This is correct. People typically describe their illness in terms of how it makes them feel or the effect it has on day-to-day life. This is incorrect. “Something to be dreaded and avoided …” is also not accurate. If a person has an external locus of control, they may view illness as a consequence of actions taken. From this viewpoint, the person may have little control over whether illness can be avoided. This is incorrect. Although some people do grow and learn in the face of illness, most people do not hold such a positive view about illness—and the question asks how people experience illness.

PTS: 1 CON: Patient-Centered Care 13. ANS: 3 Chapter: Chapter 11 Experiencing Health & Illness Objective: Compare and contrast three models of health and illness. Page: 212 (V1) Heading: Nurses Use Conceptual Models to Understand Health and Illness Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is incorrect. The effect of poor living conditions may be offset by the presence of loving family and friends. Poverty does not always have a negative effect on health. 2 This is incorrect. The presence of food, shelter, and clothing does not always convey protective health, as loneliness and hopelessness may counteract these positive influences. 3 This is correct. The home environment, community, family, friends, and support system all influence health status. The balance among these variables has a net positive or negative effect on a client’s health status. 4 This is incorrect. When examining the client’s environment, extended boundaries must be considered, especially when providing community-based care. PTS: 1 14. ANS: 4

CON: Patient-Centered Care

Chapter: Chapter 11 Experiencing Health & Illness Objective: Apply the concepts presented in this chapter to a variety of patient care situations. Page: 220 (V1) Heading: Hardiness Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is incorrect. The information presented in the scenario is useful in helping the nurse to recognize the presence or lack of hardiness in patients. 2 This is incorrect. As hardiness is a personality trait, it is unlikely that the nurse can teach or otherwise encourage the development of hardiness. 3 This is incorrect. The nurse’s own awareness of a level of hardiness helps the nurse understand the personal response to stress, but hardiness does not necessarily make a better nurse. 4 This is correct. Hardiness is a personality trait that helps many to cope with stress and illness. PTS: 1 CON: Patient-Centered Care 15. ANS: 2 Chapter: Chapter 11 Experiencing Health & Illness Objective: Apply the concepts presented in this chapter to a variety of patient care situations. Page: 223 (V1) Heading: What Does It Mean to Communicate Care and Concern? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is incorrect. Nurses need to be aware of the need to communicate care and concern, and being maximally attentive is appropriate. However, this advice is not the best to a new graduate preparing to meet the first patient. 2 This is correct. The best advice a nurse mentor can give to new graduates preparing to meet their first patient is to take a few moments for settling in. Nurses in new situations will benefit from taking a few moments to settle in to the situation, which can be helpful in establishing a therapeutic relationship and facilitating communication. 3 This is incorrect. Accepting a patient regardless of the patient’s background demonstrates acceptance. Nurses need to always be accepting of their patients,

but in this scenario, the new graduate will benefit best from the advice about taking a few moments to settle in. This is incorrect. An attitude of enjoying patients will help the nurse to establish an attitude of caring. However, the new graduate in this scenario will benefit best from the advice of settling in.

PTS: 1 CON: Patient-Centered Care 16. ANS: 1 Chapter: Chapter 11 Experiencing Health & Illness Objective: Apply the concepts presented in this chapter to a variety of patient care situations. Page: 225 (V1) Heading: Maintain Trust During Transitions Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is correct. Notifying the patient and family well in advance of the transfer allows them time to adjust emotionally and to make any necessary plans. 2 This is incorrect. A copy of the records is usually sent; however, this action does very little to assist with the patient’s emotional status or planning. 3 This is incorrect. The nurse does coordinate the transfer with the receiving facility; however, this action does very little to assist with the patient’s emotional status or planning. 4 This is incorrect. Someone from the hospital may or may not accompany the patient in the car, or the transfer may be by ambulance. Either way, this action will not help the patient and family to do the necessary planning for the transfer. PTS: 1 CON: Patient-Centered Care 17. ANS: 1 Chapter: Chapter 11 Experiencing Health & Illness Objective: Describe the five stages of illness behavior. Page: 220 (V1) Heading: Stages of Illness Behavior Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is correct. The parent is assuming sick-role behavior because of self-

identification of being ill. This is incorrect. By telling a family member of the illness, the parent is relieved of normal duties and caring for the children. However, dependence on others actually occurs when the client accepts a diagnosis and treatment from the healthcare provider. This is incorrect. Seeking professional care occurs after the sick-role behavior stage. During this stage, the client makes the decision of being ill and that professional healthcare is needed. This is incorrect. The parent is experiencing symptoms but has moved into sick role behavior when seeking assistance with responsibilities (caring for the children).

PTS: 1 CON: Patient-Centered Care 18. ANS: 4 Chapter: Chapter 11 Experiencing Health & Illness Objective: Explain what the concepts in this chapter mean to you as you work toward becoming a full-spectrum nurse. Page: 223 (V1) Heading: Planning Interventions/Implementation Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

3 4

Feedback This is incorrect. The nurse’s response to “do the best you can” is not appropriate. The nurse’s instructions to the nursing assistant must be clear and concise and include a timeline. This is incorrect. All patients may, indeed, have prescriptions to get out of bed, but telling the nursing assistant to do the best or to push the patients does not recognize that patients respond to illness and wellness differently; nor does it consider the patient-centered approach to care. This is incorrect. The nursing assistant is not responsible for explaining to patients the reasons for getting out of bed. The nurse needs to assume this role. This is correct. It is appropriate to ambulate patients who want to get out of bed and allow others to ambulate later. This promotes and facilitates patient-centered care and allows the patient some control and decision making in his environment.

PTS: 1 19. ANS: 4

CON: Patient-Centered Care

Chapter: Chapter 11 Experiencing Health & Illness Objective: Apply the concepts presented in this chapter to a variety of patient care situations. Page: 217 (V1) Heading: Permanent Loss Integrated Processes: Caring Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. At this most painful time, it is not appropriate, nor can it be expected that a spouse will accept at this time that death is part of life. 2 This is incorrect. An attempt to comfort a spouse by mentioning the age of the patient demonstrates ageism and will not comfort a spouse at this time. 3 This is incorrect. It is appropriate to contact a social worker for home assistance; however, this can be done after recognizing and acknowledging the spouse’s loss. 4 This is correct. The death of a spouse is no less traumatic for an older adult than it would be for a young spouse. Losing someone with whom one has spent most of one’s life is an incredible loss, whether it is expected or unexpected. The best response is to validate this with the spouse. PTS: 1 CON: Patient-Centered Care 20. ANS: 1 Chapter: Chapter 11 Experiencing Health & Illness Objective: Describe the various ways that people experience health and illness. Page: 215 (V1) Heading: Personal Relationships Integrated Processes: Culture and Spirituality Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is correct. The most accurately stated characteristic of healthy families is one that focuses on health-promoting lifestyles for its members. 2 This is incorrect. Healthy families do not necessarily respond to health issues only in times of serious illness. 3 This is incorrect. A healthy family is very open about expressing feelings and disagreements rather than squelching feelings to avoid conflict. 4 This is incorrect. Healthy families view the family as capable and successful in meeting and responding to illness as opposed to feeling powerless over illness.

PTS: 1 CON: Patient-Centered Care 21. ANS: 4 Chapter: Chapter 11 Experiencing Health & Illness Objective: Explain what the concepts in this chapter mean to you as you work toward becoming a full-spectrum nurse. Page: 223 (V1) Heading: Planning Interventions/Implementation Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is incorrect. Noncompliance often occurs because the effort, inconvenience, or pain involved with the plan is too much for some patients to handle. They probably do not refuse to carry out a plan of care simply out of stubbornness, hostility toward healthcare providers, or wanton disregard for their own welfare. 2 This is incorrect. Patients may fail to comply with proposed medical regimens or a plan of care if the plan has no cultural or personal relevance for the patient (or family). The nurse must consider the patient’s understanding of the plan, knowledge level, and feasibility in terms of available support, time, energy, and finances. 3 This is incorrect. If after assessing the problem and revising the plan, the patient continues to refuse to follow the plan, then the physician can be notified and the patient possibly discharged. However, these are not the first and most appropriate actions by the nurse. 4 This is correct. The challenge and best action by the nurse is to develop an individualized plan of care in collaboration with the patient, based on mutual goals and respect. PTS: 1 CON: Patient-Centered Care 22. ANS: 4 Chapter: Chapter 11 Experiencing Health & Illness Objective: Apply the concepts presented in this chapter to a variety of patient care situations. Page: 84 (V2) Heading: Procedure 11-1: Admitting a Patient to a Nursing Unit Integrated Processes: Culture and Spirituality Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care

Difficulty: Moderate Feedback 1 This is incorrect. It is appropriate to contact a family member; however, the assessment cannot be deferred until the family member’s arrival because one cannot predict the time of arrival. 2 This is incorrect. Hand gestures and facial expressions are commonly used to identify pain when a patient has a language barrier; however, there is much more information that needs to be obtained from this patient as part of the assessment process. 3 This is incorrect. It is common to check with another staff member who may be able to translate; however, one cannot predict the availability or the language proficiency of the staff member. 4 This is correct. In admitting this patient, the most appropriate action by the nurse is to activate the hospital translation system or obtain a translator. PTS: 1 CON: Patient-Centered Care 23. ANS: 4 Chapter: Chapter 11 Experiencing Health & Illness Objective: Apply the concepts presented in this chapter to a variety of patient care situations. Page: 223 (V1) Heading: How Can I Honor Each Client’s Unique Health/Illness Experience? Integrated Processes: Caring Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Most people are hungry for someone to listen to them, and meeting the patient’s needs will assist in developing a good nurse–patient relationship. However, the nurse needs to concentrate on gathering assessment information by focusing on the patient’s conversation. 2 This is incorrect. The best action is to focus on what the patient or family has to say without emphasizing a set time frame, which will diminish the patient’s ability to relate to the nurse. 3 This is incorrect. Often, listeners are so busy thinking about what they want to say that they fail to really listen. Anticipating a patient’s responses interferes with accuracy of information. 4 This is correct. Being maximally attentive is an important factor in facilitating communication. PTS: 1 24. ANS: 3

CON: Patient-Centered Care

Chapter: Chapter 11 Experiencing Health & Illness Objective: Identify factors that influence individuals’ responses to illness. Page: 213 (V1) Heading: How Do People Experience Health and Illness? Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Age is not the determining factor in one’s ability to cope, but the patient’s developmental stage is. The patient at age 30 years may not accept his illness at this time because he is not developmentally ready. 2 This is incorrect. The patient’s statements do not provide enough information to infer that the patient is in denial about the diagnosis of an illness. 3 This is correct. Developmental stage influences a person’s ability to cope with stressors that tend to move them toward the illness end of the health–illness continuum. For example, infants or children who are ill, frightened, or hurt have a limited repertoire of experiences, communication ability, and understanding to help them in their responses. This patient is a young adult who is not likely prepared to handle an ongoing medical diagnosis. 4 This is incorrect. The patient has just received the diagnosis and may not be immediately able to accept an ongoing illness. Acceptance is likely to occur over time. PTS: 1 CON: Patient-Centered Care 25. ANS: 1 Chapter: Chapter 11 Experiencing Health & Illness Objective: Differentiate between acute and chronic illnesses. Page: 218 (V1) Heading: The nature of the Illness Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is correct. Chronic illness lasts for a long period of time, usually 6 months or more and often a lifetime. Chronic illness requires the person to make life changes. These changes might be regular visits to the clinic or hospital, daily medications, or lifestyle modifications, such as following a specific diet or smoking cessation.

This is incorrect. Starting on a medication for “strep throat” is a response to an acute and short-term illness aimed at the management of an infection. This is incorrect. Starting an exercise program at the gym may be an activity begun is as part of a chronic illness lifestyle change; however, it can also be a healthy lifestyle and/or health promotion activity. This is incorrect. Starting on a medication for a tooth extraction is a reaction to acute and short-term condition for the management of pain.

2 3

PTS:

CON: Patient-Centered Care

MULTIPLE RESPONSE 26. ANS: 1, 2, 4 Chapter: Chapter 11 Experiencing Health & Illness Objective: Describe the various ways that people experience health and illness. Page: 213 (V1) Heading: How Do People Experience Health and Illness? Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

2. 3.

4. 5.

Feedback This is correct. Many people find that work is a healthy way to cope with stressors. People also experience meaningful work as a dimension of wellness. For many people, volunteering, pursuing hobbies, and engaging in pleasurable activities can be forms of meaningful work. This is correct. Starting a community garden club may be distinguished as “meaningful work” for persons who enjoyed farming, nature, and growing plants. This is incorrect. Receiving a desired salary after 10 years of work is not necessarily seen as “meaningful work.” Additionally, usually in any description of “meaningful” work, salary is not mentioned. This is correct. Some people find that singing, playing a musical instrument, or listening to music is particularly healing. This is incorrect. Deciding to return to work because of boredom is not necessarily seen as “meaningful work.” Meaningful work is meant to be pleasurable. Returning to work is only meaningful if the work is pleasurable.

PTS: 1 CON: Patient-Centered Care 27. ANS: 1, 2, 3, 5 Chapter: Chapter 11 Experiencing Health & Illness

Objective: Apply the concepts presented in this chapter to a variety of patient care situations. Page: 213 (V1) Heading: How Do People Experience Health and Illness? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

3. 4.

Feedback This is correct. Patients may fail to comply with proposed medical regimens or a plan of care if the plan has no personal relevance for the patient (or family), which indicates a lack of support system. This is correct. The nurse must consider the patient’s understanding of the plan, knowledge level, and feasibility. The patient is unlikely to be compliant if the plan is not understood. This is correct. Noncompliance often occurs because the inconvenience causes a barrier for the patient. This is incorrect. People are least likely to refuse to carry out a plan of care simply out of stubbornness, hostility toward healthcare providers, or wanton disregard for their own welfare. This is correct. If the plan of care includes interventions that are financially prohibitive, the patient is likely to be noncompliant.

PTS: 1 CON: Patient-Centered Care 28. ANS: 2, 4 Chapter: Chapter 11 Experiencing Health & Illness Objective: Apply the concepts presented in this chapter to a variety of patient care situations. Page: 222 (V1) Heading: Analysis/Nursing Diagnosis Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

1. 2.

Feedback This is incorrect. Caring for an infant during the eruption of a first tooth is considered a short-term situation. This is correct. In this item, the long-term effects of caring for a family member with mental illness, such as schizophrenia, are most likely circumstances that can case burnout. The client’s care may fluctuate with the disease process, but emotional

3. 4. 5.

stress is always high. This is incorrect. Caring for a child being treated for a broken leg is a short-term situation with an “end in sight.” This is correct. The caregiver of a person who has Alzheimer’s disease is very likely to experience burnout; the client’s care is ongoing and full time. This is incorrect. Caring for grandchildren once a week, as needed, is both short term and intermittent and not considered to be a likely cause of burnout.

PTS: 1 CON: Patient-Centered Care 29. ANS: 3, 4 Chapter: Chapter 11 Experiencing Health & Illness Objective: Explain what the concepts in this chapter mean to you as you work toward becoming a full-spectrum nurse. Page: 223 (V1) Heading: How Can I Honor Each Client’s Unique Health/Illness Experience? Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

Feedback This is incorrect. As a nurse, one can be an instrument of healing in a hurtful world. However, being an instrument of healing does not come automatically with a nursing license. This is not an appropriate response from the experienced nurse. This is incorrect. Nurses do not provide the best care by learning just one approach and applying it to every client or patient. The nurse needs to see and react to each patient as a unique individual. This is correct. Cultivating a healing presence by listening, being maximally attentive to a patient’s needs, and being respectful to others’ ways of coping is an excellent response from the experienced nurse. This is correct. An excellent way to help patients with their hospital experience is for the nurse to be aware of personal strengths and weaknesses and to understand how the nurse would respond to illness. This is incorrect. Applying all the nurse’s knowledge during each interaction with a patient is not sound advice and probably not possible. The nurse needs to focus on each patient in the present time frame.

PTS: TRUE/FALSE

CON: Patient-Centered Care

30. ANS: F Chapter: Chapter 11 Experiencing Health & Illness Objective: Explore the concepts of health and illness from a holistic perspective. Page: 213 (V1) Heading: How Do We Understand Health and Illness? Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate Feedback: There are many definitions, descriptions, and models of health. There are models of health, such as the health–illness continuum, Dunn’s Health Grid, and Neuman’s Continuum. There are also many definitions of health set forth by the World Health Organization (WHO), Florence Nightingale, and Chinese medicine and ancient Indian medicine. What is most significant and accurate is that health is personal to each individual and defined and experienced differently by that individual. The statement is false. PTS: 1 CON: Patient-Centered Care 31. ANS: F Chapter: Chapter 11 Experiencing Health & Illness Objective: Explore the concepts of health and illness from a holistic perspective. Page: 219 (V1) Heading: Isolation Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate Feedback: The sense of “aloneness” or isolation reported by seriously ill clients is related, in part, to their actual physical separation from loved ones during treatments, hospitalizations, or clinic visits. But it also stems from their feeling that there is no one who is really “in their world.” Having someone physically present does not necessarily remove the sense of aloneness a seriously ill client is experiencing. The statement is false. PTS:

CON: Patient-Centered Care

Chapter 12. Stress & Adaptation Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse is aware that when a patient becomes alarmed, the body will release a substance to promote a sense of well-being. Which substance is released? 1. Aldosterone 2. Thyroid-stimulating hormone 3. Endorphins 4. Adrenocorticotropic hormone 2. After sustaining injuries in a motor vehicle accident, a patient experiences a decrease in blood pressure and an increase in heart rate and respiratory rate despite surgical intervention and fluid resuscitation. Which stage of general adaptation syndrome (GAS) does the nurse recognize the patient is most likely experiencing? 1. Alarm 2. Resistance 3. Exhaustion 4. Recovery 3. The nurse is providing care for a patient who suddenly experiences a cardiac arrest. As the nurse responds to this emergency, which substance does the nurse’s body secrete in large amounts to help prepare the nurse to react in this situation? 1. Epinephrine 2. Corticotrophin-releasing hormone 3. Aldosterone 4. Antidiuretic hormone 4. The nurse is aware that which function of antidiuretic hormone occurs when the hormone is released in the alarm stage of the general adaptation syndrome? 1. Promotes fluid retention by increasing the reabsorption of water by kidney tubules 2. Increases efficiency of cellular metabolism and fat conversion to energy for cells and muscle 3. Increases the use of fats and proteins for energy and conserves glucose for use by the brain 4. Promotes fluid excretion by causing the kidneys to reabsorb more sodium 5. The nurse is providing care for a patient who sustains a laceration of the thigh in an industrial accident. Which step in the inflammatory process does the nurse expect the patient to experience first? 1. Cellular inflammation 2. Exudate formation 3. Tissue regeneration

4. Vascular response 6. The nurse is providing care to a patient who expresses feeling of dread and of vague uneasiness. Nursing assessment reveals the patient’s heart rate is elevated. Which nursing diagnoses is most appropriate for this patient? 1. Anger 2. Fear 3. Anxiety 4. Hopelessness 7. A patient, who has been hospitalized for weeks, becomes angry and tells the nurse who is providing care, “I hate this place; nobody knows how to take care of me or I’d be home by now.” Which response by the nurse is best in this situation? 1. “You seem angry; what’s going on that makes you hate this place?” 2. “I’m sorry that we aren’t caring for you according to your expectations.” 3. “You were very sick; don’t be angry; you’re lucky to be alive.” 4. “You shouldn’t be angry with us; we’re trying to help you.” 8. The nurse is providing care for a patient with numerous physiological complaints. A family member shares that the patient is pretending to have the symptoms of a stomach ulcer to avoid going to work. The nurse recognizes which somatoform disorder this patient is most likely experiencing? 1. Hypochondriasis 2. Somatization 3. Somatoform pain disorder 4. Malingering 9. The nurse is aware that after a patient has an argument with the patient’s spouse, the patient becomes verbally abusive to the nurse who is providing care. Which coping mechanism does the nurse recognize the patient is exhibiting? 1. Reaction formation 2. Displacement 3. Denial 4. Conversion 10. A patient diagnosed with breast cancer decides on a treatment plan and feels positive about her prognosis. Assuming the cancer diagnosis represents a crisis, this patient is most likely experiencing which phase of crisis? 1. Precrisis 2. Impact 3. Crisis 4. Adaptive

11. A nurse identifies a patient’s nursing diagnosis as “Diarrhea related to stress.” Which nursing intervention does the nurse include in the nursing care plan to help the patient relieve the cause of the diarrhea? 1. Monitor and record the frequency of stools on the graphic record. 2. Administer prescribed antidiarrheal medications, as needed. 3. Encourage the patient to verbalize about stressors and anxiety. 4. Provide oral fluids on a regular schedule. 12. The nurse is counseling a patient about behaviors to reduce stress. Which goal should the nurse put on the care plan? 1. “The patient will limit fat intake to 15% of the daily calories consumed.” 2. “The patient will eat three meals at approximately the same time each day.” 3. “The patient will limit the intake of sweet and salty foods.” 4. “The patient will consume no more than three alcoholic beverages a day.” 13. At the end of a guided imagery session, which physical assessment finding would suggest to the nurse the relaxation technique was successful? 1. Decreased blood pressure 2. Decreased peripheral skin temperature 3. Increased heart rate 4. Increased respiratory rate 14. The nurse caring for a patient with unresolved anger. For which associated complication should the nurse assess? 1. Depression 2. Hypochondriasis 3. Somatization 4. Malingering 15. Before entering the room of a patient who is angry and yelling, the nurse removes the stethoscope from around the neck. Which is the best rationale for the nurse’s action? 1. The stethoscope could be used by the patient to hurt the nurse. 2. The stethoscope may cause the patient to distrust the nurse. 3. The stethoscope can distract the nurse from focusing on the patient. 4. The stethoscope can function as another stressor for the patient. 16. The nurse is providing care for a patient who is in crisis. After assessing the situation, which action does the nurse perform first? 1. Determine the imminent cause of the crisis. 2. Intervene to relieve the patient’s anxiety. 3. Decide on the type of help the patient needs. 4. Ensure the safety of both the nurse and the patient.

17. The nurse is presenting a workshop on stress and adaptation to adolescents at the local high school. A teenager tells the nurse, “Sometimes I feel stressed when I have to take a test. I feel my heart is going a little faster but I do focus better. What do you think?” Which is the most appropriate response by the nurse? 1. “No amount of stress is healthy, especially if your heart is going faster.” 2. “As long as you are getting through the test, I think you will be just fine.” 3. “A little stress is not necessarily a bad thing. It can help you to focus.” 4. “You may need to develop some additional stress-reducing activities.” 18. An 18-year-old is accepted to nursing school in another state. The adolescent states to the parents, “I know I am going away to college, but I am nervous about going.” Which type of stressor is the student most likely experiencing? 1. External 2. Developmental 3. Situational 4. Biophysical 19. A client approaches the nurse in the health clinic and states, “I have been dealing with my spouse’s illnesses for years. Now my children want me to start babysitting my grandchildren. I don’t know whether I can handle all this.” Which is the nurse’s most accurate interpretation of the client’s statements? 1. Some events are producing more stress for the client than other events. 2. Coping abilities are extended to the limit and the client is unable to cope. 3. Many stressors or prolonged stressors make adaptation more likely to fail. 4. Coping strategies used in the past are no longer successful for the client. 20. The nurse asks, “Why do some of my patients get a headache when they have stress but others cry?” Which is the most appropriate response to the nurse’s question? 1. “All patients react to stress differently.” 2. “Stress responses can be physical, mental, behavioral, and spiritual.” 3. “Some patients are more emotional than others.” 4. “Some patients overreact to the stress they are experiencing.” 21. A female client comes to the clinic for her annual physical. During the examination, the nurse palpates a lump in the left breast and informs the client of the finding. The client responds, “Yes, I found it a few months ago but just didn’t want to think about it.” The nurse recognizes the client is using which approach to coping with the lump? 1. Altering 2. Adapting 3. Changing 4. Avoiding 22. An adult client attends a smoking cessation class. The client tells the nurse, “Even though I smoke, I don’t smoke around children, in my car, or in my house.” Which defense mechanism does the nurse recognize the client is exhibiting?

1. 2. 3. 4.

Displacement Rationalization Denial Repression

23. A patient admitted to the cardiac unit is going for a cardiac catheterization. The patient tells the nurse, “I am so anxious about this. I am afraid the procedure might trigger a heart attack.” Which is the first action by the nurse? 1. Contact the physician for an antianxiety medication prior to the procedure. 2. Assure the patient this is a very common procedure for cardiac patients. 3. Instruct the patient prior to the procedure about what to expect of the procedure. 4. Offer the patient some stress-reducing techniques to use before the procedure. 24. The nurse is providing care for a patient in an acute care facility. The patient tells the nurse, “Ever since we experienced an earthquake, I keep having flashbacks of the event. I can’t sleep for fear of another one happening during the night.” Which condition does the nurse associate with the patient’s statements? 1. Anxiety 2. Lack of coping skills 3. Post-traumatic stress disorder (PTSD) 4. Crisis Multiple Response Identify one or more choices that best complete the statement or answer the question. 25. During the alarm stage of general adaptation syndrome (GAS), which metabolic changes occur? Select all that apply. 1. Rate of metabolism decreases. 2. The liver converts more glycogen to glucose. 3. Use of amino acids decreases. 4. Amino acids and fats are more available for energy. 5. Physiological responses will last at least 24 hours. 26. Two days after a patient undergoes abdominal surgery, the surgical incision is red and slightly edematous and oozing a small amount of serosanguinous (pink-tinged serous) fluid. On the basis of these data, at which conclusion will the nurse arrive? Select all that apply. 1. The wound is most likely infected. 2. There is a vascular response to inflammation. 3. Damaged cells are being regenerated. 4. Exudate formation is occurring. 5. The wound is progressing as expected.

27. An older adult patient is tearful, shaky, and withdrawn. The patient shares with the nurse, “I am worried to death” about losing an aging spouse and being “all alone.” For which reasons does the nurse diagnose this reaction as anxiety rather than fear? Select all that apply. 1. It concerns future or anticipated events. 2. It concerns anticipation of danger rather than a present danger. 3. The response is expected in older adult patients. 4. There is a psychological threat rather than a physical threat. 5. The patient flinches when touched by the nurse. 28. For which reasons is it important for the nurse to understand stress and adaptation? Select all that apply. 1. The nurse needs to self-identify stressors and develop healthy adaptation responses. 2. Understanding stress helps the nurse identify client stressors and adaptive responses. 3. Understanding stress will aid the nurse in balancing stress experienced by patients. 4. The nurse needs to know the very specific adaptation strategies used for patients. 5. The nurse is unable to address psychological issues without understanding stress. 29. The nurse in the intensive care unit is experiencing an excessive amount of job-related stress. The nurse visits the employee health nurse and states, “I feel nervous and stressed all the time. Even when I go home, I don’t feel better. What am I going to do?” Which are the most appropriate response(s) from the health nurse? Select all that apply. 1. “If you are doing the best you can and still feel this way, maybe you need to find another job.” 2. “I’m happy to see you are here and asking for help dealing with your anxiety.” 3. “Have you talked to some of your colleagues about the way you feel?” 4. “I will make a list for you of some coping strategies that may be helpful.” 5. “I suggest you see your physician for a prescription of antianxiety medication.” 30. The nurse believes a patient is experiencing high levels of stress at home. The patient is angry and states, “It is too much for me to handle. You don’t know what I am going through.” Which are the most appropriate responses by the nurse? Select all that apply. 1. “I don’t know what you are going through. Can you tell me more?” 2. “Please don’t be angry with me. We all do the best we can here.” 3. “How long have you been dealing with this stress?” 4. “How do you usually manage your stress?” 5. “Can we set up some family counseling?”

Chapter 12. Stress & Adaptation Answer Section MULTIPLE CHOICE 1. ANS: 3 Chapter: Chapter 12 Stress & Adaptation Objective: Define stress. Page: 229 (V1) Heading: What Is Stress? Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Comprehension [Understanding] Concept: Stress Difficulty: Moderate Feedback 1 This is incorrect. Aldosterone promotes fluid retention by increasing the reabsorption of water by renal tubules. 2 This is incorrect. Thyroid-stimulating hormone increases the efficiency of cellular metabolism and fat conversion to energy for cell and muscle needs. 3 This is correct. Endorphins act like opiates to produce a sense of well-being; they are released by the hypothalamus and the posterior pituitary gland in response to alarm. 4 This is incorrect. Adrenocorticotropic hormone stimulates the adrenal cortex to produce and secrete glucocorticoids and mineralocorticoids. PTS: 1 CON: Stress 2. ANS: 3 Chapter: Chapter 12 Stress & Adaptation Objective: Describe the physical changes occurring during the three stages of Selye’s general adaptation syndrome (GAS). Page: 229 (V1) Heading: Models of Stress Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Stress Difficulty: Difficult Feedback 1 This is incorrect. During the alarm stage, heart rate and blood pressure both increase. 2 This is incorrect. In the resistance stage, the body tries to maintain homeostasis;

3 4

blood pressure and heart rate normalize. This is correct. Physiological responses in the exhaustion stage include low blood pressure and high respiratory and heart rates. This is incorrect. If adaptation is successful, recovery takes place.

PTS: 1 CON: Stress 3. ANS: 1 Chapter: Chapter 12 Stress & Adaptation Objective: Explain the relationship among stressors, responses, and adaptation. Page: 232 (V1) Heading: How Do People Respond to Stressors? Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Stress Difficulty: Moderate Feedback 1 This is correct. During the shock phase of general adaptation syndrome (GAS), epinephrine prepares the body to react in an emergency situation by increasing heart rate and blood pressure. In response to the epinephrine release, the endocrine system releases corticotrophin-releasing hormone, aldosterone, and antidiuretic hormone. 2 This is incorrect. Corticotrophin-releasing hormone (CRH) is released by the hypothalamus in response to the epinephrine release. 3 This is incorrect. Aldosterone promotes fluid retention by causing the kidneys to reabsorb more sodium. In that way, it helps to increase fluid volume and maintain or increase blood pressure. 4 This is incorrect. Antidiuretic hormone is released from the pituitary gland in response to a message from CRH, together with messages from the cerebral cortex. PTS: 1 CON: Stress 4. ANS: 1 Chapter: Chapter 12 Stress & Adaptation Objective: Describe the physical changes occurring during the three stages of Selye’s general adaptation syndrome (GAS). Page: 232 (V1) Heading: General Adaptation Syndrome Includes Nonspecific, Systemic Responses Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Comprehension [Understanding] Concept: Stress

Difficulty: Moderate Feedback 1 This is correct. Antidiuretic hormone promotes fluid retention by increasing the reabsorption of water by kidney tubules. 2 This is incorrect. Thyroid-stimulating hormone increases efficiency of cellular metabolism and fat conversion to energy for cells and muscle. 3 This is incorrect. Cortisol increases the use of fats and proteins for energy and conserves glucose for use by the brain. 4 This is incorrect. Aldosterone promotes fluid retention by causing the kidneys to reabsorb more sodium. PTS: 1 CON: Stress 5. ANS: 4 Chapter: Chapter 12 Stress & Adaptation Objective: Discuss the inflammatory response: What triggers it, and what physiological changes occur? Page: 235 (V1) Heading: The Local Adaptation Syndrome Involves a Specific Local Response Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Inflammation Difficulty: Moderate Feedback 1 This is incorrect. During the cellular response phase, white blood cells migrate to the site of injury. 2 This is incorrect. In the exudate formation phase, the fluid and white blood cells move from circulation to the site of injury, forming an exudate. 3 This is incorrect. Tissue regeneration occurs in the healing phase. 4 This is correct. Immediately after the injury, the vascular response occurs. Blood vessels at the site constrict to control bleeding. After the injured cells release histamine, the vessels dilate, causing increased blood flow to the area. PTS: 1 CON: Inflammation 6. ANS: 3 Chapter: Chapter 12 Stress & Adaptation Objective: Explain how anxiety, fear, and anger relate to stress. Page: 236 (V1) Heading: Psychological Responses to Stress Include Feelings, Thoughts, and Behaviors Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying]

Concept: Stress Difficulty: Moderate Feedback 1 This is incorrect. Anger is not a nursing diagnosis. 2 This is incorrect. Fear, which is also a nursing diagnosis, is an emotion or feeling of apprehension from an identified danger, threat, or pain. 3 This is correct. NANDA International defines Anxiety as a vague, uneasy feeling of discomfort or dread accompanied by an autonomic response. This patient is most likely experiencing anxiety. 4 This is incorrect. Hopelessness is a nursing diagnosis defined as a state in which the patient sees few or no available alternatives and cannot mobilize energy on his own behalf. PTS: 1 CON: Stress 7. ANS: 1 Chapter: Chapter 12 Stress & Adaptation Objective: Describe several interventions or activities for preventing and managing stress. Page: 236 (V1) Heading: Psychological Responses to Stress Include Feelings, Thoughts, and Behaviors Integrated Processes: Communication and Documentation Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Stress Difficulty: Moderate

1 2 3 4

Feedback This is correct. “You seem angry; what’s going on …” encourages the patient to express his feelings and may provide the nurse with more information. This is incorrect. The nurse should not take responsibility for the patient’s anger by apologizing (“I’m sorry …”). This is incorrect. Telling the patient he is lucky to be alive after being so sick places guilt on the patient for his feelings. This is incorrect. Advising the patient by saying, “Don’t be angry” or “You shouldn’t be angry” diminishes the patient’s right to be angry.

PTS: 1 CON: Stress 8. ANS: 4 Chapter: Chapter 12 Stress & Adaptation Objective: Briefly describe hypochondriasis, somatization, somatoform pain disorder, and malingering. Page: 240 (V1) Heading: What Happens When Adaptation Fails?

Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Stress Difficulty: Moderate Feedback 1 This is incorrect. With hypochondriasis, the patient is preoccupied with the idea that he is or will become seriously ill. 2 This is incorrect. In somatization, anxiety and emotional turmoil are expressed in physical symptoms. 3 This is incorrect. With somatoform pain disorder, emotional pain manifests physically. 4 This is correct. Malingering is a conscious effort to escape unpleasant situations by pretending to have symptoms of a disorder. The patient is attempting to avoid working. PTS: 1 CON: Stress 9. ANS: 2 Chapter: Chapter 12 Stress & Adaptation Objective: Provide examples and definitions of specific psychological defense mechanisms. Page: 239 (V1) Heading: Table 12-1 Psychological Defense Mechanisms Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Stress Difficulty: Moderate Feedback 1 This is incorrect. When a patient uses the coping mechanism of reaction formation, the patient is aware of feelings but acts in an opposite manner to what is really being felt. 2 This is correct. This patient is using displacement. The patient is transferring the emotions felt toward the spouse and venting them toward the nurse. 3 This is incorrect. With the coping mechanism of denial, the patient transforms reality by refusing to acknowledge thoughts, feelings, desires, or impulses. 4 This is incorrect. With conversion, emotional conflict is changed into physical symptoms that have no physical basis. PTS: 1 CON: Stress 10. ANS: 4 Chapter: Chapter 12 Stress & Adaptation Objective: Explain the difference between adaptive and maladaptive coping strategies.

Page: 241 (V1) Heading: Stress-Induced Psychological Responses Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Stress Difficulty: Moderate Feedback 1 This is incorrect. During the precrisis phase, the patient finds success using her previous coping strategies. 2 This is incorrect. Anxiety and confusion increase during the impact phase if usual coping strategies are ineffective. 3 This is incorrect. The patient may use new coping strategies, such as withdrawal, during the crisis phase. This patient is using adaptive thinking. 4 This is correct. When patients begin to think rationally and attempt to solve problems, they are most likely experiencing the adaptive phase of crisis. PTS: 1 CON: Stress 11. ANS: 3 Chapter: Chapter 12 Stress & Adaptation Objective: Describe the effects of prolonged stress and unsuccessful adaptation on the various body systems. Page: 244 (V1) Heading: Assess Stressors, Risk Factors, and Coping and Adaptation Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Stress Difficulty: Moderate Feedback 1 This is incorrect. Monitoring stool frequency is an assessment, not a nursing intervention. 2 This is incorrect. Giving medication as prescribed may be necessary to alleviate diarrhea, but this does not treat the cause. 3 This is correct. The nurse should encourage the patient to verbalize about stressors and anxiety to help relieve stress, which is the cause of the patient’s diarrhea. 4 This is incorrect. Providing oral fluids is important to prevent dehydration in a patient with diarrhea; however, this action does not treat the cause. PTS: 1 12. ANS: 3

CON: Stress

Chapter: Chapter 12 Stress & Adaptation Objective: Describe several interventions or activities for preventing and managing stress. Page: 246 (V1) Heading: Planning Interventions/Implementation Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate Feedback 1 This is incorrect. The patient needs to limit the intake of fat to no more than 30% (not 15%) of daily calories (to prevent cardiovascular disease). 2 This is incorrect. The patient needs to eat smaller, more frequent meals (rather than three meals a day) to aid in digestion. 3 This is correct. The nurse should advise the client to limit the intake of sugar (to avoid sugar highs and crashes) and salt (to avoid increasing blood pressure). 4 This is incorrect. The best advice is for the patient to consume no more than two alcoholic beverages per day, but not necessarily every day. PTS: 1 CON: Health Promotion 13. ANS: 1 Chapter: Chapter 12 Stress & Adaptation Objective: Describe several interventions or activities for preventing and managing stress. Page: 248 (V1) Heading: Stress Management Techniques Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Stress Difficulty: Moderate Feedback 1 This is correct. Reassessment findings that suggest relaxation has been effective include decreased blood pressure, increased peripheral skin temperature, decreased heart rate, and decreased respiratory rate. 2 This is incorrect. Peripheral skin temperature is increased, not decreased. 3 This is incorrect. Decreased, not increased heart rate results from relaxation. 4 This is incorrect. Increased respiratory rate is the result of guided imagery; decreased rate is not expected. PTS: 1 CON: Stress 14. ANS: 1 Chapter: Chapter 12 Stress & Adaptation

Objective: Describe the effects of prolonged stress and unsuccessful adaptation on the various body systems. Page: 237 (V1) Heading: Psychological Defense Mechanisms Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Comprehension [Understanding] Concept: Stress Difficulty: Moderate Feedback 1 This is correct. Depression is sometimes associated with unresolved anger and may result from stress. 2 This is incorrect. A person with hypochondriasis is preoccupied with feelings that he will become seriously ill. 3 This is incorrect. In somatization, anxiety and emotional turmoil are expressed in physical symptoms, loss of physical function, pain that changes location often, and depression. 4 This is incorrect. Malingering is a conscious effort to avoid unpleasant situations. Hypochondriasis, somatization, and malingering are not associated with unresolved anger. PTS: 1 CON: Stress 15. ANS: 1 Chapter: Chapter 12 Stress & Adaptation Objective: Describe several interventions or activities for preventing and managing stress. Page: 236 (V1) Heading: Box 12-3 Psychological Responses to Stressors Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Stress. Difficulty: Moderate Feedback 1 This is correct. When dealing with angry patients, nurses must be alert to their own safety needs. A stethoscope, dangling jewelry, or anything else the patient might use as a weapon to harm the nurse should be removed before entering the patient’s room. 2 This is incorrect. It is unlikely a stethoscope would cause the patient to distrust the nurse. 3 This is incorrect. The nurse’s stethoscope is unlikely to function as a stressor because stethoscopes are common in the healthcare setting; nearly every caregiver carries a stethoscope.

This is incorrect. Having a stethoscope is not likely to distract the nurse. Nurses carry stethoscopes so routinely that they likely don’t even notice this piece of equipment.

PTS: 1 CON: Stress 16. ANS: 4 Chapter: Chapter 12 Stress & Adaptation Objective: Describe several interventions or activities for preventing and managing stress. Page: 236 (V1) Heading: Box 12-3 Psychological Responses to Stressors Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Stress Difficulty: Moderate Feedback 1 This is incorrect. The nurse will determine the problem (cause of the crisis), but not until the safety of the nurse and the patient is assured. 2 This is incorrect. The nurse does need to defuse the situation and decrease the patient’s anxiety; however, this action is performed after the safety of the nurses and the patient is assured. 3 This is incorrect. The nurse will decide the type of help the patient needs, but the nurse’s first action is to assure the safety of the patient and the nurse. 4 This is correct. The goals of crisis intervention are to assess the situation first and ensure the safety of the nurse and the patient. Safety is always foremost. PTS: 1 CON: Stress 17. ANS: 3 Chapter: Chapter 12 Stress & Adaptation Objective: Explain the relationship among stressors, responses, and adaptation. Page: 236 (V1) Heading: Psychological Responses to Stress Include Feelings, Thoughts, and Behaviors Integrated Processes: Teaching and Learning Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Stress Difficulty: Moderate Feedback 1 This is incorrect. It is not true no amount of stress is healthy, especially if physiological changes occur. The heart beating fast is a normal response to stress, which is dangerous if the stress is prolonged. 2 This is incorrect. The nurse’s response, “As long as you are focusing and getting

through the test” is an acceptable one; however, this is not the best response because it will not assist the student in learning about and understanding mild stress and the motivating aspect of mild stress. This is correct. Stress is not necessarily bad. It can keep one alert and motivate one to function at a higher performance level. For example, when preparing for an examination, the desire to succeed can create just enough anxiety to motivate the student to study. This is incorrect. The scenario does not indicate the need for the adolescent to develop some additional stress-relieving activities.

PTS: 1 CON: Stress 18. ANS: 2 Chapter: Chapter 12 Stress & Adaptation Objective: Define stress. Page: 229 (V1) Heading: Types of Stressors Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Comprehension [Understanding] Concept: Stress Difficulty: Moderate Feedback 1 This is incorrect. External stressors are usually something external to a person, for example, death of a family member. 2 This is correct. Developmental stressors are those that can be predicted to occur at various stages of a person’s life. For example, most young adults face the stress of leaving home for college or beginning a new career. In this item, the young adult is expressing concern over a normal developmental stressor. 3 This is incorrect. Situational stressors are unpredictable and would include accidents or unexpected illness. 4 This is incorrect. Biophysical stressors affect body function or structures, such as cardiac problems from prolonged and/or unresolved stress. PTS: 1 CON: Stress 19. ANS: 3 Chapter: Chapter 12 Stress & Adaptation Objective: State three ways in which you could assess for each of the following: (1) stressors and risk factors, (2) coping methods and adaptation, (3) physiological responses to stress, (4) emotional and behavioral responses to stresses, (5) cognitive responses to stress, and (6) adequacy of support systems. Page: 230 (V1) Heading: How Do Coping and Adaptation Relate to Stress?

Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Stress Difficulty: Difficult Feedback 1 This is incorrect. This client has been managing one stressful event. It is the addition of another that is concerning the client. Caring for a spouse because of illness is likely to be the cause of a high level of stress. Caring for grandchildren can be the cause of an unknown level of stress. 2 This is incorrect. It is not possible to determine if the client is unable to cope based only on the statement, “I don’t know whether I can handle all this.” 3 This is correct. When there are many stressors or when stressors continue for a long period of time, adaptation is more likely to fail. In this item, the client is verbalizing both a concern in caring for a family member over a long period of time and the possibility of dealing with a new stressor: babysitting grandchildren. 4 This is incorrect. Some events produce more stress than others. However, a person with good coping skills can usually adapt to a single stressful event, even a demanding one. In this item, we are unable to determine that coping strategies are no longer successful because we do not have any information on past coping strategies. PTS: 1 CON: Stress 20. ANS: 2 Chapter: Chapter 12 Stress & Adaptation Objective: Define stress. Page: 244 (V1) Heading: Assess Responses to Stress Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Stress Difficulty: Moderate Feedback 1 This is incorrect. The most appropriate response is to cite the holistic responses to stress and not merely respond that “all patients react to stress differently.” 2 This is correct. Responses to stress are holistic. This means they can be physical, psychological, mental, behavioral, spiritual, and social. It is important for a nurse to understand these responses to assist patients to develop healthy and adaptive coping skills. 3 This is incorrect. All patients do react to stress differently; however, this is not

the most comprehensive and explanatory response to the nurse’s question. This is incorrect. Without previously developed coping skills, some patients do overreact to stress; however, this is not the most comprehensive and explanatory response to the nurse’s question.

PTS: 1 CON: Stress 21. ANS: 4 Chapter: Chapter 12 Stress & Adaptation Objective: Explain the relationship among stressors, responses, and adaptation. Page: 231 (V1) Heading: Three Approaches to Coping Are Commonly Used Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Comprehension [Understanding] Concept: Stress Difficulty: Moderate Feedback 1 This is incorrect. People use three approaches in coping with a stress. Altering the stressor is removing or changing the stressor. 2 This is incorrect. Adapting to the stressor involves changing one’s thoughts or behaviors related to the stressor. 3 This is incorrect. Due to a physical condition, the stressor cannot be changed. 4 This is correct. Avoiding the stressor at times may be effective, but in this item, it is maladaptive because the client has coped by putting it out of her mind, thus avoiding earlier medical care. PTS: 1 CON: Stress 22. ANS: 2 Chapter: Chapter 12 Stress & Adaptation Objective: Provide examples and definitions of specific psychological defense mechanisms. Page: 237 (V1) Heading: Psychological Defense Mechanisms Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Stress Difficulty: Moderate Feedback 1 This is incorrect. Displacement is a transference of emotions, ideas, or wishes from one object or situation to a substitute, inappropriate object. 2 This is correct. Defense mechanisms are unconscious mental mechanisms that make a stressful situation more tolerable by decreasing the inner tension

3 4

associated with the stressors; they protect the person from anxiety and assist with adaptation. If used sparingly, and for mild to moderate anxiety, they can be helpful. When overused, they give a false illusion of coping. In this scenario, the client is using rationalization: use of logical-sounding excuses to justify true actions or feelings. The client attends a smoking cessation class and recognizes the desire to quit smoking but is rationalizing the smoking habit by citing some socially acceptable rationales. This is incorrect. Denial is transforming reality by refusing to acknowledge thoughts, feelings, or desires. This is incorrect. Repression is an unconscious burying or forgetting of painful thoughts, feelings, memories, and ideas by pushing them from a conscious to an unconscious level. This is a step deeper than denial.

PTS: 1 CON: Stress 23. ANS: 3 Chapter: Chapter 12 Stress & Adaptation Objective: Describe several interventions or activities for preventing and managing stress. Page: 246 (V1) Heading: Planning Interventions/Implementation Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Stress Difficulty: Moderate Feedback 1 This is incorrect. Contacting the physician for an anti-anxiety medication is appropriate and many patients will receive a mild anti-anxiety medication prior to the procedure. 2 This is incorrect. Assuring the patient that the procedure is commonly performed is not likely to relieve the patient’s stress; patients are focused on their own risks and outcomes. 3 This is correct. Because anxiety is a common response to illness, medical tests, and treatments, the nurse will use anxiety-relief interventions. In this patient scenario, instructing the patient about what to expect of the procedure will lessen anxiety and is the first and best action. 4 This is incorrect. Offering the patient some stress-reducing techniques and strategies can also be appropriate, for example, instructing him to take some deep breaths. However, the first action by the nurse is to instruct the patient about the procedure. PTS: 1 24. ANS: 3

CON: Stress

Chapter: Chapter 12 Stress & Adaptation Objective: Provide examples and definitions of specific psychological defense mechanisms. Page: 240 (V1) Heading: What Happens When Adaptation Fails? Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Stress Difficulty: Moderate Feedback 1 This is incorrect. Anxiety is related to multiple physiological and psychosocial events and/or conditions. PTSD is a source of anxiety. 2 This is incorrect. Coping skills may or may not exist in the event of catastrophic events. If the event is new and unexpected, coping skills are unlikely; however, in recurring events, some coping skills may exist. 3 This is correct. The statements by this patient are most consistent with PTSD: a specific response to a violent, traumatizing event, such as a natural disaster (flood, earthquake) or physical or emotional abuse (war, rape). The victim experiences anxiety and flashbacks that may last for months or years. 4 This is incorrect. A crisis exists when an event in a person’s life drastically changes the person’s routine and is perceived as a threat to the self. Such events are usually sudden and unexpected, such as a serious illness, death of a loved one, serious financial loss, and natural disaster. It is not common, however, for people in crisis to experience flashbacks. Flashbacks are most consistent with PTSD. PTS:

CON: Stress

MULTIPLE RESPONSE 25. ANS: 2, 4 Chapter: Chapter 12 Stress & Adaptation Objective: Describe the physical changes occurring during the three stages of Selye’s general adaptation syndrome (GAS). Page: 229 (V1) Heading: Models of Stress Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Analysis [Analyzing] Concept: Stress Difficulty: Difficult

1. 2. 3. 4. 5.

Feedback This is incorrect. The metabolic changes that occur during the alarm stage of GAS result in the rate of metabolism increasing, not decreasing. This is correct. The liver converts more glycogen to glucose—a metabolic change that prepares the body for the “fight or flight” response. This is incorrect. The metabolic changes that occur during the alarm stage of GAS result in an increased use of amino acids, not a decreased use. This is correct. There is an increase amino acids and mobilization of fats for energy during GAS. This is incorrect. A surge of epinephrine (adrenaline) and various other hormones prepares the body for fight or flight. The shock phase does usually last less than 24 hours, sometimes only a minute or two.

PTS: 1 CON: Stress 26. ANS: 2, 4, 5 Chapter: Chapter 12 Stress & Adaptation Objective: Discuss the inflammatory response: What triggers it, and what physiological changes occur? Page: 235 (V1) Heading: The Local Adaptation Syndrome Involves a Specific Local Response Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Stress Difficulty: Difficult

1. 2.

Feedback This is incorrect. When a wound becomes infected, yellow, foul-smelling drainage may form at the site; there is no mention of the signs of infection in the scenario. This is correct. During the vascular response phase of the inflammatory process, blood vessels constrict to control bleeding. Fluid from the capillaries moves into tissues, causing edema. This is incorrect. Regeneration occurs when identical or similar cells replace damaged cells; although this may be occurring, it cannot be proven with the data in the scenario. This is correct. The fluid and white blood cells that move to the site of injury are called exudates; this includes the serosanguinous exudate that commonly appears at surgical incisions. This is correct. The wound is progressing as expected within the given timeframe and with the lack of support for non-healing activity.

PTS:

CON: Stress

27. ANS: 1, 2, 4 Chapter: Chapter 12 Stress & Adaptation Objective: State three ways in which you could assess for each of the following: (1) stressors and risk factors, (2) coping methods and adaptation, (3) physiological responses to stress, (4) emotional and behavioral responses to stresses, (5) cognitive responses to stress, and (6) adequacy of support systems. Page: 236 (V1) Heading: Psychological Responses to Stress Include Feelings, Thoughts, and Behaviors Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Stress Difficulty: Difficult

1. 2. 3. 4. 5.

Feedback This is correct. Anxiety is an emotional response related to future or anticipated events. This is correct. The patient’s behavior is focused on an event that has not occurred; therefore, it is more indicative of anxiety than of fear. This is incorrect. The response of either anxiety or fear is not expected from older adult patients; this option represents ageism. This is correct. Anxiety results from psychological conflict, whereas fear can result from either a psychological or physical threat. This is incorrect. Flinching when touched is most commonly associated with fear, either real or anticipated.

PTS: 1 CON: Stress 28. ANS: 1, 2 Chapter: Chapter 12 Stress & Adaptation Objective: Describe several interventions or activities for preventing and managing stress. Page: 229 (V1) Heading: What Is Stress? Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Stress Difficulty: Difficult

1. 2.

Feedback This is correct. Nurses encounter many stressful situations in the work arena and must develop healthful ways of responding. This is correct. As a nurse, it is necessary to understand stress in order to help clients

4. 5.

cope effectively and adapt to the stressors of illness and/or caregiving. This is incorrect. Nurses cannot balance alone the stress for a patient but can assist the patient in identifying the stressors and adaptive responses that will “fit” the patient. This is incorrect. There are many adaptation strategies, but not all strategies will help all patients because each patient is unique. This is incorrect. Not all psychological issues need an understanding of stress in order to be addressed; some psychological issues are biological, physical, or chemical in nature.

PTS: 1 CON: Stress 29. ANS: 2, 3 Chapter: Chapter 12 Stress & Adaptation Objective: Compare and contrast crisis and burnout. Page: 242 (V1) Heading: Box 12-4 Stressors That Can Lead to Burnout Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Stress Difficulty: Difficult

2. 3.

Feedback This is incorrect. Leaving employment is the final option and not necessarily appropriate at this time. When all options have been explored or exhausted and a high level of stress remains or continues, then the person may not have any option other than leaving employment. This is correct. In this item, the nurse is seeing the employee health nurse and is beginning an assessment of concerns. This is correct. The health nurse has not yet explored the stressors, length of time of the stress, or what strategies have been used. An appropriate response by the health nurse is to ask about colleague sharing. This is incorrect. The employee health nurse would not alone make a list of coping strategies for the employee; as in all plans of care, this is to be developed collaboratively. This is incorrect. Suggesting the nurse seek antianxiety medication is not necessarily appropriate. The nurse needs to be high-functioning and not medicated with drugs that can interfere with thought processes. The use of antianxiety medications may require a period of leave from the job.

PTS: 1 30. ANS: 1, 3, 4

CON: Stress

Chapter: Chapter 12 Stress & Adaptation Objective: State three ways in which you could assess for each of the following: (1) stressors and risk factors, (2) coping methods and adaptation, (3) physiological responses to stress, (4) emotional and behavioral responses to stresses, (5) cognitive responses to stress, and (6) adequacy of support systems. Page: 242 (V1) Heading: Assessment Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Stress Difficulty: Difficult

3. 4. 5.

Feedback This is correct. When a patient is experiencing stress and verbalizing complaints to the nurse, it is expected for the patient to be anxious and angry. However, the patient’s comment is open ended, and the nurse needs to seek additional information from the patient for clarification. This is incorrect. When expressed appropriately and clearly, some anger can be adaptive because it temporarily releases the person’s feelings of tension. However, if the nurse personalizes the patient’s comments, the nurse is being nontherapeutic. This is correct. It is appropriate for the nurse to ask the patient how long the stress has existed. This is correct. It is very important for the nurse to ascertain the patient’s coping skills by asking how stress had been managed in the past. This is incorrect. By making an inquiry about family counseling, the nurse is making an assumption. The source of the stress must be determined first.

PTS:

CON: Stress

Chapter 13. Psychosocial Health & Illness Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse understands the necessity of focusing nursing care on the entire person. Which focus is considered most appropriate for the nursing profession? 1. Biomedical focus 2. Psychosocial focus 3. Biopsychosocial focus 4. Physical focus 2. The nurse is providing care for a patient with cancer who is receiving chemotherapy. Based on Maslow’s Hierarchy of Needs, which nursing intervention is the first priority? 1. Assess for and treat pain. 2. Determine if the patient is hungry or thirsty. 3. Explore feelings about dying. 4. Observe client’s self-care abilities. 3. A female client tells the nurse, “I see how people look at me with my crooked back and short leg. No one has to tell me that I’m not pretty.” Which conclusion does the nurse draw from the client’s statements? 1. The client has an overinflated sense of self-esteem. 2. The client possesses a well-developed self-concept. 3. The client is dealing with an overactive imagination. 4. The client is experiencing a state of low self-concept. 4. The nurse is providing care for a client newly diagnosed with anxiety. Which outcome is most realistic and appropriate in planning care for this client? 1. Describes coping strategies for anxious situations 2. Discusses the reasons for episodes with significant others 3. Establishes two new social relationships 4. Verbalizes the client has been episode free 5. An adolescent patient is admitted to the hospital. The nurse is aware the patient has no medical restriction on visitation. Which group of potential visitors is it most important for the nurse to encourage to help maintain the patient’s social identity while hospitalized? 1. Peers 2. Grandparents 3. Siblings 4. Parents 6. The nurse is providing care for a group of patients in an acute care setting. Which comment by one of the patients demonstrates an internal locus of control?

1. 2. 3. 4.

“My blood sugar wouldn’t be out of control if my wife prepared better foods.” “I knew I shouldn’t have come to this hospital; I’d be better if I hadn’t.” “God must be getting even with me for some of my past behavior.” “I’m just glad to be alive; my accident could’ve been a lot worse.”

7. A patient diagnosed with testicular cancer is undergoing chemotherapy, which leaves him unable to help care for his young children. As a result, his spouse misses work whenever the children are ill. The spouse is becoming increasingly distressed over the situation. Which experience does the nurse identify? 1. Role strain 2. Interpersonal role conflict 3. Role performance 4. Interrole conflict 8. The nurse is working with a group of clients who recently experienced health alterations that impacted physical and psychosocial functioning. When the nurse addresses self-concept, which statement best describes self-esteem? 1. View of oneself as a unique human being 2. One’s mental image of one’s physical self 3. One’s overall view of oneself 4. How well one likes oneself 9. A patient undergoing fertility treatments for the past 9 months learns that despite in vitro fertilization she still is not pregnant. This patient is at risk for experiencing a crisis in which component of self-concept? 1. Body image 2. Self-esteem 3. Personal identity 4. Role performance 10. An adolescent female patient sustained facial fractures and a 6-inch laceration on the left side of her face in a motor vehicle accident. The patient tells the nurse that she does not want anyone to see her “looking this way.” Which statement by the nurse is most appropriate? 1. “Tell me what you mean by ‘looking this way.’” 2. “Okay, I’ll restrict your visitors until your face heals.” 3. “Your friends and family love you no matter what.” 4. “You’re young; your face will heal quickly.” 11. The nurse is updating a plan of care for a patient who with a nursing diagnosis of Anxiety. Which patient behavior indicates to the nurse that the problem is resolving? 1. Pacing in the hallway at intervals 2. Using relaxation techniques 3. Speaking rapidly when spoken to 4. Avoiding eye contact

12. The nurse understands that which is the best description of personal identity? 1. It is a continually evolving sense of individuality and uniqueness. 2. It involves the same information as the demographic data. 3. It is a part of the person’s genetic and cultural heritage. 4. It includes individual information guarded to avoid identity theft. 13. The nurse is providing care for a patient diagnosed with clinical depression. Which statement by the nurse is best when communicating with this patient? 1. “It’s a beautiful day today; you’ll feel better if you look out the window.” 2. “You’re having a bad day; I’m sure you’ll feel better soon.” 3. “Life seems overwhelming at times; would you like to discuss how you’re feeling?” 4. “You are very lucky to have such a supportive family.” 14. A patient who lost their job last month has now been told that the patient’s spouse wants a divorce. The patient states, “I know I don’t have much to offer a spouse who wants more from life, and now I’m not even bringing home any money.” Which nursing diagnosis is most appropriate for the patient? 1. Chronic Low Self-Esteem 2. Situational Low Self-Esteem 3. Disturbed Personal Identity 4. Disturbed Body Image 15. The nurse is updating the plan of care for a patient scheduled to undergo a mastectomy for breast cancer. Which nursing diagnosis does the nurse anticipate in expectation of the body changes associated with the upcoming surgery? 1. Deficient Knowledge 2. Impaired Adjustment 3. Hopelessness 4. Grieving 16. A patient admitted with depression has a nursing diagnosis of Chronic Low Self-Esteem. Which Nursing Outcomes Classification (NOC) outcome is essential for this nursing diagnosis? 1. Decision Making 2. Distorted Thought Content 3. Role Performance 4. Depression Level 17. The nursing diagnosis Disturbed Personal Identity is identified for a newly admitted patient. Which is an example of an individualized goal for that patient? 1. Distorted Thought Control 2. Anxiety Level 3. Self-Mutilation Restraint 4. No Self-Injury, Consistently Demonstrated

18. The nurse is developing a plan of care for a patient who has been admitted with a serious acute illness, which is likely to continue long term. The patient is the parent of three small children. The nurse writes the following intervention: “Facilitate communication between patient and significant other regarding the sharing of responsibilities to accommodate changes brought on by illness.” Which purpose does this intervention address? 1. Promotes self-esteem 2. Increases positive body image 3. Facilitates role enhancement 4. Prevents depersonalization 19. The nurse is providing care for patient who comes to the emergency department experiencing headache, palpitations, nausea, and dizziness. After determining that the patient has tachycardia and trembling, the nurse suspects anxiety. Which level of anxiety does the nurse recognize? 1. Mild 2. Moderate 3. Severe 4. Panic 20. The nurse is assessing a patient admitted with a newly diagnosed bleeding duodenal ulcer. The patient is exhibiting physiological signs of anxiety and seems to have difficulty concentrating. During the interview, the patient tells the nurse that he is often “short of breath” and states, “I lie awake nights worrying about everything.” The patient has been unable to work or care for family for the past 6 months. Which is the nurse’s priority after documenting this information in the nurses’ notes? 1. Provide emotional support for the patient using reflective listening technique. 2. Do nothing; people with duodenal ulcers typically cannot work. 3. Question the patient’s family about the information received from the patient. 4. Notify the primary care provider, and ask for a referral to a mental health professional. 21. An adult patient is diagnosed with lung cancer, and surgery to remove the right lung is recommended. The patient is uncertain about consenting to the surgery because of the risks involved. Which nursing diagnosis is most appropriate for this patient? 1. Decisional Conflict 2. Death Anxiety 3. Powerlessness 4. Ineffective Denial 22. Which nursing intervention specifically helps reduce a patient’s anxiety? 1. Teaching the importance of adequate nutrition and hydration 2. Giving clear facts pertaining to the patient’s circumstances 3. Promoting small-group activities to improve self-esteem 4. Monitoring the patient for the risk of suicide

23. The nurse is providing care for a patient admitted with severe depression and identifies a nursing diagnosis of Hopelessness on the patient’s plan of care. Which outcome is appropriate for this diagnosis? 1. Displays stabilization and control of mood 2. Sleeps 6 to 8 hours per night with report of feeling rested 3. Does not engage in risky, self-injurious behavior 4. Eats a well-balanced diet to prevent weight change 24. The nurse is assessing a patient for depression. Which sets of behavioral symptoms may indicate depression to the nurse? 1. Preoccupation with loss, self-blame, and ambivalence 2. Anger, helplessness, guilt, and sadness 3. Anorexia, insomnia, headache, and constipation 4. Tearfulness, withdrawal, and present substance abuse 25. A frail, older adult patient admitted with dehydration to a medical-surgical unit is exhibiting confusion, distractibility, memory loss, and irritability. Which is the most important action for the nurse? 1. Recognize these symptoms as signs of normal, physiologic aging. 2. Obtain a urine specimen before notifying the primary care provider. 3. Be sure the patient is placed in a room occupied with another patient. 4. Interview the patient in order to perform screening for clinical depression. 26. An older adult patient is admitted from a skilled nursing residence to a medical-surgical unit is exhibiting confusion, distractibility, memory loss, and irritability. The patient has a medical diagnosis of Dehydration. Which finding leads the nurse to suspect dementia, rather than depression or dehydration, as the source of the symptoms? 1. Rambles, speaks incoherently, answers questions inappropriately 2. Speaks slowly with delayed response to questions, but responds appropriately 3. Awakens early in the day yet sleeps almost constantly during the day 4. Sometimes has difficulty concentrating on details of the present situation 27. The nurse is providing care for a patient with a history of depression. The patient states, “Sometimes I just don’t believe in using all the medications the doctor orders for me, so I use a lot of over-the-counter herbal medications.” Which is the most appropriate response by the nurse? 1. “Yes, there are many good herbal therapies, but you’ll want to let your doctor know about these therapies in addition to the medications ordered for you.” 2. “Some over-the-counter medications work very well for depression; however, you cannot take them without your doctor’s permission.” 3. “You shouldn’t be treating yourself because you don’t know how these medications work with your depression.” 4. “I think it’s a great idea! If they make you feel better, then continue doing what you’re doing.”

28. The nurse is providing care for several patients on a medical-surgical unit. To which patient statement is the nurse most alerted for making a mental health referral? 1. “Since finding out I have cancer, I feel nervous and uneasy all the time.” 2. “I can feel down about my job, but if I go to the gym and exercise, I feel better.” 3. “When things really bother me, I just put them right out of my head and go on.” 4. “Things at home are just piling up. I just feel so alone and empty inside of me.” 29. A client who is 45 years of age has a history of anxiety and comes into the emergency department with chest pain. The patient is diagnosed with a myocardial infarction (MI). The patient tells the nurse, “This is the most ridiculous thing I’ve ever heard of. I eat well, exercise, and am too young to have a heart attack.” Which reaction does the nurse recognize the patient is most likely experiencing? 1. Fear related to the diagnosis 2. Decisional conflict 3. Ineffective denial 4. Overreaction 30. The nurse on a psychiatric unit is providing care for a client with severe depression. The client states, “I just cannot go on. It is hopeless for me, and there is no end in sight. My family would be better off without me burdening them.” For which condition does nurse recognize this client as being most likely at risk? 1. Ineffective coping 2. Denial 3. Impaired recovery 4. Suicide 31. There are many theories and treatments for depression. Based on current research, which is considered to be the most effective treatment for serious depression? 1. Psychotherapy 2. Antidepressant medications 3. Education 4. Social support networks 32. A client is at the clinic and tells the nurse, “I was taking my blood pressure medications and watching my diet, but that didn’t help my blood pressure. So now I have stopped the medication and will just eat whatever I want.” Which is the most appropriate nursing diagnosis for this client? 1. Anxiety 2. Risk for Hopelessness 3. Ineffective health maintenance 4. Depression 33. The nurse is seeing a home-care client with a history of mental illness. The client is home after undergoing a mastectomy for breast cancer, which requires regular dressing changes. The client states, “Every time I have a nurse come here, they do this dressing differently. I can’t seem to have a nurse that does it right.” Which is the best response by the nurse?

1. “I don’t know how other nurses do your dressing change, but I will do it correctly.” 2. “I have done this type of dressing many times, so you don’t need to worry.” 3. “How would you like this dressing change done? Tell me how you think it should be done.” 4. “It seems you have some concerns about our agency. You may need to talk to the supervisor.” Multiple Response Identify one or more choices that best complete the statement or answer the question. 34. Which assessment findings might suggest that the patient has low self-esteem and requires more in-depth assessment? Select all that apply. 1. Infrequent eye contact 2. Straight posture 3. Being overly critical of others 4. Careful grooming 5. Clear personal identity 35. Which interventions by the nurse might help the patient maintain a sense of personhood during hospitalization? Select all that apply. 1. Addressing the patient by the first name 2. Making eye contact if it is comfortable for the patient 3. Always offering an explanation before beginning a procedure 4. Speaking to others about the patient so that the patient can hear you 5. Asking if the patient has cultural practices that impact their care 36. A client is admitted to the psychiatric unit of a local hospital. During the nursing assessment, the nurse finds the client poorly groomed, wearing dirty clothes, and tearful, and the client reports weight loss with poor appetite. The nurse formulates a nursing diagnosis of Depressed Mood. Which are the most appropriate nursing outcomes for this client? Select all that apply. 1. Eats a well-balanced diet 2. Depressed mood resolves by discharge 3. Bathes, washes, and maintains grooming and hygiene 4. Develops a spiritual belief system or engages in a religious affiliation 5. Is able to discuss lifestyle and living arrangements by the time of discharge 37. The school nurse at the elementary school is preparing a presentation for parents on promoting self-esteem in children. Which are some self-esteem promotion strategies the nurse will teach at the presentation? Select all that apply. 1. Treat children with respect. 2. Be firm and consistent in applying rules. 3. Do not allow children to make decisions independently. 4. Provide frequent positive and negative criticism.

5. Insist children to exhibit maturity of privileges. 38. The nurse is developing a plan of care for a client with anxiety. Which are appropriate nursing interventions the nurse can use for assisting the client in reducing anxiety? Select all that apply. 1. Assist the client to identify triggers and situations that create anxiety. 2. Be vague in answering questions because of not knowing how the client will react. 3. Develop coping strategies and behavior modification techniques with the client. 4. Remind the patient not to engage in any negative thinking to avoid anxiety. 5. Teach the client relaxation techniques to be used as required or needed. 39. Which are the best communication strategies a nurse can use to encourage patients to share personal and sensitive information during the interviewing process? Select all that apply. 1. Be aware of personal biases and opinions with regard to the patient’s information. 2. Ask very specific yes and no questions to keep the patient focused and attentive. 3. Start by asking very broad questions, and then proceed to more specific questions. 4. Avoid any questions related to culture- and gender-specific details about the person. 5. Use an open and positive tone of voice, facial expression, and body language.

Chapter 13. Psychosocial Health & Illness Answer Section MULTIPLE CHOICE 1. ANS: 3 Chapter: Chapter 13 Psychosocial Health & Illness Objective: Explain the relationship of psychosocial factors to overall health and development. Page: 254 (V1) Heading: Psychosocial Health Integrated Processes: Caring Client Need: Psychosocial Integrity Cognitive Level: Comprehension [Understanding] Concept: Self Difficulty: Moderate Feedback 1 This is incorrect. Biomedical focus is not focused on nursing care for the entire person. A biomedical focus is most likely focused on body functions and disease processes. 2 This is incorrect. Psychosocial focus is not focused on nursing care for the entire person. A psychosocial focus is most likely focused on psychological functioning. 3 This is correct. A strength of the nursing profession is the ability to go beyond the biomedical, psychosocial, or physical focus to care for the entire person. This approach focuses on the overall biopsychosocial well-being of the patient. 4 This is incorrect. Physical focus places nursing care on the physiological functioning of a person, and not on the entire person. PTS: 1 CON: Self 2. ANS: 2 Chapter: Chapter 13 Psychosocial Health & Illness Objective: Explain the relationship of psychosocial factors to overall health and development. Page: 254 (V1) Heading: What Is Psychosocial Therapy? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Untreated pain can affect biological/physiological needs. Maslow’s Hierarchy of Needs states that until the pain is controlled (safety and

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security need), the patient cannot consider exploring feelings or participating in self-care. Pain management will be the nurse’s second focus. This is correct. According to Abraham Maslow and his Hierarchy of Needs, lower-level needs (physiological) must be met before higher needs can be achieved. Hunger and thirst are basic physiological needs. This is incorrect. There is no information in the scenario that indicates the patient is dying. This is incorrect. The patient will not be able to perform self-care until the first two levels of Maslow’s Hierarchy of Needs are met. Basic needs (hunger and thirst) are met first, followed by Safety and Security needs (pain).

PTS: 1 CON: Patient-Centered Care 3. ANS: 4 Chapter: Chapter 13 Psychosocial Health & Illness Objective: Identify the factors that influence the development and stability of self-concept. Page: 255 (V1) Heading: What Is Self-Concept? Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Self Difficulty: Moderate Feedback 1 This is incorrect. An overinflated sense of self-esteem exists when the patient has a high regard for personal physical appearance. This patient’s expressions are negative. 2 This is incorrect. The patient’s comments are not indicative of a well-developed self- concept. The patient focuses entirely on physical appearances. 3 This is incorrect. The patient’s comments are not a product of an overactive imagination; the comments are stating some physical conditions. However, the rest is based on the patient’s self-perception and not on imagination. 4 This is correct. Self-concept forms out of a person’s evaluation of physical appearance, intellectual ability, success in the workplace, friendship, and approval from others. A person with a low self-concept has a mostly negative perception of these evaluations of self. A low self-concept may cause withdrawal from social interactions and make it difficult to form relationships. PTS: 1 CON: Self 4. ANS: 1 Chapter: Chapter 13 Psychosocial Health & Illness Objective: Devise a nursing care plan for the nursing diagnosis of Anxiety. Page: 265 (V1)

Heading: Example Problem: Anxiety Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Stress Difficulty: Difficult Feedback 1 This is correct. Identifying the source of the client’s anxiety will allow the client to recognize the conflict and use a conscious, rational mind to deal with it by identifying and planning strategies for anxiety-producing situations. 2 This is incorrect. Discussing the reasons for episodes with significant others is not necessarily realistic or appropriate. The client may experience symptoms as a result of trauma and may have associated feelings of shame. 3 This is incorrect. For newly diagnosed clients, establishing two new social relationships, given the energy required for trust to develop, may not be attainable. 4 This is incorrect. Expecting the client to be episode free is not realistic and may put unrealistic expectations on the client. PTS: 1 CON: Stress 5. ANS: 1 Chapter: Chapter 13 Psychosocial Health & Illness Objective: Describe interventions for preventing depersonalization. Page: 257 (V1) Heading: What Factors Affect a Person’s Self-Concept? Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Self Difficulty: Moderate Feedback 1 This is correct. Peers are more important than family in maintaining social identity in this age group. 2 This is incorrect. Grandparents are not likely to help an adolescent patient to maintain social identity. 3 This is incorrect. Siblings may or may not help an adolescent patient to maintain social identity; peers are a better group for a patient in this age group. 4 This is incorrect. Parents may play an important role for the adolescent who is hospitalized; however, peers are the group most likely to help an adolescent patient to maintain social identity. PTS:

CON: Self

6. ANS: 4 Chapter: Chapter 13 Psychosocial Health & Illness Objective: Describe interventions for preventing depersonalization. Page: 256 (V1) Heading: Locus of Control Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Self Difficulty: Moderate Feedback 1 This is incorrect. Blaming a reason for uncontrolled blood glucose on another person’s actions or behaviors demonstrates the patient putting control of the situation on external factors. 2 This is incorrect. The patient is attributing the situation of not getting well to the work of external factors. 3 This is incorrect. When a patient expresses that God is punishing them for past behaviors, the patient is demonstrating an external locus of control. 4 This is correct. People who demonstrate an internal locus of control take responsibility for their life experiences and their responses to them. This allows them to interpret unexpected events in a positive light, as the response “. . . the accident could’ve been a lot worse” illustrates. PTS: 1 CON: Self 7. ANS: 4 Chapter: Chapter 13 Psychosocial Health & Illness Objective: Describe interventions for preventing depersonalization. Page: 257 (V1) Heading: Role Performance Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Family Dynamics Difficulty: Difficult Feedback 1 This is incorrect. Role strain is a mismatch between role expectations and role performance. 2 This is incorrect. Interpersonal role conflict results when another person’s idea about how a role should be performed differs from that of the person who is performing the role. 3 This is incorrect. Role performance is defined as the actions a person takes and the behaviors demonstrated in performing a role.

This is correct. The patient’s spouse is most likely experiencing interrole conflict, in which the roles as a parent and worker are making competing demands on the spouse.

PTS: 1 CON: Family Dynamics 8. ANS: 4 Chapter: Chapter 13 Psychosocial Health & Illness Objective: List the four interrelated components of self-concept. Page: 261 (V1) Heading: What Are the Components of Self-Concept? Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Comprehension [Understanding] Concept: Self Difficulty: Moderate Feedback 1 This is incorrect. Personal identity is one’s view of oneself as a unique human being. 2 This is incorrect. Body image is described as one’s mental image of one’s physical self. 3 This is incorrect. Self-concept is defined as one’s overall view of oneself. 4 This is correct. Self-esteem is a favorable impression of oneself, or self-respect —that is, how well one likes oneself. PTS: 1 CON: Self 9. ANS: 2 Chapter: Chapter 13 Psychosocial Health & Illness Objective: List the four interrelated components of self-concept. Page: 261 (V1) Heading: What Are the Components of Self-Concept? Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Self Difficulty: Difficult Feedback 1 This is incorrect. The patient is not at risk for experiencing a crisis in body image, which is the mental image of a person’s physical self, including physical appearance and physical functioning. 2 This is correct. Setbacks such as not becoming pregnant after months of fertility treatment can cause the patient to question her self-worth. This might provoke a crisis in self-esteem.

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This is incorrect. Personal identity is the view of oneself as a unique human being, different and separate from all others. This is incorrect. Role performance can be defined as the actions a person takes and the behaviors demonstrated in fulfilling a role. Instead of expectations, role performance is the reality.

PTS: 1 CON: Self 10. ANS: 1 Chapter: Chapter 13 Psychosocial Health & Illness Objective: Identify nursing diagnoses, outcomes, and interventions specific to body image disturbance. Page: 256 (V1) Heading: What Factors Affect a Person’s Self-Concept? Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Self Difficulty: Moderate

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Feedback This is correct. “Tell me what you mean …” encourages the patient to clarify her statement so that the nurse knows exactly what the patient means. The nurse cannot assume that the patient is talking about her facial wounds. This is incorrect. “I’ll restrict your visitors …” assumes that the patient is speaking about her facial wounds when she might not be. This is incorrect. Telling the patient that family and friends will love her is an example of false reassurance and does not address the patient’s concern. This is incorrect. The nurse telling the patient that she is young and will heal quickly does not address the patient’s concerns about the here and now. It is also an example of false reassurance.

PTS: 1 CON: Self 11. ANS: 2 Chapter: Chapter 13 Psychosocial Health & Illness Objective: List the psychological and physiological effects of anxiety. Page: 265 (V1) Heading: Example Problem: Anxiety Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Comprehension [Understanding] Concept: Stress Difficulty: Moderate

Feedback 1 2

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This is incorrect. Pacing in the hallways suggests that anxiety is still a problem for the patient. This is correct. Recognizing the use of and benefits of relaxation techniques suggests that the patient’s anxiety is resolving. The patient’s use of relaxation techniques indicates problem solving by the patient. This is incorrect. Rapid speech can be indicative of a patient experiencing anxiety. This is incorrect. Patients who are anxious are likely to avoid eye contact with other persons.

PTS: 1 CON: Stress 12. ANS: 1 Chapter: Chapter 13 Psychosocial Health & Illness Objective: Describe interventions for preventing depersonalization. Page: 257 (V1) Heading: Personal Identity Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Comprehension [Understanding] Concept: Self Difficulty: Moderate Feedback 1 This is correct. Personal identity is a person’s view of self as a unique human being, different and separate from all others. Identity develops over time, beginning in childhood when a child identifies with parents, and then later with teachers, peers, and others, and once developed, identity is relatively constant and consistent. 2 This is incorrect. Personal identity is not associated with demographic data. 3 This is incorrect. Genetic and cultural heritage can influence personal identity but has a limited role in how a person views self as a unique human being. 4 This is incorrect. In the medical and nursing arena, personal identity does not include individual information guarded to avoid identity theft. PTS: 1 CON: Self 13. ANS: 3 Chapter: Chapter 13 Psychosocial Health & Illness Objective: Plan outcomes and nursing interventions for patients who are depressed. Page: 270 (V1) Heading: Example Problem: Depression Integrated Processes: Nursing Process Client Need: Psychosocial Integrity

Cognitive Level: Application [Applying] Concept: Mood Difficulty: Moderate Feedback 1 This is incorrect. “It’s a beautiful day ….” offers false reassurance. The nurse is making an assumption that the client will feel better by looking out the window. 2 This is incorrect. “You’re having a bad day ….” is judgmental and telling the patient he will feel better soon is offering false assurance. 3 This is correct. When caring for a patient with depression, the nurse should encourage the patient to discuss feelings. 4 This is incorrect. It would not be therapeutic to say, “You are very lucky ….”; it is an example of making a judgment about the patient’s family. If the patient does not share the nurse’s opinion, communication can be interrupted. PTS: 1 CON: Mood 14. ANS: 2 Chapter: Chapter 13 Psychosocial Health & Illness Objective: Develop a nursing care plan for patients exhibiting disturbances in self-concept and self-esteem. Page: 257 (V1) Heading: Self-Esteem Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Self Difficulty: Moderate Feedback 1 This is incorrect. There are no data to indicate long-standing (chronic) Low SelfEsteem. 2 This is correct. Situational Low Self-Esteem occurs when a person exhibits selfdisapproval and negative self-evaluations as a specific reaction to loss or change (in this case, of job and marriage). 3 This is incorrect. This client has no defining characteristics for Disturbed Personal Identity, which is an inability to determine boundaries between self and others. 4 This is incorrect. The client does not mention anything that supports Disturbed Body Image. The client expresses overall dissatisfaction with self-performance. PTS: 1 CON: Self 15. ANS: 4 Chapter: Chapter 13 Psychosocial Health & Illness

Objective: Identify nursing diagnoses, outcomes, and interventions specific to body image disturbance. Page: 256 (V1) Heading: Body Image Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Self Difficulty: Moderate Feedback 1 This is incorrect. Deficient Knowledge is not associated with the upcoming surgery; the patient is well informed about the procedure and results of a mastectomy. 2 This is incorrect. Impaired adjustment is not routinely associated with the expected body changes associated with a mastectomy. However, impaired adjustment may occur, at which time the nurse will expand the plan of care. 3 This is incorrect. Hopelessness is not usually associated with the performance of a mastectomy. This diagnosis would be more likely associated with the medical diagnosis of breast cancer. 4 This is correct. Grieving may occur as a result of body changes associated with mastectomy. PTS: 1 CON: Self 16. ANS: 4 Chapter: Chapter 13 Psychosocial Health & Illness Objective: Develop a nursing care plan for patients exhibiting disturbances in self-concept and self-esteem. Page: 270 (V1) Heading: Example Problem: Depression Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Mood Difficulty: Moderate Feedback 1 This is incorrect. Decision Making is associated with the nursing diagnosis Situational Low Self-Esteem. But, the nurse needs to address the admitting diagnosis of depression. 2 This is incorrect. Distorted Thought Content with Disturbed Personal Identity may contribute to the patient’s low self-esteem, but the nurse must write one goal that specifically addresses the admitting diagnosis of depression. 3 This is incorrect. Ineffective role performance may contribute to the patient’s

low self-esteem; however, the nurse must write one goal (outcome) that specifically addresses the admitting diagnosis of depression. This is correct. Depression Level is the appropriate NOC outcome for the patient admitted with depression who has the nursing diagnosis Chronic Low SelfEsteem.

PTS: 1 CON: Mood 17. ANS: 4 Chapter: Chapter 13 Psychosocial Health & Illness Objective: Plan outcomes and nursing interventions for patients with a diagnosis of Risk for Suicide. Page: 270 (V1) Heading: Example Problem: Depression Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Mood Difficulty: Difficult Feedback 1 This is incorrect. Distorted Thought Control is an example of Nursing Outcomes Classification (NOC) outcomes; it is not written as a goal. 2 This is incorrect. Anxiety Level is an example of NOC outcomes; it is not written as a goal. 3 This is incorrect. Self-Mutilation Restraint is an example of NOC outcomes; it is not written as a goal. 4 This is correct. No Self-Injury, Consistently Demonstrated is an example of using NOC indicators and outcomes to write an individualized goal. PTS: 1 CON: Mood 18. ANS: 3 Chapter: Chapter 13 Psychosocial Health & Illness Objective: Describe interventions for preventing depersonalization. Page: 257 (V1) Heading: Role Performance Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Comprehension [Understanding] Concept: Self Difficulty: Moderate Feedback 1 This is incorrect. The intervention is not designed to promote self-esteem. 2 This is incorrect. Positive body image is not promoted by the stated intervention.

This is correct. Facilitating communication between the patient and significant other regarding sharing of responsibilities to accommodate changes brought on by the illness can help facilitate role enhancement in the patient. This is incorrect. Prevent depersonalization is not an intervention stated in this scenario.

PTS: 1 CON: Self 19. ANS: 3 Chapter: Chapter 13 Psychosocial Health & Illness Objective: List the psychological and physiological effects of anxiety. Page: 265 (V1) Heading: Levels of Anxiety Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Stress Difficulty: Moderate Feedback 1 This is incorrect. Symptoms associated with mild anxiety include muscle tension, restlessness, irritability, and a sense of unease. 2 This is incorrect. The patient experiencing moderate anxiety might exhibit a rise in heart rate and respiratory rate, increased perspiration, gastric discomfort, and increased muscle tension. 3 This is correct. The patient experiencing severe anxiety may experience physical symptoms, including headache, palpitations, tachycardia, insomnia, dizziness, nausea, trembling, hyperventilation, urinary frequency, and diarrhea. 4 This is incorrect. Patients experiencing panic anxiety might feel as if they have a life-threatening illness. Physical symptoms include dilated pupils, labored breathing, severe trembling, sleeplessness, palpitations, diaphoresis, pallor, and uncoordinated muscle movements. PTS: 1 CON: Stress 20. ANS: 4 Chapter: Chapter 13 Psychosocial Health & Illness Objective: Recognize the levels and symptoms of anxiety that are severe enough to merit referral to a mental health professional. Page: 266 (V1) Heading: Coping With Anxiety Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Stress

Difficulty: Difficult Feedback 1 This is incorrect. Although it is important for the nurse to provide emotional support for the patient, a mental health professional is needed for this patient. 2 This is incorrect. Doing nothing is neglectful. 3 This is incorrect. Questioning the patient’s family about the information violates the patient’s right to privacy, unless the nurse obtains the patient’s permission to do so. 4 This is correct. The nurse should involve a mental health professional immediately because the patient is exhibiting signs of a disabling anxiety disorder. PTS: 1 CON: Stress 21. ANS: 1 Chapter: Chapter 13 Psychosocial Health & Illness Objective: List the psychological and physiological effects of anxiety. Page: 264 (V1) Heading: Planning Psychosocial Interventions/Implementation Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Stress Difficulty: Moderate Feedback 1 This is correct. Decisional Conflict is the most appropriate nursing diagnosis for this patient because of uncertainty about whether taking a surgical risk. 2 This is incorrect. Death Anxiety is apprehension, worry, or fear related to death or dying; there is nothing to suggest that this patient is suffering from Death Anxiety at this time. 3 This is incorrect. Powerlessness is a perceived lack of control over a current situation; this patient is trying to exert some control over the care. 4 This is incorrect. Ineffective Denial is appropriate when the patient consciously or unconsciously rejects knowledge; there is nothing in this scenario to suggest that the patient is rejecting knowledge. PTS: 1 CON: Stress 22. ANS: 2 Chapter: Chapter 13 Psychosocial Health & Illness Objective: Devise a nursing care plan for the nursing diagnosis of Anxiety. Page: 264 (V1) Heading: Planning Psychosocial Interventions/Implementation Integrated Processes: Nursing Process

Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Stress Difficulty: Moderate Feedback 1 This is incorrect. Teaching the importance of adequate nutrition and hydration addresses physiological needs. 2 This is correct. Using clear and factual knowledge that is tailored to the patient’s circumstances helps reduce anxiety. 3 This is incorrect. Promoting small-group activities is most likely to improve the patient’s self-esteem. 4 This is incorrect. Monitoring the patient for suicide risk is an intervention designed to help the patient with depression. PTS: 1 CON: Stress 23. ANS: 1 Chapter: Chapter 13 Psychosocial Health & Illness Objective: Plan outcomes and nursing interventions for patients who are depressed. Page: 270 (V1) Heading: Example Problem: Depression Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Mood Difficulty: Difficult Feedback 1 This is correct. “Displays stabilization and control of mood” is an outcome for the nursing diagnosis Hopelessness. 2 This is incorrect. “Sleeps 6 to 8 hours per night and reports feeling rested” is an example of an outcome for the diagnosis Depressed Mood. 3 This is incorrect. “Does not engage in risky, self-injurious behavior” is an outcome for the nursing diagnosis Risk for Suicide. 4 This is incorrect. “Eats a well-balanced diet to prevent weight change” is an example of an outcome for the diagnosis Depressed Mood. PTS: 1 CON: Mood 24. ANS: 4 Chapter: Chapter 13 Psychosocial Health & Illness Objective: Differentiate between mild depression and that which should be referred to a mental health professional. Page: 270 (V1) Heading: Example Problem: Depression

Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Comprehension [Understanding] Concept: Mood Difficulty: Moderate Feedback 1 This is incorrect. Denial of feelings, anger, anxiety, guilt, helplessness, hopelessness, and sadness are affective findings associated with depression. 2 This is incorrect. Cognitive findings in depression include preoccupation with loss, self-blame, ambivalence, and blaming others. 3 This is incorrect. Physiological findings of depression include anorexia, overeating, insomnia, hypersomnia, headache, backache, chest pain, and constipation. 4 This is correct. Tearfulness, regression, restlessness, agitation, withdrawal, past or present substance abuse, and a past history of suicide attempts are all behavioral symptoms of depression. PTS: 1 CON: Mood 25. ANS: 4 Chapter: Chapter 13 Psychosocial Health & Illness Objective: Assess older adults for manifestations of depression. Page: 270 (V1) Heading: Assessment and Interventions For Older Adults: Depression, Delirium, or Dementia? Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Mood Difficulty: Moderate Feedback 1 This is incorrect. Associating the symptoms with normal physiological aging is an example of ageism. 2 This is incorrect. Any one of the symptoms might occur as a result of physical illness. Before exploring physiological causes for the symptom (as with a urine specimen), the nurse needs to interview and screen the patient for depression. 3 This is incorrect. Placing the patient in a room with another patient would be indicated for social isolation, which can be associated with depression; however, the nurse needs to screen for depression before looking for causes. 4 This is correct. Depression is often masked in older adults and expressed as physical and personality changes. Memory loss and confusion are also common symptoms of depression in older adults. PTS:

CON: Mood

26. ANS: 1 Chapter: Chapter 13 Psychosocial Health & Illness Objective: Assess older adults for manifestations of depression. Page: 270 (V1) Heading: Assessment and Interventions for Older Adults: Depression, Delirium, or Dementia? Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Mood Difficulty: Difficult Feedback 1 This is correct. In dementia, a patient’s language is disoriented, rambling, and incoherent; and the patient responds to questions inappropriately or with “near misses.” 2 This is incorrect. Speaking slowly and being slow to respond to verbal stimuli are signs of depression; in depression, the patient usually answers questions appropriately. 3 This is incorrect. Awakening early and sleeping constantly during the day are signs of depression; in dementia, sleep is fragmented and the person awakens often during the night. 4 This is incorrect. Difficulty concentrating on details is a thinking pattern seen more often in depression; in dementia, there is difficulty finding words, difficulty calculating, and decreased judgment. PTS: 1 CON: Mood 27. ANS: 1 Chapter: Chapter 13 Psychosocial Health & Illness Objective: Plan outcomes and nursing interventions for patients who are depressed. Page: 270 (V1) Heading: Example Problem: Depression Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Mood Difficulty: Moderate Feedback 1 This is correct. Many people use herbal therapies to relieve symptoms of anxiety and depression. Patients may self-treat, or herbal therapies may be prescribed by complementary and alternative modalities (CAM) practitioners. However, the nurse needs to encourage the patient to let the physician know about CAM being used. 2 This is incorrect. The nurse should assess for CAM use to be sure the method is

not contraindicated and that the patient has informed the primary care provider about their use. This is incorrect. While CAM can be effective, many of these modalities such as ginkgo biloba, ginseng, and kava have side effects, cause adverse reactions, and are contraindicated with other medications. This is incorrect. The nurse should neither approve nor disapprove of the patient’s actions but should make clear that the physician should be informed about all medications, including over-the-counter ones.

PTS: 1 CON: Mood 28. ANS: 4 Chapter: Chapter 13 Psychosocial Health & Illness Objective: Differentiate between mild depression and that which should be referred to a mental health professional. Page: 270 (V1) Heading: Example Problem: Depression Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Mood Difficulty: Difficult Feedback 1 This is incorrect. Feelings of nervousness and uneasiness may be symptoms of anxiety. This patient should first talk to the primary care provider about the diagnosis and the associated feelings. 2 This is incorrect. The patient has found an effective coping method at this time and does not warrant a mental health referral. Learning to manage stress with exercise is a positive behavior. 3 This is incorrect. Some patients will deal with stress by learning not to dwell on problems; therefore, this does not warrant a mental health referral. 4 This is correct. Unlike the feeling of true sadness, such as feelings that may accompany a divorce, death, or other loss, the depressed mood is typically marked by a sense of emptiness. The patient in most need of a mental health referral is the patient who verbalizes the feeling of loneliness and emptiness. PTS: 1 CON: Mood 29. ANS: 3 Chapter: Chapter 13 Psychosocial Health & Illness Objective: List the psychological and physiological effects of anxiety. Page: 266 (V1) Heading: Coping With Anxiety Integrated Processes: Nursing Process

Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Stress Difficulty: Moderate Feedback 1 This is incorrect. Fear is a response associated with anxiety; however, it is usually a response to a perceived threat that is recognized as a danger. 2 This is incorrect. Decisional conflict arises when a person is uncertain about what action to take when making choices among alternatives. There is no evidence in this item that the person is making any decisions. 3 This is correct. Ineffective denial occurs when a person consciously or unconsciously rejects the knowledge or meaning of an event, such as having a heart attack. The patient may frequently respond with statements such as “This can’t be me,” “They’ve made a mistake.” In this item, the patient is denying a heart attack because of the belief of being too healthy and too young to be having a heart attack. 4 This is incorrect. Overreaction can occur with some psychosocial disorders; however, the patient statements are not reflective of overreacting because of the actual diagnosis of a heart attack. PTS: 1 CON: Stress 30. ANS: 4 Chapter: Chapter 13 Psychosocial Health & Illness Objective: Plan outcomes and nursing interventions for patients with a diagnosis of Risk for Suicide. Page: 260 (V1) Heading: Box 13-1 Cues Indicating a Possible Risk for Suicide Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Violence Difficulty: Moderate Feedback 1 This is incorrect. Ineffective coping is present and is, therefore, an actual, rather than a risk, problem. 2 This is incorrect. The client’s statements do not indicate evidence of denial. 3 This is incorrect. There is no implication of impaired recovery in the client’s statements. 4 This is correct. Risk for suicide must always be considered when a client is depressed, especially when the client has a history of prior attempts or is verbalizing the desire to die or the intent to kill himself. In this item, the client is most at risk for suicide based on the statements verbalized.

PTS: 1 CON: Violence 31. ANS: 2 Chapter: Chapter 13 Psychosocial Health & Illness Objective: Plan outcomes and nursing interventions for patients who are depressed. Page: 270 (V1) Heading: Example Problem: Depression Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Mood Difficulty: Moderate

1 2

3 4

Feedback This is incorrect. Psychotherapists acknowledge that psychotherapy is effective when used in conjunction with medications. This is correct. The physiological theory of depression predominates in the medical community, and current evidence shows that biochemical processes determine moods, thought, cognition, and perception. Therefore, treatment of serious depression relies more heavily on antidepressant medications than on psychotherapy. This is incorrect. Education promotes understanding about the patient’s depression and is effective when used with appropriate medications. This is incorrect. Social networks can impact a patient’s depression positively. The use of antidepressant medications is an appropriate adjunct.

PTS: 1 CON: Mood 32. ANS: 3 Chapter: Chapter 13 Psychosocial Health & Illness Objective: Identify nursing diagnoses, outcomes, and interventions specific to body image disturbance. Page: 260 (V1) Heading: Analysis/Nursing Diagnosis: Self-Concept and Self-Esteem Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Self Difficulty: Moderate Feedback 1 This is incorrect. In this item, there is no evidence of anxiety. 2 This is incorrect. This scenario does not have indicators of the patient being at risk for hopelessness.

This is correct. Ineffective health maintenance may occur as a result of low selfesteem: not perceiving one’s self as capable, or feeling there is no point in making the effort. This patient should not arbitrarily and abruptly stop his medications; instead, he should be instructed to see his primary care provider for follow-up regarding medications. This is incorrect. The client’s statements dos not support the presence of depression.

PTS: 1 CON: Self 33. ANS: 3 Chapter: Chapter 13 Psychosocial Health & Illness Objective: Explain the relationship of psychosocial factors to overall health and development. Page: 254 (V1) Heading: Psychosocial Health Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Self Difficulty: Moderate Feedback 1 This is incorrect. Telling the client the nurse will do the dressing correctly does not foster participation or control for this client. 2 This is incorrect. Telling the client not to worry does not foster participation or control for this client. 3 This is correct. In this item, the client has a history of mental illness and a medical condition. There are specific interventions and actions a nurse can use in caring for such clients. One of the best strategies is to have the client participate in care and allow the client some control over the dressing change. Asking the client, “How do you usually do the dressing?” or “How would you like the dressing done?” is completely appropriate as long as the client’s preference is consistent with safe and effective nursing practice. 4 This is incorrect. The assumption by the nurse about client dissatisfaction is not appropriate. The nurse needs to use the strategy of allowing the client to participate in care and allowing the client some control over the dressing change. PTS:

CON: Self

MULTIPLE RESPONSE 34. ANS: 1, 3 Chapter: Chapter 13 Psychosocial Health & Illness

Objective: Identify the factors that influence the development and stability of self-concept. Page: 256 (V1) Heading: What Are the Components of Self-Concept? Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Self Difficulty: Difficult

1. 2. 3. 4. 5.

Feedback This is correct. Assessment findings that suggest low self-esteem include avoiding eye contact. This is incorrect. The nurse does not associate straight posture as an indication of low self-esteem. This is correct. Being overly critical of others is often an assessment finding that suggests low self-esteem. This is incorrect. Careful grooming is most frequently associated with high selfesteem. This is incorrect. When a patient has a clear personal identity, it is often associated with a high self-esteem.

PTS: 1 CON: Self 35. ANS: 2, 3, 5 Chapter: Chapter 13 Psychosocial Health & Illness Objective: Identify the factors that influence the development and stability of self-concept. Page: 255 (V1) Heading: What Factors Affect a Person’s Self-Concept? Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Self Difficulty: Difficult

2. 3. 4.

Feedback This is incorrect. The nurse can help the patient maintain a sense of personhood by addressing the patient by the preferred name, which might be the first name or might be the surname with a title. This is correct. Making eye contact if it is comfortable for the patient is a way for the nurse to offer care that respects the patient’s rights. This is correct. The nurse needs to always offer an explanation before beginning a procedure, so that the patient feels comfortable with and aware of procedures. This is incorrect. The nurse belittles the patient’s sense of self if the nurse talks to

others in the room about the patient. This is correct. In order to promote feelings of self for the hospitalized patient, the nurse needs to inquire about and address cultural needs of the patient.

PTS: 1 CON: Self 36. ANS: 1, 3 Chapter: Chapter 13 Psychosocial Health & Illness Objective: Plan outcomes and nursing interventions for patients who are depressed. Page: 270 (V1) Heading: Example Problem: Depression Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Mood Difficulty: Difficult

Feedback This is correct. Based on the description of this client in this item, the nurse has developed the nursing diagnosis of Depressed Mood. An appropriate outcome includes a well-balanced dietary intake based on stated weight loss and decreased appetite. This is incorrect. An appropriate outcome may be that the client reports feeling less sad and depressed; however, it may not be realistic or attainable that this client’s depressed mood will be resolved by discharge. This is correct. Maintaining adequate grooming and hygiene is an appropriate outcome for a client who is depressed. Grooming and hygiene may both be neglected when a client is depressed. This is incorrect. The nurse can discuss and explore spirituality with this client; however, this outcome may or may not contribute to resolution of a problem of Depressed Mood. This is incorrect. The client with depression may or may not be able to discuss lifestyle or living arrangements by the time of discharge. Management of depression is likely to be ongoing and require additional assistance.

PTS: 1 CON: Mood 37. ANS: 1, 2 Chapter: Chapter 13 Psychosocial Health & Illness Objective: Identify the factors that influence the development and stability of self-concept. Page: 254 (V1) Heading: What Is Psychosocial Theory? Integrated Processes: Nursing Process Client Need: Psychosocial Integrity

Cognitive Level: Analysis [Analyzing] Concept: Family Dynamics Difficulty: Difficult

1. 2.

Feedback This is correct. Teaching parents to promote self-esteem in children is important. One effective strategy involves treating the child with respect. This is correct. Teaching parents to promote self-esteem in children is important. A strategy involving rules with clearly defined limits, having consequences for breaking rules, being firm and consistent in applying rules, and making sure rules are reasonable can be effective in building positive self-esteem. This is incorrect. Not allowing children to make decisions independently is not an effective way to promote self-esteem; however, the process should always take place within defined limits. This is incorrect. Building self-esteem in children is best achieved with the use of positive feedback. Frequent negative criticism can hinder the development of positive self-esteem. This is incorrect. Children do not always need to exhibit a certain level of maturity to gain privileges. Sometimes, children respond to rewards that are safe and age appropriate without the rigors of having to prove themselves worthy.

PTS: 1 CON: Family Dynamics 38. ANS: 1, 3, 5 Chapter: Chapter 13 Psychosocial Health & Illness Objective: Devise a nursing care plan for the nursing diagnosis of Anxiety. Page: 267 (V1) Heading: Nursing Care for Example Problem: Anxiety Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Stress Difficulty: Difficulty

1. 2.

3. 4.

Feedback This is correct. Specific nursing interventions for reducing anxiety include helping the client identify triggers and situations that create anxiety. This is incorrect. The nurse always needs to use clear and factual knowledge and information tailored to the client’s circumstances; using vague answers and communications is not helpful in reducing anxiety. This is correct. The nurse can help the client reduce anxiety by developing coping strategies and behavior modification techniques specific to the purpose. This is incorrect. Although the nurse should discourage negative thinking, the nurse

cannot tell the client that it cannot be used. The nurse should avoid using such terms as “shouldn’t” or “you ought to,” as these can be interpreted as being judgmental. Instead, the nurse needs to provide the client with methods to change anxiety inducing thoughts and behaviors. This is correct. An effective way reduce anxiety is to teach the client relaxation techniques that can be used by the client as required or needed.

PTS: 1 CON: Stress 39. ANS: 1, 3, 5 Chapter: Chapter 13 Psychosocial Health & Illness Objective: Describe interventions for preventing depersonalization. Page: 258 (V1) Heading: Assessment: Psychosocial Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Self Difficulty: Difficult

2. 3.

4. 5.

Feedback This is correct. Psychosocial information is personal and sometimes sensitive. The nurse needs to be aware of personal biases and discomforts that could influence the patient’s assessment. This is incorrect. The nurse needs to avoid specific yes and no questions to keep the patient focused and attentive. This is correct. To encourage patients to share information, the nurse needs to use good communication skills. The nurse needs to begin with broad general details and questions and then proceed to specific details and questions. This is incorrect. The nurse does not avoid questions related to culture and gender. However, these questions and answers need to be handled with respect. This is correct. In order to assist in the attainment of psychosocial information, the nurse uses an open and positive tone of voice, facial expression, and body language.

PTS:

CON: Self

Chapter 14. The Family Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The graduate nurse tells the preceptor that the newly admitted patient has a strange living arrangement. The patient lives in a household that consists of two aunts, a grandparent, a niece, a nephew, and her best friend. Which response by the preceptor is best? 1. “You are correct. That is a different type of household.” 2. “That is an example of a family defined by a different culture.” 3. “This is considered an extended family, which is not unusual.” 4. “This type of blended family is statistically shown to be increasing.” 2. An older adult patient is admitted to the hospital with heart failure. The patient’s best friend is present during admission. The couple has shared a home since each were widowed 3 years ago. Both have grown children who live out of state. Which family nursing approach does the nurse use? 1. Involve the friend and patient’s children in the care, discharge planning, and home care. 2. Encourage the friend to wait until discharge to provide care for the patient at home. 3. Explain to the friend an inability to be involved in patient care for confidentiality reasons. 4. Encourage liberal visiting hours by the friend and the patient’s children. 3. The nurse is providing care for a patient diagnosed with lung cancer. The patient and the spouse are 2 years from retirement. The nurse is aware that a variety of developmental stages among families can exist due to delayed childbearing. However, which typical stage of family development is this couple likely experiencing? 1. Family launching young adults 2. Postparental family 3. Family with frail elderly 4. Family with teenagers and young adults 4. A nurse is providing care for a patient newly diagnosed with type 1 diabetes mellitus. The patient’s spouse states, “We are a family of diabetics.” The nurse advises attendance to the free nutrition, cooking, and exercise classes at the health center near their neighborhood. The nurse also provides the name of the public health nurse for their area. Which perspective of family nursing is the nurse practicing? 1. Family as a unit of care 2. Family as a system 3. Family as the context of care 4. Family as a resource and stressor

5. The parents of three children, aged 3, 6, and 8 years, comment that although the children are close in age, they each seem to have different needs. The nurse teaches the parents what tasks the children should accomplish based on the different age groups and provide strategies to help meet the children’s needs. Which theory best explains the nurse’s teaching plan? 1. General systems theory 2. Family interactional theory 3. Family as a context theory 4. Developmental theory 6. The nurse is aware of which situation best depicting a mid-life crisis? 1. A college graduate moves in with parents because of an inability to find employment. 2. Parents enroll their two toddlers in day care because two incomes are needed meet the household’s financial demands. 3. After the couple’s daughter leaves for college, the husband quits his job and decides to “see the world.” 4. An older adult widower rejects the children’s advice to move into an assisted living facility. 7. To prevent a reduction in herd immunity, which information does the nurse teach in a class of pregnant women? 1. “You should increase your intake of milk to meet your growing calcium needs.” 2. “It is important to take prenatal vitamins daily to provide the essential vitamins and minerals your body needs.” 3. “You should ensure your child gets immunizations at the recommended scheduled times.” 4. “You should limit the time your child is in crowded environments for the first 6 months of life.” 8. For which patient in the emergency room is it most important that the nurse conduct a thorough assessment for abuse and neglect? 1. A 6-year-old African American male with complaints of abdominal pain 2. A 2-year-old Caucasian male with injuries from a fall 3. A 7-year-old Caucasian female with a broken arm from a motor vehicle accident 4. A 4-year-old Hispanic female who complains of an earache 9. The nurse on a medical-surgical unit is providing care for a patient with diabetes mellitus. During a teaching session with the patient and the family, the nurse asks questions regarding care at home, ability to perform blood glucose testing, and administering insulin. Which perspective of family nursing is the nurse providing? 1. Family as context for care 2. Family as unit of care 3. Family as a system 4. A blend of all of the above

10. The nurse is participating in a family conference regarding one of the patients on the geriatric unit. During the conference, each family member is asked about their role in the family, communication style, coping strategies, and relationship with other family members. This type of family conference best illustrates the use of which theory related to family care? 1. General systems theory 2. Structural-functional theory 3. Family interactional theory 4. Developmental theory 11. The grown child of an older adult patient tells the nurse, “I’m starting to worry about my father’s eating habits. He lives alone and has been able to cook, but now he doesn’t want to cook and says he is too tired to go to the store.” Which is the most appropriate response by the nurse? 1. “We may need to contact the physician for a nutritional assessment.” 2. “Your family members will need to get together and bring him meals.” 3. “It may be time for you to think about nursing home placement.” 4. “What are your feelings on using some community resources for meals?” 12. The Americans with Disabilities Act (ADA) defines a disability as a physical or mental impairment that substantially interferes with a person’s ability to engage in major life activities. Among the various disabilities in the United States, which is the most prevalent? 1. Vision 2. Hearing 3. Ambulation 4. Learning 13. According to Maslow’s Hierarchy of Needs, which is the nurse’s primary focus in caring for a homeless family? 1. Food and shelter 2. Access to healthcare 3. Strengthening family relationships 4. Decreasing social isolation 14. The nurse is developing a teaching plan about coping strategies for an extended family of a severely disabled 11-year-old child. Which step does the nurse take first in developing this plan? 1. Assess the current coping patterns. 2. Establish each member’s role. 3. Assign specific tasks and deadlines for each member. 4. Identify the family member with the most ineffective coping patterns. 15. The nurse schedules a meeting with a family to assess and assist with improving the family’s communication patterns. Which is of primary importance for the nurse to focus on during the assessment? 1. Identifying how family decisions are made 2. Documenting the number of family members attending the meeting 3. Assessing for the most frequently used means of communication among family

members 4. Making careful observations of body language and nonverbal expressions during the meeting 16. The nurse is providing care for a seriously ill child on the pediatric unit. Many family members are present, including parents, aunts, and uncles. The nurse tells the nurse manager, “Every time I go into the room, everyone is shouting at each other, they shout at me, and they ask me the same questions over and over.” Which is the most appropriate response by the nurse? 1. “This is unacceptable and disruptive behavior. Tell them if the behavior continues, we may need to call security.” 2. “Families experience a range of emotions when caring for an ill member, and these can be normal reactions. Don’t take it personally.” 3. “There may be too many people in the room. You might consider limiting the number of visitors at a time.” 4. “I know about this family’s culture and expect this behavior. Don’t worry about it; it is just the way they are.” 17. The nurse is working with a spouse who is caring for a chronically ill patient who requires aroundthe-clock care. The nurse notices the spouse often speaks to the patient sharply. The bed linens are soiled with food and the patient has a strong body odor. Both the house and the spouse are unkempt. When encouraged to talk, the spouse says, “I just drag around. I can’t make myself do anything. I’m so tired of it all.” Which nursing diagnosis best fits these defining characteristics? 1. Dysfunctional Family Processes 2. Caregiver Role Strain 3. Defensive Coping 4. Impaired Verbal Communication Multiple Response Identify one or more choices that best complete the statement or answer the question. 18. Which family functions are outlined in the structural–functional family theory? Select all that apply. 1. Meeting the emotional needs of family members 2. Reinforcing ethical and moral values 3. Promoting joint decision making among parents and children 4. Being productive members of society 5. Possessing certain features common to small groups 19. The nurse is conducting a family assessment. Which assessment findings suggest a family health problem may exist? Select all that apply. 1. Family members respect each other’s need for privacy. 2. Family members enact decisions made by the most powerful member. 3. Family members consider a conflict resolved when everyone agrees.

4. Family members set boundaries between family members. 5. Family members seem unaffected by an unkempt environment. 20. The nurse is aware a family assessment includes which areas? Select all that apply. 1. Coping patterns 2. Health beliefs 3. Medical history 4. Physical examination 5. Medication information 21. The nurse is aware that homelessness is a growing problem in the United States. The nurse is aware of which primary causes of homelessness? Select all that apply. 1. Lack of job skills 2. Lack of social skills 3. Underlying mental illness 4. Substance abuse 5. Loss of a job 22. The nurse is aware the study of genomics and the use of a genogram are playing a larger role in personalizing a patient’s plan of care. In which manner are genomics and the use of a genogram helpful to the nurse in personalizing a patient plan of care? Select all that apply. 1. Assists in development of better preventive care by identifying at-risk individuals 2. Helps to more accurately detect illness, even before symptoms appear 3. Provides insight to how people respond differently to specific drugs and treatments 4. Increases the trust a patient and family have in the healthcare professionals 5. Prevents a disease-related crisis from developing for patients and families 23. A young adult couple with two children tell the nurse in the pediatric department they have been struggling with raising them. They state, “We just don’t know what we are doing sometimes and feel we are not always making good decisions for our children. It is time we sit down and figure this out.” The nurse arrives at a nursing diagnosis of Family Processes: Readiness for Enhanced Parenting. Which nursing interventions are most appropriate for this family? Select all that apply. 1. Collaborate with the couple in problem solving and decision making. 2. Assign specific roles to each member of the couple’s extended family. 3. Encourage the couple to verbalize concerns, fears, and perceptions. 4. Obtain a comprehensive family health assessment from each parent. 5. Promote adaptability, ability to deal with stress, and an openness to change.

Chapter 14. The Family Answer Section MULTIPLE CHOICE 1. ANS: 3 Chapter: Chapter 14 The Family Objective: Distinguish among different family structures. Page: 282 (V1) Heading: Extended Families Integrated Processes: Culture and Spirituality Client Need: Psychological Integrity Cognitive Level: Comprehension [Understanding] Concept: Family Dynamics Difficulty: Moderate Feedback 1 This is incorrect. This comment by the preceptor does not offer any information to the nurse. 2 This is incorrect. Although extended family arrangements may occur in some cultures, this is not the best response to the nurse’s interpretation of the family living arrangement. 3 This is correct. The description fits the definition for an extended family, which can consist of various biological relatives and also nonrelatives who live together or in close proximity. 4 This is incorrect. A blended family consists of two single parents who marry and raise their children together. PTS: 1 CON: Family Dynamics 2. ANS: 1 Chapter: Chapter 14 The Family Objective: Describe approaches to working with various types of families to provide optimal care to both well and ill clients. Page: 283 (V1) Heading: Approaches to Family Nursing Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Family Dynamics Difficulty: Moderate Feedback 1 This is correct. The nurse can best intervene by involving the friend and the patient’s children in the patient’s care, discharge planning, and home care.

This is incorrect. The friend may or may not be able to care for the patient at home. But, if planning to provide home care, the patient’s friend should be informed of the patient’s needs while in the hospital and have an opportunity to participate prior to discharge. This is incorrect. The nurse can involve the friend with the patient’s consent without infringing on the patient’s privacy. The friend’s name needs to be listed on the patient privacy (Health Insurance Portability and Accountability Act of 1996 [HIPAA]) form. This is incorrect. The nurse can encourage liberal visiting hours by the friend and the patient’s children if it is beneficial for the patient’s recovery.

PTS: 1 CON: Family Dynamics 3. ANS: 2 Chapter: Chapter 14 The Family Objective: Explain how family theories provide a framework to understand family functioning. Page: 284 (V1) Heading: Developmental Theories Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Family Dynamics Difficulty: Moderate Feedback 1 This is incorrect. In the stage of family launching young adults, the parents maintain support of young adults as they leave the security of family and the parents rediscover marriage. 2 This is correct. This couple is most likely experiencing the postparental stage of family development. During this stage, the parents prepare for retirement and adjust to their children moving into phases of adulthood. 3 This is incorrect. The family stage where frail elderly live with the family is called the “sandwich family.” There is not information to support the existence of this stage. 4 This is incorrect. During the stage of family with teenagers and young adults, open communication is maintained among family members, ethical and moral values are reinforced, and there is a balance established between rules and independence among teens. PTS: 1 CON: Family Dynamics 4. ANS: 2 Chapter: Chapter 14 The Family Objective: Explain how family theories provide a framework to understand family functioning. Page: 284 (V1)

Heading: General Systems Theory Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Family Dynamics Difficulty: Moderate Feedback 1 This is incorrect. A slightly more complex approach views the family as the unit of care. The nurse must assess and provide care to each member because wellness is critical to promoting family health. 2 This is correct. The nurse is viewing the family as a system because the nurse is providing information based on the spouse’s response that will benefit the entire family. A system approach looks beyond the immediate family and views the community and its resources as a part of the suprasystem. 3 This is incorrect. The nurse needs to be prepared to work, at a minimum, with the family as the context for care of an individual person. The nurse’s focus in this approach is on the ill individual. 4 This is incorrect. When the nurse views the family as either a resource or stressor to the patient, the nurse is looking at the family as the context for care of an individual person. PTS: 1 CON: Family Dynamics 5. ANS: 4 Chapter: Chapter 14 The Family Objective: Explain how family theories provide a framework to understand family functioning. Page: 284 (V1) Heading: What Theories Are Useful for Family Care? Integrated Processes: Culture and Spirituality Client Need: Psychological Integrity Cognitive Level: Analysis [Analyzing] Concept: Family Dynamics Difficulty: Moderate Feedback 1 This is incorrect. General Systems Theory focuses on interactions between systems and the changes that result from these interactions. Developmental theory is part of the General Systems Theory. 2 This is incorrect. Family interactional theory views the family as a unit of interacting personalities. Nurses working from an interactional perspective focus family healthcare on the interaction and communication between family members; their roles and power; family coping; and relationships with other people outside the direct family unit. 3 This is incorrect. There is no part of the General Systems Theory specifically

identified as “family as a context theory.” This is correct. Developmental theories focus on the stage of development of each family member, usually based on age or growth stage. These theories have developmental tasks that should be accomplished at each stage of development to successfully progress and master the next stage. These stages begin at birth and continue through old age. Thus, each child will have different developmental tasks based on his or her age and stage of development; because tasks are different, so are each child’s needs.

PTS: 1 CON: Family Dynamics 6. ANS: 3 Chapter: Chapter 14 The Family Objective: Identify family risk factors across five different stages. Page: 287 (V1) Heading: Families With Middle-Aged Adults Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Family Dynamics Difficulty: Difficult Feedback 1 This is incorrect. Although a college graduate moving in with parents may involve middle-aged adults, it does not necessarily precipitate a mid-life crisis for the parents. 2 This is incorrect. It is not unusual, or a crisis, for parents to enroll young children in to child care in order for both parents to work. It often takes two paychecks to meet the household financial needs. 3 This is correct. The middle-aged years occur after the demands of raising children are over. This can be a time of personal fulfillment, career success, and social expansion. It can also be a time of intense questioning about the meaning of life, longing for one’s youth, and seeking direction in life (mid-life crisis). It is not uncommon for couples who have been married for many years to get a divorce or for one spouse to engage in atypical behaviors. 4 This is incorrect. It is not considered a mid-life crisis when an older adult rejects children’s advice to move into an assisted living facility. PTS: 1 CON: Family Dynamics 7. ANS: 3 Chapter: Chapter 14 The Family Objective: Identify family risk factors across five different stages. Page: 287 (V1) Heading: Families With Young Children

Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Comprehension [Understanding] Concept: Family Dynamics Difficulty: Moderate Feedback 1 This is incorrect. Instructing a pregnant woman on the need to increase her milk intake is not addressing the reduction in herd immunity. 2 This is incorrect. Instructing a pregnant woman on the necessity of taking prenatal vitamins does not address the reduction in herd immunity. 3 This is correct. A reduction in herd immunity occurs when families do not follow the immunization schedule. Old diseases, once thought eradicated, begin to reappear and cause illness and even death in persons who are not adequately protected through immunizations. Such diseases include pertussis (whooping cough), measles, polio, mumps, and small pox. 4 This is incorrect. Limiting crowd exposure of an infant for the first 6 months of life may or may not be necessary, depending on the health of the infant, the season of the year, and/or incidences of communicable disease/illness. PTS: 1 CON: Family Dynamics 8. ANS: 2 Chapter: Chapter 14 The Family Objective: Demonstrate an understanding of family violence. Page: 290 (V1) Heading: Violence and Neglect Within Families Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Family Dynamics Difficulty: Difficult Feedback 1 This is incorrect. Abdominal pain can result from a variety of conditions/illnesses. Unless the nurse finds other supporting signs of abuse or neglect, the nurse is not likely to suspect this child as being in danger. 2 This is correct. The younger the child, the more vulnerable he or she is to abuse owing to their dependency, small size, and inability to defend themselves. Statistics indicate that Caucasian children are at a high risk for abuse. The 2year-old child is the youngest and of the high-risk race, and the injuries are from a fall. The nurse should assess all children and adults for signs of violence and neglect; however, the 2-year-old has priority. 3 This is incorrect. When a child experiences a broken bone resulting from a definitive cause, there is no reason for the nurse to suspect abuse or neglect.

This is incorrect. Many children suffer from otitis media (ear infection), which manifests as earache; this child is not a priority concern for abuse or neglect.

PTS: 1 CON: Family Dynamics 9. ANS: 1 Chapter: Chapter 14 The Family Objective: Describe approaches to working with various types of families to provide optimal care to both well and ill clients. Page: 283 (V1) Heading: Approaches to Family Nursing Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Comprehension [Understanding] Concept: Family Dynamics Difficulty: Moderate Feedback 1 This is correct. The nurse is using family as the context for care. In this approach, the focus is on the ill individual, and family is viewed as either a resource or stressor to the patient. 2 This is incorrect. Unit of care is more complex, as wellness of each member is critical to promoting family health. The family is viewed as the sum of all individual members, and assessment and care are provided for all family members. 3 This is incorrect. Family as a system focuses on the family as a whole and as an interactional system. This approach sees the family as embedded in and interacting with a larger community. 4 This is incorrect. The nurse’s teaching approach is not a blend of the provided options. PTS: 1 CON: Family Dynamics 10. ANS: 3 Chapter: Chapter 14 The Family Objective: Explain how family theories provide a framework to understand family functioning. Page: 283 (V1) Heading: What Theories Are Useful for Family Care? Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Family Dynamics Difficulty: Moderate Feedback 1 This is incorrect. Several theories have been proposed to help us understand

family functioning. Four such theories are general systems theory, structural– functional theories, family interactional theory, and developmental theory. This is incorrect. Structural–functional theories include the concepts of family roles and interaction; however, the focus is on outcome rather than on process. This theory is best used to assess family function, both internally among family members and externally with outside systems. This is correct. Family interactional theory views the family as a unit of interacting personalities. The major emphasis is on family roles. This approach to understanding families de-emphasizes the influence of the external world on what occurs within the family. The focus is on interaction, communication roles and power, family coping, and relationships. This is incorrect. Developmental theories focus on the stage of family development, typically the eight stages in the family life cycle.

PTS: 1 CON: Family Dynamics 11. ANS: 4 Chapter: Chapter 14 The Family Objective: Describe approaches to working with various types of families to provide optimal care to both well and ill clients. Page: 287 (V1) Heading: Families With Older Adults Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Family Dynamics Difficulty: Moderate Feedback 1 This is incorrect. A nutritional assessment may be needed at some point if poor eating or weight loss continues. 2 This is incorrect. Instructing family members to bring meals over is inappropriate, as the nurse has not assessed family circumstances and availability. 3 This is incorrect. In this item, we have no indication that the patient has any deficits, so the best and initial response by the nurse is to offer/educate the family on outside community resources for meals. There is no specific need to discuss nursing home placement. 4 This is correct. Maintaining good nutrition and hydration becomes more difficult as a person ages. Nutrition in older adults may be compromised for a multitude of reasons, such as forgetting to eat, inadequate transportation to shop, lack of money, loss of appetite, and physical changes. It is easy to understand how one of the above problems can affect another.

PTS: 1 CON: Family Dynamics 12. ANS: 3 Chapter: Chapter 14 The Family Objective: Discuss the effects of chronic and life-threatening illness on families. Page: 289 (V1) Heading: Chronic Illness and Disability Integrated Processes: Culture and Spirituality Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Knowledge [Remembering] Concept: Family Dynamics Difficulty: Moderate Feedback 1 This is incorrect. The ADA defines one component of disability as a physical or mental impairment that substantially interferes with a person’s ability to engage in major life activities; 3.5 million have a vision disability. 2 This is incorrect. In the United States (U.S. Census Bureau, 2017), the number of people 18 and older in 2015 with: significant hearing difficulty or reported deafness—8 million overall; 6.9 million of those were aged 65 years or older. 3 This is correct. The ADA defines one component of disability as a physical or mental impairment that substantially interferes with a person’s ability to engage in major life activities. Among the various types of disabilities, 10.2 million are people with ambulatory disabilities. 4 This is incorrect. In the United States (U.S. Census Bureau, 2017), the number of people 18 and older in 2015 with: a physical, mental or emotion condition that resulted in serious difficulty concentrating, remembering or making decisions—12.9 million overall, with 4.2 million aged 65 years or older. PTS: 1 CON: Family Dynamics 13. ANS: 1 Chapter: Chapter 14 The Family Objective: Identify populations most at risk for homelessness. Page: 289 (V1) Heading: Homelessness Integrated Processes: Caring Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Moderate Feedback 1 This is correct. Homelessness is a growing problem in many U.S. cities, not only for individuals but also for families. The primary focus is on meeting basic needs of food and shelter, which, according to Maslow, must be met before the

2 3 4

family can grow and address other areas. This is incorrect. Physical health is considered a risk for the homeless; however, the basic needs of food and shelter must be met first according to Maslow. This is incorrect. Homelessness threatens family relationships, but this is not the primary need according to Maslow. This is incorrect. Because of social isolation, the homeless are at emotional risk related to lack of a sense of belonging. However, Maslow states the need for food and shelter needs to be met first.

PTS: 1 CON: Safety 14. ANS: 1 Chapter: Chapter 14 The Family Objective: Review how risk factors such as illness and death, substance abuse, violence, mental health disorders, financial hardship, unemployment, and other issues, can change a family’s structure, communication, and coping strategies. Page: 289 (V1) Heading: Chronic Illness and Disability Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Family Dynamics Difficulty: Difficult Feedback 1 This is correct. Assessing family coping is the first step to helping the family develop more effective coping patterns. 2 This is incorrect. After identifying family coping ability, the nurse can assess for and address family member roles. 3 This is incorrect. After assessing family coping, the nurse can define the interactions between family members and role expectations. 4 This is incorrect. Family members who are not coping effectively may cause the patient to become stressed, anxious, or have problems sleeping. PTS: 1 CON: Family Dynamics 15. ANS: 4 Chapter: Chapter 14 The Family Objective: Review how risk factors such as illness and death, substance abuse, violence, mental health disorders, financial hardship, unemployment, and other issues, can change a family’s structure, communication, and coping strategies. Page: 290 (V1) Heading: Assessment Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity

Cognitive Level: Analysis [Analyzing] Concept: Family Dynamics Difficulty: Difficult Feedback 1 This is incorrect. It is important to uncover information such as how decisions are made within the family, but the primary focus is on careful observation of nonverbal cues. 2 This is incorrect. How much participation by the family is a relevant observation for the nurse to make during the meeting; however, the primary focus is careful observation of nonverbal cues. 3 This is incorrect. What means of communication are used (telephone calls, texting, visiting) by the family is important information, but it is not the primary focus for the nurse. 4 This is correct. Do not rely solely on the information provided by the family members during the interview process. Families usually want to “put on the best face” for healthcare providers, so they may be careful to give socially desirable responses. Carefully observe the words people use and other cues involved in communication, such as body language, direct eye contact, and other nonverbal expressions, particularly among family members. PTS: 1 CON: Family Dynamics 16. ANS: 2 Chapter: Chapter 14 The Family Objective: Identify common health beliefs and communication patterns in families. Page: 290 (V1) Heading: Assessment Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Family Dynamics Difficulty: Moderate Feedback 1 This is incorrect. There are times to call security if the behavior escalates and begins to affect other patients and families. 2 This is correct. When a family member is ill or hospitalized, the other family members experience a range of emotions—especially when the illness is severe or of sudden onset. Family members may display signs of stress in a variety of ways, for example, by arguing with each other or with healthcare providers, in insisting on immediate care for their loved one, by being critical of the care provided, or by frequently asking that information be repeated. These are normal reactions; do not take them personally. 3 This is incorrect. Limiting visiting hours is not always beneficial, especially

when dealing with children. This is incorrect. In this instance, citing a cultural connection is inappropriate as it reflects stereotyping and is judgmental.

PTS: 1 CON: Family Dynamics 17. ANS: 2 Chapter: Chapter 14 The Family Objective: Discuss the effects of chronic and life-threatening illness on families. Page: 293 (V1) Heading: Assessing for Example Problem: Caregiver Role Strain Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Family Dynamics Difficulty: Difficult Feedback 1 This is incorrect. Dysfunctional Family Processes usually include denial of problems, resistance to change, and a series of crises; depression is not a symptom. 2 This is correct. The defining characteristics best fit a nursing diagnosis of Caregiver Role Strain. The caregiver exhibits dysfunctional communication (speaking sharply), is not performing well in the caregiver role (soiled bed linens, patient’s body odor), and is experiencing and expressing depressive symptoms. 3 This is incorrect. Defensive coping is more about a falsely positive selfevaluation; the spouse does not seem defensive but admits to having difficulty. Although the spouse’s communication may sound angry, verbal communication is not really impaired. 4 This is incorrect. Impaired Verbal Communication is characterized by difficulty receiving, processing, and/or using words to communicate. Furthermore, a diagnosis of Impaired Verbal Communication would not address the spouse’s depression and inability to provide satisfactory care. PTS:

CON: Family Dynamics

MULTIPLE RESPONSE 18. ANS: 1, 4, 5 Chapter: Chapter 14 The Family Objective: Explain how family theories provide a framework to understand family functioning. Page: 284 (V1) Heading: Structural–Functional Theories

Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Family Dynamics Difficulty: Difficult

2. 3. 4. 5.

Feedback This is correct. Family functions outlined in the structural–functional family theory include meeting physical and emotional needs of family members. This model is more focused on the outcomes of family function than the process by which action occurs. This is incorrect. Reinforcing ethical and moral values is a task outlined in family development theories. This is incorrect. Promoting joint decision making among parents and children is an example of family development theories. This is correct. Family functions outlined in the structural–functional family theory include being productive members of society. This is correct. According to the structural–functional theories, a family is a small group possessing certain features common to small groups.

PTS: 1 CON: Family Dynamics 19. ANS: 2, 3, 5 Chapter: Chapter 14 The Family Objective: Conduct a family assessment. Page: 290 (V1) Heading: Assessment Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Family Dynamics Difficulty: Difficult

Feedback This is incorrect. Respect for privacy and clear boundaries between family members are characteristics of a healthy family; lack of respect is a sign of a family health problem. This is correct. In healthy families, there is typically egalitarian distribution of power. When family members enact decisions made by the most powerful member, the nurse can suspect a family health problem. This is correct. In healthy families, it is not always necessary for all members to agree; instead, they have the ability to compromise, and members feel free to disagree. If family members consider a conflict is resolved when everyone agrees,

4. 5.

the behavior is likely indicative of a family health problem. This is incorrect. In a healthy family, boundaries define the responsibilities of adults that are clear and separate from responsibilities of growing children. This is correct. In a healthy family, the environment is most likely to be well kept. If the family seems unconcerned about the orderliness of the surroundings, the nurse recognizes the probability of a family health problem.

PTS: 1 CON: Family Dynamics 20. ANS: 1, 2 Chapter: Chapter 14 The Family Objective: Conduct a family assessment. Page: 290 (V1) Heading: Assessment Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Family Dynamics Difficulty: Difficult

1. 2. 3.

4. 5.

Feedback This is correct. Conducting a family assessment includes identifying family stressors and coping patterns. This is correct. Conducting a family assessment includes identifying health beliefs. This is incorrect. Obtaining a medical history of individuals are only relevant to the family assessment if the information affects an individual family member or members. This is incorrect. A physical examination of individuals is relevant to the family assessment only if it affects an individual family member or members. This is incorrect. During a family assessment, it is unlikely for the nurse to assess medication information unless it affects and individual family member or members.

PTS: 1 CON: Family Dynamics 21. ANS: 1, 2, 3, 4, 5 Chapter: Chapter 14 The Family Objective: Identify populations most at risk for homelessness. Page: 289 (V1) Heading: Homelessness Integrated Processes: Safe and Effective Care Environment: Safety and Infection Control Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Difficult

1. 2. 3.

4. 5.

Feedback This is correct. A cause of homelessness is directly impacted by a lack of job skills, a situation that causes a person to be unemployable. This is correct. Lacking social skills is a key factor in being able to obtain a job. Persons who cannot interact appropriately with other are likely to be unemployable. This is correct. Many homeless persons are affected by underlying mental illness, which makes the person difficult to place in programs aimed at resolving the homeless situation. This is correct. Because persons who engage in substance abuse use whatever money they obtain for drugs, they are often homeless due to financial distress. This is correct. Persons who are employed but lose their jobs are often times at high risk for becoming homeless. This is most frequent among persons with low job skills and menial pay scales.

PTS: 1 CON: Safety 22. ANS: 1, 2, 3 Chapter: Chapter 14 The Family Objective: Identify appropriate nursing interventions when a family member is ill. Page: 291 (V1) Heading: Assessing the Family’s Genetic History Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Health Promotion Difficulty: Difficult

Feedback This is correct. Genomics can be used to personalize a patient’s plan of care by identifying at-risk individuals for certain conditions so more effective preventive care can be provided. This is correct. Genomics allows for more accurate detection of illness, even before symptoms appear, and promotes tailoring healthcare to the individual while reducing a trial-and-error approach. This is correct. The use of genomics assists in evaluating a person’s response to care, and helping to understand how people respond differently to particular drugs and medical treatments. This is incorrect. There is no evidence to support that the use of genomics and genograms has any effect on trust. Many individuals and families have an intense skepticism or mistrust of medical care and hospitals based on their own health belief systems or on past experiences with medical care and hospitals. This is incorrect. Genomics does not prevent a disease-related crisis from developing

for patients and families. However, attempts at prevention, detection, and treatment can be enhanced. PTS: 1 CON: Health Promotion 23. ANS: 1, 3, 5 Chapter: Chapter 14 The Family Objective: Describe approaches to working with various types of families to provide optimal care to both well and ill clients. Page: 295 (V1) Heading: Box 14-2 Characteristics of a Healthy Family Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Family Dynamics Difficulty: Difficult

1. 2. 3.

Feedback This is correct. The most appropriate interventions for this family are to collaborate with them in problem solving and decision making. This is incorrect. Roles for each member should not be “assigned” by the nurse, as this should be a collaborative process between the nurse and family. This is correct. Because communication is vital to a health family, the nurse encourages each member to verbalize concerns, fears, and perceptions. Honesty and freedom of expression include different opinions or viewpoints. This is incorrect. Obtaining a comprehensive health history is not indicated at this time, as there are no health issues identified and a health history is usually only relevant for a family assessment if it affects an individual family member. This is correct. The nurse will promote adaptability, ability to deal with stress, and an openness to change, which are characteristics of a healthy family.

PTS:

CON: Family Dynamics

Chapter 15. Culture & Ethnicity Multiple Choice Identify the choice that best completes the statement or answers the question. 1. An adult patient of Hispanic heritage is admitted for observation after sustaining injuries in a motor vehicle accident. Which view of pain by patient the does the nurse consider when assessing the patient’s injuries? 1. Embraces the taboos against narcotic use to relieve pain 2. Expects immediate and effective treatment to relieve pain 3. Endures pain longer and reports it less frequently than other patients 4. Uses herbal teas, heat application, and prayers to manage the pain 2. The nurse is aware of many terms related to culture. Which is considered a “practice” (as opposed to a “belief” or “value”)? 1. Always drinking water after exercise 2. Thinking often about cleanliness 3. Placing an emphasis on success 4. Maintaining youth 3. The nurse is providing care for a patient who emigrated from Puerto Rico. Which information about the patient will enable the nurse to best care for this patient? 1. Practices of the patient’s ethnic group 2. Patient’s individual cultural beliefs 3. Values of the nurse’s own culture 4. Patient’s Spanish-speaking culture 4. The nurse is teaching a clinic patient about hypertension. Which statement by the patient suggests the patient is present-oriented? 1. “I know I need to lose weight; I’ll have to begin an exercise program right away.” 2. “If I change my diet and begin exercising, maybe I can control my blood pressure without medications.” 3. “I know I need to give up foods that contain a lot of salt, but with teenagers in the house it is very difficult.” 4. “I will reduce the amount of calories, salt, and fat that I eat; I certainly do not want to have a stroke.” 5. A patient of Asian heritage avoids asking for narcotics for pain relief. The nurse writes a nursing diagnosis of “Pain related to reluctance to take medication secondary to cultural beliefs.” Which possible patient view of pain is reflected as a cultural archetype in the nursing diagnosis? 1. A punishment for immoral behavior 2. An expected, normal part of life 3. Best treated with herbal teas and prayer 4. A virtue and a matter of family honor

6. The nurse is developing a plan of care for a patient of Aleut descent who sustained a hip fracture. Which intervention by the nurse recognizes the patient’s indigenous healthcare system and should be included in the plan of care? 1. Asking the family to bring in medals and amulets 2. Scheduling a visit from the local shaman 3. Providing the patient with a favorite herbal tea 4. Requesting the physician consult the patient’s acupuncturist 7. The nurse is aware a client incorporates alternative healthcare into regular health practices. The nurse self-identifies as being culturally competent. For which alternative therapy is the nurse aware that the patient visits a formally trained practitioner? 1. Use of herbs and roots 2. Application of oils and poultices 3. Burning of dried plants 4. Acupuncture 8. An older female patient tells the charge nurse that she wants a change in the nurse providing her care. When the charge nurse questions the patient, the patient states, “I don’t want a man taking care of me.” Which cultural barrier is this patient exhibiting? 1. Ethnocentrism 2. Racism 3. Sexism 4. Chauvinism 9. The nurse is providing care to a patient who had surgery 8 hours ago and has not voided. The physician has prescribed an indwelling urinary catheter be inserted. Which of the following statements should the nurse use to describe the procedure to the patient? 1. “I will put a Foley in you because you haven’t voided since your surgical procedure.” 2. “I will insert a tube into your bladder to drain the urine because you haven’t urinated since surgery.” 3. “The physician has prescribed catheterization because you haven’t urinated since having your surgery.” 4. “I need to place a catheter in your bladder because you haven’t voided since surgery.” 10. Nurses encounter many patients from diverse cultures. When caring for a culturally diverse patient, which initial question does the nurse ask a patient that best assists the nurse with improving cultural competency? 1. “Can you tell me about your culture and cultural practices?” 2. “Do you understand how we do things here in the United States?” 3. “What matters most to you about your illness and treatment?” 4. “Can you please make me a list of your cultural preferences?”

11. The nurse is performing an assessment on an adult patient who appears to be of Asian descent. As part of the nurse’s cultural assessment, which question is most appropriate for the nurse to ask prior to documenting the patient’s race? 1. “You appear to be Asian. Am I correct?” 2. “Can you tell me a little about your oriental background?” 3. “What race do you identify with and what name do you call it?” 4. “Which Asian country are you from?” 12. At a clinical postconference, a nursing student states, “I had a Chinese patient today and while I understand some of her cultural practices, she needs to understand that she is in the United States now and should follow our practices because we use scientific evidence.” Which cultural barrier is the student demonstrating? 1. Racism 2. Archetyping 3. Ethnocentrism 4. Stereotyping 13. Vulnerable populations are those most likely to develop health problems and experience poorer outcomes because of limited access to care and a wide variety of other stressors. Which is most important for the nurse to focus on when caring for a patient from a vulnerable group? 1. Methods to connect the patient with a social worker 2. Interactions of family members in planning care 3. Consideration of the patient’s difficulties and risks 4. Identification of the patient’s strengths and resources 14. A patient who speaks a different language is being prepared for surgery and needs to sign the surgical consent form. Existing regulations determine the healthcare organization’s responsibility for obtaining informed consent from this patient. Which action is the healthcare organization required to do? 1. Provide a licensed interpreter 2. Provide a translator approved by the organization 3. Ensure adequate resources necessary to comply with patient needs 4. Choose an interpreter, a translator, or a family member to interpret 15. The nurse shares with the nurse manager, “My patient is Jewish, and when I tried to teach her about her antihypertensive medication, she said, ‘I’d rather eat chicken soup than take those medications.’” Which is the most appropriate response by the nurse manager? 1. “This is common folk medicine among some Jewish people. You can talk to her about taking her medications and eating chicken soup.” 2. “There is no scientific evidence to support chicken soup as a substitute for antihypertensive medications. Maybe you should do some research on this.” 3. “The patient can make her own choices and decisions, and there is nothing we can do about this.” 4. “You can tell the patient she can eat her soup, but she needs to understand that she

has to take her medications first.” 16. Which statement is most reflective of Madeleine Leininger’s theory of cultural care? 1. The goal of the theory is to guide research that will assist nurses to provide culturally congruent care. 2. The model for cultural competence stresses teamwork in providing culturally sensitive and competent care to improve outcomes for individuals, families, and communities. 3. The model focuses on five components of cultural competence: awareness, skills, knowledge, encounters, and desire. 4. The theory focuses on increasing levels of one’s consciousness to improve the possibilities to provide culturally competent care. Multiple Response Identify one or more choices that best complete the statement or answer the question. 17. Which statement(s) about culture is/are true? Select all that apply. 1. Culture exists on both material and nonmaterial levels. 2. Culture mainly influences food choices and special holidays. 3. Cultural customs change over time at different rates. 4. Culture is learned through life experiences shared by culture members. 5. Cultural practices are tightly regulated by customs. 18. The nurse is caring for a patient of Asian heritage who refuses opioid pain medication despite the nurse’s explaining its importance in the healing process. Which intervention(s) by the nurse is/are appropriate for this patient? Select all that apply. 1. Assess the patient’s pain levels at less frequent intervals. 2. Document in the record that the patient does not want to take opioids. 3. Use nonpharmacological measures to help control the patient’s pain. 4. Notify the primary care provider of the patient’s noncompliance. 5. Ask the patient about cultural influences on pain management. 19. Which statements about race and ethnicity is/are true? Select all that apply. 1. Ethnicity refers to a person’s cultural use of the indigenous healthcare system. 2. A person can have several aspects of a racial culture or be multicultural. 3. Ethnicity refers to groups whose members share a common and social heritage that is transmitted to the next generation. 4. Race primarily reflects biology and refers to grouping of people based on biological similarities. 5. People of Hispanic, Latino, or Spanish origin self-identify as members of the same race. 20. Which statement(s) is/are most true about the concept of acculturation? Select all that apply. 1. An acculturated person accepts both their own culture and a new culture, adopting

2. 3. 4. 5.

elements of each. It may take years and even generations for an immigrant group to acculturate. Integrating essential values, beliefs, and behaviors of the dominant culture is acculturation. Acculturation results from a minority group’s need to survive and flourish in a new culture. Acculturation is the maintenance of a culture within the presence of a dominant culture.

21. Which are some strategies a new nurse can use to develop skills in achieving cultural competence? Select all that apply. 1. Read the literature and study nursing theories and principles pertaining to culture. 2. Take advantage of opportunities to interact with persons from diverse cultures. 3. Reinforce the need for different cultures to follow the medical and nursing plan of care. 4. Embrace practices of common cultures, and select the best interventions from those cultures. 5. Learn and follow the culture guidelines created by regulating bodies in healthcare. 22. The nurse is caring for a Native American in a rural rehabilitation facility. The nurse notices that the patient has eaten very little since admission 10 days ago. When the nurse asks the patient about eating, the patient states, “I can’t eat any of this food. It just isn’t what I eat at home, and we don’t prepare our foods this way.” The nurse explains that the patient is on a very specific cardiac diet as a result of a heart attack and that the patient has lost 7 pounds since admission. Based on this scenario, what are the most appropriate nursing diagnoses for this patient? Select all that apply. 1. Noncompliance related to difficulty adhering to the medical regimen 2. Possible Knowledge Deficit related to disease process 3. Imbalanced Nutrition: Less Than Body Requirement related to cultural dietary practices 4. Decreased Appetite related to anxiety secondary to a heart attack 5. Inability to adjust to a therapeutically prescribed diet due to cultural conflicts 23. What are common beliefs and practices associated with the North American (Western) professional healthcare system? Select all that apply. 1. Values emphasize individualism and self-reliance. 2. Health is defined as living in harmony with nature. 3. Health is defined as absence or minimization of disease. 4. Primarily dominated by a biomedical healthcare system. 5. The system is run by a set of professional healthcare providers. 24. Which statement(s) is/are most accurate regarding values and beliefs? Select all that apply. 1. A value is a standard or principle that has meaning and worth to an individual. 2. Values are a set of behaviors that one follows to guide health practices. 3. All members of certain cultures will share the same values and beliefs.

4. A belief is something one accepts as being true. 5. It is safe to assume a client shares the beliefs of the dominant culture.

Chapter 15. Culture & Ethnicity Answer Section MULTIPLE CHOICE 1. ANS: 3 Chapter: Chapter 15 Culture & Ethnicity Objective: Describe nursing strategies that promote delivery of culturally competent care to clients and their families. Page: 303 (V1) Heading: How Do Cultural Values, Beliefs, and Practices Effect Health? Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Culture Difficulty: Difficult Feedback 1 This is incorrect. Patients of Japanese heritage may have taboos against narcotic use to relieve pain. 2 This is incorrect. Remember that all of these are archetypes, and are not necessarily true for all members of a cultural group. 3 This is correct. In general, patients of Hispanic heritage may endure pain longer and report it less frequently than will some other patients. 4 This is incorrect. Patients of Puerto Rican heritage may use herbal teas, heat application, and prayers to manage pain. PTS: 1 CON: Culture 2. ANS: 1 Chapter: Chapter 15 Culture & Ethnicity Objective: Discuss concepts pertaining to cultural diversity in nursing. Page: 300 (V1) Heading: Characteristics of Culture Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Comprehension [Understanding] Concept: Culture Difficulty: Easy Feedback 1 This is correct. A practice is a set of behaviors that one follows, such as always drinking water after exercise. 2 This is incorrect. Being preoccupied with cleanliness is an example of a value that is dominant in the United States.

3 4

This is incorrect. Placing an emphasis on success is an example of a value that is dominant in the United States. This is incorrect. The importance of maintaining youth is an example of a value that is dominant in U.S. culture.

PTS: 1 CON: Culture 3. ANS: 2 Chapter: Chapter 15 Culture & Ethnicity Objective: Explain why cultural competence is important for nurses. Page: 299 (V1) Heading: Why Learn About Culture? Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Culture Difficulty: Moderate Feedback 1 This is incorrect. It is helpful to become familiar with the patient’s ethnic group; however, the nurse should not assume that the individual holds the same values, beliefs, and practices as patient’s ethnic group or community. 2 This is correct. The nurse cares for this patient by becoming familiar with the patient’s individual cultural and ethnic beliefs and values. 3 This is incorrect. The nurse should explore her own culture but not assume that the patient holds those same beliefs and practices. 4 This is incorrect. Being aware of the language of the patient’s culture is not necessarily information that will aid the nurse in providing the best care for this patient. PTS: 1 CON: Culture 4. ANS: 3 Chapter: Chapter 15 Culture & Ethnicity Objective: Identify the phenomena of culture, including how they can affect the nursing care needs of clients and families. Page: 304 (V1) Heading: Time Orientation Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Culture Difficulty: Difficult Feedback 1 This is incorrect. Recognition of a problem (being overweight) and planning a

2 3

lifestyle change (exercise) is an example future-oriented thinking that will affect the patient’s future. This is incorrect. The “if” thinking of the patient indicates future-oriented thinking; this thinking can lead to lifestyle changes and desirable outcomes. This is correct. Knowing an action is needed, but giving reasons for not beginning it “just now” shows a focus on the present. The patient understands sodium intake needs reduced, but a present situation is preventing the change. Therefore, the patient is disregarding the impact consuming sodium might have on future health. This is incorrect. When a patient’s thinking is related to avoiding a future health problem, the thinking is future-oriented.

PTS: 1 CON: Culture 5. ANS: 4 Chapter: Chapter 15 Culture & Ethnicity Objective: Differentiate between cultural archetypes and cultural stereotypes. Page: 303 (V1) Heading: Archetype or Stereotype? Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Comprehension [Understanding] Concept: Culture Difficulty: Moderate Feedback 1 This is incorrect. There is no specific connection between the patient’s heritage and a belief that pain is punishment for immoral behavior. The nurse’s diagnosis does not address this connection. 2 This is incorrect. The patient’s heritage does not necessarily expect pain to be a normal part of life. The nurse’s diagnosis does not address this connection. 3 This is incorrect. The patient’s heritage does not necessarily support treating pain with herbal teas and prayer. The nurse’s diagnosis does not address this connection. 4 This is correct. The nurse is using a cultural archetype to define the patient’s reluctance to ask for pain medication, which may be inaccurate. The guiding principle in nursing practice is that each person must be seen as unique—as a member of an ethnic group, influenced by the person’s heritage, but not defined by it. PTS: 1 CON: Culture 6. ANS: 2 Chapter: Chapter 15 Culture & Ethnicity

Objective: Describe nursing strategies that promote delivery of culturally competent care to clients and their families. Page: 306 (V1) Heading: The Indigenous Healthcare System Integrated Processes: Culture and Spirituality Client Need. Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Culture Difficulty: Difficult Feedback 1 This is incorrect. Patients of Hispanic descent might benefit from medals and amulets brought in by the family. This practice does not need to be included in plan of care. 2 This is correct. For the patient of Aleut descent, contacting the shaman and scheduling a visit with the patient might be helpful in recovery. Including this practice in the plan of care assures the patient that care is arranged to support the visit. 3 This is incorrect. Patients of Hispanic descent might benefit from herbal tea; however, it is important to check with the physician before administering any herbal preparations that might interfere with prescribed medications. 4 This is incorrect. Asians and Pacific Islanders might benefit from a visit by the acupuncturist. PTS: 1 CON: Culture 7. ANS: 4 Chapter: Chapter 15 Culture & Ethnicity Objective: Discuss the differing views of culturally diverse clients, including biomedical, holistic, and alternative health systems, such as folk medicine. Page: 309 (V1) Heading: Traditional and Alternative Healing Systems Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Comprehension [Understanding] Concept: Culture Difficulty: Moderate Feedback 1 This is incorrect. The nurse is aware that the use of herbs and roots does not require formally trained practitioners; however, patients should be advised to inform their traditional primary healthcare provider when using various herbal remedies, as they can interfere with other prescribed medication and cause untoward side effects. 2 This is incorrect. The nurse is aware that the application of oils and poultices

3 4

does not require a formally trained practitioner. However, the patient needs to be aware of the substances used and take note of the location of applications in the event of an untoward reaction. This is incorrect. The burning of dried plants does not require formally trained practitioners. This is correct. The nurse is aware acupuncture requires a formally trained practitioner, specifically because of the process being invasive.

PTS: 1 CON: Culture 8. ANS: 3 Chapter: Chapter 15 Culture & Ethnicity Objective: Identify the phenomena of culture, including how they can affect the nursing care needs of clients and families. Page: 303 (V1) Heading: Gender as a Subculture Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Culture Difficulty: Moderate Feedback 1 This is incorrect. Ethnocentrism occurs when a person is positively biased toward her own culture. This is not validated by the scenario. 2 This is incorrect. Racism is a form of prejudice and discrimination based on race. The scenario does not indicate racism. 3 This is correct. This patient is exhibiting sexism; she is objecting to the nurse merely because of his sex. Although we tend to think of sexism in a negative light, this woman may merely be reflecting a cultural attitude. The patient is in no position to actually discriminate against the nurse, in terms of employment, and so on. Therefore, her preferences should be respected. 4 This is incorrect. Chauvinism occurs when a person assumes that he is superior, which is not indicated in the scenario. PTS: 1 CON: Culture 9. ANS: 2 Chapter: Chapter 15 Culture & Ethnicity Objective: Describe nursing strategies that promote delivery of culturally competent care to clients and their families. Page: 311 (V1) Heading: Healthcare Jargon Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity

Cognitive Level: Application [Applying] Concept: Culture Difficulty: Moderate Feedback 1 This is incorrect. The nurse refers to the catheter as a “Foley,” which is jargon the patient is not likely to understand. 2 This is correct. I need to insert a tube into your bladder … ” best describes the procedure for the patient because the explanation is in terms most patients will understand. 3 This is incorrect. The nurse uses the term “catheterization,” which is medical jargon that may be confusing to the patient. 4 This is incorrect. Even use of the word “catheter” may be confusing to the patient. The nurse needs to use simple language and avoid the use of all medical jargon. PTS: 1 CON: Culture 10. ANS: 3 Chapter: Chapter 15 Culture & Ethnicity Objective: Discuss concepts pertaining to cultural diversity in nursing. Page: 316 (V1) Heading: What Is Culturally Competent Care? Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Culture Difficulty: Difficult Feedback 1 This is incorrect. Asking the patient about their culture and cultural practices is information the nurse can gather after asking the patient about what matters most about their illness and treatment. 2 This is incorrect. Asking the patient if they understand how things are done in the United States is culturally insensitive. Culturally competent care involves formulating a plan of care that takes the patient’s culture and cultural practices into consideration. 3 This is correct. If there were only one intervention or question the nurse could use to improve cultural competence, it should be to routinely ask patients what matters most to them in their illness and treatment. No matter how busy the nurse is, time can be found to do this. From that point, the nurse can use this information to incorporate cultural needs and preferences into the patient’s plan of care. 4 This is incorrect. There is no need or benefit from asking a patient to make a list of the patient’s cultural preferences. The culturally competent nurse will gather

this information through a culturally sensitive assessment. PTS: 1 CON: Culture 11. ANS: 3 Chapter: Chapter 15 Culture & Ethnicity Objective: Describe nursing strategies that promote delivery of culturally competent care to clients and their families. Page: 300 (V1) Heading: Ethnicity, Race, and Religion Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Culture Difficulty: Moderate

1 2

Feedback This is incorrect. Nurses must avoid using assumptions and categories as the basis for determining race. This is incorrect. Asking for information about the patient’s “oriental background” is making an assumption about the patient’s race and should be avoided. This is correct. Although we commonly think of race as being based on biological characteristics, many, including the U.S. Census Bureau, believe that race is socially, rather than biologically, determined. For a culturally sensitive nurse, it is most appropriate to ask the patient what race the patient identifies with and what name for it is preferred. This is incorrect. The nurse must avoid making an assumption based on the patient’s appearance; the patient may not have been born in an Asian country.

PTS: 1 CON: Culture 12. ANS: 3 Chapter: Chapter 15 Culture & Ethnicity Objective: Identify the phenomena of culture, including how they can affect the nursing care needs of clients and families. Page: 302 (V1) Heading: Dominant Cultures, Subcultures, and Minority Groups Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Culture Difficulty: Moderate Feedback

This is incorrect. Racism is a form of prejudice and discrimination based on the belief that a race is the principal determining factor of human traits and capabilities and that racial difference produce an inherent superiority or inferiority. This is incorrect. Archetype is a symbol for remembering some of the culture specifics and is usually not negative. The guiding principle for nursing practice is that each person must be seen as unique—as a member of an ethnic group, influenced by heritage, but not defined by it. This is correct. Ethnocentrism is the tendency to think that a person’s own group (cultural, professional, ethnic, or social) is superior to others and to view behaviors and beliefs that differ greatly from a person’s own as somehow wrong, strange, or unenlightened. The tendency to ethnocentrism exists in all groups, not just in the dominant culture. This is incorrect. Stereotyping is a widely held belief that all people from a certain racial or ethnic group are alike in certain respects.

PTS: 1 CON: Culture 13. ANS: 4 Chapter: Chapter 15 Culture & Ethnicity Objective: Identify vulnerable populations in the United States. Page: 298 (V1) Heading: Why Learn About Culture? Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Culture Difficulty: Difficult Feedback 1 This is incorrect. When working with a patient from a vulnerable population it may be important for the nurse to contact a social worker if the situation warrants doing so. However, it is always important to focus on the patient’s strengths and resources. 2 This is incorrect. Working with family members is important in developing a plan of care; however, the focus is first on the patient and the patient’s strengths and resources. 3 This is incorrect. When working with a patient who is identified as a member of a vulnerable population, the nurse will take into consideration the patient’s difficulties and risks; however, it is most important to look at strengths and resources. 4 This is correct. Vulnerable populations are groups who are more likely to develop health problems and experience poorer outcomes because of limited access to care. Examples of vulnerable populations include the homeless, the

poor, children, the elderly, and some ethnic and minority groups. When caring for patients from vulnerable groups, it is most important that the focus be on the patient’s strengths and resources. PTS: 1 CON: Culture 14. ANS: 3 Chapter: Chapter 15 Culture & Ethnicity Objective: Identify techniques for communicating with clients when there is a language barrier. Page: 310 (V1) Heading: What Are Some Barriers to Culturally Competent Care? Integrated Processes: Culture and Spirituality Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Culture Difficulty: Difficult Feedback 1 This is incorrect. An interpreter is usually used for explaining the meaning of information, but there are requirements for licensing and approval. 2 This is incorrect. At times, a translator is used, but this person usually only translates or restates information and does not necessarily explain the meaning of information. 3 This is correct. There are times when a nurse may use gestures, pictures, and family members in communicating with a patient. This is usually the case for some assessment issues, such as locating pain. However, if and when there is a consent issue, the hospital or healthcare organization must ensure adequate resources to comply with informed consent requirements. 4 This is incorrect. The selection of an interpreter, translator, or family member is all too specific; the best answer is to ensure adequate resources that will comply with informed consent requirements. PTS: 1 CON: Culture 15. ANS: 1 Chapter: Chapter 15 Culture & Ethnicity Objective: Discuss the differing views of culturally diverse clients, including biomedical, holistic, and alternative health systems, such as folk medicine. Page: 305 (V1) Heading: How Do Cultural Values, Beliefs, and Practices Affect Health? Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Culture Difficulty: Difficult

Feedback This is correct. It is not uncommon for any group, including those of the Jewish faith, to practice folk medicine and use folklore remedies. Eating chicken soup is folk medicine, although it certainly may have some health value unrelated to hypertension. Folk medicine is defined as the belief and practice that the members of a group follow when they are ill as opposed to more conventional (biomedical or professional) standards. In this item, the most appropriate response by the instructor is to ask the nurse to talk to the patient about using both, as neither will interfere with the other and the patient most likely needs the antihypertensive medications. This is incorrect. Asking the nurse to complete some research may be appropriate at another time, but this response will not assist the nurse in working with the patient. This is incorrect. A patient can make his or her own choices and decisions, but it is more appropriate to talk to the patient, provide some teaching, and gain insight before just “throwing in the towel.” This is incorrect. Permitting the patient to eat the soup with the prerequisite that the medication must be taken first is an example of coercing the patient.

PTS: 1 CON: Culture 16. ANS: 1 Chapter: Chapter 15 Culture & Ethnicity Objective: Explain guidelines for performing a transcultural assessment, including a cultural assessment model. Page: 309 (V1) Heading: What Is Culturally Competent Care? Integrated Processes: Culture and Spirituality Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Culture Difficulty: Difficult Feedback 1 This is correct. Although Madeleine Leininger does not use the specific term “cultural competence,” her theory fits with that concept. The goal of her theory is to guide research that will assist nurses to provide culturally congruent care using her three modes of nursing care actions and decisions. 2 This is incorrect. The Purnell model for cultural competence stresses teamwork in providing culturally sensitive and competent care and the Purnell model identifies several levels of consciousness in achieving cultural competence. 3 This is incorrect. The Campinha-Bacote model identifies the mnemonic ASKED (awareness, skills, knowledge, encounters, and desire). 4 This is incorrect. There are several strategies for the nurse to consider and many

resources to help the nurse develop strategies specific to various cultural groups. Some strategies include: reflect and know yourself; keep learning; accommodate and negotiate; collaborate; and respect. PTS:

CON: Culture

MULTIPLE RESPONSE 17. ANS: 1, 3, 4 Chapter: Chapter 15 Culture & Ethnicity Objective: Discuss concepts pertaining to cultural diversity in nursing. Page: 299 (V1) Heading: What Is Meant by Culture? Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Culture Difficulty: Difficult

1. 2.

3. 4.

Feedback This is correct. Culture exists at many levels, both material and nonmaterial. This is incorrect. Culture is all encompassing and affects everything its members think and do. It is not limited to food and holidays, although those are visible manifestations of a culture. Dietary practices and cultural calendars are not the essence of true and meaningful culture. This is correct. It is true that culture changes over times and at different rates. Some influences are societal changes, current events, and other significant people. This is correct. Culture is learned through life experiences that are shared by other members of the culture, such as family members, those sharing similar religious beliefs, and people of similar cultural heritage in the same community. This is incorrect. Culture practices are not tightly regulated by customs. As culture changes over time, culture practices also change.

PTS: 1 CON: Culture 18. ANS: 2, 3 Chapter: Chapter 15 Culture & Ethnicity Objective: Identify the phenomena of culture, including how they can affect the nursing care needs of clients and families. Page: 303 (V1) Heading: How Do Cultural Values, Beliefs, and Practices Affect Health? Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity

Cognitive Level: Analysis [Analyzing] Concept: Culture Difficulty: Difficult

Feedback This is incorrect. The nurse should continue to assess pain levels in this patient at the same frequency as before. Nursing interventions are altered based on a perceived cultural influence. This is correct. Patients of Asian heritage commonly avoid opioid use; however, they sometimes reconsider after healthcare personnel explain that the medication can improve the healing process. The nurse should document in the nurse’s notes that the patient wishes to avoid opioid use. This is correct. When the patient continues to refuse pain medications despite explanation, the nurse should respect the patient’s wishes and employ nonpharmacological measures to control pain. This is incorrect. The nurse should recognize and respect the patient’s cultural beliefs and not label the patient as noncompliant. It would be necessary to contact the primary provider only if nonpharmacological measures are ineffective and the patient experiences severe pain. This is incorrect. It is not appropriate for the nurse to ask the patient specifically about cultural influences on pain management. This approach may make the patient either culturally or personally defensive.

PTS: 1 CON: Culture 19. ANS: 3, 4 Chapter: Chapter 15 Culture & Ethnicity Objective: Define and give examples of culture universals and of culture specifics. Page: 300 (V1) Heading: Ethnicity, Race, and Religion Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Culture Difficulty: Difficult

1. 2. 3.

Feedback This is incorrect. Ethnicity does not refer to a person’s cultural use of the indigenous healthcare system. This is incorrect. A person can be biracial; however, “multicultural” describes groups rather than individuals. This is correct. Ethnicity refers to groups whose members share a common and social heritage that is transmitted to the next generation.

4. 5.

This is correct. Race refers to the grouping of individuals who share similar biological characteristics, such as blood type, skin color, and so forth. This is incorrect. People of Hispanic, Latino, or Spanish origin may be of any race, because the U.S. Census Bureau includes Hispanic/Latino/Spanish as a sociocultural, rather than a race, category.

PTS: 1 CON: Culture 20. ANS: 1, 2, 4 Chapter: Chapter 15 Culture & Ethnicity Objective: Explain what is meant by culture and acculturation. Page: 301 (V1) Heading: Concepts Related to Culture Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Culture Difficulty: Difficult

2. 3.

4. 5.

Feedback This is correct. Immigrants or new members of a group or country assume the characteristics of that culture through a learning process called acculturation. A person who is acculturated accepts both his own and the new culture, while adopting elements of each. This is correct. Many experts theorize that it takes years, perhaps three generations, for an immigrant group to become acculturated. This is incorrect. Assimilation, not acculturation, occurs when the new members gradually learn and take on the essential values, beliefs, and behavior of the dominant culture. This is correct. Acculturation is the result of a minority group’s need to survive and flourish in the new culture. This is incorrect. Acculturation is not the maintenance of a culture within the presence of a dominant culture; instead, it is a blending of certain aspects of both the original culture and the dominant culture.

PTS: 1 CON: Culture 21. ANS: 1, 2 Chapter: Chapter 15 Culture & Ethnicity Objective: Describe nursing strategies that promote delivery of culturally competent care to clients and their families. Page: 310 (V1) Heading: What Are Some Barriers to Culturally Competent Care? Integrated Processes: Culture and Spirituality

Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Culture Difficulty: Difficult

Feedback This is correct. There are numerous strategies to assist in increasing one’s skill level in cultural competency. One of which is to keep learning; the new nurse needs to read as much as possible and study nursing theories and principles pertaining to culture. This is correct. Take advantage of every opportunity to interact with persons from different cultural groups. Make an effort to incorporate beliefs and practices from various cultures into the nursing care and teaching materials. This is incorrect. Recognizing that persons from different cultures have different healthcare practices is important; however, we cannot force or coerce patients into following our (medical or nursing) healthcare practices. This is incorrect. It is important to understand basic practices of the most common cultures, but one does not make generalizations about that culture or embrace cultural interventions on a grand scale. Each patient is unique and influenced by their own culture but not defined by it. Health care is not based on culture alone. This is incorrect. Learning about and following the culture guidelines created by regulating bodies in health care does not alone help a new nurse to become culturally competent.

PTS: 1 CON: Culture 22. ANS: 2, 3 Chapter: Chapter 15 Culture & Ethnicity Objective: Identify the phenomena of culture, including how they can affect the nursing care needs of clients and families. Page: 304 (V1) Heading: How Do Cultural Values, Beliefs, and Practices Affect Health? Integrated Processes: Culture Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Culture Difficulty: Difficult

Feedback This is incorrect. One must be careful using “noncompliance” as a nursing diagnosis as (1) it has a negative connotation, and (2) it is used when the plan of care is mutually agreed upon and then the patient does not follow the plan. In this item, there is no indication that the plan (diet) was mutually agreed upon.

This is correct. One of the most appropriate nursing diagnoses for this patient is “Possible Knowledge Deficit related to disease process.” Given the scenario, it seems likely the patient does not understand the relationship of diet and cardiac health, but there are no specific data to support lack of knowledge. This is correct. “Imbalanced Nutrition related to dietary preferences” is another appropriate nursing diagnosis. This diagnosis relates to the patient’s verbalization of different food choices and preparations. This is incorrect. There is no information in this item indicating the patient is anxious about having a heart attack, or that anxiety has affected the patient’s appetite. This is incorrect. There is no information in the question to validate an inability to adjust to a therapeutically prescribed diet due to cultural conflicts. At this time, the nurse can assess how much the patient knows, teach the patient about the disease process, and present how the cardiac diet relates to the diagnosis. The patient can then participate in planning food choices and food preparations congruent with the patient’s diagnosis and culture.

PTS: 1 CON: Culture 23. ANS: 1, 3, 4, 5 Chapter: Chapter 15 Culture & Ethnicity Objective: Describe the culture of the North American healthcare system, including professional subcultures. Page: 306 (V1) Heading: What Is “Culture of Healthcare”? Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Culture Difficulty: Difficult

2. 3. 4.

Feedback This is correct. This system is also known as Western medicine and allopathic medicine. It relies on the biomedical system that combines Western biomedical beliefs with traditional North American values of self-reliance, individualism, and aggressive action. This is incorrect. The definition of health as living in harmony with nature is most reflective of the Native American health and illness belief system. This is correct. This system defines health as absence of disease or minimization of disease. This is correct. In North America, professional healthcare is dominated by a biomedical healthcare system that combines Western biomedical beliefs with traditional North American values of self-reliance, individualism, and aggressive

action. This is correct. The Professional Healthcare System is run by a set of professional healthcare providers who have been formally educated and trained for their appropriate roles and responsibilities.

PTS: 1 CON: Culture 24. ANS: 1, 4 Chapter: Chapter 15 Culture & Ethnicity Objective: Recognize the cultural implications inherent in nursing diagnoses. Page: 304 (V1) Heading: How Do Cultural Values, Beliefs, and Practices Affect Health? Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Culture Difficulty: Difficult

1. 2.

4. 5.

Feedback This is correct. Values are important because they help shape health-related beliefs and practices. This is incorrect. A value is a principle or standard that has meaning or worth to an individual. A value is not necessarily grounded in healthcare, or is it necessarily a set of behaviors. This is incorrect. Not all members of certain cultures will share the same values and beliefs. Nurses should not assume that clients share values, beliefs, or practices as the other members of the same culture. This is correct. It is understood a belief is something that one accepts as being true. This is incorrect. It is not safe to assume a client shares the nurse’s values, beliefs, and practices—nor those of the dominant culture.

PTS:

CON: Culture

Chapter 16. Spirituality Multiple Choice Identify the choice that best completes the statement or answers the question. 1. Which statement made by the student nurse to a Jehovah’s Witness patient indicates a need for further learning? 1. “I documented in your medical records that you do not want blood transfusions or blood products.” 2. “I am your nurse and I will help prepare you for a corneal transplant.” 3. “Happy Birthday. I will have the dietary department send up a cake for you.” 4. “The organ procurement (donation) center was notified that you did not want to donate an organ.” 2. A nurse is preparing a Mormon female for surgery. Which statement made or question asked by the nurse indicates an understanding of the patient’s religious practices or beliefs? 1. “This is a new gown. No one else has worn it.” 2. “How would you like me to handle your undergarments?” 3. “I will let your surgical team know that only females can touch you.” 4. “Would you like me to pray with you?” 3. Which question is most important to ask of a newly admitted patient to effectively incorporate spiritual care in the nursing care plan? 1. “What is your family’s religious background?” 2. “With what organized religion are you affiliated?” 3. “Do you go to church, and if so, how often?” 4. “What are your personal spiritual beliefs?” 4. A female patient tells the charge nurse that she does not want a male nurse caring for her. Which intervention by the charge nurse is best? 1. Explain that hospital policy does not allow nursing assignments based on the gender of the nurse. 2. Explore with the patient her beliefs and determine which might have caused her to make this statement. 3. Assure the patient that each nurse is capable of providing professional nursing care, regardless of gender. 4. Immediately comply with the patient’s request and assign a female nurse to care for the patient. 5. A patient of Orthodox Jewish faith is admitted to the hospital with heart failure on Yom Kippur. The physician prescribes digoxin 0.25 mg to be given orally to this patient. Based on the patient’s religious affiliation, which action should the nurse take? 1. Administer the medication as prescribed. 2. Hold the medication until after Yom Kippur.

3. Explain the importance of taking the medication despite the holiday. 4. Ask the physician to change the route of administration. 6. Which special consideration may the nurse need to make when caring for a female Rastafarian patient? 1. Allow the patient to wear her own clothing. 2. Provide a diet that is caffeine-free. 3. Allow the patient to wear jewelry with religious symbols. 4. Provide free-flowing water for bathing. 7. Which action is most effective for the female nurse to take when delivering spiritual care to a patient of the same religion as the nurse? 1. Understanding that the patient shares the same beliefs 2. Striving to meet the patient’s spiritual needs independently 3. Explaining her own religious beliefs to the patient 4. Developing a greater awareness of her own spirituality 8. Which type of medicine do those of the Hindu faith typically practice? 1. Ayurvedic medicine 2. Western medicine 3. Chiropractic medicine 4. Tribal medicine 9. A patient tells the nurse, “I feel that God has abandoned me. I am so angry that I can’t even pray.” The patient refuses to see the minister. Which nursing diagnosis is most appropriate for this patient? 1. Spiritual Distress 2. Risk for Spiritual Distress 3. Impaired Religiosity 4. Moral Distress 10. The nurse is asking the patient reflective, clarifying questions to help the patient make a list of what is important and unimportant in life and the time commitment for each. Which standardized (Nursing Interventions Classification [NIC]) intervention does this action represent? 1. Spiritual Support 2. Self-Esteem Enhancement 3. Values Clarification 4. Hope Inspiration 11. The nurse, a Christian, is caring for a Jewish patient who has asked the nurse to offer a prayer at the bedside. The nurse feels comfortable doing so. Which action by the nurse is appropriate? 1. Offer a prayer for healing using the nurse’s usual words and format. 2. Begin the prayer with “Jehovah God,” while avoiding the name of Jesus. 3. Avoid saying any name for the Supreme Being while praying, and quote an Old Testament Bible scripture as the prayer.

4. Say, “What name would you like for me to use to address the Supreme Being when I am praying for you?” 12. Over the past few centuries, nurses have placed less attention on spiritual care primarily because of which aspect? 1. Nurses providing care are less religious and spiritual now. 2. Spirituality and religion are unproven with regard to influencing health. 3. Greater emphasis has been placed on science and scientific evidence. 4. Nurses are uncomfortable when discussing spiritual aspects of care. 13. The nurse is caring for a patient recently diagnosed with cancer. The patient states, “I really never believed in a god or followed any religion. Should I do something now?” What is the most appropriate response by the nurse? 1. “Religion and spirituality are not for everyone. If you’ve not had it in your life to this point, you may not need it.” 2. “I am a Catholic and it works for me. Would you like me to tell you about my religion?” 3. “It is important to have some religion or spirituality in your life as it can help you get through difficult times.” 4. “It is up to you. If you would like, I can arrange for one of our nondenominational chaplains to come and speak with you.” 14. The nurse is speaking with a 40-year-old woman at a fund-raiser. The woman states, “I have never had a mammogram. I am a Buddhist and I believe if I get cancer, then that is what my fate will be.” What is the most appropriate response by the nurse? 1. “You are 40 years old and really should start thinking about having a mammogram.” 2. “This type of religion does not give you an opportunity to think about your own health.” 3. “I don’t know of any religion that just allows people to die. You may need to rethink this.” 4. “This is certainly your decision and I respect that. If you have any questions, I’ll help.” 15. The nursing student is completing her clinical rotation in the intensive care unit. While caring for a patient, she says to the primary nurse, “This family is bringing in all kinds of beads and medals and putting them on the patient and bed. This is intensive care! What should I do?” What is the most appropriate response by the primary nurse? 1. “Remove the medals from the patient so they don’t get in the way of your work.” 2. “Take the beads off the bed so they don’t distract or interfere with care.” 3. “Explain to the family that these objects cannot be brought into intensive care as our work is too intricate and these things can get in the way.” 4. “This is not uncommon in intensive care. Try to work around this as best you can, as these objects are important to the family and patient.”

16. The nurse is caring for a Native American patient. Which action should the nurse take? 1. Discuss health as harmony with nature. 2. Keep silence to a minimum. 3. Take notes during an assessment. 4. Encourage focus on “nirvana.” 17. The nurse is working in a pediatric intensive care unit. A young couple has just been informed that their 6-year-old son has died after being in the unit for 1 month. The couple is grief stricken and says to the nurse, “We can’t believe this has happened. He was too young. God is watching over him. Do you believe he is with God?” What is the most appropriate response by the nurse? 1. “It was his time. He is in a better place.” 2. “He suffered enough. He is at peace now.” 3. “I believe he is with angels, but tell me what you think.” 4. “Even though he is gone, you can have more children later.” 18. The nurse asks the patient to talk about the spiritual significance of being baptized in the Jordan River. Which spiritual technique is the nurse using? 1. Hope inspiration 2. Forgiveness facilitation 3. Reminiscence therapy 4. Feelings expression 19. The nurse is caring for a 68-year-old patient who has terminal cancer. Which specific assessment tool would the nurse use for this patient? 1. JAREL 2. SPIRIT 3. HOPE 4. LOVE Multiple Response Identify one or more choices that best complete the statement or answer the question. 20. Which statements indicate the nurse has a good understanding of religion? Select all that apply. 1. “Religion is like a lifelong journey.” 2. “Religion provides a code for a way of living.” 3. “Religion describes the relationship between patients and the divine.” 4. “Religion is a dynamic relationship that transcends.” 5. “Religion is experienced by all patients at some point in time.” 21. What are some possible barriers for nurses in providing spiritual care? Select all that apply. 1. Spiritual care is related to end-of-life care, and many nurses do not work in this area. 2. Greater emphasis in nursing is placed on meeting patients’ physical needs. 3. Many nurses experience time constraints and inadequate staffing.

4. Many nurses lack an understanding of their own spiritual belief systems. 5. Many nurses believe that spiritual care is not a component of the professional role. 22. Which actions indicate the nurse is using presence as an intervention with a patient? Select all that apply. 1. Being open to patient’s beliefs and concerns 2. Setting the agenda for the patient 3. Allowing the patient to tell stories about the illness 4. Using active listening skills 5. Leading the discussions about spirituality 23. What are some activities nurses can do to gain a broader view of spirituality? Select all that apply. 1. Develop critical and reflective thinking abilities. 2. Participate in religious and spiritual practices regularly. 3. Increase knowledge base of religion and spirituality. 4. Recognize that all spirituality is deeply ingrained in religion. 5. Examine thoughts and feelings about end-of-life issues. 24. The nurse is using the HOPE approach to perform a spiritual assessment. Which questions would the nurse ask when focusing on the “H” in HOPE? Select all that apply. 1. “Do you belong to a religious or spiritual community?” 2. “What are your sources of internal support?” 3. “Do you have any dietary restrictions I should know about?” 4. “What do you do to get through tough times?” 5. “What aspects of your spirituality are most helpful?”

Chapter 16. Spirituality Answer Section MULTIPLE CHOICE 1. ANS: 3 Chapter: Chapter 16 Spirituality Objective: Describe the major beliefs and their implications for nursing care for each of the religions briefly covered in this chapter. Page: 325 (V1) Heading: Jehovah’s Witnesses Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Spirituality Difficulty: Difficult Feedback 1 This is incorrect. The student nurse does not need further learning since Jehovah’s Witnesses do not accept blood transfusions or products. 2 This is incorrect. The student nurse does not need further learning since Jehovah’s Witnesses can accept a transplant as long as there is no blood involved. Corneal transplants are acceptable for Jehovah’s Witnesses. 3 This is correct. The student nurse needs further learning about the beliefs and values of Jehovah’s Witnesses. Jehovah’s Witnesses do not celebrate birthdays or holidays, with the exception of the anniversary of Christ’s death. Thus, asking the dietary department to send up a birthday cake for a celebration indicates that the student nurse does not understand the Jehovah’s Witnesses beliefs and practices. 4 This is incorrect. The student nurse does not need further learning since Jehovah’s Witnesses do not donate their organs. PTS: 1 CON: Spirituality 2. ANS: 2 Chapter: Chapter 16 Spirituality Objective: Describe the major beliefs and their implications for nursing care for each of the religions briefly covered in this chapter. Page: 325 (V1) Heading: Mormonism Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Spirituality

Difficulty: Moderate Feedback 1 This is incorrect. Rastafarian females will not wear second-hand clothes and require a gown that has not been worn by others. 2 This is correct. Both male and female Mormons wear special sacred undergarments that are removed only for hygiene, intimacy, and bathroom use. Nurses may also remove it before surgery, but it must be considered intensely private and be treated with respect. 3 This is incorrect. Muslim women prefer to be treated by female staff. 4 This is incorrect. Inquiring about prayer is inappropriate because the patient should initiate the request; further, prayer is not specific to this religion. PTS: 1 CON: Spirituality 3. ANS: 4 Chapter: Chapter 16 Spirituality Objective: Perform a spiritual assessment. Page: 330 (V1) Heading: Assessment Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Comprehension [Understanding] Concept: Spirituality Difficulty: Moderate Feedback 1 This is incorrect. The patient is the focus of care, not the family. Therefore, this is not the most important question to ask. 2 This is incorrect. Patient’s beliefs may be associated with or independent of religious affiliations. Therefore, this is not the most important question to ask. 3 This is incorrect. Not all people of a religious group adhere to its norms, rituals, and/or practices; questions should extend beyond focusing only on the patient’s church attendance. Therefore, this is not the most important question to ask. 4 This is correct. Identifying the patient’s personal spiritual belief will provide the nurse with more information to incorporate into the plan of care. Therefore, this is the most important question to ask. PTS: 1 CON: Spirituality 4. ANS: 2 Chapter: Chapter 16 Spirituality Objective: Perform a spiritual assessment. Page: 330 (V1) Heading: Assessment Integrated Processes: Culture and Spirituality

Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Spirituality Difficulty: Difficult Feedback 1 This is incorrect. Explaining hospital policy does not help the nurse understand the primary reason for the request, nor promote patient trust. 2 This is correct. The nurse should explore the reason behind the patient’s request, which may have implications for additional nursing needs. If the reason is religious or spiritual, this provides an optimal time to engage in spiritual care. 3 This is incorrect. Reassuring the patient of the nurse’s competence does not meet the patient’s needs and ignores the patient’s request, hindering trust. 4 This is incorrect. Simply complying immediately with the patient’s request does not help the nurse understand the primary reason for the request, nor promotes holistic patient care. PTS: 1 CON: Spirituality 5. ANS: 4 Chapter: Chapter 16 Spirituality Objective: Describe the major beliefs and their implications for nursing care for each of the religions briefly covered in this chapter. Page: 323 (V1) Heading: Judaism Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Spirituality Difficulty: Moderate Feedback 1 This is incorrect. Administering the medications as prescribed could create internal conflict between adhering to religious practices and complying with the medical regimen. This action would indicate care is being provided by a spiritually insensitive nurse. There is a better alternative. 2 This is incorrect. The patient is in heart failure and needs the medication; thus, withholding the medication is not an option. 3 This is incorrect. Although the patient may understand the importance of the medication, it is not appropriate to create internal conflict between adhering to religious practices and complying with the medical regimen. 4 This is correct. Yom Kippur is one of the holiest of the Jewish holidays. Selfdenial includes abstaining from eating, drinking, bathing, and other rituals. So, the most spiritually appropriate nursing intervention is to ask the provider to change the route of administration.

PTS: 1 CON: Spirituality 6. ANS: 1 Chapter: Chapter 16 Spirituality Objective: Describe the major beliefs and their implications for nursing care for each of the religions briefly covered in this chapter. Page: 327 (V1) Heading: Rastafarianism Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Spirituality Difficulty: Moderate Feedback 1 This is correct. Wearing second-hand clothes is taboo in the Rastafarian faith; therefore, the nurse should allow the patient to wear her own bedclothes instead of a hospital gown. 2 This is incorrect. Rastafarians typically consume tea; however, some do not drink milk or coffee. 3 This is incorrect. Muslim women may wear a locket containing religious writing around the neck in a small leather bag. These are worn for protection and strength and should not be removed. 4 This is incorrect. Hindus prefer washing with free-flowing water for bathing, which should be provided when possible. PTS: 1 CON: Spirituality 7. ANS: 4 Chapter: Chapter 16 Spirituality Objective: Examine your own level of comfort in terms of performing spiritual interventions. Page: 328 (V1) Heading: What Are Your Personal Biases? > Lack of General Awareness of Spirituality and Lack of Awareness of Your Own Spiritual Belief System Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Comprehension [Understanding] Concept: Spirituality Difficulty: Moderate Feedback 1 This is incorrect. The nurse should avoid assuming that a patient who shares the same religious affiliation has the same beliefs. 2 This is incorrect. The nurse should avoid trying to meet the patient’s spiritual needs independently. A team approach to spirituality provides more

3 4

comprehensive care. This is incorrect. Unless asked, the nurse should avoid explaining her own religious beliefs, which might offend the patient. This is correct. The nurse can best deliver spiritual care by developing a greater awareness of her own spirituality. This allows the nurse to be a better listener and provide better care for the patient.

PTS: 1 CON: Spirituality 8. ANS: 1 Chapter: Chapter 16 Spirituality Objective: Describe the major beliefs and their implications for nursing care for each of the religions briefly covered in this chapter. Page: 326 (V1) Heading: Hinduism Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Comprehension [Understanding] Concept: Spirituality Difficulty: Moderate Feedback 1 This is correct. Those of Hindu faith typically practice Ayurvedic medicine, which encompasses all aspects of life, including diet, sleep, elimination, and hygiene. Some believe in the medicinal properties of “hot” and “cold” foods, which have nothing to do with temperature or degree of spiciness. 2 This is incorrect. People who practice Hinduism do not typically practice Western medicine. 3 This is incorrect. People of the Hindu faith do not typically practice chiropractic medicine. 4 This is incorrect. Native Americans practice tribal medicine or remedies that incorporate natural remedies. PTS: 1 CON: Spirituality 9. ANS: 1 Chapter: Chapter 16 Spirituality Objective: Recognize the differences between spiritual care diagnoses and those that may serve as etiologies of other nursing diagnoses. Page: 332 (V1) Heading: Analysis/Nursing Diagnosis and Box 16-1 Spirituality Diagnoses, Examples Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Spirituality

Difficulty: Moderate Feedback 1 This is correct. This patient exhibits three defining characteristics for Spiritual Distress (feeling abandoned by God, inability to pray, refusing to see a religious leader). Therefore, the actual problem of Spiritual Distress does exist. 2 This is incorrect. Since the patient is experiencing actual spiritual distress, the nursing diagnosis is not a potential problem or risk. 3 This is incorrect. Impaired Religiosity is difficulty in exercising or impaired ability to exercise reliance on beliefs or to participate in rituals of a faith tradition (e.g., going to church). This patient is not unable to see the minister, but chooses not to. 4 This is incorrect. The patient is not experiencing moral distress. Moral Distress occurs when a person makes a moral decision but is prevented from carrying out the chosen action. PTS: 1 CON: Spirituality 10. ANS: 3 Chapter: Chapter 16 Spirituality Objective: Plan nursing interventions based on the data obtained in a spiritual assessment. Page: 152 (V2) Heading: Standardized Language > Nursing Interventions and Nursing Activities > Values Clarification Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Spirituality Difficulty: Moderate Feedback 1 This is incorrect. Spiritual support is assisting the patient to feel balance and connection with a greater power, based on a focused spiritual assessment. 2 This is incorrect. Self-awareness enhancement assists the patient to realize that everyone is unique and to identify life priorities, guilty feelings, and sources of motivation. 3 This is correct. One of the steps of most values clarification processes is to list values (what is important and not important in life) and the time commitment for each. The nurse facilitates this by asking reflective, clarifying questions of the patient. 4 This is incorrect. Hope inspiration focuses on hope and spiritual/religious growth. PTS: 1 11. ANS: 4

CON: Spirituality

Chapter: Chapter 16 Spirituality Objective: Plan nursing interventions based on the data obtained in a spiritual assessment. Page: 149 (V2) Heading: Clinical Insight 16-2 Praying with Patients Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Spirituality Difficulty: Moderate Feedback 1 This is incorrect. The nurse should focus on the patient’s beliefs, not on the nurse’s beliefs. Seek direction from the patient in these matters: most people are honored to be able to explain their beliefs and practices to someone who is open to the experience. 2 This is incorrect. The nurse should not assume that avoiding the name “Jesus” and using “Jehovah God” would be supportive to the patient. The nurse should obtain the patient’s preferences. 3 This is incorrect. The nurse does not need to avoid addressing God by a name, but the most supportive way to do so is to find out the name the patient wishes to use. The nurse should not assume that the patient would find an Old Testament Bible verse to be helpful spiritually. 4 This is correct. Ask how the patient prefers to address the divine. Some people prefer the use of parental language in their prayers, for example, Father God or Divine Mother. Some use Jehovah, Yahweh, Allah, or even multiple names depending on the religion. PTS: 1 CON: Spirituality 12. ANS: 3 Chapter: Chapter 16 Spirituality Objective: Identify five barriers to spiritual care. Page: 319 (V1) Heading: History of Spirituality in Nursing Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Comprehension [Understanding] Concept: Spirituality Difficulty: Moderate Feedback 1 This is incorrect. The nurse’s own beliefs and practices are not what affected spiritual care. 2 This is incorrect. Research suggest that religion and spirituality have positive influences on health outcomes.

This is correct. By the mid-20th century, with advances in the sciences and as more nurses studied in university settings, the spiritual underpinnings of nursing were replaced by what could be “seen and tested” by the scientific method. Only recently has nursing reclaimed the spiritual dimension as a vital part of its identity and recognized its power to influence health. This is incorrect. This is not the reason nurses have placed less attention on spiritual care. Some nurses are very comfortable in this area.

PTS: 1 CON: Spirituality 13. ANS: 4 Chapter: Chapter 16 Spirituality Objective: Describe collaborative efforts to ensure the spiritual care of clients. Page: 321 (V1) Heading: What is Spirituality? and Other Nursing Activities Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Spirituality Difficulty: Moderate Feedback 1 This is incorrect. A person may not have any religion or spirituality in his or her life; however, this does not mean that with changes in health status, aging, and developmental levels, a person should not reach out to ask for help or seek guidance. 2 This is incorrect. The primary goal is to support patients’ healing, not convert them to a different view. 3 This is incorrect. It is important not to impose or convert others to one’s own beliefs. 4 This is correct. There are times when a nurse may not know the answer to a patient’s question regarding spirituality or religion. Clearly, there are times when the nurse should then refer to others with more knowledge and experience, and with the patient’s permission. Offering to refer the patient to a facility chaplain is the best response by the nurse. PTS: 1 CON: Spirituality 14. ANS: 4 Chapter: Chapter 16 Spirituality Objective: Plan nursing interventions based on the data obtained in a spiritual assessment. Page: 322 (V1) Heading: How Might Spiritual Beliefs Affect Health? and Standardized (NIC) Spirituality Interventions Integrated Processes: Culture and Spirituality

Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Spirituality Difficulty: Easy Feedback 1 This is incorrect. Nurses cannot tell patients what they should and should not do. 2 This is incorrect. The nurse must follow the patient’s lead and be caring and respectful without belittling the patient’s religion. 3 This is incorrect. The nurse should not be critical of a patient’s religion. 4 This is correct. The most appropriate response by the nurse is to first acknowledge and accept the patient’s belief in her religion or way of life; however, the nurse should also provide a nonthreatening opportunity to explore options, if so desired by the patient. PTS: 1 CON: Spirituality 15. ANS: 4 Chapter: Chapter 16 Spirituality Objective: Examine your own level of comfort in terms of performing spiritual interventions. Page: 328 (V1) Heading: What Are Your Personal Biases? Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Spirituality Difficulty: Moderate Feedback 1 This is incorrect. Nurses must respect a patient’s dress and other requirements or symbols as determined by his or her religion. 2 This is incorrect. The goal is to provide holistic care which involves the inclusion of religious and spiritual beliefs. 3 This is incorrect. Placing the nurses’ needs above the patient is inappropriate. 4 This is correct. Spiritual care demands a nonjudgmental attitude and an open manner of thinking that invites rather than excludes. It is not uncommon for religious groups, such as Hindus and Roman Catholics, to wear medals or beads as symbolic icons of their religion. The most appropriate response by the nurse is to inform the student that this practice is common in all units of care and must be respected. PTS: 1 CON: Spirituality 16. ANS: 1 Chapter: Chapter 16 Spirituality

Objective: Describe the major beliefs and their implications for nursing care for each of the religions briefly covered in this chapter. Page: 327 (V1) Heading: Native American Religions Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Spirituality Difficulty: Moderate Feedback 1 This is correct. Native Americans consider health as a state of harmony with nature. 2 This is incorrect. Silence is valued by Native Americans and should be used, not kept to a minimum. 3 This is incorrect. For some tribes, note taking by the professional is forbidden. 4 This is incorrect. Buddhism, not Native American religions, focuses on “nirvana.” PTS: 1 CON: Spirituality 17. ANS: 3 Chapter: Chapter 16 Spirituality Objective: Plan nursing interventions based on the data obtained in a spiritual assessment. Page: 334 (V1) Heading: Other Nursing Activities Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Spirituality Difficulty: Moderate Feedback 1 This is incorrect. A seemingly harmless statement such as “He is in a better place,” may be hurtful and even offensive for the family. 2 This is incorrect. It is better not to offer opinions or judgments, which may be seen as hurtful or offensive to the family. 3 This is correct. If the nurse is asked, the nurse can briefly share beliefs, but reflect the question back to the family. 4 This is incorrect. Giving the young couple advice at this time is inappropriate. The nurse’s role is to comfort the parents, not tell them what to do. PTS: 1 CON: Spirituality 18. ANS: 3 Chapter: Chapter 16 Spirituality

Objective: Plan nursing interventions based on the data obtained in a spiritual assessment. Page: 154 (V2) Heading: Active Listening (NIC) > Reminiscence Therapy (NIC) Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Spirituality Difficulty: Moderate Feedback 1 This is incorrect. Hope is a subjective state of confidence in the possibility of a better future. It includes a positive orientation, faith, and will to live. To intervene effectively, it is important to know the source of the person’s hope and the factors underlying the feelings of hopelessness. 2 This is incorrect. Forgiveness is the act of pardoning or being pardoned for an offense, debt, or obligation. Letting go of the resentment felt for another promotes constructive changes in a person’s life; a sense of renewal; and reconciliation with God, church, and one’s inner being. To provide this intervention, the nurse must first assess the patient’s needs for reconciliation with self, others, and God. 3 This is correct. Reminiscence is the recalling and sharing of past life events with another person. It promotes meaning-making through rethinking and clarifying previous experiences. As the patient reminisces, he or she may make spiritual links by expressing personal beliefs that helped him or her live through difficult life events. 4 This is incorrect. While feelings may be expressed during the discussion, the technique is not feelings expression. Expression of feelings would require the nurse to ask the patient about feelings. PTS: 1 CON: Spirituality 19. ANS: 1 Chapter: Chapter 16 Spirituality Objective: Perform a spiritual assessment. Page: 150 (V2) Heading: Spiritual Assessment Tools Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Spirituality Difficulty: Moderate Feedback 1 This is correct. JAREL is a spiritual assessment tool designed especially for patients over 65 years and older. Since the patient is 68, this is the best tool to

use. This is incorrect. While SPIRIT is a spiritual assessment tool, it is not designed specifically for patients over 65. This is incorrect. The HOPE assessment tool is the most comprehensive assessment in palliative care, but it was not specifically designed for the older adult patient. This is incorrect. While love is an important component in spirituality, it is not an assessment tool specifically designed for patients over 65 years old.

2 3

PTS:

CON: Spirituality

MULTIPLE RESPONSE 20. ANS: 2, 3 Chapter: Chapter 16 Spirituality Objective: Describe the differences and similarities between religion and spirituality. Page: 320 (V1) Heading: What Are Religion and Spirituality? > What Is Religion? and Table 16-1 Comparison of Religion and Spirituality Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Spirituality Difficulty: Difficult

1. 2. 3.

4. 5.

Feedback This is incorrect. Spirituality, not religion, is like a lifelong journey. Religion is the map. This is correct. Religion provides codes of conduct that integrate beliefs and values into a way of living. This is correct. Regardless of their differences, many of the world religions have the following in common: an explanation of the relationship between humans and the divine. This is incorrect. Spirituality, not religion, is a dynamic relationship that transcends. This is incorrect. Spirituality, not religion, is experienced by all patients at some point in time. Atheists and agnostics do not practice a religion but they do experience spiritual needs.

PTS: 1 CON: Spirituality 21. ANS: 2, 3, 4, 5 Chapter: Chapter 16 Spirituality Objective: Identify five barriers to spiritual care.

Page: 328 (V1) Heading: What Are Some Barriers to Spiritual Care? Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Comprehension [Understanding] Concept: Spirituality Difficulty: Moderate

2. 3. 4. 5.

Feedback This is incorrect. Spiritual interventions and care, although prevalent in critical care areas and at end-of-life events, can take place in any area and at any time in the patient’s life journey. This is not an identified barrier to spiritual care. This is correct. A barrier to spiritual care is the emphasis on high-tech physical care, rather than on spiritual care. This is correct. Barriers to spiritual care include time constraints and poor staffing. This is correct. A barrier to spiritual care is a lack of awareness of one’s own spirituality. This is correct. A barrier to spiritual care is a belief that spiritual care is not a component of the professional role.

PTS: 1 CON: Spirituality 22. ANS: 1, 3, 4 Chapter: Chapter 16 Spirituality Objective: Plan nursing interventions based on the data obtained in a spiritual assessment. Page: 152 (V2) Heading: Standardized (NIC) Spirituality Interventions > Active Listening > Presence (NIC) Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Spirituality Difficulty: Moderate

2. 3. 4. 5.

Feedback This is correct. Practicing presence means to be with the patient and family in meaningful ways. This requires not only a nurse’s actual presence at the bedside but also the nurse’s openness to issues and concerns of the patient. This is incorrect. Presence allows the patient to set the agenda, not the nurse. This is correct. Presence involves sincere communication and being fully available to the patient and includes listening to the patient’s “stories” about the illness. This is correct. Active and focused listening is also a quality of practicing presence with the patient. This is incorrect. Presence allows the patient to lead the discussion about spirituality,

not the nurse. PTS: 1 CON: Spirituality 23. ANS: 1, 3, 5 Chapter: Chapter 16 Spirituality Objective: Identify five barriers to spiritual care. Page: 328 (V1) Heading: What Are Some Barriers to Spiritual Care? > Lack of Awareness of Your Own Spiritual Belief System Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Spirituality Difficulty: Moderate

2. 3.

4. 5.

Feedback This is correct. There are many activities nurses can engage in to gain a broader view and understanding of spirituality. Nurses can increase their knowledge about spirituality by developing critical and reflective thinking abilities. This is incorrect. There is nothing that supports nurses participating in religious and spiritual practices on a regular basis to gain a broader view of spirituality. This is correct. Nurses can increase knowledge about spirituality by increasing their knowledge base and understanding the differences among religion, spirituality, and spiritual care. Spirituality is understood in different ways by patients, families, and nurses. This is incorrect. Spirituality may be deeply ingrained in or totally separate from formal religion. A person can be spiritual without being religious. This is correct. Spirituality can be broadened by examining thoughts and feelings about end-of-life issues.

PTS: 1 CON: Spirituality 24. ANS: 2, 4 Chapter: Chapter 16 Spirituality Objective: Perform a spiritual assessment. Page: 150 (V2) Heading: Assessment Guidelines and Tools: Focused Assessment Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Spirituality Difficulty: Difficult

1. 2. 3. 4. 5.

Feedback This is incorrect. Organized religion questions focus on the “O” in HOPE. This is correct. Sources of Hope and internal support questions focus on the “H” in HOPE. This is incorrect. Effects on medical care questions, like diet, focus on the “E” in HOPE. This is correct. Asking questions about tough times focus on the “H” in HOPE. This is incorrect. Questions about Personal spirituality/Practices focus on the “P” in HOPE.

PTS:

CON: Spirituality

Chapter 17. Loss, Grief, & Dying Multiple Choice Identify the choice that best completes the statement or answers the question. 1. A 73-year-old female patient who suffered a stroke is being transferred from the acute care hospital to a nursing home for ongoing care because she is unable to care for herself at home. Which type of loss is this patient most likely experiencing? 1. Environmental loss 2. Internal loss 3. Perceived loss 4. Psychological loss 2. For the majority of grief theories and models, which response typically occurs in the initial stage/phase? 1. Awareness 2. Adjustment 3. Disbelief 4. Confrontation 3. Which statement regarding palliative sedation is true? 1. Palliative sedation is a type of assisted suicide that is legal in a few states. 2. Involuntary euthanasia is a type of palliative sedation that is legal in several states. 3. The American Nurses Association enforces the legalities of palliative sedation for terminally ill patients. 4. The Hospice and Palliative Nurses Association promotes palliative sedation to manage unendurable and refractory symptoms. 4. What is the American Nurses Association’s (ANA) position on assisted suicide? 1. Since it is legal in some states, nurses can participate in assisted suicide. 2. Nurses must follow the policies of their employing agency. 3. Because it is legal in some states, the ANA refuses to take a position that may contradict a state law. 4. Participation by nurses in assisted suicide is prohibited. 5. Which patient is at most risk for experiencing difficult grieving? 1. The middle-aged woman whose grandmother died of advanced Parkinson’s disease 2. A young adult with three small children whose wife died suddenly in an accident 3. The middle-aged person whose spouse suffered a chronic, painful death 4. An older adult whose spouse died of complications of chronic renal disease 6. During a health history, a patient whose wife died unexpectedly 6 months ago in a motor vehicle accident admits to drinking at least six bourbon and waters every night before going to bed. Which type of grief does this best illustrate?

1. 2. 3. 4.

Delayed Uncomplicated Disenfranchised Masked

7. The nurse is caring for a patient in a persistent vegetative state (PVS). Which finding would the nurse expect to observe? 1. Is aware of family, but can’t respond to them 2. Obeys the nurse’s commands 3. Has occasional grimaces and tears 4. Speaks intermittently 8. A patient’s wife has told nurses that she wants to be with her husband when he dies. The patient’s respirations are irregular, and he is congested. The wife tells the nurse that she would like to go home to shower but that she is afraid her husband might die before she returns. Which response by the nurse is best? 1. “Certainly, go ahead; your husband will most likely hold on until you return.” 2. “Your husband could live for days or a few hours; you can do whatever you are comfortable with.” 3. “I’ll stay continuously at his bedside while you are gone.” 4. “Don’t worry. Your husband is in good hands; I’ll look out for him.” 9. Which intervention takes priority for the patient receiving hospice care? 1. Turning and repositioning the patient every 2 hours 2. Assisting the patient out of bed into a chair twice a day 3. Administering pain medication to keep the patient comfortable 4. Providing the patient with small frequent, nutritious meals 10. The nurse has been explaining advance directives to a patient. Which response by the patient would indicate successful teaching? 1. “It specifies your healthcare instructions should you become unable to make selfdirected decisions.” 2. “It identifies the activities considered to be evidence of quality care.” 3. “It verifies your understanding of the risks and benefits associated with a procedure.” 4. “It allows you the autonomy to leave the hospital when you decide, even if it is against medical advice.” 11. Which sign would the nurse observe in a client who is days to hours before death? 1. Absence of heart activity 2. Yellowish pallor 3. Excessive urine output 4. Dry mucous membranes

12. A male patient dying of heart failure has changed his choice about end-of-life treatment measures several times. He says, “I just can’t make up my mind about it.” Which nursing diagnosis is most appropriate for this patient? 1. Deficient Knowledge 2. Spiritual Distress 3. Decisional Conflict 4. Complicated Grieving 13. Which nursing intervention should be included in the plan of care for a patient dying of cancer? 1. Have at least one family member remain at the bedside at all times. 2. Follow up weekly with other healthcare team members about family concerns. 3. Avoid discussing the dying process with the family to reduce sadness. 4. Encourage family members to participate in care of the patient, when possible. 14. Which intervention by the nurse is most appropriate when a patient who is dying develops a “death rattle”? 1. Turn the patient to the prone position. 2. Raise the head of the bed. 3. Provide intravenous (IV) fluids. 4. Administer pain medication intravenously. 15. Which patient goal is most appropriate when managing the patient dying of cancer? The patient will: 1. Request pain medication when needed 2. Report or demonstrate satisfactory pain control 3. Use only nonpharmacological measures to control pain 4. Verbalize understanding that it may not be possible to control the pain 16. When providing postmortem care, the nurse places dentures in the mouth and closes the eyes and mouth of the patient within 2 to 4 hours after death. Why is the timing of the action so important? 1. To prevent blood from settling in the head, neck, and shoulders 2. To perform these actions more easily before rigor mortis develops 3. To set the mouth in a natural position for viewing by the family 4. To avoid discoloration caused by blood settling in the facial area 17. How should the nurse respond to a family immediately after a patient dies? 1. Ask the family to leave the patient’s room so postmortem care can be performed. 2. Leave tubes and IV lines in place until the family has the opportunity to view the body. 3. Express sympathy to the family by saying, “I am sorry for your loss.” 4. Tell the family that they will have limited time with their loved one. 18. The mother of a preschool child dies suddenly of a ruptured cerebral aneurysm. What recommendation should the nurse make to the family regarding how to most therapeutically care for the child?

1. 2. 3. 4.

Take the child to the funeral even if the child is frightened. Notify the physician immediately if the child shows signs of regression. Spend as much time as possible with the child. Provide distraction whenever the child begins to express feelings of sadness.

19. Throughout the course of the illness, a patient has denied its seriousness, even though the health professionals have explained prognosis of death very clearly. Physiological signs now indicate that the patient will probably die, but the patient is still firmly in a state of emotional denial. The patient says to the nurse, “Tell my wife to stop hovering and go home. I’m going to be fine.” How should the nurse respond? 1. “Your physical signs indicate that you will likely not live more than a few more hours.” 2. “You seem very sure that you are not going to die. Please tell me more about what you are feeling.” 3. “It seems to me you would be feeling some anger and wondering why all this is happening to you.” 4. “It would be best for your family if you were able to work through this and come to accept the reality of your situation.” 20. A patient previously lived with a sister for more than 20 years. Although it has been more than a year since the sister died, the patient tells the home health nurse, “It’s no worse now, but I never feel any relief from this overwhelming sadness. I still can’t sleep a full night. The house is a mess; I even feel too tired to take a bath.” The patient’s clothing is not clean, and hair is not combed. The patient is apparently not eating adequately. What can the nurse conclude about this patient? 1. Is grieving longer than usual because of the closeness of the relationship with the sister 2. Is experiencing a depressive disorder rather than simply grieving the loss of the sister 3. Is feeling guilt and worthlessness because the sister died and the patient is still alive 4. Is interpreting the holiday as a trigger event, which is causing the patient to grieve 21. A nursing student attending a conference on grief says to one of the presenters, “The patient I cared for last week in clinical told me she cried for 4 months after she lost her cat. Isn’t that an excessive amount of time to cry over a cat?” What is the most appropriate response by the presenter? 1. “Yes, 4 months is an excessive amount of time. Encourage her to obtain counseling.” 2. “No, when I lost my dog, I cried for 4 months. It was a difficult experience for me” 3. “As long as the patient is able to get to other things in her life, then it is okay.” 4. “No, all people grieve differently depending on how meaningful the loss was in their life.” 22. Which statement best describes the difference between a “DNAR” and an “AND” order?

1. There is no difference in the two terms. Both are used synonymously. 2. A DNAR is an order not to resuscitate; an AND is an order to attempt to resuscitate. 3. AND contains the word death, so the intent of the order by the provider is clear. 4. A DNAR order provides specific instructions for hydration and feeding. An AND does not. 23. The nurse had been caring for a patient in a hospice facility for 1 month. When the patient dies, the family invites the nurse to attend the calling hours and funeral. What is the most appropriate action for the nurse to take? 1. Attend the services, if the nurse wishes to do so, as this can help to diffuse the nurse’s feelings of loss and can be meaningful to the family. 2. Ask another nurse for an opinion on this matter, because the nurse’s own judgment may not be reliable at this time. 3. Do not attend the service, because nurses cannot become attached or overly involved with family members after the death of their patients. 4. Be present at the service but stay for only a short period of time, as these occasions are reserved for close friends and family. 24. A patient in a cancer clinic says to the nurse, “I’m just so angry. I feel like God is punishing me. I know this is a bad way to think, but I don’t deserve to die of cancer.” What is the most appropriate response by the nurse? 1. “Death is part of life. With the passing of more time, you will learn to accept this.” 2. “It sounds like you are losing your faith in God. God does not punish people.” 3. “It is normal for you to feel this way. I’m interested in hearing more about how you feel.” 4. “Anger is not good for you at this time. We can talk about some more helpful, positive feelings.” 25. Which component is contained within the definition of the Uniform Determination of Death Act? 1. Cessation of blood flow to vital organs 2. Cessation of spontaneous respirations 3. Irreversible cessation of higher-brain functions 4. Irreversible cessation of brain and brainstem function 26. A 16-year-old boy recently lost his father in a tragic motorcycle accident. In assessing how well this teenager is managing and coping with the death of his father, the nurse should be most alert for which high-priority behavior? 1. Exhibiting excessive crying 2. Engaging in health risk behaviors 3. Not doing his homework 4. Distancing himself from friends

27. The nurse is caring for an unresponsive, near-death patient in the intensive care unit, and it is unclear whether or not this patient is an organ donor. The family states, “I think he put ‘organ donor’ on his license but we don’t want to donate his organs.” What is the nurse’s priority action at this time? 1. Review the driver’s license and prepare for donation. 2. Honor the family’s wishes, as the patient is unable to make a decision. 3. Maintain the viability of organs until a resolution is made. 4. Contact the primary care provider. Multiple Response Identify one or more choices that best complete the statement or answer the question. 28. Which interventions are appropriate for a client receiving palliative care? Select all that apply. 1. Surgically inserting a device to decrease the workload of the heart in a client awaiting heart transplantation 2. Infusing intravenous dopamine to raise the blood pressure of a client with endstage lung cancer 3. Providing moisturizing eye drops to an unconscious client whose eyes are dry 4. Administering a medication to relieve the nausea of a client with end-stage leukemia 5. Withholding pain medication from a terminally ill client with bone cancer 29. For a patient to be eligible for insurance benefits covering hospice care, a physician must certify which conditions? Select all that apply. 1. Life expectancy is not more than 6 months. 2. Life expectancy is not more than 12 months. 3. The condition is expected to improve slightly. 4. The condition is not expected to improve. 5. The condition is severe and long-term. 30. Which warning signs would indicate that a child needs professional help after the death of a loved one? Select all that apply. 1. Interested in usual activities 2. Extended regression 3. Withdrawal from friends 4. Inability to sleep 5. Intermittent sadness 31. Which statements describe legal responsibilities after the death of a patient? Select all that apply. 1. Next of kin must sign a consent before any autopsy can be performed. 2. If the patient is donating organs, necessary arrangements must be made. 3. The person who pronounces death must sign the death certificate. 4. Family members are not allowed to participate in postmortem care.

5. Special preparations must be followed when the patient dies from a communicable disease. 32. The American Nurses Association (ANA) lists recommendations concerning DNARs and ANDs. Which statements indicate the nurse has a correct understanding of the ANA recommendations? Select all that apply. 1. A DNAR means that the nurse can discontinue care including removal of a feeding tube. 2. If there is no DNAR or AND written, the nurse can participate in a “slow code” until a written order is obtained. 3. Nurses should take an active role in developing policies related to DNARs and ANDs. 4. If there is any conflict or confusion regarding a DNAR or AND, the competent patient’s choices will always have the highest priority. 5. Nurses should advocate for a patient’s end-of-life preference to be honored over the family’s. 33. Nurses frequently encounter death of patients in many healthcare settings. What are some strategies nurses can use to better care for themselves when dealing with death and the dying? Select all that apply. 1. Remain detached and unemotional when working with dying patients. 2. Talk with colleagues about feelings related to death and dying. 3. Use relaxation and focus on peaceful thoughts. 4. Understand own feelings about death and dying. 5. Suppress grieving when patients die. 34. The nurse is caring for a patient who has cancer and is terminally ill. What are the most appropriate actions by the nurse in providing end-of-life care that will address the patient’s spiritual needs? Select all that apply. 1. Be an empathetic listener for the patient. 2. Allow the patient to participate in spiritual rituals. 3. Recognize that this is an emotional time and prepare for intense crying. 4. Contact pastoral care or the patient’s clergyperson before the patient asks. 5. Provide time for meditation, if requested. 35. Which statements indicate the nurse has a good understanding of Dr. Elisabeth Kübler-Ross’s theory? Select all that apply. 1. Patients must pass through each of the five stages of death and dying. 2. Kübler-Ross’s theory includes psychological responses from the terminal diagnosis to the actual death. 3. The nurse’s role is to help patients move from one stage to the next, and finally to acceptance. 4. Patients may experience two or three stages at the same time. 5. Kübler-Ross’s theory includes completing one stage and moving on to the next in

sequence.

Chapter 17. Loss, Grief, & Dying Answer Section MULTIPLE CHOICE 1. ANS: 1 Chapter: Chapter 17 Loss, Grief, & Dying Objective: Name and describe at least four types of loss. Page: 339 (V1) Heading: Categories of Loss > Environmental Loss Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Grief and Loss Difficulty: Easy Feedback 1 This is correct. This patient is most likely experiencing an environmental loss because she is unable to return to her familiar home setting. Instead, she is being transferred to the new environment of a nursing home. 2 This is incorrect. Internal loss is another term for perceived or psychological loss, which the patient did not experience. The patient lost her home, which is an external loss. 3 This is incorrect. The patient experienced an actual loss, not a perceived loss. 4 This is incorrect. The patient experienced a physical loss, not a psychological loss. PTS: 1 CON: Grief and Loss 2. ANS: 3 Chapter: Chapter 17 Loss, Grief, & Dying Objective: Identify the stages of grief as described by major theorists. Page: 340 (V1) Heading: Table 17-1 Theories and Models of Grief Integrated Processes: Caring Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Evidence-Based Practice Difficulty: Easy Feedback 1 This is incorrect. Awareness is not the first response in the majority of grief theories and models. Awareness occurs later in the process. 2 This is incorrect. Adjustment is not the first response in the majority of grief theories and models. Adjustment occurs later in the process.

3 4

This is correct. Disbelief is the typical response in the initial stages of grief. It can also be called shock, denial, and numbness. This is incorrect. Confrontation is not the first response in the majority of grief theories and models. Confrontation occurs later in the process.

PTS: 1 CON: Evidence-Based Practice 3. ANS: 4 Chapter: Chapter 17 Loss, Grief, & Dying Objective: Identify the legal and ethical issues involved in death and dying. Page: 347 (V1) Heading: Legal and Ethical Considerations at End of Life > Assisted Suicide Integrated Processes: Caring Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Comprehension [Understanding] Concept: Comfort Difficulty: Moderate Feedback 1 This is incorrect. Palliative sedation is not assisted suicide, where the person assisting makes available the means for the patient to end his or her own life. Palliative sedation is continuous sedation until death. 2 This is incorrect. Palliative sedation is not involuntary euthanasia, the direct action of a person that ends the patient’s life without the patient’s consent (giving an overdose of medication). Palliative sedation is continuous sedation until death. 3 This is incorrect. The American Nurses Association does not enforce legalities of palliative sedation for terminally ill patients. 4 This is correct. Palliative sedation—controlled and monitored non-opioid and sedative medications to lower the patient’s level of consciousness to the extent necessary, for relief of awareness of refractory and unendurable symptoms—is advocated by the Hospice and Palliative Nurses Association. PTS: 1 CON: Comfort 4. ANS: 4 Chapter: Chapter 17 Loss, Grief, & Dying Objective: Identify the legal and ethical issues involved in death and dying. Page: 347 (V1) Heading: Legal and Ethical Considerations at End of Life > Assisted Suicide Integrated Processes: Caring Client Need: Psychosocial Integrity Cognitive Level: Comprehension [Understanding] Concept: Evidence-Based Practice Difficulty: Moderate

1 2 3 4

Feedback This is incorrect. Nurses cannot participate in assisted suicide regardless of state laws. This is incorrect. ANA opposes assisted suicide regardless of the policies of the employing agency. This is incorrect. ANA has taken a direct stand on the issue of assisted suicide, even if it contradicts a state law. This is correct. The American Nurses Association recognizes that assisted suicide is legal in a few states, but is opposed to the practice. Nurses are prohibited from participation in assisted suicide because it is a direct violation of the Code of Ethics.

PTS: 1 CON: Evidence-Based Practice 5. ANS: 2 Chapter: Chapter 17 Loss, Grief, & Dying Objective: List and discuss at least five factors that affect grieving. Page: 339 (V1) Heading: Factors Affecting Grief Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Grief and Loss Difficulty: Moderate Feedback 1 This is incorrect. Family of persons with chronic illnesses, such as advanced Parkinson’s disease, have usually had time to prepare emotionally for the death. 2 This is correct. Although it is impossible to predict with certainty and the grieving process is highly individual and personal, those who suffer a sudden loss typically have more difficult grieving than those who have had the time to prepare for the death. 3 This is incorrect. Although the death was painful, it was chronic, allowing the spouse time to grieve before the actual death. 4 This is incorrect. Family members and spouses of patients with chronic illnesses, such as chronic renal disease, have usually begun the grieving process before the death occurs. PTS: 1 CON: Grief and Loss 6. ANS: 4 Chapter: Chapter 17 Loss, Grief, & Dying Objective: Compare and contrast four types of grief. Page: 343 (V1) Heading: Types of Grief > Dysfunctional (Complicated Grief)

Integrated Processes: Caring Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Grief and Loss Difficulty: Moderate Feedback 1 This is incorrect. Delayed grief occurs when grief is put off until a later time. 2 This is incorrect. Uncomplicated grief is the natural response to a loss. The patient is exhibiting complicated grief, not uncomplicated. 3 This is incorrect. Disenfranchised grief is experienced when a loss is not socially supported. 4 This is correct. Masked grief occurs when the person is grieving, but it may look as though something else is occurring; in this case, the person is abusing alcohol. PTS: 1 CON: Grief and Loss 7. ANS: 3 Chapter: Chapter 17 Loss, Grief, & Dying Objective: Apply the nursing process in the care of dying patients and their families. Page: 345 (V1) Heading: What Are Coma and Persistent Vegetative State? Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Neurologic Regulation Difficulty: Moderate Feedback 1 This is incorrect. The patient in a PVS is not cognitively aware of the environment and has no cognitive or affective mental functions. 2 This is incorrect. The patient in a PVS cannot obey commands because the person does not purposefully respond to stimuli. 3 This is correct. A patient in a PVS may occasionally grimace, cry, or laugh. A patient in a PVS has lost the higher cerebral functions. 4 This is incorrect. A patient in PVS cannot speak, even though the patient may look somewhat normal. PTS: 1 CON: Neurologic Regulation 8. ANS: 2 Chapter: Chapter 17 Loss, Grief, & Dying Objective: Apply the nursing process in the care of dying patients and their families. Page: 349 (V1)

Heading: Helping Families of Dying Patients and Clinical Insight 17-2 Helping Families of Dying Patients Integrated Processes: Communication and Documentation Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Grief and Loss Difficulty: Moderate Feedback 1 This is incorrect. The nurse should not offer false reassurance by stating that the patient will most likely be fine until the wife’s return. 2 This is correct. The patient is exhibiting signs that typically occur days to a few hours before death. The nurse should provide information to the wife so she can make an informed decision about whether to leave her husband’s bedside. 3 This is incorrect. It is unrealistic for the nurse to stay with the patient until his wife returns. 4 This is incorrect. The issue for the family member is not trust in the competency of the healthcare provider but rather wanting to be present with her spouse at the time of death. The nurse would be minimizing the wife’s concern by telling her not to worry because her husband is in good hands. PTS: 1 CON: Grief and Loss 9. ANS: 3 Chapter: Chapter 17 Loss, Grief, & Dying Objective: Apply the nursing process in the care of dying patients and their families Page: 347 (V1) Heading: Palliative Care and Hospice Care Integrated Processes: Caring Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Grief and Loss Difficulty: Difficult Feedback 1 This is incorrect. Turning the patient to prevent skin breakdown and promote comfort is also important, but it does not take priority over controlling pain. 2 This is incorrect. The priority intervention for the hospice team is not sitting the patient in a chair. 3 This is correct. A priority intervention for the hospice team is administering pain medications to keep the patient comfortable. 4 This is incorrect. While food is important, frequent meals is not a priority. When the body begins to die, it becomes difficult for the body to digest food, especially meats. Anorexia develops which may be protective, as anorexia can diminish pain and increase the person’s sense of well-being.

PTS: 1 CON: Grief and Loss 10. ANS: 1 Chapter: Chapter 17 Loss, Grief, & Dying Objective: Identify the legal and ethical issues involved in death and dying. Page: 347 (V1) Heading: Advance Directives Integrated Processes: Caring Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Legal Difficulty: Moderate Feedback 1 This is correct. An advance directive is a group of instructions stating the patient’s healthcare wishes should he or she become unable to make decisions. 2 This is incorrect. Advance directive is not a document that helps ensure patients receive quality care. 3 This is incorrect. An informed consent form (not advance directives) verifies the patient’s understanding of risks and benefits associated with a procedure. 4 This is incorrect. An advance directive does not allow the patient to leave the hospital against medical advice nor does it release the hospital from responsibility for the patient. PTS: 1 CON: Legal 11. ANS: 4 Chapter: Chapter 17 Loss, Grief, & Dying Objective: Create a time line of the dying process, indicating the physiological signs and symptoms common to each stage. Page: 345 (V1) Heading: Physiological Stages of Dying > Days to Hours Before Death Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Grief and Loss Difficulty: Difficult Feedback 1 This is incorrect. Absence of heart activity is a sign of death, not impending death. 2 This is incorrect. Yellowish pallor occurs 1 to 2 weeks before death, not days to hours before death. 3 This is incorrect. Excessive urine output does not occur. Urine output decreases days to hours before death.

This is correct. Dry mucous membranes occur days to hours before death.

PTS: 1 CON: Grief and Loss 12. ANS: 3 Chapter: Chapter 17 Loss, Grief, & Dying Objective: Apply the nursing process in the care of dying patients and their families. Page: 350 (V1) Heading: Analysis/Diagnosis Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Grief and Loss Difficulty: Moderate Feedback 1 This is incorrect. The patient does not have Deficient Knowledge; the patient is experiencing indecision. 2 This is incorrect. The patient does not have Spiritual Distress (issues related to a higher being); the patient is exhibiting indecision about treatment options. 3 This is correct. This patient is experiencing Decisional Conflict related to his end-of-life treatment measures because he states that he cannot make up his mind, indicating indecision about treatment options. 4 This is incorrect. The patient does not have Complicated Grieving, which is repetitive use of ineffective coping behaviors or relieving of past experiences with little or no reduction in intensity of grief. PTS: 1 CON: Grief and Loss 13. ANS: 4 Chapter: Chapter 17 Loss, Grief, & Dying Objective: Apply the nursing process in the care of dying patients and their families. Page: 349 (V1) Heading: Planning Outcomes/Evaluation and Clinical Insight 17-2 Helping Families of Dying Patients Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Grief and Loss Difficulty: Moderate Feedback 1 This is incorrect. Family members should be encouraged to take care of themselves. They often need to be encouraged to take breaks to eat or rest. 2 This is incorrect. Nurses should follow up promptly (not weekly) with other healthcare team members to address family concerns.

This is incorrect. Nurses should provide family members with anticipatory guidance about the stages of death so that they know what to expect. It is inappropriate to avoid discussing the dying process. This is correct. The plan of care should include encouraging family members to help with the patient’s care when they are able.

PTS: 1 CON: Grief and Loss 14. ANS: 2 Chapter: Chapter 17 Loss, Grief, & Dying Objective: Apply the nursing process in the care of dying patients and their families. Page: 356 (V1) Heading: Clinical Insight 17-3 Caring for the Dying Person: Meeting Physiological Needs Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 This is incorrect. If a “death rattle” occurs, turn the patient to the side, not prone. 2 This is correct. If a “death rattle” occurs, turn the patient to the side, and elevate the head of the bed. 3 This is incorrect. IV fluids should be avoided; IV fluids can cause edema, nausea, and even pain in a patient who is actively dying. 4 This is incorrect. The patient may require IV pain medication to treat pain, but it does not help stop a “death rattle.” PTS: 1 CON: Oxygenation 15. ANS: 2 Chapter: Chapter 17 Loss, Grief, & Dying Objective: Apply the nursing process in the care of dying patients and their families. Page: 351 (V1) Heading: Planning Outcomes/Evaluation Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Grief and Loss Difficulty: Moderate Feedback 1 This is incorrect. The nurse should administer pain medication on a regular schedule to ensure satisfactory pain control; pain may not be controlled if medication is administered on an “as needed” basis. 2 This is correct. The most important goal is that the patient will report or

demonstrate satisfactory pain control. This is incorrect. Nonpharmacological measures can be a helpful adjunct in controlling pain, but they are not likely to be adequate for pain associated with cancer. This is incorrect. Effective pain-control medications are available and can be administered by several routes; it should be possible to control the pain.

PTS: 1 CON: Grief and Loss 16. ANS: 2 Chapter: Chapter 17 Loss, Grief, & Dying Objective: Describe the responsibilities of the nurse regarding postmortem care. Page: 351 (V1) Heading: Clinical Insight 17-5 Providing Postmortem Care Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Grief and Loss Difficulty: Moderate Feedback 1 This is incorrect. The nurse should place a pillow under the head and shoulders to prevent blood from settling there and causing discoloration. 2 This is correct. Rigor mortis develops 2 to 4 hours after death; therefore, the nurse should place dentures in the mouth and close the patient’s eyes and mouth before that time. 3 This is incorrect. Closing the patient’s mouth and tying a strip of soft gauze under the chin and around the head keeps the mouth set in a natural position for a viewing later. Closing the eyes after death creates a peaceful resting appearance when the body is later viewed but has nothing to do with setting the mouth. 4 This is incorrect. Placing dentures in the mouth and closing the eyes and mouth do not prevent discoloration in the facial area. PTS: 1 CON: Grief and Loss 17. ANS: 3 Chapter: Chapter 17 Loss, Grief, & Dying Objective: Describe the responsibilities of the nurse regarding postmortem care. Page: 351 (V1) Heading: Clinical Insight 17-5 Providing Postmortem Care Integrated Processes: Communication and Documentation Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Grief and Loss

Difficulty: Moderate Feedback 1 This is incorrect. The nurse should give the family as much time as they need with their loved one and take care to present the body in a restful pose. 2 This is incorrect. If family members are not present at the time of death, remove tubes and IV lines before they see the body, unless an autopsy is planned or the death is being investigated by the coroner. 3 This is correct. The nurse should express sympathy to the family immediately after the patient’s death. 4 This is incorrect. The body should not be removed from the patient care area until the family is ready. PTS: 1 CON: Grief and Loss 18. ANS: 3 Chapter: Chapter 17 Loss, Grief, & Dying Objective: Identify nursing interventions to help clients who are grieving. Page: 360 (V1) Heading: Self-Care Box > Helping Children Deal With Loss Integrated Processes: Caring Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Grief and Loss Difficulty: Moderate Feedback 1 This is incorrect. If the child is frightened about attending the funeral, he or she should not be forced to attend. 2 This is incorrect. Signs of regression are a normal reaction to the loss of a loved one, especially a parent, and should not lead to immediate notification of the physician. 3 This is correct. The nurse should advise the family to spend as much time as possible with the child. 4 This is incorrect. The child should be encouraged to express feelings and fears. PTS: 1 CON: Grief and Loss 19. ANS: 2 Chapter: Chapter 17 Loss, Grief, & Dying Objective: Apply the nursing process in the care of dying patients and their families. Page: 345 (V1) Heading: Psychological Stages of Dying > Key Point and Clinical Insight 17-4 Caring for the Dying Person: Meeting Psychological Needs Integrated Processes: Communication and Documentation Client Need: Psychosocial Integrity

Cognitive Level: Application [Applying] Concept: Grief and Loss Difficulty: Difficult Feedback 1 This is incorrect. Telling the patient that the physical signs indicate that death is imminent is inappropriate at this time since the patient is using denial as a coping mechanism. The exact time of death is not always predictable. Presenting reality is appropriate in certain circumstances earlier in the dying process, but not in this situation because it has already been tried with no change in the patient. 2 This is correct. “You seem very sure … Please tell me …. what you are feeling” repeat what the patient has said (indicating understanding) and encourage expression of feelings—both are supportive. Remember that it is not the nurse’s responsibility to move people to the next stage so that dying patients accept death. It is the nurse’s responsibility to accept and support people “where they are” and to help them verbalize their feelings. Nurses need to understand patients, not change them. 3 This is incorrect. Saying “It seems to me you would be feeling some anger …” is directed toward moving the patient from denial and suggesting something the patient has not yet expressed. This is not therapeutic. 4 This is incorrect. Saying “It would be best for your family …” presumes that the nurse knows more about what is “best” for the patient’s family more than the patient does. This statement is also judgmental and giving advice, both of which are nontherapeutic. PTS: 1 CON: Grief and Loss 20. ANS: 2 Chapter: Chapter 17 Loss, Grief, & Dying Objective: Apply the nursing process in the care of dying patients and their families. Page: 339 (V1) Heading: Assessment Guidelines and Tools > Box Assessing Grief and Loss > Differentiate between grief and depressive disorder Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Mood Difficulty: Difficult Feedback 1 This is incorrect. The patient is not exhibiting grief which tends to come and go or be triggered by a holiday. There is, of course, no “correct” time line for what constitutes “longer than usual” grieving; however, the patient’s symptoms are not typical of grief.

3 4

This is correct. The patient is likely experiencing a depressive disorder. The patient’s symptoms include unrelieved, overwhelming sadness; insomnia; difficulty carrying out activities of daily living (grooming and eating); and fatigue. Note that the sadness is pervasive, not created by a trigger event (holiday). Grief comes and goes; it is not constant. This is incorrect. The patient has not said he or she feels guilty or worthless, and there is nothing from which the nurse could infer that. This is incorrect. The patient has specifically said that it feels no worse now— that is, it has not been a trigger event.

PTS: 1 CON: Mood 21. ANS: 4 Chapter: Chapter 17 Loss, Grief, & Dying Objective: List and discuss at least five factors that affect grieving. Page: 338 (V1) Heading: What Is Grief? Integrated Processes: Teaching and Learning Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Grief and Loss Difficulty: Moderate Feedback 1 This is incorrect. One cannot say the patient needs counseling, as there is no evidence of dysfunctional grieving. 2 This is incorrect. Acknowledging a personal experience to make a point is helpful and sometimes useful; however, this is not the best answer and will not help the student learn the significance and meaningfulness of loss. 3 This is incorrect. Stating that as long as the patient is getting to other things in her life may be correct; however, this does not fully answer the student’s question and is not the most appropriate response. 4 This is correct. It is almost impossible to determine the appropriate amount of time needed for grieving and mourning a loss. Much is determined by the meaning of the loss and how significant the loss is to one’s life. The best answer is to acknowledge that all people will grieve differently depending on the meaning of that loss. PTS: 1 CON: Grief and Loss 22. ANS: 3 Chapter: Chapter 17 Loss, Grief, & Dying Objective: Identify the legal and ethical issues involved in death and dying. Page: 348 (V1) Heading: Prescriptions for DNR/DNAR

Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Grief and Loss Difficulty: Moderate Feedback 1 This is incorrect. There is a difference between a DNAR and an AND order. They are not synonymous. 2 This is incorrect. Both DNAR and an AND orders relate to no resuscitation attempts in the event of cardiac or respiratory failure. “AND” stands for allow natural death. 3 This is correct. The acronym “AND” stands for allow natural death and is being recommended to replace the term do not resuscitate (DNR) and do not attempt to resuscitate (DNAR) because “AND” contains the word death, so the intent of the provider’s order is clear. 4 This is incorrect. Usually a DNR, DNAR, and an AND order do not provide explicit instructions for hydration and feeding, as this is usually written as part of an advance directive/living will. PTS: 1 CON: Grief and Loss 23. ANS: 1 Chapter: Chapter 17 Loss, Grief, & Dying Objective: Apply the nursing process in the care of dying patients and their families. Page: 359 (V1) Heading: Taking Care of Yourself Integrated Processes: Caring Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Grief and Loss Difficulty: Moderate Feedback 1 This is correct. If the nurse wishes to do so, it is appropriate to attend calling hours or attend funeral services. This often helps a nurse to diffuse some of his or her own feelings associated with the loss and is very meaningful to family members. It acknowledges that a nurse took the time to remember them and their loved one. 2 This is incorrect. One can ask another nurse for an opinion; however, this is not necessary as it is perfectly acceptable for a nurse to attend services. 3 This is incorrect. It is perfectly acceptable to attend calling hours and/or the funeral. 4 This is incorrect. There is no recommended “time frame” for how long a nurse should be in attendance at a service. This is at the discretion of the nurse.

PTS: 1 CON: Grief and Loss 24. ANS: 3 Chapter: Chapter 17 Loss, Grief, & Dying Objective: Identify nursing interventions to help clients who are grieving. Page: 359 (V1) Heading: Therapeutic Communication and Clinical Insight 17-1 Communicating With People Who Are Grieving Integrated Processes: Communication and Documentation Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Grief and Loss Difficulty: Difficult Feedback 1 This is incorrect. While death is a part of life, this is belittling the patient’s feelings and telling a patient how he or she will feel in time is inappropriate. 2 This is incorrect. The nurse should not push own religious views onto the patient (God does not punish people). Patients need to be able to express their feelings and have reassurance that their feelings are normal and not “wrong.” 3 This is correct. Reassure the patient that it is not wrong or bad to feel anger, guilt, relief, or other feelings he or she may believe are unacceptable. Patients need to feel that their feelings are not wrong and that they are going through a difficult time and a normal process. It is further helpful to allow the patient to express these feelings by asking patients how they are feeling. 4 This is incorrect. Letting patients know their feelings are not good for them is judgmental and incorrect. Nurses allow patients to express their feelings. In this situation the nurse changed the subject, which is nontherapeutic. PTS: 1 CON: Grief and Loss 25. ANS: 4 Chapter: Chapter 17 Loss, Grief, & Dying Objective: Define death according to the Uniform Determination of Death Act. Page: 344 (V1) Heading: Death and Dying > How is Death Defined? and Box 17-1 Uniform Determination of Death Act Integrated Processes: Caring Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Legal Difficulty: Moderate Feedback 1 This is incorrect. The Uniform Determination of Death Act includes the

3 4

irreversible cessation of circulatory and respiratory functions, not cessation of blood flow to vital organs. Cessation of blood flow (circulation) can be reversed with cardiopulmonary resuscitation. This is incorrect. The Uniform Determination of Death Act includes the irreversible cessation of circulatory and respiratory functions, not cessation of spontaneous respirations. Cessation of spontaneous respirations (breathing) can be reversed with cardiopulmonary resuscitation. This is incorrect. The Uniform Determination of Death Act includes not only the irreversible cessation of higher brain functions but that of the brain stem, too. This is correct. Irreversible cessation of all functions of the entire brain, including the brain stem, is one component of the Uniform Determination of Death Act. The other component is irreversible cessation of circulatory and respiratory functions.

PTS: 1 CON: Legal 26. ANS: 2 Chapter: Chapter 17 Loss, Grief, & Dying Objective: Identify nursing interventions to help clients who are grieving. Page: 343 (V1) Heading: Developmental Stages and Grief > Adolescence Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Grief and Loss Difficulty: Moderate Feedback 1 This is incorrect. Excessive crying is an expected behavior and is not a highpriority behavior. 2 This is correct. Research shows that bereaved youths who have lost a parent have a high frequency of engaging in health risk behaviors. The nurse must be alert to these behaviors and make appropriate interventions as these are of the highest priority. 3 This is incorrect. Not doing homework is an expected behavior. There is another behavior that is more high priority. 4 This is incorrect. Adolescents may distance themselves from friends during a recent loss of a parent but there is another behavior that is more high priority. PTS: 1 CON: Grief and Loss 27. ANS: 3 Chapter: Chapter 17 Loss, Grief, & Dying Objective: Identify the legal and ethical issues involved in death and dying. Page: 353 (V1)

Heading: Legal and Ethical Considerations at End of Life > Organ Donation Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Ethics Difficulty: Difficult Feedback 1 This is incorrect. Many states issue identification cards or allow driver’s licenses to be amended to identify a person as an organ donor. However, even though donor cards are legal in all states, many institutions will not procure organs from the deceased if there is strong family objection. 2 This is incorrect. According to the Uniform Anatomical Gift Act, relatives cannot revoke a person’s donation, even after death. 3 This is correct. Until a resolution is made maintaining the viability of the organs has the highest priority. A conflict between a potential organ donor’s wishes, advance directive, and measures to ensure viability of the organs must be resolved as soon as possible by checking with the donor (if possible), the surrogate decision maker, or another person as authorized under state law. 4 This is incorrect. Contacting the primary care provider is not the priority action, as the patient has the first right to the decision, then a surrogate decision maker, or last, another person as authorized under state law. PTS:

CON: Ethics

MULTIPLE RESPONSE 28. ANS: 3, 4 Chapter: Chapter 17 Loss, Grief, & Dying Objective: Define end-of-life care, hospice care, and palliative care. Page: 347 (V1) Heading: What Is End-of-Life Care? > Palliative Care Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Grief and Loss Difficulty: Moderate

Feedback This is incorrect. Surgically inserting a device to decrease heart workload is an aggressive treatment measure, not palliative care. Palliative care focuses on relieving symptoms for clients whose disease process no longer responds to treatment. This is incorrect. Administering dopamine is an aggressive treatment measure, not

palliative care. Palliative care focuses on relieving symptoms for clients whose disease process no longer responds to treatment. This is correct. Providing moisturizing eye drops to an unconscious client whose eyes are dry is palliative care. Palliative care focuses on relieving symptoms for clients whose disease process no longer responds to treatment. This is correct. Administering antinausea medication to a client with end-stage leukemia is an example of palliative care. Palliative care focuses on relieving symptoms for clients whose disease process no longer responds to treatment. This is incorrect. Palliative care involves administering pain medication (not withholding) to help make terminally ill clients comfortable. Withholding pain medication is unethical and inappropriate.

PTS: 1 CON: Grief and Loss 29. ANS: 1, 4 Chapter: Chapter 17 Loss, Grief, & Dying Objective: Define end-of-life care, hospice care, and palliative care. Page: 347 (V1) Heading: What Is End-of-Life Care? > Hospice Care Integrated Processes: Caring Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Knowledge [Remembering] Concept: Health Care Systems Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is correct. For a patient to be eligible for hospice care insurance benefits, a physician must certify that the patient will most likely die within 6 months. This is incorrect. Twelve months is too long of a time period. Hospice care is less than 12 months. This is incorrect. For hospice care, the condition cannot improve, not even slightly. This is correct. For a patient to be eligible for hospice care insurance benefits, a physician must certify that the condition will not improve. This is incorrect. A severe, long-term condition does not qualify for hospice care. Hospice care focuses on holistic care of patients who are dying or debilitated and not expected to improve.

PTS: 1 CON: Health Care Systems 30. ANS: 2, 3, 4 Chapter: Chapter 17 Loss, Grief, & Dying Objective: Identify nursing interventions to help clients who are grieving. Page: 342 (V1) Heading: Self-Care Box Helping Children Deal With Loss > Childhood

Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Grief and Loss Difficulty: Moderate

2. 3. 4. 5.

Feedback This is incorrect. A warning sign would be a loss of interest in daily activities, not interested in usual activities. Remaining interested in usual activities is a sign of coping. This is correct. A warning sign in children is extended regression. This is correct. Withdrawal from friends is a warning sign in children. This is correct. A warning sign in children is inability to sleep. This is incorrect. Intermittent expressions of sadness and anger are to be expected, even over a long period of time, so this would not indicate a need for professional help.

PTS: 1 CON: Grief and Loss 31. ANS: 2, 3, 5 Chapter: Chapter 17 Loss, Grief, & Dying Objective: Describe the responsibilities of the nurse regarding postmortem care. Page: 349 (V1) Heading: Legal and Ethical Considerations at End of Life >Autopsy and Clinical Insight 17-5 Providing Postmortem Care Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Legal Difficulty: Moderate

2. 3. 4.

Feedback This is incorrect. An autopsy requires signed permission from the next of kin, except in cases in which an autopsy is required by law (e.g., a suspicious or unwitnessed death). This is correct. Legal responsibilities when a death has occurred includes reviewing and making any necessary arrangements for organ donation. This is correct. The person who pronounces death must sign the death certificate. This is incorrect. Postmortem care is usually provided by the nurse; however, this is often per agency policy. There is no law about family members’ participation in postmortem care; in fact, family members are encouraged if they choose to participate in postmortem care. This is correct. By law, there are special preparations to perform when the patient

has died of a communicable disease. PTS: 1 CON: Legal 32. ANS: 3, 4, 5 Chapter: Chapter 17 Loss, Grief, & Dying Objective: Identify the legal and ethical issues involved in death and dying. Page: 348 (V1) Heading: Prescriptions for DNR/DNAR and Box 17-2 Highlights of ANA Recommendations Concerning DNR/AND Integrated Processes: Caring Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Evidence-Based Practice Difficulty: Moderate

2. 3. 4.

Feedback This is incorrect. A DNAR does not mean to discontinue care or provide substandard care. There is nothing written by the ANA to address removal of a feeding tube when a DNAR is written. This is incorrect. The ANA recommends that nurses have a responsibility to avoid participation in “slow codes” or “partial codes.” This is correct. Nurses should be aware of and have an active role in developing DNR policies in the institutions where they work. This is correct. The competent patient’s choices have highest priority when there is conflict. If the patient is not competent, highest priority is given to the advance directive or surrogate decision makers. This is correct. Nurse have a duty to advocate for a patient’s end-of-life preferences to be honored above the family’s.

PTS: 1 CON: Evidence-Based Practice 33. ANS: 2, 3, 4 Chapter: Chapter 17 Loss, Grief, & Dying Objective: Apply the nursing process in the care of dying patients and their families. Page: 359 (V1) Heading: Taking Care of Yourself Integrated Processes: Caring Client Need: Psychosocial Integrity Cognitive Level: Comprehension [Understanding] Concept: Grief and Loss Difficulty: Moderate Feedback

2. 3. 4.

This is incorrect. When nurses become involved with dying persons and their families at such an intimate time in their lives, nurses become connected to them. There is nothing wrong with this emotional involvement; it helps nurses be effective in their work. This is correct. Nurses should talk with other colleagues about feelings. Don’t be afraid to ask for what is needed. This is correct. When away from work, do some nice things, like taking time for relaxing and a little “pampering” (e.g., a bubble bath or a massage). This is correct. When caring for dying patients, nurses will confront their own feelings of mortality. It is important to understand your own attitudes, fears, and beliefs concerning death, so think about these before you encounter dying patients. This is incorrect. Suppressing feelings associated with death of patients can take a heavy toll on nurses emotionally. There is nothing wrong with grieving.

PTS: 1 CON: Grief and Loss 34. ANS: 1, 2, 5 Chapter: Chapter 17 Loss, Grief, & Dying Objective: Apply the nursing process in the care of dying patients and their families. Page: 357 (V1) Heading: Care for the Dying Person > Addressing Spiritual Needs Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Spirituality Difficulty: Moderate

2. 3. 4. 5.

Feedback This is correct. One way to address spirituality needs is to be an empathetic listener. Some cultures may emphasize keeping emotions more subdued and limiting expressions of grief to private settings, whereas others gauge the value of the deceased by the amount of crying that occurs. This is correct. One way to address spirituality needs is to allow special, spiritual rituals. This is incorrect. Nurses cannot assume that all persons will engage in intense crying or wailing. This is incorrect. Only contact pastoral care or clergy, if the person asks for them, not before. This is correct. One way to address spirituality needs is to provide time for meditation, if so requested.

PTS: 1 35. ANS: 2, 4

CON: Spirituality

Chapter: Chapter 17 Loss, Grief, & Dying Objective: List and describe the models and theories of grief and bereavement. Page: 358 (V1) Heading: Psychological Stages of Dying and Table 17-1 Theories and Models of Grief Integrated Processes: Caring Client Need: Psychosocial Integrity Cognitive Level: Comprehension [Understanding] Concept: Evidence-Based Practice Difficulty: Moderate

1. 2.

4. 5.

Feedback This is incorrect. The theory states that a person may not go through every stage, not that a patient must pass through each of the five stages. This is correct. Kübler-Ross found that people tend to experience one or more of five psychological stages during the period from the terminal diagnosis to the actual death. This is incorrect. Kübler-Ross does not address the nurse’s specific role; however, it should be noted that as nurses, it is not our responsibility to move people to the next stage so that the dying patient accepts death. It is the nurse’s responsibility to accept and support people “where they are” and help them to verbalize their feelings. This is correct. Kübler-Ross’s theory states that patients may experience two or three stages simultaneously. This is incorrect. Kübler-Ross’s theory states that patients do not necessarily complete one stage and move on to the next; it can be in random order, not in sequence.

PTS:

CON: Evidence-Based Practice

Chapter 18. Documenting & Reporting Multiple Choice Identify the choice that best completes the statement or answers the question. 1. A client admitted to the inpatient medical-surgical unit has suffered sudden respiratory failure. The client’s condition is getting worse; the client is cyanotic (turning blue) with periods of labored breathing. Which action should the nurse take first? 1. Study the discharge plan. 2. Check the progress notes for vital signs. 3. Examine the history and physical examination. 4. Look for an advance directive. 2. A hospital uses a source-oriented medical record. What is a major disadvantage of this charting system? 1. It involves a cooperative effort among various disciplines. 2. The system requires diligence in maintaining a current problem list. 3. Data may be fragmented and scattered throughout the chart. 4. Oversights of care may result from disagreement over what constitutes a significant variation. 3. A student nurse makes the following comments to the preceptor: “I love getting information from the chart. Everything related to the patient’s problem is together and addressed by various members of the healthcare team.” The student nurse has been introduced to which type of charting system? 1. Narrative 2. Focus 3. Source-oriented 4. Problem-oriented 4. The department of nursing at a local hospital is considering changing to charting by exception (CBE). Which example would be a major disadvantage of CBE? 1. Increases the time nurses spend on charting in narrative format 2. Does not clearly identify deviations from normal expectations 3. Requires all providers to document in the same sections of the chart 4. Can increase the risk of omissions in client care 5. Which prescription would the nurse question since it is inconsistent with the standards established by The Joint Commission? 1. Administer Lasix 20 mg PO daily at 1000. 2. Administer Lasix 10.0 mg PO daily at 1000. 3. Administer digoxin 10 mg PO daily at 1000. 4. Administer digoxin 0.3 mg IV daily at 1000.

6. A patient with a history of hypertension and rheumatoid arthritis is admitted for surgery, a colon resection, for colon cancer. Which integrated plan of care (IPOC) would be priority for the nurse to implement? 1. Hypertension 2. Rheumatoid arthritis 3. Postoperative colon resection 4. Diabetes mellitus 7. The nurse notifies the primary care provider that the patient is experiencing pain. The provider gives the nurse a telephone prescription for morphine 4 mg intravenously every hour as needed for pain. How should the nurse document this telephone order? 1. 09/02/19 0845 morphine 4 mg intravenously q 1 hour prn pain. Kay Andrews, RN 2. 09/02/19 0845 morphine 4 mg intravenously q 1 hour prn pain. TO Dr. D. Kelly/Kay Andrews, RN 3. 09/02/19 0845 morphine 4 mg intravenously q 1 hour prn pain. VO Dr. D. Kelly/Kay Andrews, RN 4. 09/02/19 0845 morphine 4 mg intravenously q 1 hour prn pain. VO Kay Andrews, RN 8. A patient refuses a dose of medication. How should the nurse document the event? 1. Patient is uncooperative and refuses the prescribed dose of digoxin. 2. Patient refuses the 0900 dose of digoxin. 3. Patient is belligerent, argumentative, and refuses the 0900 dose of digoxin. 4. 0900 dose of digoxin not given. 9. At 1000 on 11/14/19, the nurse takes a telephone prescription for “metoprolol 5 mg intravenously now.” What is the latest date and time the nurse will expect the prescriber to countersign the order? 1. 11/14/19 at 1200 2. 11/14/19 at 2200 3. 11/15/19 at 1000 4. 11/16/19 at 1000 10. The nurse takes a telephone order from a primary care provider for 40 mEq potassium chloride in 100 mL of sterile water for injection to be infused over 4 hours. Which action must the nurse take to ensure the accuracy of the order? 1. Repeat the order to the prescriber, even if the nurse believes the order was understood correctly. 2. Immediately notify the pharmacy of the order, and verify it with a pharmacist. 3. Ask the unit secretary to listen to the prescriber on the phone to verify the order. 4. Transcribe the order on notepaper, and verify the dosage in a drug handbook. 11. A resident being admitted to a long-term care facility is unable to provide self-care due to dementia and is receiving Medicare funds. At which time must the Resident Assessment and Care Screening be completed? 1. Within 2 weeks

2. Each shift 3. Every week 4. When the provider orders it 12. Which charting entry would the nurse use for the “A” in SOAP charting? 1. Intractable pain 2. “I can’t get any relief from this pain in my abdomen.” 3. Holding abdomen and moaning 4. Notified provider to change pain medication. 13. A client is admitted to a long-term care facility. The nurse would use which form to follow federal law? 1. The Minimum Data Set (MDS) for assessment 2. Situation-Background-Assessment-Recommendation (SBAR) for reporting 3. Health Care Financing Administration (HCFA) guidelines prior to surgery 4. The Joint Commission guidelines for discharge planning 14. The surgeon enters a computerized order for a patient in the postoperative period after a unilateral thoracotomy for lung cancer. The order states: OOB in AM. Which action indicates the nurse is following the surgeon’s order? 1. Performs oral care 2. Assists the patient out of bed 3. Helps the patient with bathing 4. Changes the patient’s operative dressings 15. Which instruction by a registered nurse should the student nurse clarify with the clinical instructor about transcribing the provider’s orders? 1. “Write drug names in full—rather than using abbreviations.” 2. “Use apothecary units—instead of metric units.” 3. “Use ‘at’ or ‘each’—rather than use the ‘@’symbol.” 4. “Write ‘mL’ or ‘milliliters’—in place of the ‘cc’ abbreviation.” 16. The nursing instructor is teaching the student about occurrence reports. Which statement by the student indicates correct understanding of the purpose of occurrence reports? 1. “These reports track problems and identify areas for quality improvement.” 2. “These reports are required by the Food and Drug Administration (FDA) to report drug errors.” 3. “These reports are required by The Joint Commission for all client falls.” 4. “These reports provide legal information should the patient seek legal action after an unusual occurrence.” 17. Which aspect is the most beneficial for electronic documentation systems when compared with written documentation systems? 1. Assists collaboration 2. Provides different terminology

3. Improves legibility 4. Serves as a resource 18. The unlicensed assistive personnel (UAP) informs the nurse that a patient has fallen out of bed and is in pain. The nurse assesses the patient and provides care. Identify the correct documentation of the fall. 1. Patient found on floor after falling out of bed and verbalizes (L) hip pain. 2. Patient found on floor by UAP Smith and verbalizing (L) hip pain. 3. Patient fell out of bed but is currently in bed. 4. Patient reminded not to climb OOB after falling. 19. Which set of topics makes up a handoff report given in a recommended format? 1. Data-action-response (DAR) 2. Subjective-objective-assessment-plan (SOAP) 3. Situation-background-assessment-recommendation (SBAR) 4. Flowsheets-assessment-concise-timely (FACT) 20. What is one advantage of problem-intervention-evaluation (PIE) charting? 1. Focuses on a complete list of client problems 2. Assesses the client in a comprehensive manner 3. Documents the planning portion of the client’s care 4. Establishes an ongoing plan of care for the client 21. A client is admitted to the birthing unit to rule out preterm labor. The nurse charts only abnormal findings. Which type of charting is the nurse using? 1. Narrative charting 2. Charting by inclusion 3. Charting by exception 4. Source-oriented charting 22. At the end of a 12-hour shift, the nurse gives a verbal report to the oncoming nurse. This face-toface reporting, using the acronym “CUBAN,” does which of the following? 1. Ensures that the nurse is able to finish the shift as quickly as possible 2. Provides a guide for the nurse’s report to the oncoming nurse 3. Requires the nurses to engage in walking rounds for the report 4. Offers a detailed cultural report on Latino patients 23. The instructor is teaching the nursing students about electronic health records (EHRs). Which student statement indicates the need for further instruction? 1. “I have had EHR instruction and understand the basics of the system. If I need assistance, I will ask for it.” 2. “The EHR integrates the patient’s health information documented by the entire healthcare team into one electronic system.” 3. “The EHR can track problems and errors, which can direct quality improvement efforts in a given institution.”

4. “I am proficient with a computer; therefore, I am completely prepared to use the EHR in any institution.” 24. A medical provider has prescribed milk of magnesia (magnesium hydroxide) 30 mL, PO bid. What does bid mean? 1. Once every day 2. Two times every day 3. Three times every day 4. Four times a day 25. Why might a healthcare provider choose narrative charting instead of using forms or checklists? 1. Narrative charting tracks the client’s changing health status as it occurs. 2. Free form documentation is inconsistent among healthcare providers. 3. Less charting time by healthcare provider is needed for narrative charting. 4. Less interdisciplinary discussion occurs with the narrative style of charting. Multiple Response Identify one or more choices that best complete the statement or answer the question. 26. Which statements by the student nurse indicates a correct understanding of the nursing Kardex? Select all that apply. 1. “It pulls data from multiple areas of the patient’s chart.” 2. “It is usually kept at the patient’s bedside.” 3. “It is used to document patient response to interventions.” 4. “It summarizes the plan of care and guides nursing care.” 5. “It is a component of the patient’s permanent health record.” 27. Which actions by the nurse breach patient confidentiality? Select all that apply. 1. Leaving patient data displayed on a computer screen where others may view it 2. Remaining logged on to the computer system after documenting patient care 3. Faxing a patient report to the nurses’ station where the patient is being transferred 4. Informing the nurse manager of a change in the patient’s condition 5. Accessing records of patients assigned to the nurse 28. Which statements by the new graduate nurse indicate a need for further instruction about documentation? Select all that apply. 1. “I can wait until the end of the shift to document my care.” 2. “Charting every 2 hours is the most appropriate way to document nursing care.” 3. “I find it easier to chart before I go to lunch and then after my shift report.” 4. “I should chart as soon as possible after nursing care is given.” 5. “Charting after performing an intervention is acceptable.” 29. The implementation of electronic health records (EHRs) allows the nurse to carry out which actions? Select all that apply.

1. 2. 3. 4. 5.

Use data to facilitate evidence-based nursing practice. Promote efficient use of time spent charting. Reduce the opportunity for interdisciplinary collaboration. Activate the system’s safeguards to improve quality of care. Access patient information at the same time as other team members.

30. In performing a handoff report, the nurse should communicate information on which parameters? Select all that apply. 1. Teaching performed 2. Any change in client status 3. Treatments administered 4. Hygiene measures performed 5. Insurance status 31. Which points regarding discharge summaries must the nurse remember? Select all that apply. 1. The discharge summary is important because clients require follow-up care. 2. A complete discharge summary is a guide for healthcare professionals in the community. 3. The nurse can give a verbal transfer report, which is the same as a discharge summary. 4. The discharge summary is the final note in the client’s paper record. 5. A complete discharge summary must be handwritten using the narrative note format. 32. The nurse is administering the 0900 dose of heparin (an anticoagulant) 5,000 units subcutaneously ordered every 6 hours to a patient with deep vein thrombosis (DVT). At 0800, the patient’s laboratory values show partial thromboplastin time (PTT) and clotting times are four times the normal range (excessively elevated). The nurse observes bruising on the patient’s buttocks and back and recognizes these as signs of risk for significant bleeding. Which actions would the nurse take? Select all that apply. 1. Notify the prescriber. 2. Give subcutaneous heparin, as ordered. 3. Hold the medication dose at this time. 4. Chart the reason the medication was not given. 5. Record abnormal findings in the patient’s health record. 33. The electronic health record (EHR) is used to document client care. Which purposes are applicable to the EHR? Select all that apply. 1. Is a legal record 2. Is used for utilization review 3. Provides continuity of care 4. Is used for quality improvement 5. Acts as an occurrence report

Chapter 18. Documenting & Reporting Answer Section MULTIPLE CHOICE 1. ANS: 4 Chapter: Chapter 18 Documenting & Reporting Objective: Identify a variety of charting formats and their purposes. Page: 365 (V1) Heading: How Are Health Records Systems Organized? > Source-Oriented Record Systems Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Communication Difficulty: Easy Feedback 1 This is incorrect. The discharge plan contains data from utilization review, case managers, or discharge planners on anticipated needs after discharge. This is not the first action the nurse should take. 2 This is incorrect. Progress notes are chronological documentation by healthcare team members including client exams, problem identification, and response to therapy. Graphic data records, not progress notes, contain the vital signs. 3 This is incorrect. The history and physical examination provide a detailed summary of the client’s current problem, past medical and social history, medications taken by the client, review of systems, and physical examination data. This is not the first action the nurse should take. 4 This is correct. The advance directive, which should be located in a special section of the client’s medical record, should be examined first because the client’s symptoms indicate that resuscitation may be needed. The advance directive contains information about the client’s wishes for intensity of care and actions that should be taken in the event of a life-threatening event. PTS: 1 CON: Communication 2. ANS: 3 Chapter: Chapter 18 Documenting & Reporting Objective: Identify a variety of charting formats and their purposes. Page: 365 (V1) Heading: How Are Health Records Systems Organized? > Source-Oriented Record Systems Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Knowledge [Remembering] Concept: Communication

Difficulty: Moderate Feedback 1 This is incorrect. The problem-oriented (not source-oriented) medical record requires a cooperative effort among disciplines. 2 This is incorrect. The problem-oriented (not source-oriented) medical record requires diligence in maintaining a current problem list. 3 This is correct. A major disadvantage of a source-oriented medical record is that data may be fragmented and scattered throughout the chart. 4 This is incorrect. Charting by exception (not source-oriented) medical record can result in omissions from disagreement over what constitutes a significant variation. PTS: 1 CON: Communication 3. ANS: 4 Chapter: Chapter 18 Documenting & Reporting Objective: Identify a variety of charting formats and their purposes. Page: 365 (V1) Heading: How Are Health Records Systems Organized? > Problem-Oriented Record (POR) Systems Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Communication Difficulty: Moderate Feedback 1 This is incorrect. Narrative charting is a free text description of the patient status and nursing care, not usually organized according to patient problems. 2 This is incorrect. Focus charting highlights the patient’s concerns, problems, and strengths in a three-column format. 3 This is incorrect. Source-oriented record systems require members of each discipline to record their findings in a separately labeled section of the chart. 4 This is correct. A problem-oriented record system is organized around the patient’s problems and each member of the healthcare team document in the area designated for that problem. This method makes it easier to view the patient’s progress and integrate the interdisciplinary perspective. PTS: 1 CON: Communication 4. ANS: 4 Chapter: Chapter 18 Documenting & Reporting Objective: Identify a variety of charting formats and their purposes. Page: 365 (V1) Heading: How Are Health Records Systems Organized? > Charting by Exception

Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Communication Difficulty: Moderate Feedback 1 This is incorrect. CBE reduces the amount of time spent in charting because if nurses document only deviations from the normal CBE, then it is assumed that unless a separate entry is made, all standards have been met with a normal response. 2 This is incorrect. CBE clearly identifies deviations from normal expectations. 3 This is incorrect. Problem-oriented charting requires all providers to document in the same sections of the chart; CBE does not. 4 This is correct. A major disadvantage of CBE is that it can result in omissions in documenting client care because of either varying views of what is abnormal or deviations. Another disadvantage is that is does not capture the application of critical thinking by the nurse in the provision of care. PTS: 1 CON: Communication 5. ANS: 2 Chapter: Chapter 18 Documenting & Reporting Objective: Identify approved abbreviations to use in documenting in clinical environments. Page: 370 (V1) Heading: What Are Some Common Formats for Nursing Progress Notes? > Use of Abbreviations and Table 18-1 Joint Commission “Do Not Use” List Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Communication Difficulty: Moderate Feedback 1 This is incorrect. The nurse would not question this order because it is consistent (not inconsistent) with the standards established by The Joint Commission. The word daily should be written out instead of using qd or q.d. 2 This is correct. The nurse would question this order because it is inconsistent with the standards by The Joint Commission. The Joint Commission recommends that certain words are written out instead of using symbols and abbreviations to minimize the risk of medication errors. The trailing zero should not be used in medication prescriptions; thus, 10.0 mg is incorrect. It should be correctly written as 10 mg. 3 This is incorrect. The nurse would not question this order because it is consistent (not inconsistent) with the standards established by The Joint Commission. The

order is correctly written. This is incorrect. The nurse would not question this order because it is consistent (not inconsistent) with the standards established by The Joint Commission. The Joint Commission does not support the lack of a leading zero; thus, 0.3 mg is correctly written.

PTS: 1 CON: Communication 6. ANS: 3 Chapter: Chapter 18 Documenting & Reporting Objective: Follow documentation guidelines to accurately record client health status, nursing interventions, and client outcomes in written and electronic formats. Page: 370 (V1) Heading: What Forms Do Nurses Use to Document Nursing Care? > Integrated Plan of Care Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Leadership and Management Difficulty: Difficult Feedback 1 This is incorrect. While the patient does have hypertension, it is not the priority IPOC the nurse should use. 2 This is incorrect. While the patient does have rheumatoid arthritis, it is not the priority IPOC the nurse should use. 3 This is correct. The postoperative colon resection integrated plan of care should be followed; however, modifications should be made to meet the patient’s other health needs. 4 This is incorrect. The patient’s scenario does not have any mention of diabetes mellitus, so this IPOC should not be used. PTS: 1 CON: Leadership and Management 7. ANS: 2 Chapter: Chapter 18 Documenting & Reporting Objective: Follow documentation guidelines to accurately record client health status, nursing interventions, and client outcomes in written and electronic formats. Page: 383 (V1) Heading: Clinical Insight 18-2 Receiving Telephone and Verbal Prescriptions Integrated Processes: Communication and Documentation Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback

1 2

3 4

This is incorrect. The nurse must include TO and the primary provider’s name. This is correct. Correct documentation of a telephone order is as follows: “09/02/19 0845 morphine 4 mg intravenously q 1 hour prn pain TO Dr. D. Kelly/Kay Andrews, RN” (date, time, medication, route, frequency of dose, circumstances under which it is to be given, prescriber’s name and title, nurses name and title.) This is incorrect. VO stands for verbal order, not telephone order (TO). This is incorrect. The nurse should not include VO in front of the nurse’s name. VO stands for verbal order.

PTS: 1 CON: Safety 8. ANS: 2 Chapter: Chapter 18 Documenting & Reporting Objective: Follow documentation guidelines to accurately record client health status, nursing interventions, and client outcomes in written and electronic formats. Page: 385 (V1) Heading: Charting Additional Information About Medications and Clinical Insight 18-3 Guidelines for Documentation Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Communication Difficulty: Moderate Feedback 1 This is incorrect. “Uncooperative” is judgmental and is an example of subjective charting, which should be avoided. 2 This is correct. “Patient refuses the 0900 dose of digoxin” objectively describes the event in which the patient refuses to take the 0900 dose of digoxin. 3 This is incorrect. “Belligerent and argumentative” is judgmental and is an example of subjective charting, which should be avoided. 4 This is incorrect. “0900 dose of digoxin not given” provides no explanation why the medication was not given. PTS: 1 CON: Communication 9. ANS: 3 Chapter: Chapter 18 Documenting & Reporting Objective: Follow documentation guidelines to accurately record client health status, nursing interventions, and client outcomes in written and electronic formats. Page: 384 (V1) Heading: Clinical Insight 18-2 Receiving Telephone and Verbal Prescriptions Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care

Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. This is not the latest date and time, but it is an acceptable time frame to sign the order. 2 This is incorrect. This is not the latest date and time, but it is an acceptable time frame to sign the order. 3 This is correct. This is the latest date and time for the prescriber to countersign the order. The prescriber must countersign all verbal and telephone orders within 24 hours. 4 This is incorrect. This is too long of a time frame for the provider to sign the orders. PTS: 1 CON: Safety 10. ANS: 1 Chapter: Chapter 18 Documenting & Reporting Objective: Follow documentation guidelines to accurately record client health status, nursing interventions, and client outcomes in written and electronic formats. Page: 384 (V1) Heading: Clinical Insight 18-2 Receiving Telephone and Verbal Prescriptions Integrated Processes: Communication and Documentation Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 This is correct. The nurse should repeat the order to the prescriber, even if he or she believes the order was understood entirely. 2 This is incorrect. Only the prescribing provider, not the pharmacist, can verify the order. 3 This is incorrect. If possible, the nurse should have a second nurse (not the unit secretary) listen to the order to verify accuracy. 4 This is incorrect. The nurse should transcribe the order directly on the patient’s chart. Transcribing it on a piece of paper and then copying it again introduces one more chance of error. PTS: 1 CON: Safety 11. ANS: 1 Chapter: Chapter 18 Documenting & Reporting Objective: Identify a variety of charting formats and their purposes. Page: 374 (V1)

Heading: What Is Unique About Documentation in Long-Term Care? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Knowledge [Remembering] Concept: Legal Difficulty: Moderate Feedback 1 This is correct. Federal law requires that a resident be evaluated using the Minimum Data Set (MDS) for Resident Assessment and Care Screening within 14 days of admission. 2 This is incorrect. Every shift is too often. 3 This is incorrect. Every week is too often. 4 This is incorrect. The Minimum Data Set time line is set by law, not by the provider. PTS: 1 CON: Legal 12. ANS: 1 Chapter: Chapter 18 Documenting & Reporting Objective: Follow documentation guidelines to accurately record client health status, nursing interventions, and client outcomes in written and electronic formats. Page: 371 (V1) Heading: What Are Some Common Formats for Nursing Progress Notes? > SOAP/SOAPIE/SOAP(IER) Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Communication Difficulty: Moderate Feedback 1 This is correct. “A” in SOAP charting stands for Assessment, which, in this case, is intractable pain. Assessment is the client’s problem or nursing diagnoses. 2 This is incorrect. “I can’t get any relief from this pain in my abdomen” is subjective data and goes with the “S.” 3 This is incorrect. Holding abdomen and moaning is objective data and goes with the “O.” 4 This is incorrect. Notified provider to change pain medication is the plan and goes with the “P” in SOAP. PTS: 1 CON: Communication 13. ANS: 1 Chapter: Chapter 18 Documenting & Reporting

Objective: Follow documentation guidelines to accurately record client health status, nursing interventions, and client outcomes in written and electronic formats. Page: 381 (V1) Heading: What Is Unique About Documentation in Long-Term Care? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Knowledge [Remembering] Concept: Legal Difficulty: Easy Feedback 1 This is correct. Federal regulations require that a resident be evaluated using the Minimum Data Set (MDS) within 14 days of admission to a long-term care facility. 2 This is incorrect. SBAR is a technique used for communicating and organizing a handoff report. It is not used for long-term care admissions. 3 This is incorrect. HCFA guidelines govern home healthcare documentation, not for long-term care. 4 This is incorrect. Joint Commission guidelines do apply to long-term care facilities. However, only the MDS assessment is mandated by federal law. PTS: 1 CON: Legal 14. ANS: 2 Chapter: Chapter 18 Documenting & Reporting Objective: Identify approved abbreviations to use in documenting in clinical environments. Page: 370 (V1) Heading: Tables: Abbreviations Commonly Used in Healthcare Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Knowledge [Remembering] Concept: Communication Difficulty: Easy Feedback 1 This is incorrect. OOB does not indicate that the nurse should perform oral care. 2 This is correct. OOB is the abbreviation for “out of bed.” The nurse is following the physician’s order when she assists the patient out of bed in the morning. 3 This is incorrect. OOB does not indicate that the nurse should help with bathing. 4 This is incorrect. OOB does not indicate the nurse should change the patient’s operative dressings. PTS: 1 CON: Communication 15. ANS: 2 Chapter: Chapter 18 Documenting & Reporting

Objective: Identify approved abbreviations to use in documenting in clinical environments. Page: 371 (V1) Heading: Table 18-1 Joint Commission “Do Not Use” List Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Knowledge [Remembering] Concept: Communication Difficulty: Moderate Feedback 1 This is incorrect. The student nurse would not question this instruction since it is an approved abbreviation. 2 This is correct. The student nurse should question the instruction to use apothecary units—instead of metric units. Nurses are encouraged to use metric units instead of the rarely used apothecary system. 3 This is incorrect. The student nurse would not question this instruction as it follows the correct standards for abbreviations. 4 This is incorrect. The student nurse would not question this instruction because it is an approved abbreviation. PTS: 1 CON: Communication 16. ANS: 1 Chapter: Chapter 18 Documenting & Reporting Objective: Follow documentation guidelines to accurately record client health status, nursing interventions, and client outcomes in written and electronic formats. Page: 370 (V1) Heading: What Forms Do Nurses Use to Document Nursing Care? > Occurrence Reports Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Communication Difficulty: Moderate Feedback 1 This is correct. Occurrence reports are used to track problems and identify areas for quality improvement. 2 This is incorrect. As an internal communication and documentation tool, occurrence reports are not required to be reported to the FDA. 3 This is incorrect. While occurrence reports are required for client falls, it is not for The Joint Commission; it is for the facility to improve quality. 4 This is incorrect. Occurrence reports are not used to provide legal information should a client seek legal action. PTS:

CON: Communication

17. ANS: 3 Chapter: Chapter 18 Documenting & Reporting Objective: Compare and contrast electronic and written documentation. Page: 373 (V1) Heading: Electronic Health Record (EHR) Systems and Box 18-2 Advantages and Disadvantages of a Paper Health Record Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Communication Difficulty: Moderate Feedback 1 This is incorrect. Both types of charting can assist with collaboration. 2 This is incorrect. Charting terminology is similar in both types of charting. 3 This is correct. One of the most beneficial aspects of electronic documentation systems is its ability to improve legibility, which reduces the risk for medication administration and other errors. 4 This is incorrect. Both electronic and written charting can serve as resources. PTS: 1 CON: Communication 18. ANS: 2 Chapter: Chapter 18 Documenting & Reporting Objective: Follow documentation guidelines to accurately record client health status, nursing interventions, and client outcomes in written and electronic formats. Page: 380 (V1) Heading: Occurrence Reports and Clinical Insight 18-3 Guidelines for Documentation Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Communication Difficulty: Moderate Feedback 1 This is incorrect. Do not chart what others have observed as the nurse’s own observation. 2 This is correct. Charting must be accurate and succinct: only chart what the nurse observes. 3 This is incorrect. Since the nurse did not see the patient fall, this should not be used as a chart entry. 4 This is incorrect. While the nurse can remind the patient not to get out of bed, after falling should not be charted since the nurse did not see this occur. PTS:

CON: Communication

19. ANS: 3 Chapter: Chapter 18 Documenting & Reporting Objective: Discuss the key elements of giving a verbal patient report. Page: 371 (V1) Heading: How Do I Give a Handoff Report? > Standardized Report Formats Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Communication Difficulty: Easy Feedback 1 This is incorrect. DAR is used in Focus Charting®, not for a handoff report. 2 This is incorrect. SOAP is a method for documenting nursing care, not for a handoff report. 3 This is correct. The SBAR technique is used as a mechanism to give a handoff report by enabling a focused communication between healthcare team members. 4 This is incorrect. FACT is a type of documentation model (not a handoff report) that incorporates many charting-by-exception principles. PTS: 1 CON: Communication 20. ANS: 4 Chapter: Chapter 18 Documenting & Reporting Objective: Identify a variety of charting formats and their purposes. Page: 371 (V1) Heading: What Are Some Common Formats for Nursing Progress Notes? > Problem-InterventionEvaluation (PIE) Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Communication Difficulty: Moderate Feedback 1 This is incorrect. This style of charting tends to focus only on the listed problems and not on the client as a whole. Therefore, this is a disadvantage, not an advantage. 2 This is incorrect. This type of charting does not focus on the client as a whole. This is a disadvantage, not an advantage. 3 This is incorrect. The primary disadvantage (not advantage) of PIE charting is that it does not document the planning portion of the nursing process. 4 This is correct. The PIE charting format organizes information by the client’s problems and requires a daily assessment record and progress notes, thus eliminating the need for a nursing care plan.

PTS: 1 CON: Communication 21. ANS: 3 Chapter: Chapter 18 Documenting & Reporting Objective: Identify a variety of charting formats and their purposes. Page: 376 (V1) Heading: Charting by Exception Integrated Processes: Communication and Documentation Client Needs: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Communication Difficulty: Easy Feedback 1 This is incorrect. Narrative charting records all findings, both normal and abnormal. 2 This is incorrect. Charting by inclusion does not chart only abnormal findings. 3 This is correct. Charting by exception is a system of charting where only exceptions to the normal findings or to the unit standards are charted. These are directed by organizational, professional, and legal guidelines. 4 This is incorrect. Source-oriented charting refers to each healthcare practitioner’s charting in a specific section of the chart. For example, nurses would document in the nurses’ notes section and physicians would document in the physician section of the healthcare record. PTS: 1 CON: Communication 22. ANS: 2 Chapter: Chapter 18 Documenting & Reporting Objective: Discuss the key elements of giving a verbal patient report. Page: 381 (V1) Heading: Clinical Insight 18-1 Giving Oral Reports Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Communication Difficulty: Moderate Feedback 1 This is incorrect. Report should not be rushed in order for a nurse to finish the shift as quickly as possible. However, the nurse should try to begin report before the shift is over, early enough to complete report before the next shift begins. 2 This is correct. The CUBAN acronym is used in all types of report formats and stands for Confidential, Uninterrupted, Brief, Accurate, Named nurse. Following this format, the nurse giving report has a guide to remember the

3 4

important data that need to be shared with the oncoming nurse who will care for the patient. This is incorrect. The CUBAN approach does not require walking rounds. This is incorrect. The CUBAN acronym can be used for report about any patient regardless of race, ethnicity, or religion and does not necessarily provide cultural information. It is not specific to Latino patients.

PTS: 1 CON: Communication 23. ANS: 4 Chapter: Chapter 18 Documenting & Reporting Objective: Compare and contrast electronic and written documentation. Page: 374 (V1) Heading: Disadvantages of Electronic Health Records Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Communication Difficulty: Moderate Feedback 1 This is incorrect. This student does not need further instructions. A person needs to be taught the specifics of each system. Even though the system has been taught to him or her, a student who understands also knows that the instructor will be a resource for EHR questions that may arise. 2 This is incorrect. This student does not need further instructions. The EHR generally integrates information to be used by the healthcare team. 3 This is incorrect. This student does not need further instructions. Data can be collected and analyzed in multiple ways to evaluate and improve patient care (quality improvement). 4 This is correct. This student needs further instructions. The EHR can vary according to institution and may not be user-friendly. Although a student knows how to use a computer, this knowledge may not directly translate so that the student is able to accurately document in any particular institution. PTS: 1 CON: Communication 24. ANS: 2 Chapter: Chapter 18 Documenting & Reporting Objective: Identify approved abbreviations to use in documenting in clinical environments. Page: 183 (V2) Heading: TABLES Abbreviations Commonly Used in Healthcare Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Knowledge [Remembering]

Concept: Communication Difficulty: Easy Feedback 1 This is incorrect. Once a day is written as “daily.” The abbreviation qd is not used for once a day but is written as “daily.” Abbreviations are used with caution to reduce errors by nurses and the healthcare teams. 2 This is correct. “Bid” is the abbreviation for twice a day, which is generally 12 hours between doses. Abbreviations are used with caution to reduce errors by the nurse and the healthcare teams. 3 This is incorrect. Three times a day is “tid.” Abbreviations are used with caution to reduce errors by the nurse and the healthcare teams. 4 This is incorrect. Four times a day is “qid.” Abbreviations are used with caution to reduce errors by the nurse and the healthcare teams. PTS: 1 CON: Communication 25. ANS: 1 Chapter: Chapter 18 Documenting & Reporting Objective: Identify a variety of charting formats and their purposes. Page: 370 (V1) Heading: Narrative Format Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Communication Difficulty: Moderate Feedback 1 This is correct. A narrative chart entry tells the story of the client’s experience as it occurs in a chronological format with the goal to track a client’s changing medical and health status. It also documents progress toward goals for the client. 2 This is incorrect. A disadvantage to narrative charting includes the following: inconsistency among healthcare providers and the manner in which they document using narrative charting. 3 This is incorrect. More charting time is needed for narrative charting. 4 This is incorrect. A concern with narrative charting is a decrease in interdisciplinary discussion of client progress owing to lengthy and redundant documentation by healthcare team members. PTS:

MULTIPLE RESPONSE 26. ANS: 1, 4

CON: Communication

Chapter: Chapter 18 Documenting & Reporting Objective: Identify a variety of charting formats and their purposes. Page: 371 (V1) Heading: What Forms Do Nurses Use to Document Nursing Care? > Kardex® or Patient Care Summary Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Communication Difficulty: Moderate

1. 2.

3. 4. 5.

Feedback This is correct. The Kardex is a tool that pulls data from multiple areas of the patient’s health record and helps guide nursing care. This is incorrect. Paper Kardexes are usually kept together in a portable file in a central location in the nurses’ station to allow all team members access to patients’ summary information. This is incorrect. Responses to interventions are documented on flowsheets and in nurses’ notes, not the Kardex®. This is correct. The Kardex® is a special paper form or folding card that briefly summarizes a patient’s status and plan of care. This is incorrect. Neither the paper Kardex® nor the electronic care summary is a permanent part of the patient’s health record.

PTS: 1 CON: Communication 27. ANS: 1, 2 Chapter: Chapter 18 Documenting & Reporting Objective: Compare and contrast electronic and written documentation. Page: 384 (V1) Heading: Guidelines for Electronic Health Records > How Do I Maintain Confidentiality and Data Security? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Informatics Difficulty: Moderate

1. 2.

Feedback This is correct. Leaving patient data displayed on a computer screen where others may view them breaches patient confidentiality. This is correct. The nurse should log off the computer immediately after use. This breaks patient confidentiality.

4. 5.

This is incorrect. Faxing a report to the nurses’ station receiving a patient does not breach patient confidentiality because it is located at the nurses’ station out of others’ view. This is incorrect. Anyone directly involved in the patient’s care has the right to know about the patient’s condition without breaching patient confidentiality. This is incorrect. The nurse can directly access patient records for whom the nurse is caring. However, never access client health records that the nurse has no professional reason to view. This is a severe breach of client privacy rules.

PTS: 1 CON: Informatics 28. ANS: 1, 2, 3 Chapter: Chapter 18 Documenting & Reporting Objective: Follow documentation guidelines to accurately record client health status, nursing interventions, and client outcomes in written and electronic formats. Page: 384 (V1) Heading: Clinical Insight 18-3 Guidelines for Documentation Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Communication Difficulty: Moderate

2. 3.

4. 5.

Feedback This is correct. The nurse graduate needs further instruction. Documentation should be performed as soon as possible after the nurse makes an assessment or provides care. The longer the nurse waits, the less accurate the documentation will be. Leaving documentation until the end of the shift may cause important details to be omitted or mistaken. This is correct. The nurse graduate needs further instruction. It is not necessary to complete documentation on a strict schedule, such as every 2 to 4 hours. This is correct. The nurse graduate needs further instruction. Even waiting until lunch or report after the shift is over is too long a period of time for accurate documentation. This is incorrect. The nurse graduate does not need further instruction. Charting as soon as possible after nursing care is appropriate. This is incorrect. The nurse graduate nurse does not need further instruction. Charting after performing an intervention is appropriate. However, the nurse should never document before performing an intervention.

PTS: 1 CON: Communication 29. ANS: 1, 2, 4, 5 Chapter: Chapter 18 Documenting & Reporting

Objective: Compare and contrast electronic and written documentation. Page: 385 (V1) Heading: Electronic Health Record (EHR) Systems > Advantages Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Informatics Difficulty: Moderate

2. 3. 4. 5.

Feedback This is correct. The implementation of electronic health records (EHRs) has many advantages for the nurse. This includes the ability to identify data to facilitate evidence-based nursing practice. This is correct. EHR promotes the efficient use of time nurses spend documenting client care. Nurses spend up to 25% less time charting. This is incorrect. EHR does not impair interdisciplinary collaboration; rather, EHR fosters communication and collaboration among healthcare team members. This is correct. EHR has protocols and programmed alerts and safeguards to improve the quality of client care. This is correct. Multiple healthcare providers can access the same information at the same time.

PTS: 1 CON: Informatics 30. ANS: 1, 2, 3 Chapter: Chapter 18 Documenting & Reporting Objective: Discuss the key elements of giving a verbal patient report. Page: 381 (V1) Heading: Clinical Insight 18-1 Giving Oral Reports Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Knowledge [Remembering] Concept: Communication Difficulty: Moderate

1. 2. 3. 4.

Feedback This is correct. Handoff reports include any client teaching done. This is correct. Any change in client status is included in a handoff report. This is correct. Handoff reports include therapies and treatments administered. This is incorrect. Hygiene care is routinely done in inpatient settings and is usually recorded on a flowsheet. Handoff reports should be succinct and not contain routine information. This is incorrect. Insurance status is not included in a handoff report.

PTS: 1 CON: Communication 31. ANS: 1, 2, 4 Chapter: Chapter 18 Documenting & Reporting Objective: Identify a variety of charting formats and their purposes. Page: 375 (V1) Heading: Discharge Summary Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Communication Difficulty: Moderate

1. 2. 3.

4. 5.

Feedback This is correct. The discharge summary is important because clients require followup care. This is correct. The discharge summary serves as baseline data for the healthcare professionals who will provide follow up care. This is incorrect. A verbal transfer report is not a replacement for the comprehensive discharge summary. A complete discharge summary must be completed even if a complete verbal transfer report is given to ensure that all important and specific information is communicated to another healthcare provider when the client is discharged from the hospital. This is correct. A discharge summary is the last entry made in the paper record. This is incorrect. A discharge summary can be done in the electronic medical record (EMR) formats, a narrative note, or on a discharge summary form.

PTS: 1 CON: Communication 32. ANS: 1, 3, 4, 5 Chapter: Chapter 18 Documenting & Reporting Objective: Follow documentation guidelines to accurately record client health status, nursing interventions, and client outcomes in written and electronic formats. Page: 376 (V1) Heading: Medication Administration Records and Clinical Insight 18-3 Guidelines for Documentation Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Difficult Feedback

1. 2. 3. 4. 5.

This is correct. The physician should be notified immediately. Heparin, an anticoagulant, would make the situation worse if given. This is incorrect. In this situation, the heparin should not be given. This action would exacerbate the bleeding. This is correct. Heparin must be held since the patient is at risk for bleeding and the laboratory values are excessively abnormal. This is correct. If a medication is held, the nurse should chart the reason. This is correct. Abnormal findings are charted in the patient’s health record.

PTS: 1 CON: Patient-Centered Care 33. ANS: 1, 2, 3, 4 Chapter: Chapter 18 Documenting & Reporting Objective: Explain the purposes of documentation. Page: 365 (V1) Heading: How Do Healthcare Providers Use Documentation? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Communication Difficulty: Moderate

2. 3. 4. 5.

Feedback This is correct. One purpose of the EHR and documentation is to act as a legal record. In court, the health record is legal evidence of the care given to a client and is used to judge whether the interventions were timely and appropriate. This is correct. The health record is used for utilization review to determinate whether the medical treatments and interventions were necessary and appropriate. This is correct. One purpose of the EHR and documentation is to communicate, enhancing continuity of care. This is correct. One purpose of the EHR and documentation is quality improvement. This is incorrect. An occurrence report is not part of the client’s health record. And should never be referenced in the nurse’ notes or in other sections of the health record.

PTS:

CON: Communication

Chapter 19. Teaching & Learning Multiple Choice Identify the choice that best completes the statement or answers the question. 1. Which technique is best for teaching a nursing assistant how to perform finger-stick glucose testing? 1. Provide a manufacturer’s pamphlet with detailed instruction. 2. Explain the best technique for performing glucose testing. 3. Demonstrate the procedure, then ask for a return demonstration. 4. Suggest that the assistant watch a DVD showing the procedure. 2. A patient with a diabetic foot ulcer will need to perform dressing changes after discharge. When should the nurse schedule the teaching sessions? 1. Within 10 minutes after the next dose of oral pain medication 2. After the patient wakes up from a restful nap 3. Right before the surgeon debrides the wound 4. Before the patient undergoes flow studies of the affected leg 3. Which intervention by the nurse would be best to motivate a patient newly diagnosed with hypertension to learn about the prescribed treatment plan? 1. Explain that when left untreated, hypertension may lead to stroke. 2. Ask the patient to let the nurse know when ready to learn. 3. Encourage the patient to learn about various treatment options. 4. Reassure the patient that adhering to the treatment produces a good outcome. 4. Assume all of the following written instructions about digoxin provide correct information for patient care. Which one is best worded for patient understanding in a culturally competent manner? 1. Obtain your radial pulse q a.m. before taking your digoxin dose. 2. Return to your healthcare provider for monthly laboratory studies of your digoxin levels. 3. Call your provider if you notice that objects look yellow or green. 4. Always take the same brand of medication because certain brands may not be interchangeable. 5. Which teaching strategy is typically most effective for presenting information to large groups about health promotion? 1. Distributing printed materials 2. Lecturing using audiovisual format 3. Using online sources of information 4. Role modeling 6. A patient with diabetes is admitted to the hospital for possible amputation from an infected foot wound. Which nursing diagnosis would be appropriate for this patient?

1. 2. 3. 4.

Impaired Ability to Learn r/t fear and anxiety Deficient Knowledge r/t foot care Inability to Learn r/t learning disability Lack of Knowledge r/t inability to learn

7. Which phrase would the nurse include in the plan of care as a teaching goal for a patient who had bowel resection with creation of a colostomy? The patient: 1. Empties the colostomy appliance when half filled 2. Performs skin care around the stoma site 3. Will perform ostomy self-care within 3 days after surgery 4. Applies a new ostomy appliance, making sure it adheres properly 8. During advanced cardiac life support (ACLS) training, a nurse learns about defibrillation by using a mannequin. Which teaching tool is being employed? 1. Journaling 2. Computer-assisted instruction 3. Role modeling 4. Simulation model 9. An older adult patient who underwent bowel resection is recovering from surgery without complication. During the healthcare team’s morning rounds, the surgeon informs the patient that the lesion removed was cancerous. Which factor will likely be the patient’s most significant obstacle for learning? 1. The patient’s baseline physical condition 2. A negative environmental influence 3. Anxiety associated with the new diagnosis 4. Reduced ability to understand the diagnosis 10. How can the nurse best provide teaching for a patient whose primary spoken language is not the same as the nurse’s? 1. Offer written materials in the patient’s primary language. 2. Make arrangements to teach using an interpreter. 3. Provide a demonstration and request a return demonstration. 4. Use visual teaching aids to convey information. 11. A preschool-age child is scheduled for a tonsillectomy. Which strategy might help lessen the child’s anxiety before surgery? 1. Give the child a coloring book about the surgery. 2. Offer the child a detailed rationale for the surgery. 3. Allow the child to use online sources of information to learn about the surgery. 4. Provide one-to-one instruction about the care the child will need after surgery. 12. The nurse manager is devising a teaching schedule for the staff who are about to begin using a new type of patient bed in the ICU. Implementation is planned in 6 weeks. When is the best time for the manager to schedule the teaching sessions?

1. 2. 3. 4.

One hour before implementation One day before implementation One week before implementation One month before implementation

13. For which patient is the nursing diagnosis Knowledge Deficit most appropriate? 1. Adolescent with Down syndrome with a long history of cardiac problem 2. Young adult admitted with acute renal failure who requires hemodialysis immediately 3. Middle-aged woman with breast cancer receiving the last round of chemotherapy 4. Older adult with a long-standing history of type 1 diabetes admitted with a foot ulcer 14. Prior to discharge, a patient with diabetes needs to learn how to check a finger-stick blood sugar reading before taking insulin. Which action will best help the patient remember proper technique? 1. Encouraging the patient to check the blood sugar each time the nurse gives insulin 2. Providing feedback after the patient takes the blood sugar reading for the first time 3. Verbally instructing the patient about how to obtain a finger-stick blood sugar reading 4. Offering a brochure that describes the technique for checking a blood sugar reading 15. It is a busy day on the medical-surgical floor, and the nurse must teach a patient ready for discharge about the medications. How can the nurse most efficiently use the time and provide this education? 1. Write down instructions so the patient can read them at home. 2. Discuss the information while assisting the patient with the bath. 3. Educate the patient about the medications as each one is given. 4. Follow up with the patient after discharge with a phone call. 16. The nurse preparing a teaching plan ensures that the information is tailored to the client’s life experiences and learning level. These are examples of which “right” of teaching? 1. Right time 2. Right context 3. Right content 4. Right goal 17. Which statement by the patient demonstrates health literacy? 1. “I speak and understand little English but will do what I am told.” 2. “I will take my medications after I ask the nurse a few questions.” 3. “I have not taken my prescribed antibiotics because I can’t read the labels.” 4. “I stopped my medications when I started feeling better.”

18. When the nurse is about to give instructions for discharge, the nurse notices that the television is on and the patient is eating a meal. What is the best action for the nurse to take to ensure that the patient’s discharge teaching is understood? 1. Review all important discharge teaching while in the room. 2. Ask whether the patient has any questions about the discharge. 3. Inform the patient that the instructions are on the discharge sheet. 4. Arrange another time with the patient to review the discharge teaching. 19. The client with iron deficiency anemia does not know it is caused by low levels of iron in the body that can be improved by a diet high in iron. Based on this information, which nursing diagnosis is best? 1. Imbalanced nutrition: Less Than Body Requirements for iron r/t Deficient Knowledge of foods high in iron 2. Deficient Recall r/t Imbalanced Nutrition due to less than body requirements of iron 3. Imbalanced Nutrition: Less Than Body Requirements r/t Inability to Access Information 4. Inability to Access Information r/t Deficient Knowledge about dietary needs for iron 20. The nurse is preparing to teach a client about crutch walking. Which action would the nurse take first? 1. Mutually develop learning goals for crutch walking. 2. Demonstrate how to use the crutches. 3. Determine what the client already knows about crutches. 4. Create a teaching plan for crutch walking. 21. The nurse is preparing to teach an older adult about hypertension. Which action would the nurse take? 1. Avoid the use of sharing life experiences about high blood pressure. 2. Print information about hypertension in a blue font color. 3. Use long stories to emphasize high blood pressure problems. 4. Cover diet and exercise to help control hypertension in one teaching session. Multiple Response Identify one or more choices that best complete the statement or answer the question. 22. A mother tells the nurse she is worried that her 20-year-old daughter lacks the understanding regarding the need for follow-up care after her discharge. Which behaviors suggests that the patient needs further discharge teaching? Select all that apply. The patient: 1. States she will be on time for her scheduled appointment 2. Demonstrates correct care of the dressing 3. States she does not understand much English

4. Watches television while the nurse is speaking to her 5. Plans to get medications from the pharmacy on her way home 23. The nurse is giving the oncoming nurse the shift report. The nurse states the client’s diagnoses, treatments, and course of hospitalization. When describing the client, the nurse states, “Whenever I try to teach him something, he becomes difficult and argumentative.” What client information about patient teaching should the oncoming nurse ask? Select all that apply. 1. Level of literacy 2. Primary language 3. Need for humor 4. Level of anxiety 5. Insurance status 24. The nurse explains to a patient that dressing changes will improve healing and decrease infection and then demonstrates the correct aseptic technique to the patient. The patient is asked to return a demonstration of this dressing change and to describe the reasons for it to the nurse. This example includes which type of learning and which learning domains? Select all that apply. 1. Affective 2. Active 3. Cognitive 4. Psychomotor 5. Passive 25. The nurse is assessing a client’s learning needs regarding changing an ostomy bag. Which parameters would the nurse assess? Select all that apply. 1. Client’s learning needs for changing the bag 2. Client’s beliefs about an ostomy 3. Client’s emotional readiness 4. Client’s ability to move arms and hands 5. Client’s relationship with parents

Chapter 19. Teaching & Learning Answer Section MULTIPLE CHOICE 1. ANS: 3 Chapter: Chapter 19 Teaching & Learning Objective: Name, define, and give one example of each of Bloom’s three domains of learning. Page: 390 (V1) Heading: Learning Occurs in Three Domains > Psychomotor Learning Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Leadership and Management Difficulty: Moderate

3 4

Feedback This is incorrect. Supplementary written information can also be supplied to the patient to reinforce learning. However, this is not the best method for teaching a psychomotor skill; enacting the procedure is more effective. This is incorrect. While explaining the procedure is needed, it is not the best method for teaching a psychomotor skill; enacting the procedure is more effective. This is correct. The best way to teach a psychomotor skill is to demonstrate the procedure and then ask for a return demonstration. This is incorrect. A DVD can also be supplied to the patient to reinforce learning. However, this is not the best method for teaching a psychomotor skill.

PTS: 1 CON: Leadership and Management 2. ANS: 2 Chapter: Chapter 19 Teaching & Learning Objective: Discuss the various factors that can affect learning (e.g., motivation, developmental stage). Page: 391 (V1) Heading: Many Factors Affect Client Learning > Readiness Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is incorrect. Ten minutes is not enough time for oral medication to take

3 4

effect and relieve pain. Pain can interfere with learning. This is correct. For learning to be most effective, teaching must occur when the patient is most receptive. Therefore, the best time to teach this patient is when he or she is rested, such as after a restful nap. This is incorrect. A patient’s capacity to take in new information is reduced when anxious, in this example right before a treatment. This is incorrect. A patient’s capacity to take in new information is reduced when anxious, in this example about diagnostic testing of the affected leg.

PTS: 1 CON: Patient-Centered Care 3. ANS: 1 Chapter: Chapter 19 Teaching & Learning Objective: Describe some strategies for motivating learners. Page: 391 (V1) Heading: Many Factors Affect Client Learning > Motivation and Emotions Integrated Processes: Teaching and Learning Client Need: Physiological Integrity > Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is correct. A patient newly diagnosed with hypertension may not be motivated to learn because he or she most likely has not experienced physical symptoms or other outward complications. Therefore, the nurse should motivate the patient by pointing out serious risks to the quality of life if the blood pressure control is not achieved. 2 This is incorrect. Although readiness to learn is an important consideration, treatment might be delayed too long if the patient does not appropriately perceive the immediacy of the health risk. 3 This is incorrect. Simply encouraging a patient to learn about blood pressure and treatment options might not be suitable motivation to engage in active learning and to comply with prescribed treatment. 4 This is incorrect. Reassuring the patient and promising a good outcome by complying with medical treatment is not appropriate to motivate a patient. Adhering to medical therapy reduces the risk for stroke and other complications; however, this can’t be guaranteed. PTS: 1 CON: Patient-Centered Care 4. ANS: 3 Chapter: Chapter 19 Teaching & Learning Objective: Develop strategies for working with clients with cultural or learning differences. Page: 398 (V1)

Heading: Promoting Health Literacy and Box 19-3 Culturally Competent Teaching and Table 19-4 Formats for Patient Teaching: Benefits and Limitations Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Health Promotion Difficulty: Difficult Feedback 1 This is incorrect. If instructions are written at too high a reading level, the patient may not understand and make a harmful error in dosing. Patient instructions must not contain words that require a higher level of reading or medical jargon (q a.m. is medical jargon for every morning). 2 This is incorrect. The sentence is too long and contains medical terms (monthly laboratory studies of your digoxin levels) that can be confusing for patients of all cultures. 3 This is correct. The nurse should provide written instructions that contain short sentences and easy-to-read words. Calling the provider when objects look yellow or green is the clearest statement for patient teaching because the instruction is short, concrete, and written with easy-to-understand words. 4 This is incorrect. The instruction pertaining to being consistent with brand use is too wordy, especially for patients who are ill or for whom English is not a primary language. PTS: 1 CON: Health Promotion 5. ANS: 2 Chapter: Chapter 19 Teaching & Learning Objective: Develop teaching plans for clients. Page: 402 (V1) Heading: Creating Teaching Plans > Selecting Specific Teaching Strategies and Table 19-4 Formats for Patient Teaching: Benefits and Limitations Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Knowledge [Remembering] Concept: Health Promotion Difficulty: Easy Feedback 1 This is incorrect. Printed materials are not the best method for a large group. Although printed materials can help to reinforce information taught during a lecture, this can be problematic for auditory learners or those whose primary spoken language is not English. 2 This is correct. Lecturing using audiovisual materials appeals to learners who best process information by hearing and seeing. From a practical point of view, a

lecture format (traditional classroom or webinar) is efficient and effective with large groups. This is incorrect. Online sources of information are not the best method for a large group. Online sources of information are ideal for learners who learn best by doing (kinesthetic learners). This is incorrect. Role modeling is most effective for individuals or small groups of learners, especially when the relationship between the instructor and learner is meaningful.

PTS: 1 CON: Health Promotion 6. ANS: 1 Chapter: Chapter 19 Teaching & Learning Objective: Discuss correct and incorrect uses of the nursing diagnosis Knowledge Deficit. Page: 400 (V1) Heading: Analysis/Nursing Diagnosis Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate

1 2 3 4

Feedback This is correct. Since the patient is admitted for possible amputation, fear and anxiety would be appropriate for this patient. This is incorrect. A person with a foot ulcer secondary to long-standing diabetes may already know more than the nurse does about foot care. This is incorrect. There is nothing in the question that related the patient has a learning disability. Thus, this diagnosis would be inappropriate. This is incorrect. There is nothing in the question to indicate that the patient has an inability to learn, making this diagnosis inaccurate.

PTS: 1 CON: Patient-Centered Care 7. ANS: 3 Chapter: Chapter 19 Teaching & Learning Objective: List four methods for evaluating the outcomes of teaching and learning. Page: 400 (V1) Heading: Planning Outcomes Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

1 2 3

Feedback This is incorrect. Emptying the colostomy appliance demonstrates a learning objective, not a broad teaching goal. This is incorrect. Performing skin care is also a desired skill stated as a learning objective. It is not a teaching goal which is broad in scope. This is correct. Performing ostomy self-care is an appropriate teaching goal for a patient who needs to learn colostomy self-care after surgery. Teaching goals are broad in scope and set down what is expected as the final outcome of the teaching and learning process. This is incorrect. Applying an ostomy device is an observable learning objective, not a teaching goal.

PTS: 1 CON: Patient-Centered Care 8. ANS: 4 Chapter: Chapter 19 Teaching & Learning Objective: Name, define, and give one example of each of Bloom’s three domains of learning. Page: 390 (V1) Heading: Psychomotor Learning Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Professionalism Difficulty: Moderate Feedback 1 This is incorrect. Journaling involves recording the experiences and feelings about an event. This is not the tool being used. 2 This is incorrect. Computer-assisted instruction involves the material presented on a computer. This is not the tool being used. 3 This is incorrect. In role modeling, the teacher teaches by example, demonstrating the behaviors (not skills) that need to be acquired by learners. 4 This is correct. ACLS training uses simulation models by using resuscitation mannequins and teaching healthcare workers to respond appropriately to lifethreatening cardiopulmonary events. PTS: 1 CON: Professionalism 9. ANS: 3 Chapter: Chapter 19 Teaching & Learning Objective: List at least six barriers to teaching and learning. Page: 391 (V1) Heading: Many Factors Affect Client Learning > Emotions Integrated Processes: Teaching and Learning Client Need: Psychosocial Integrity

Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

2 3

Feedback This is incorrect. The patient has been recovering with no complications; therefore, the physical condition is probably not the most significant barrier to learning. This is incorrect. While the patient did receive negative news, this does not make the environment a negative influence. This is correct. Anxiety associated with the new diagnosis of cancer will most likely be a barrier to learning in this patient. Fear of the unknown, fear of pain, fear of physical discomfort with treatment options, fear of altered role in home or work life, and many other fears accompany the anxiety that patients often experience when potentially life-threatening diagnoses are communicated. This is incorrect. Simply because the patient is an older adult does not suggest the patient has reduced capacity to learn.

PTS: 1 CON: Patient-Centered Care 10. ANS: 2 Chapter: Chapter 19 Teaching & Learning Objective: Develop strategies for working with clients with cultural or learning differences. Page: 391 (V1) Heading: Many Factors Affect Client Learning > Cultural Factors Integrated Processes: Teaching and Learning Client Need: Psychosocial Integrity Cognitive Level: Comprehension [Understanding] Concept: Culture Difficulty: Easy Feedback 1 This is incorrect. Written materials in the patient’s primary language can help reinforce teaching, but it is not the best method. 2 This is correct. If the patient is not fluent in the prevalent language, the nurse may need to use an interpreter or use a translator application. 3 This is incorrect. Demonstrating and requesting a return demonstration may be difficult if the patient does not understand the spoken language of the nurse. 4 This is incorrect. Visual aids may also be helpful for some learners, but they should not be the primary method for teaching, nor do they offer an opportunity for the exchange of information through questions, demonstration, or discussion. PTS: 1 11. ANS: 1

CON: Culture

Chapter: Chapter 19 Teaching & Learning Objective: Discuss the various factors that can affect learning (e.g., motivation, developmental stage). Page: 394 (V1) Heading: Teaching Children Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Growth and Development Difficulty: Moderate Feedback 1 This is correct. To reduce anxiety in a preschool-age child requiring surgery, give the child a coloring book about what surgery might be like to take home. 2 This is incorrect. A preschooler will not understand detailed rationale about the surgery. 3 This is incorrect. Online sources of information are too high-level for a preschool child. Online sources of information is a teaching strategy for adults and older children. 4 This is incorrect. The child does not need to know about care after surgery in a one-to-one manner. Anxiety should be reduced, not elevated. One-to-one instruction is a teaching strategy for adults and older children. PTS: 1 CON: Growth and Development 12. ANS: 3 Chapter: Chapter 19 Teaching & Learning Objective: Discuss the various factors that can affect learning (e.g., motivation, developmental stage). Page: 403 (V1) Heading: Timing Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Leadership and Management Difficulty: Moderate Feedback 1 This is incorrect. If the teaching is offered immediately before use with patients, there wouldn’t be an adequate opportunity to practice skills and ask appropriate questions regarding use of the new device. 2 This is incorrect. One day before implementation is not enough time to process the new information or use the bed correctly. 3 This is correct. People retain information better when they have the opportunity to use it soon after it is presented. Therefore, the nurse manager should schedule

teaching sessions 1 week before implementation of the equipment. This is incorrect. If classes are scheduled too early, the nurses might forget how to use the equipment before it is implemented.

PTS: 1 CON: Leadership and Management 13. ANS: 2 Chapter: Chapter 19 Teaching & Learning Objective: Discuss correct and incorrect uses of the nursing diagnosis Knowledge Deficit. Page: 400 (V1) Heading: Analysis/Nursing Diagnosis Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is incorrect. The adolescent patient with Down syndrome would have a nursing diagnosis of Impaired Ability to Learn, not Knowledge Deficit. 2 This is correct. The young adult patient admitted with acute renal failure who needs hemodialysis will probably have Knowledge Deficient related to the treatment regimen of hemodialysis. 3 This is incorrect. Patients with chronic illness, such as cancer, are most likely to be knowledgeable about the disease and course of treatment; therefore, the nursing diagnosis Knowledge Deficit is less relevant than it is to a patient who is newly diagnosed. 4 This is incorrect. A patient with a chronic illness, such as diabetes, is most likely to be knowledgeable about the disease and course of treatment; therefore, the nursing diagnosis Knowledge Deficit is less relevant than it is to a patient who is newly diagnosed. PTS: 1 CON: Patient-Centered Care 14. ANS: 1 Chapter: Chapter 19 Teaching & Learning Objective: Discuss the various factors that can affect learning (e.g., motivation, developmental stage). Page: 403 (V1) Heading: Repetition Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate

2 3 4

Feedback This is correct. Having the patient perform a finger stick with the nurse each time insulin is administered is the best way to practice the correct technique and gain confidence prior to discharge. Repetition increases the likelihood that the patient will retain information and incorporate it into the daily management of diabetes care. This is incorrect. Although feedback is important, the patient might need it on more than one occasion. This is incorrect. Verbal instructions are not the most useful technique for remembering correct steps of a skill. This is incorrect. A brochure is informative and useful for later reference; however, information about performing a new skill is best offered when the patient can see it demonstrated and has the opportunity to practice it with the feedback from the nurse.

PTS: 1 CON: Patient-Centered Care 15. ANS: 3 Chapter: Chapter 19 Teaching & Learning Objective: Describe the concepts of teaching and learning. Page: 393 (V1) Heading: Scheduling the Session, Who Are the Learners?, and Box 19-2 Teachable Moments Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Providing the patient written instructions without discussing the information does not allow the patient an opportunity to ask questions or the nurse to verify that the patient understands the instruction. 2 This is incorrect. A teaching session about wound care would be appropriate during bathing but not for medication teaching. 3 This is correct. Teaching does not have to be performed in a formal session but is often most effective as a teachable moment when the information is perceived as most relevant, such as at the time the medication is given to the patient. Additionally, the information is more memorable when the patient can see the actual dose and identify it with the information presented. 4 This is incorrect. A follow-up phone call is inappropriate. The patient should not be discharged without education about the prescribed medications, including what it is for, how to take it, instructions regarding dosing, what side effects can occur, and when to stop taking the medication.

PTS: 1 CON: Patient-Centered Care 16. ANS: 3 Chapter: Chapter 19 Teaching & Learning Objective: Describe the concepts of teaching and learning. Page: 389 (V1) Heading: Box 19-1 Five Rights of Teaching Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. The right time is when the learner is free of pain, anxiety, and stress, which can affect the ability to learn. The nurse must have sufficient time to do the teaching. 2 This is incorrect. The right context includes a calm environment free from distractions, and one that is private with a soothing atmosphere. 3 This is correct. The right content needs to be aligned with the client’s needs, learning level, and life experiences. 4 This is incorrect. The right goal focuses on learning objectives and a mutual commitment to reaching those goals. PTS: 1 CON: Patient-Centered Care 17. ANS: 2 Chapter: Chapter 19 Teaching & Learning Objective: Discuss the various factors that can affect learning (e.g., motivation, developmental stage). Page: 395 (V1) Heading: Many Factors Affect Client Learning > Health Literacy Integrated Processes: Teaching and Learning Client Needs: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Health teaching cannot be effective if either or both the patient and nurse cannot communicate effectively in the same language. 2 This is correct. Taking medication as prescribed after asking the nurse questions to clarify information demonstrates health literacy. Health literacy is the ability to understand basic health information and services needed to make appropriate healthcare decisions. 3 This is incorrect. If the patient is unable to read the prescription labels, then this

can negatively impact decision making regarding healthcare, indicating health illiteracy. This is incorrect. If the patient is unable to understand the need for the medications to continue feeling well, then this can negatively impact health, indicating health illiteracy, not health literacy.

PTS: 1 CON: Patient-Centered Care 18. ANS: 4 Chapter: Chapter 19 Teaching & Learning Objective: List at least six barriers to teaching and learning. Page: 393 and 402 (V1) Heading: Learning Environment and Patient Teaching Box Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Difficult

1 2

Feedback This is incorrect. Attempting to review important information will be less effective with the many distractions occurring in this scenario. This is incorrect. Just asking the patient if he or she has any questions is not effective. The nurse must review the information with the patient when the patient is not distracted. This is incorrect. Providing a patient a written set of instructions does not guarantee understanding of the information and it is imperative for the nurse to review all of this information with the patient before discharge. This is correct. The nurse understands that multiple distractions in the patient’s room, including having the television on and eating a meal, can be barriers to learning. The nurse must assess each situation to identify the best time to effectively teach the patient. Therefore, the nurse identifies that there are too many distractions at that time and speaks to the patient to determine a mutually agreeable time for the discharge teaching to be done.

PTS: 1 CON: Patient-Centered Care 19. ANS: 1 Chapter: Chapter 19 Teaching & Learning Objective: Discuss correct and incorrect uses of the nursing diagnosis Knowledge Deficit. Page: 400 (V1) Heading: Analysis/Nursing Diagnosis Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care

Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is correct. The best use of the diagnosis Deficient Knowledge is as an etiology related to the primary diagnosis. Here, the primary nursing diagnosis is Imbalanced Nutrition: Less Than Body Requirements of iron (supported by presence of iron-deficiency anemia) r/t Deficient Knowledge of foods high in iron. 2 This is incorrect. There are no data to support a diagnosis of Deficient Recall r/t Imbalanced Nutrition due to less than body requirements of iron. 3 This is incorrect. There is not sufficient information to support the diagnosis Imbalanced Nutrition: Less Than Body Requirements r/t Inability to Access Information. 4 This is incorrect. There are no data about the client’s access to information for a low-iron diet. PTS: 1 CON: Patient-Centered Care 20. ANS: 3 Chapter: Chapter 19 Teaching & Learning Objective: Describe the contents of a learning assessment. Page: 399 (V1) Heading: Assessment Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. The nurse would not develop learning goals first. There is another action the nurse would take first. 2 This is incorrect. Demonstrating how to use the crutches is not first. There is another action the nurse would take first. 3 This is correct. Assessing what the client already knows is the first action the nurse would take. Assessment must start the teaching process. 4 This is incorrect. Creating a teaching plan is not the first action the nurse would take. There is another action the nurse would perform first. PTS: 1 CON: Patient-Centered Care 21. ANS: 4 Chapter: Chapter 19 Teaching & Learning Objective: Develop teaching plans for clients.

Page: 403 (V1) Heading: Incorporating Principles of Adult Learning Into the Teaching of Older Adults Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Growth and Development Difficulty: Moderate Feedback 1 This is incorrect. The nurse should allow the older adult client to share life experiences during teaching and learning. 2 This is incorrect. Avoid colors such as blue, green, and lavender, because they are difficult for older adults to differentiate. 3 This is incorrect. Stories should be kept short, not long. 4 This is correct. Diet and exercise are only two topics and are within the range of topics to introduce. Usually, tackling one to three new topics or skills is enough for older adults. PTS:

CON: Growth and Development

MULTIPLE RESPONSE 22. ANS: 3, 4 Chapter: Chapter 19 Teaching & Learning Objective: List four methods for evaluating the outcomes of teaching and learning. Page: 406 (V1) Heading: Evaluation of Learning Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate

1. 2. 3. 4.

Feedback This is incorrect. Stating she will be on time for her scheduled appointment indicates the client understands the discharge teaching and does not need further follow-up. This is incorrect. Demonstrating correct care of the dressing indicates the client understands the discharge teaching and does not need further follow-up. This is correct. This indicates the client needs further discharge teaching. Poor language fluency and comprehension interfere with learning. This is correct. This indicates the client needs further discharge teaching. The client watching television while the nurse is giving discharge instructions shows a lack of readiness for learning.

This is incorrect. Planning to get medications from the pharmacy on her way home indicates the client understands the discharge teaching and does not need further follow-up.

PTS: 1 CON: Patient-Centered Care 23. ANS: 1, 2, 4 Chapter: Chapter 19 Teaching & Learning Objective: List at least six barriers to teaching and learning. Page: 395 (V1) Heading: Emotions and Cultural Factors and Health Literacy Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate

3. 4.

Feedback This is correct. If using print-based materials or providing verbal instructions for patient teaching, the nurse would need to know the client’s literacy level and make sure information is presented at the appropriate level. This is correct. The nurse must be aware of the client’s primary language to communicate effectively with the client. The nurse might plan to use various tools for translation, if language proficiency is a problem. This is incorrect. Humor should not be used, especially if the client does not speak the same language as the nurse, as it may be misinterpreted or misunderstood. This is correct. When the nurse starts teaching, the client shows anxiety about the health topic by the difficult and argumentative behavior. The level of client anxiety can be a barrier to learning, the nurse must assess anxiety and stress to make sure the teaching is done at a time of the lowest levels of anxiety and stress. This is incorrect. Insurance status is not a priority to follow up on with regard to teaching and learning.

PTS: 1 CON: Patient-Centered Care 24. ANS: 2, 3, 4 Chapter: Chapter 19 Teaching & Learning Objective: Name, define, and give one example of each of Bloom’s three domains of learning. Page: 390 (V1) Heading: Learning Occurs in Three Domains and Active Involvement Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care

Difficulty: Moderate

3. 4.

Feedback This is incorrect. Affective learning includes integrating new ideas, considering one’s own preferences, and committing to a new idea. The question does not address the patient’s attitudes toward the learning experience. This is correct. Active learning involves the learner’s participation. A return demonstration is a classic example of active learning in which the participant experiences the content. This is correct. The item shows cognitive learning; from the nurse’s description of the task, the patient learns why to do the dressing change. This is correct. Psychomotor learning occurs as the patient returns the demonstration of the dressing change. With the patient describing the task and demonstrating it, the nurse can evaluate the patient’s level of understanding and skill as well. This is incorrect. Passive learning occurs when the learner is a recipient of information but does not engage in it, ask questions, or demonstrate mastery of learning.

PTS: 1 CON: Patient-Centered Care 25. ANS: 1, 2, 3, 4 Chapter: Chapter 19 Teaching & Learning Objective: Describe the content of a learning assessment. Page: 399 (V1) Heading: Assessment Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is correct. The nurse would assess learning needs for changing the bag. This is correct. The nurse must assess the client’s beliefs about an ostomy. This is correct. Assessing the client’s emotional readiness to learn about an ostomy is essential. This is correct. The nurse must assess the manual dexterity of the client since will be manipulating and changing the ostomy bag. This is incorrect. While the client’s relationship is important, it is not important in assessing the learning needs of the client.

PTS:

CON: Patient-Centered Care

Chapter 20. Measuring Vital Signs Multiple Choice Identify the choice that best completes the statement or answers the question. 1. A client’s vital signs at the beginning of the shift are as follows: oral temperature 99.3°F (37°C), heart rate 82 beats/min, respiratory rate 14 breaths/min, and blood pressure 118/76 mm Hg. Four hours later, the client’s oral temperature is 102.3°F (39.1°C). Based on the temperature change, the nurse should anticipate the client’s heart rate would be how many beats/min? 1. 62 2. 82 3. 112 4. 132 2. The nurse is assessing vital signs for a client after a surgical procedure on the left leg. Intravenous (IV) fluids are infusing. Which action would be most important for the nurse to take? 1. Compare the left pedal pulse with the right pedal pulse. 2. Count the client’s respiratory rate for 1 full minute. 3. Take blood pressure in the arm without an IV line. 4. Obtain oral temperature with an electronic thermometer. 3. The nurse hears rhonchi when auscultating a client’s lungs. Which nursing intervention would be appropriate for the nurse to implement before reassessing lung sounds? 1. Have the client take several deep breaths. 2. Ask the client to take a deep breath and cough. 3. Take the client’s blood pressure and apical pulse readings. 4. Count the client’s respiratory rate for 1 minute. 4. Which set of vital signs are all within normal limits for patients at rest? 1. Infant: Temperature (T) 98.8°F (37.1°C) (rectal); heart rate (HR) 160; respiratory rate (RR) 16; blood pressure (BP) 120/54 mm Hg 2. Adolescent: T 98.2°F (37°C) (oral); HR 80; RR 18; BP 108/68 mm Hg 3. Adult: T 99.6°F (37.6°C) (oral); HR 48; RR 22; BP 130/84 mm Hg 4. Older adult: T 98.6°F 37°C) (oral); HR 110; RR 28; BP 170/100 mm Hg 5. The nurse assesses the following changes in a client’s vital signs. Which client situation should be reported to the primary care provider? 1. Decreased blood pressure (BP) after standing up 2. Decreased temperature after a period of diaphoresis 3. Increased heart rate after walking down the hall 4. Increased respiratory rate when the heart rate increases 6. A 1-day postoperative client has a temperature of 36.8°C. What is the nurse’s next best action? 1. Contact the primary care provider for guidance.

2. Document the temperature, and continue with nursing care. 3. Administer the prescribed antipyretic medication. 4. Instruct the client to drink more fluids. 7. The client has an order for the drug digitalis, which has the effect of decreasing the heart rate. Which site should the nurse use to obtain a pulse rate prior to administering the medication? 1. Radial 2. Temporal 3. Apical 4. Brachial 8. A client’s vital signs 4 hours ago were temperature (oral) 101.4F (38.6C), heart rate 110 beats/min, respiratory rate 26 breaths/min, and blood pressure 124/78 mm Hg. The temperature is now 99.4F (37.4C). Based only on the expected relationship between temperature and respiratory rate, which respiratory rate would the nurse expect to find? 1. 16 2. 18 3. 20 4. 22 9. Which client would probably have a higher than normal respiratory rate? A client who has: 1. Had surgery and is receiving a narcotic analgesic 2. Had surgery and lost a unit of blood intraoperatively 3. Lived at a high altitude and then moved to sea level 4. Been exposed to the cold and is now hypothermic 10. For which adult client should the nurse make follow-up observations and monitor the vital signs closely? A client whose: 1. Resting morning blood pressure (BP) is 128/78 mm Hg, whereas the afternoon BP is 122/76 mm Hg 2. Oral temperature is 97.9°F (36.6°C) in the morning and 99.8°F (37.7°C) in the evening 3. Heart rate is 76 beats/min before eating and 88 beats/min after eating 4. Respiratory rate is 16 breaths/min when standing and 18 breaths/min when lying down 11. A client who has been hospitalized for an infection states, “The nursing assistant told me my vital signs are all within normal limits; that means I’m cured.” Which is the best response by the nurse? 1. “The vital signs confirm that your infection is resolved; how do you feel?” 2. “I’ll let your healthcare provider know so that you can be discharged.” 3. “Your vital signs are stable, but there are other things to monitor.” 4. “We still need to keep monitoring your blood pressure for a while.” 12. After obtaining a full set of vital signs, the nurse assesses the client’s fifth vital sign as a 7 on a scale of 1 to 10 (or 7/10). Which parameter would the nurse document as a 7/10?

1. 2. 3. 4.

Pulse pressure Pain Oxygen saturation Emotional distress

13. A client’s axillary temperature is 100.8°F (38.2°C). The nurse realizes that this is outside the normal range for this client and that axillary temperatures do not reflect the core temperature. What should the nurse do to obtain a good estimate of the core temperature? 1. Add 1°F to 100.8°F to obtain an oral equivalent. 2. Add 2°F to 100.8°F to obtain a rectal equivalent. 3. Obtain a rectal temperature reading. 4. Obtain a tympanic membrane reading. 14. A 42-year-old female client has a rectal temperature reading of 39.2°C (102.6°F). Her blood pressure has decreased from 124/76 to 118/70 mm Hg since taken 4 hours earlier. Her pulse rate has increased from 68 to 78 beats/min. What is the nurse’s best initial action? 1. Document the vital signs, and discontinue the assessment. 2. Contact the provider immediately due to the alarming changes in the vital signs. 3. Obtain a pulmonary artery temperature reading before initiating any type of treatment. 4. Ask the unlicensed assistive personnel (UAP) to obtain another set of vital signs in 4 hours. 15. The nurse is teaching a client how to use a portable blood pressure device to monitor the blood pressure at home. Which action is most important for the nurse to take? 1. Ask the client to demonstrate the use of the blood pressure device. 2. Explain the importance of frequent calibration of the device. 3. Give the client a chart to record the blood pressure readings. 4. Provide written instructions of the information taught. 16. At last measurement, the client’s vital signs were as follows: oral temperature 98°F (36.7°C), heart rate 76 beats/min, respiratory rate 16 breaths/min, and blood pressure (BP) 118/60 mm Hg. Four hours later, the vital signs are as follows: oral temperature 103.2°F (39.6°C), heart rate 76 beats/min, respiratory rate 14 breaths/min, and blood pressure 120/66 mm Hg. Which should be the nurse’s first intervention at this time? 1. Ask the client whether he has had a warm drink in the last 30 minutes. 2. Notify the primary care provider of the client’s temperature. 3. Determine if the client is feeling chilled. 4. Take the temperature by a different route. 17. A client’s average normal temperature is 98°F (36.7°C). Which temperature would be expected during the night in this healthy, young adult client who does not have a fever, inflammatory process, or underlying health problems? 1. 97.2°F (36.2°C) 2. 98.0°F (36.7°C)

3. 98.6°F (37°C) 4. 99.2°F (37.3°C) 18. The nurse is instructing a client how to appropriately dress an infant in cold weather. Which instruction would be most important for the nurse to include? 1. Be sure to put mittens on the infant. 2. Layer the infant’s clothing. 3. Place a cap on the infant’s head. 4. Put warm booties on the infant. 19. In evaluating a client’s blood pressure (BP) for hypertension, it would be most important for the nurse to take which action? 1. Use the same type of manometer each time. 2. Auscultate all five Korotkoff sounds. 3. Measure BP in both arms. 4. Monitor BP for a pattern. 20. The nurse enters the client’s room and before taking vital signs, the nurse hears a piercing, highpitched sound coming from the client when breathing. Which best action should the nurse take initially? 1. Document the finding, and continue with the assessment. 2. Ask the client to cough and deep breathe over the next 24 hours. 3. Give the client extra fluids to loosen the secretions of mucus. 4. Assess the client’s airway patency. 21. The nurse provides client education regarding hypertension prevention and management. Which statement indicates the client understands the instructions? 1. “I don’t have to worry if my blood pressure (BP) is high once in a while.” 2. “I guess I will have to make sure I don’t drink too much water.” 3. “I can lose some weight to help lower my BP.” 4. “I will need to reduce the amount milk and other dairy products I use.” 22. For which patient would it be most important to obtain an apical–radial pulse and calculate the pulse deficit? A patient who: 1. Had abdominal surgery 2 hours ago 2. Suffered a fractured hip yesterday 3. Is dehydrated from vomiting 4. Has a heart or lung disease 23. Which procedure technique has the most effect on the accuracy of an irregular apical pulse count? 1. Counting the rate for 1 full minute 2. Exposing only the left side of the chest 3. Determining why assessment of apical pulse is indicated 4. Using the ring finger to palpate the intercostal spaces

24. Which assessment data best supports a report of severe pain in an adult client whose baseline vital signs are within an average normal range? 1. Oral temperature: 100°F (37.8°C) 2. Respiratory rate: 26 breaths/min and shallow 3. Apical heart rate: 56 beats/min 4. Blood pressure: 124/72 mm Hg 25. During a clinic interview, a client states he has been experiencing dizziness upon standing. Which nursing action is appropriate for the nurse to implement? 1. Ask the client when in the day dizziness occurs. 2. Help the client to assume the Trendelenburg position. 3. Take both heart rate and blood pressure with the client standing. 4. Measure vital signs with the client supine, sitting, and standing. 26. The nurse obtains a blood pressure (BP) reading of 160/90 mm Hg from a cardiac patient. What is the first action by the nurse? 1. Obtain BP readings with the client in the lying, sitting, and standing positions. 2. Contact the primary care provider for medication orders. 3. Recheck BP in 30 minutes. 4. Check the patient’s BP pattern over the past 3 days. 27. The nurse obtains the following vital signs on an adult patient: temperature (T) 100.6°F (38.1°C); blood pressure (BP) 100/60 mm Hg; heart rate (HR) 110 beats/min; respiratory rate (RR) 36 breaths/min. What is the first action by the nurse? 1. Offer oral fluids. 2. Begin an intravenous (IV) infusion. 3. Obtain a pulse oximetry reading. 4. Administer oxygen. 28. The nurse is caring for a patient in a skilled nursing center. What is the likely schedule for measuring the patient’s vital signs? 1. Every 4 hours 2. Once per shift 3. Once a week 4. Every 2 hours for 24 hours 29. The nurse administers two blood pressure (BP) medications to a patient and asks the certified nurse assistant (CNA) to obtain a BP reading in 30 minutes. The CNA states, “I just took the BP.” What is the most appropriate response by the nurse? 1. “Take it again so that we can be sure nothing else is wrong with the patient.” 2. “I need to check the patient’s response to the BP medications.” 3. “If BP drops too much, I’ll need to discontinue one of the medications.” 4. “If you just took the BP, then recheck it in 2 hours instead.”

30. The nurse is caring for a critically ill patient with a severe midbrain injury involving the hypothalamus. Which vital sign is most critical for the nurse to monitor closely for this patient? 1. Temperature 2. Pulse 3. Respirations 4. Blood pressure 31. The nurse volunteers to work at the annual summer 20-mile marathon in the community. Which assessment finding will alert the nurse a runner is experiencing heat exhaustion? 1. Slurred speech 2. Impaired judgment 3. Bradycardia 4. Diaphoresis 32. The nurse documents a patient’s radial pulse rate as 100 beats/min and regular. One hour later, the nurse rechecks the pulse, and it is irregular at 120 beats/min. What is the most appropriate nursing action? 1. Ask another nurse to check the pulse. 2. Administer fluids while the patient is in bed. 3. Place the patient on a cardiac monitor. 4. Check the pulse in the opposite arm. 33. The nurse palpates a radial pulse on an 80-year-old patient and notes that it feels irregular. What is the most appropriate method to count this patient’s pulse? 1. Count for 15 seconds, multiply by 4. 2. Count for 30 seconds, multiply by 2. 3. Count for 1 full minute. 4. Count for 10 seconds multiply by 6. 34. The nurse is caring for a patient with a history of postural hypotension. The nurse obtains a blood pressure (BP) reading of 130/80 mm Hg with the patient lying and 100/60 mm Hg with the patient standing. What is the highest priority nursing diagnosis for this patient? 1. Risk for falls 2. Risk for fatigue 3. Risk for dizziness 4. Risk for activity intolerance 35. The nurse on a medical-surgical unit palpates a patient’s carotid pulse for 30 seconds and obtains a rate of 80 beats/min. The nurse knows in obtaining a patient’s carotid pulse, careful technique must be followed to prevent which response? 1. Increase in heart rate 2. Decrease in heart rate 3. Increase in blood pressure 4. Irregular heart rhythm

36. The nurse is obtaining vital signs on a newborn infant and notes respirations at 56 breaths/min. What is the most appropriate action by the nurse? 1. Apply oxygen immediately. 2. Document the finding while continuing the assessment. 3. Contact the obstetrician for orders. 4. Compare the finding with other infants in the nursery. Multiple Response Identify one or more choices that best complete the statement or answer the question. 37. The nurse caring for a postsurgical patient obtains an oral temperature reading of 102°F (38.9°C). The nurse contacts the surgeon, obtains an order, and administers acetaminophen 650 mg orally. Which clinical data should the nurse document? Select all that apply. 1. Oral temperature 102°F (38.9°C) 2. Called the surgeon to obtain the order 3. Administered acetaminophen 650 mg orally 4. Administered aspirin 650 mg orally 5. Rectal temperature 102°F (38.9°C) 38. Which blood pressure reading has a pulse pressure within normal limits? Select all that apply. 1. 104/50 mm Hg 2. 120/62 mm Hg 3. 120/80 mm Hg 4. 130/86 mm Hg 5. 180/70 mm Hg 39. Which interventions would be appropriate for a client who has a fever? Select all that apply. 1. Put an ice pack on the client’s neck and axillae. 2. Provide the client with several blankets. 3. Offer the client fluids to drink every 1 to 2 hours. 4. Take the temperature using a tympanic thermometer. 5. Place caffeinated drinks by patient’s bedside. 40. Comparing the changes in vital signs as a person ages, which statements are correct? Select all that apply. 1. Blood pressure decreases, but less than heart rate and respiratory rate. 2. Respiratory rate remains fairly stable throughout a person’s life. 3. Blood pressure increases; respiratory rate declines. 4. Men have higher blood pressure than women until after menopause. 5. Body temperature rises slightly as one ages. 41. Which of these steps in taking a blood pressure are correct? Select all that apply. 1. Use a bladder that encircles 40% of the arm. 2. Wrap the cuff snugly around the client’s arm.

3. Ask the client to hold the arm at heart level. 4. Have the client sit with feet flat on the floor. 5. Identify client with one identifier. 42. When assessing the quality of a client’s pedal pulses, what is the nurse assessing? Select all that apply. 1. Rhythm of the pulses 2. Strength of the pulses 3. Bilateral equality of pulses 4. Rate compared with apical pulse 5. Intervals between heartbeats 43. Which nursing interventions are appropriate for a patient who has been admitted with a diagnosis of Dehydration and has a temperature of 101.5°F (38.6°C)? Select all that apply. 1. Provide oral and/or intravenous (IV) fluids. 2. Take vital signs every 2 hours. 3. Contact the provider for respirations of 18 breaths/min. 4. Keep the patient on a “nothing by mouth” (NPO) diet until defervescence occurs. 5. Increase physical activity level. 44. A 70-year-old homeless man is admitted to the emergency department with heat stroke following 3 days of overexposure to outside temperatures. The nurse is most alert to which signs and symptoms associated with heat stroke? Select all that apply. 1. Temperature of 103.8°F (39.9°C) 2. Throbbing headache 3. Diaphoresis 4. Confusion 5. Red, hot dry skin

Chapter 20. Measuring Vital Signs Answer Section MULTIPLE CHOICE 1. ANS: 3 Chapter: Chapter 20 Measuring Vital Signs Objective: Describe the physiological processes involved in regulating body temperature, pulse, respirations, and blood pressure. Page: 427 (V1) Heading: What Factors Influence Pulse Rate? Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Thermo-regulation Difficulty: Moderate

1 2 3

Feedback This is incorrect. Sixty-two beats/min is too low. Pulse rate would increase with a fever. This is incorrect. With an increase in fever, pulse rate should have increased to greater than 82 beats/min. With a fever, heart rate would not stay the same. This is correct. Heart rate would have increased from 82 to 112 beats/min. Temperature increased by 3°C (3  10 = 30; 82 + 30 = 112). Heart rate increases about 10 beats/min for each degree Fahrenheit of temperature to meet increased metabolic needs and compensate for peripheral dilation. This is incorrect. A heart rate of 132 beats/min is too high for this temperature increase.

PTS: 1 CON: Thermo-regulation 2. ANS: 1 Chapter: Chapter 20 Measuring Vital Signs Objective: Describe nursing interventions for the client (1) with temperature alterations; (2) with impaired respiratory status; (3) diagnosed with high blood pressure (hypertension); and (4) with alterations in pulse parameters. Page: 200 (V1) Heading: highlights of procedures, box: Highlights of Procedures 20-1 through 20-6 and Procedure Steps > Palpate the Dorsalis Pedis Pulse Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Perfusion

Difficulty: Moderate Feedback 1 This is correct. For a client having surgery on the leg, the most important data would be whether the circulation has been compromised because of the surgery. This assessment can be made only by comparing one leg with the other. 2 This is incorrect. While the nurse would count the respiratory rate for 1 full minute, it is not the most important. 3 This is incorrect. Taking the BP in the arm without the IV is standard practice but there is another action that is more important. 4 This is incorrect. Oral temperatures are commonly obtained using electronic thermometers. However, this is not the most important. PTS: 1 CON: Perfusion 3. ANS: 2 Chapter: Chapter 20 Measuring Vital Signs Objective: Demonstrate correct technique and procedures for measuring temperature, pulse, respiration, and blood pressure. Page: 437 (V1) Heading: What Data Should I Obtain? > Breath Sounds Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 This is incorrect. Deep breathing will not help clear rhonchi. 2 This is correct. Rhonchi are caused by secretions in the large airways and may clear with coughing. This is how the nurse differentiates between rhonchi and other adventitious sounds. 3 This is incorrect. Taking blood pressure and apical pulse readings are not effective for clearing rhonchi, and would not be sufficient for the nurse to identify whether the sounds were, indeed, rhonchi. 4 This is incorrect. Counting the respiratory rate is not effective for clearing rhonchi and would not be sufficient for the nurse to identify whether the sounds were, indeed, rhonchi. PTS: 1 CON: Oxygenation 4. ANS: 2 Chapter: Chapter 20 Measuring Vital Signs Objective: Discuss expected normal vital signs findings for various age groups. Page: 414 (V1) Heading: Table 20-2 Comparison of Normal Vital Signs for Various Ages

Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is incorrect. The infant’s temperature is below normal for a rectal reading because the core temperature is approximately 1 degree higher than readings from other sites. HR for an infant is normal, RR is low, and BP is high for the age. 2 This is correct. All of the adolescent’s vital signs are within normal parameters for the age. 3 This is incorrect. For the typical adult, the temperature is high, HR is low, RR is high, and BP is elevated for the age. 4 This is incorrect. For the older adult, the temperature is high-end normal, HR is high, RR is high, and BP is high for the age. PTS: 1 CON: Patient-Centered Care 5. ANS: 1 Chapter: Chapter 20 Measuring Vital Signs Objective: Recognize client vital signs readings that should be referred to the primary care provider. Page: 446 (V1) Heading: Example Problem: Hypotension Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Collaboration Difficulty: Moderate Feedback 1 This is correct. A decrease in the client’s blood pressure when standing indicates orthostatic hypotension, and the cause should be investigated. 2 This is incorrect. Temperature decreasing after a period of diaphoresis is a normal finding and should not be referred to the primary care provider. 3 This is incorrect. Heart rate increases after activity and does not have to be reported. 4 This is incorrect. Respiratory rate increases when the heart rate increases and does not have to be referred to the primary care provider. PTS: 1 CON: Collaboration 6. ANS: 2 Chapter: Chapter 20 Measuring Vital Signs

Objective: Convert between the Fahrenheit and centigrade temperature scales. Page: 413 (V1) Heading: What Is Thermoregulation? and What Is a Normal Temperature? Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Thermo-regulation Difficulty: Difficult Feedback 1 This is incorrect. The primary care provider does not have to be contacted for a normal temperature. 2 This is correct. The temperature of 36.8°C is equivalent to 98.2°F. This is a normal temperature for a postoperative client. To convert Fahrenheit to centigrade, subtract 32 from the temperature, and multiply by 5/9. Because this is a normal temperature, no change in action is needed. The nurse should compare this reading with the previous temperature reading and document the temperature in the medical records. 3 This is incorrect. The client’s temperature is not elevated and should not require antipyretic medication. 4 This is incorrect. Since the client’s temperature is not elevated, extra fluids are not needed. PTS: 1 CON: Thermo-regulation 7. ANS: 3 Chapter: Chapter 20 Measuring Vital Signs Objective: Select the correct site and equipment for measuring the temperature, pulse, respiration, and blood pressure of patients in various age groups. Page: 423 (V1) Heading: What Sites Should I Use? > When Should I Take an Apical Pulse? Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback 1 This is incorrect. The radial pulse is not the best site when the client is taking digitalis. 2 This is incorrect. The temporal site is not used when the client is taking digitalis. 3 This is correct. The nurse should use count the pulse rate for 1 full minute using the apical site. It is the most accurate of any of the peripheral sites. When administering medications that affect the heart rate, an accurate rate is essential. 4 This is incorrect. When the client is taking digitalis, the brachial pulse is not

used. There is a better site that is more accurate. PTS: 1 CON: Perfusion 8. ANS: 2 Chapter: Chapter 20 Measuring Vital Signs Objective: Describe the physiological processes involved in regulating body temperature, pulse, respirations, and blood pressure. Page: 534 (V1) Heading: What Factors Influence Respiration? Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Thermo-regulation Difficulty: Moderate

1 2

3 4

Feedback This is incorrect. This rate (16 breaths/min) is too low when compared with the temperature drop. This is correct. For every degree Fahrenheit (0.6C) the temperature falls, the respiratory rate may decrease up to four breaths per minute. The client’s temperature has fallen by 2F; multiplied by 4, this is 8. Respiratory rate was 26 breaths/min. Thus, 26 minus 8 = 18 breaths/min. This is incorrect. The respirations would decrease by more than 6 breaths/min from the drop in temperature. This is incorrect. The respirations would decrease by more than 4 breaths/min from the drop in temperature.

PTS: 1 CON: Thermo-regulation 9. ANS: 2 Chapter: Chapter 20 Measuring Vital Signs Objective: Describe the physiological processes involved in regulating body temperature, pulse, respirations, and blood pressure. Page: 434 (V1) Heading: What Factors Influence Respiration? Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 This is incorrect. Narcotics slow respiratory rate. 2 This is correct. A reduction in hemoglobin from blood loss would increase

3 4

respiratory rate. This is incorrect. Although high altitudes increase respirations, going to a lower altitude would decrease respiratory rate or have no effect. This is incorrect. Hypothermia decreases metabolic rate, so respiratory rate would decrease.

PTS: 1 CON: Oxygenation 10. ANS: 1 Chapter: Chapter 20 Measuring Vital Signs Objective: Define hypotension, hypertension, essential hypertension, and secondary hypertension. Page: 448 (V1) Heading: Example Problem: Hypertension Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is correct. Both systolic and diastolic BP would be classified as elevated, and the resting BP is higher than the afternoon BP, so the client would need further observation. 2 This is incorrect. Body temperature normally increases during the course of a day and does not require follow-up. 3 This is incorrect. Heart rate increases for several hours after eating and does not require follow-up. 4 This is incorrect. Respiratory depth decreases when lying down; both rates are within normal limits, indicating that no follow-up is needed. PTS: 1 CON: Patient-Centered Care 11. ANS: 3 Chapter: Chapter 20 Measuring Vital Signs Objective: Describe the physiological processes involved in regulating body temperature, pulse, respirations, and blood pressure. Page: 412 (V1) Heading: What Are Vital Signs? Integrated Processes: Communication and Documentation Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Communication Difficulty: Difficult Feedback 1 This is incorrect. Vitals signs alone cannot indicate a client’s infection is gone.

Other parameters must be included. This is incorrect. The healthcare provider’s decision regarding the client’s readiness for discharge is not based exclusively on the vital signs but, rather, is based on a compilation of other sources of information, primarily the client’s clinical status. This is correct. Vital signs are one indicator of a client’s physiological status, but they are not an absolute indicator of well-being from every aspect. It may be inaccurate to state that the vital signs indicate the infection is resolved; vital signs could stabilize even if the infection remains active. This is incorrect. Although the nurse will need to continue monitoring blood pressure, other clinical signs (e.g., temperature) must also be monitored; therefore, the statement “We still need to keep monitoring your blood pressure …” is incomplete.

PTS: 1 CON: Communication 12. ANS: 2 Chapter: Chapter 20 Measuring Vital Signs Objective: Discuss expected normal vital signs findings for various age groups. Page: 450 (V1) Heading: Other Vital Signs Integrated Processes: Communication and Documentation Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Comfort Difficulty: Easy Feedback 1 This is incorrect. Pulse pressure is the difference between the systolic and diastolic pressures, not the “fifth vital sign.” 2 This is correct. Pain is considered the “fifth vital sign.” 3 This is incorrect. Oxygen saturation is measured by pulse oximetry, which provides important information on arterial blood oxygen concentration levels. 4 This is incorrect. Emotional distress can have an impact on overall physiological functioning, but it is not the “fifth vital sign.” PTS: 1 CON: Comfort 13. ANS: 3 Chapter: Chapter 20 Measuring Vital Signs Objective: Select the correct site and equipment for measuring the temperature, pulse, respiration, and blood pressure of patients in various age groups. Page: 413 (V1) Heading: What Is Thermoregulation? > Core Temperature Integrated Processes: Nursing Process

Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Thermo-regulation Difficulty: Moderate Feedback 1 This is incorrect. For oral, axillary, and rectal temperatures, there is a 1°F degree difference between each site and the next higher one. However, mathematical conversions between sites are not reliable and should be used only when a rough estimate is needed because it does not reflect the core temperature. 2 This is incorrect. There is a 2°F difference between an axillary reading and a rectal reading, but it is only an estimate and not a reflection of the core temperature. 3 This is correct. Rectal temperatures are reliable and accurately reflect the core temperature. Body temperatures, from lowest to highest, are axillary, oral, tympanic, rectal, and temporal. 4 This is incorrect. A tympanic reading does not indicate the core temperature. PTS: 1 CON: Thermo-regulation 14. ANS: 4 Chapter: Chapter 20 Measuring Vital Signs Objective: Describe nursing interventions for the client (1) with temperature alterations; (2) with impaired respiratory status; (3) diagnosed with high blood pressure (hypertension); and (4) with alterations in pulse parameters. Page: 450 (V1) Heading: Evaluating Vital Signs Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Thermo-regulation Difficulty: Moderate Feedback 1 This is incorrect. While the nurse would document the vital signs, the nurse would not discontinue the assessment. The nurse needs to finish the assessment. 2 This is incorrect. While there are changes in the vital signs, it does not require contacting the provider immediately. If the vital signs continue to worsen then the provider may need to be notified. 3 This is incorrect. Obtaining a pulmonary artery temperature is invasive and not a recommended course of action. 4 This is correct. The nurse simply needs to continue monitoring the client’s vital signs. The client’s temperature of 102.5°F (39.2°C) is not considered an emergency temperature for an adult. A moderate fever of up to 103°F (39.5°C) is considered a mechanism by which the body fights off infection. The

metabolic rate is expected to increase with a fever, which will lead to an increase in the pulse rate. Blood pressure is more likely to decrease with a fever because of peripheral vasodilation. PTS: 1 CON: Thermo-regulation 15. ANS: 1 Chapter: Chapter 20 Measuring Vital Signs Objective: Identify important tips to teach your clients in managing their hypertension. Page: 442 (V1) Heading: Unnumbered HC box side bar: Home Care > Teaching Your Client Self-Monitoring of Blood Pressure Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is correct. Self-monitoring of blood pressure is of little value unless it is done using proper technique. Requesting the client demonstrate the procedure would allow the nurse to evaluate the client’s technique. 2 This is incorrect. Calibration of the home-monitoring device occurs at least once a year or according to the manufacturer’s instructions; it does not have to be done frequently. 3 This is incorrect. While a chart is helpful, it is not the most important. 4 This is incorrect. Written instructions are needed, but the technique itself is the most important. PTS: 1 CON: Patient-Centered Care 16. ANS: 1 Chapter: Chapter 20 Measuring Vital Signs Objective: Demonstrate correct technique and procedures for measuring temperature, pulse, respiration, and blood pressure. Page: 427 (V1) Heading: Table 20-4 Disadvantages and Contraindications of Various Sites for Measuring Temperature > Oral Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Thermo-regulation Difficulty: Moderate Feedback 1 This is correct. With a fever, heart rate and respiratory rate are usually elevated.

2 3

In this case, they are within normal limits, so the nurse should wonder about the accuracy of the temperature reading and validate it in some way. Because having a hot drink is a common cause of false readings, the nurse should determine whether that has occurred before retaking or otherwise validating the reading. This is incorrect. The nurse should investigate further before notifying the provider. This is incorrect. If the other vital signs were altered, this would be a good question to ask, but because the only significant change in vital signs is the temperature, asking this question is incorrect. This is incorrect. The nurse should assess further before implementing a plan of action.

PTS: 1 CON: Thermo-regulation 17. ANS: 1 Chapter: Chapter 20 Measuring Vital Signs Objective: Discuss expected normal vital signs findings for various age groups. Page: 416 (V1) Heading: What Factors Influence Body Temperature? Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Thermo-regulation Difficulty: Easy Feedback 1 This is correct. The lowest temperature occurs during sleep (usually at night) when metabolic rate is lowest. Temperature normally increases throughout the day until it peaks in the early evening. 2 This is incorrect. Temperature is affected by the circadian rhythm, making temperature fluctuate, not stay the same. 3 This is incorrect. Because of the circadian rhythm, body temperature will fluctuate and decrease during sleep. 4 This is incorrect. Temperature usually decreases, not increases, during sleep. PTS: 1 CON: Thermo-regulation 18. ANS: 3 Chapter: Chapter 20 Measuring Vital Signs Objective: Describe the physiological processes involved in regulating body temperature, pulse, respirations, and blood pressure. Page: 416 (V1) Heading: What Factors Influence Body Temperature? > Developmental Level Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance

Cognitive Level: Application [Applying] Concept: Thermo-regulation Difficulty: Moderate Feedback 1 This is incorrect. The hands are not the area that from which infants lose most of their body heat. 2 This is incorrect. Although layering can be used, it is not the most important for infants; however, it can be useful in older adults. 3 This is correct. Because of the many blood vessels close to the skin surface in the head, infants lose approximately one-third of their body heat through the head. Therefore, to prevent heat loss, it is most important to cover the head. 4 This is incorrect. The feet are not the area from which infants lose most of their body heat. PTS: 1 CON: Thermo-regulation 19. ANS: 4 Chapter: Chapter 20 Measuring Vital Signs Objective: Explain the importance of several measurements to interpret a client’s blood pressure. Page: 448 (V1) Heading: Example Problem: Hypertension Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Evidence-Based Practice Difficulty: Moderate Feedback 1 This is incorrect. The type of manometer does not greatly influence the reliability of BP readings. 2 This is incorrect. Only the first and last Korotkoff sounds are necessary to determine a BP reading. 3 This is incorrect. The first time BP is assessed in a client, the nurse should compare the reading in the left and right arm; however, this is not specific to evaluating for hypertension. 4 This is correct. BP fluctuates a great deal during the day and is influenced by age, gender, activity, and many other factors. Any determination of hypertension must be made after two or more BP readings have been taken on 2 separate occasions. PTS: 1 CON: Evidence-Based Practice 20. ANS: 4 Chapter: Chapter 20 Measuring Vital Signs

Objective: Demonstrate correct technique and procedures for measuring temperature, pulse, respiration, and blood pressure. Page: 436 (V1) Heading: What Data Should I Obtain? > Breath Sounds Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Oxygenation Difficulty: Moderate Feedback 1 This is incorrect. The nurse should stop the assessment and treat the respiratory complication first. 2 This is incorrect. Coughing would help if the problem involved rhonchi, but based on the data in the question, the problem is not rhonchi. 3 This is incorrect. The client is experiencing a respiratory complication that needs to be addressed, but not with fluids. 4 This is correct. These sounds are known as stridor and indicate that the client is in respiratory distress or has an obstructed airway. The nurse’s initial action is to assess the patency of the airway. PTS: 1 CON: Oxygenation 21. ANS: 3 Chapter: Chapter 20 Measuring Vital Signs Objective: Identify important tips to teach your clients in managing their hypertension. Page: 448 (V1) Heading: Example Problem: Hypertension and Clinical Insight 20-3 Teaching Your Client About Hypertension Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Whenever the client has an elevated BP, the reading should be monitored even when it occurs just occasionally. 2 This is incorrect. Drinking too much alcohol and increased sodium consumption are associated with hypertension, but water consumption is not. 3 This is correct. A single lifestyle change, such as weight loss, can lower BP. 4 This is incorrect. A diet high in calcium is recommended to prevent and manage hypertension; therefore, it is not advisable to limit the intake of dietary calcium found in dairy products.

PTS: 1 CON: Patient-Centered Care 22. ANS: 4 Chapter: Chapter 20 Measuring Vital Signs Objective: Demonstrate correct technique and procedures for measuring temperature, pulse, respiration, and blood pressure. Page: 432 (V1) Heading: When Should I Take an Apical-Radial Pulse? and Procedure 20-4 Assessing for an Apical Radial Pulse Deficit Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate Feedback 1 This is incorrect. Abdominal surgery does not routinely require an apical–radial pulse deficit. 2 This is incorrect. An apical–radial pulse deficit is not required for a fractured hip. 3 This is incorrect. An apical–radial pulse deficit is required for oxygenation problems, not vomiting. 4 This is correct. Conditions that require assessment of pulse deficit include digitalis therapy, blood loss, cardiac or respiratory disease, and other conditions that affect oxygenation status. PTS: 1 CON: Perfusion 23. ANS: 1 Chapter: Chapter 20 Measuring Vital Signs Objective: Demonstrate correct technique and procedures for measuring temperature, pulse, respiration, and blood pressure. Page: 414 (V1) Heading: Procedure 20-2 Assessing Peripheral Pulses Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback 1 This is correct. Apical pulse is generally indicated for patients with cardiac conditions or who are taking cardiac medications. Often, they have irregular heartbeats or slow rates. A more accurate count is obtained when such heartbeats are counted for 1 full minute. 2 This is incorrect. Exposing the chest is, of course, necessary; exposing only the

3 4

left side protects the patient’s privacy but does not improve the accuracy. This is incorrect. The nurse should know why an apical pulse is indicated, but this would not affect the accuracy of the count. This is incorrect. Which finger the nurse uses to palpate depends on which hand is used. Even if the nurse failed to use the index or ring finger, this would be unlikely to affect the accuracy of the counting.

PTS: 1 CON: Perfusion 24. ANS: 2 Chapter: Chapter 20 Measuring Vital Signs Objective: Describe the physiological processes involved in regulating body temperature, pulse, respirations, and blood pressure. Page: 434 (V1) Heading: What Factors Influence Respiration? Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Comfort Difficulty: Easy Feedback 1 This is incorrect. Elevated temperature does not indicate pain. 2 This is incorrect. “Respiratory rate 26 breaths/min and shallow” best supports a report of severe pain in such a client. Acute pain causes an increase in respiratory rate, but a decrease in depth. 3 This is incorrect. The apical pulse is lower than normal, but because pulse rate increases with pain, a rate of 56 beats/min does not indicate pain. 4 This is incorrect. Usually, blood pressure becomes elevated temporarily with acute pain; it may decrease over time with unremitting chronic pain. A blood pressure of 124/72 mm Hg is within normal limits for most people. PTS: 1 CON: Comfort 25. ANS: 4 Chapter: Chapter 20 Measuring Vital Signs Objective: Explain the importance of several measurements to interpret a client’s blood pressure. Page: 446 (V1) Heading: Example Problem: Hypotension > Interventions for Orthostatic Hypotension Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback

1 2

3 4

This is incorrect. The time of day is irrelevant to the diagnosis. This is incorrect. If the nurse observes the client becomes dizzy upon standing, the first action would be to help the client lie down, not place the client in the Trendelenburg position. This is incorrect. The nurse needs to measure both heart rate and blood pressure, but not in the standing position only. This is correct. Dizziness upon standing is a symptom of orthostatic hypotension. The nurse should obtain orthostatic vital signs (measure pulse and blood pressure with the client supine, sitting, and standing) to assess for orthostatic hypotension.

PTS: 1 CON: Perfusion 26. ANS: 4 Chapter: Chapter 20 Measuring Vital Signs Objective: Explain the importance of several measurements to interpret a client’s blood pressure. Page: 440 (V1) Heading: What Factors Influence Blood Pressure? Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. The nurse will assess the patient’s pattern of BP before implementing an intervention. 2 This is incorrect. Before notifying the provider, the nurse would determine whether this is a normal or abnormal finding for this patient. 3 This is incorrect. In this situation, it would not be prudent to wait 30 minutes to recheck the BP because 160/90 mm Hg is an elevated value. 4 This is correct. Blood pressure normally changes from minute to minute with changes in activity or in body position. Therefore, the nurse must establish BP patterns rather than relying on individual BP readings when determining whether a patient’s BP is normal or abnormal. PTS: 1 CON: Patient-Centered Care 27. ANS: 3 Chapter: Chapter 20 Measuring Vital Signs Objective: Demonstrate correct technique and procedures for measuring temperature, pulse, respiration, and blood pressure. Page: 436 (V1) Heading: Procedure 20-5 Assessing Respirations > Evaluation Integrated Processes: Nursing Process

Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Even though temperature is elevated, offering fluids is not the first action the nurse should take in this situation. 2 This is incorrect. Beginning IV fluids is not indicated at this time. 3 This is correct. In this item, all vital signs values are slightly abnormal; however, the most significant abnormality is an RR of 36 breaths/min. If the patient has an elevated temperature, the respiratory rate will increase. Corresponding elevation in pulse with RR may indicate hypoxemia. If respirations are not within normal parameters, oxygenation should be assessed with a pulse oximeter. 4 This is incorrect. The nurse may need to administer oxygen to this patient, given the RR of 36 breaths/min; however, this is another action that must be taken first. PTS: 1 CON: Patient-Centered Care 28. ANS: 3 Chapter: Chapter 20 Measuring Vital Signs Objective: Demonstrate correct technique and procedures for measuring temperature, pulse, respiration, and blood pressure. Page: 412 (V1) Heading: When Should I Measure a Patient’s Vital Signs? Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. The schedule for in the hospital is usually once every 4 to 8 hours. The patient is in a skilled nursing facility, not a hospital. 2 This is incorrect. Once per shift is too often for measuring vital signs in a convalescent hospital or skilled nursing facility. 3 This is correct. In skilled nursing facilities, vital signs can be taken weekly or monthly. 4 This is incorrect. Every 2 hours for 24 hours is too often for measuring a patient’s vital signs in a skilled nursing center. PTS: 1 CON: Patient-Centered Care 29. ANS: 2 Chapter: Chapter 20 Measuring Vital Signs

Objective: Describe nursing interventions for the client (1) with temperature alterations; (2) with impaired respiratory status; (3) diagnosed with high blood pressure (hypertension); and (4) with alterations in pulse parameters. Page: 440 (V1) Heading: What Factors Influence Blood Pressure? > Medications Integrated Processes: Communication and Documentation Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate

3 4

Feedback This is incorrect. In this question, the nurse has just administered BP medications to the patient. Telling the CNA “to make sure nothing is wrong with the patient” is too vague. The nurse needs to determine the effect of the medicine. This is correct. The nurse must evaluate the effectiveness of the BP medications and also unintended effects, such as too great a fall in BP. This effect may be intended, as with antihypertensive medications, or unintended, such as the drop in BP that often results when a patient receives pain medication. This is incorrect. Nurses may contact the prescriber regarding the BP medications, but they cannot discontinue the medications without an order. This is incorrect. Two hours is too long to wait to evaluate medication effects because the effect will likely peak before that.

PTS: 1 CON: Patient-Centered Care 30. ANS: 1 Chapter: Chapter 20 Measuring Vital Signs Objective: Describe the physiological processes involved in regulating body temperature, pulse, respirations, and blood pressure. Page: 413 (V1) Heading: What Is Thermoregulation? Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Thermo-regulation Difficulty: Difficult Feedback 1 This is correct. Temperature regulation is controlled by the hypothalamus; therefore, the nurse would monitor temperature closely. To keep the body temperature constant, the body must balance heat production and heat loss. This balance is controlled by the hypothalamus, which is located between the

2 3

cerebral hemispheres of the brain. This is incorrect. The pulse wave begins when the left heart ventricle (not the hypothalamus) contracts and ends when it relaxes. This is incorrect. Special respiratory centers in the medulla oblongata and pons of the brain (not the hypothalamus), along with nerve fibers of the autonomic nervous system, regulate breathing in response to minute changes in the concentrations of oxygen (O2) and carbon dioxide (CO2) in arterial blood. This is incorrect. Blood pressure regulation is a highly complex process. It is influenced by three factors: cardiac function, peripheral vascular resistance, and blood volume. Blood pressure is not controlled by the hypothalamus.

PTS: 1 CON: Thermo-regulation 31. ANS: 4 Chapter: Chapter 20 Measuring Vital Signs Objective: Describe nursing interventions for the client (1) with temperature alterations; (2) with impaired respiratory status; (3) diagnosed with high blood pressure (hypertension); and (4) with alterations in pulse parameters. Page: 420 (V1) Heading: Example Problem: Hyperthermia/Heat Stroke Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Slurred speech occurs with heat stroke, not heat exhaustion. 2 This is incorrect. Impaired judgment occurs with heat stroke, not heat exhaustion. 3 This is incorrect. A runner with heat exhaustion will experience tachycardia, not bradycardia. 4 This is correct. A runner with heat exhaustion will experience diaphoresis (heavy sweating). PTS: 1 CON: Patient-Centered Care 32. ANS: 3 Chapter: Chapter 20 Measuring Vital Signs Objective: Describe nursing interventions for the client (1) with temperature alterations; (2) with impaired respiratory status; (3) diagnosed with high blood pressure (hypertension); and (4) with alterations in pulse parameters. Page: 427 (V1) Heading: What Is a Normal Pulse Rate? Integrated Processes: Nursing Process

Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Although asking another nurse to check the pulse is acceptable, it is not the most appropriate action. 2 This is incorrect. An irregular heart rate does not indicate the patient needs fluids. 3 This is correct. When heart rate is of concern, the nurse will most likely place a patient on a cardiac monitor to determine not only the rate but also the rhythm and intensity of the pulse. 4 This is incorrect. If the pulse is irregular, peripheral pulses are not the best choice to determine rhythm and intensity. PTS: 1 CON: Patient-Centered Care 33. ANS: 3 Chapter: Chapter 20 Measuring Vital Signs Objective: Demonstrate correct technique and procedures for measuring temperature, pulse, respiration, and blood pressure. Page: 428 (V1) Heading: What Data Should I Collect? > Pulse Rhythm Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Perfusion Difficulty: Easy Feedback 1 This is incorrect. For a normal, healthy adult with a regular rhythm, counting for 15 seconds and multiplying by 4 is acceptable. This technique is not acceptable with an irregular pulse. 2 This is incorrect. If the pulse is irregular, counting for 30 seconds and multiplying by 2 is not acceptable practice. However, this counting technique can be used when the heart rate is regular. 3 This is correct. When assessing an irregular pulse, it is important to determine whether the beat is regularly irregular (an irregular rhythm that forms a pattern) or irregularly irregular (an unpredictable rhythm). To make this distinction, the nurse must count the rate for 1 full minute. 4 This is incorrect. It is not standard practice to count for 10 seconds and multiply by 6 for any type of heartbeat. PTS:

CON: Perfusion

34. ANS: 1 Chapter: Chapter 20 Measuring Vital Signs Objective: State at least one nursing diagnosis to describe a problem for each of the vital signs: temperature, pulse, respirations, and blood pressure. Page: 432 (V1) Heading: Analysis/Nursing Diagnosis Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is correct. Orthostatic or postural hypotension occurs when a person’s BP drops suddenly on moving from the lying position to the sitting or standing position. Orthostatic hypotension is defined as a decrease of 10 mm Hg in standing BP when associated with dizziness and or fainting. With this decrease, the patient is most at risk for falls. 2 This is incorrect. Although fatigue may occur with postural hypotension, it is not the highest priority. 3 This is incorrect. The highest priority is safety, not dizziness. 4 This is incorrect. Safety is the highest priority, not activity intolerance. PTS: 1 CON: Patient-Centered Care 35. ANS: 2 Chapter: Chapter 20 Measuring Vital Signs Objective: Demonstrate correct technique and procedures for measuring temperature, pulse, respiration, and blood pressure. Page: 208 (V2) Heading: Procedure 20-2C Assessing the Carotid Pulse Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback 1 This is incorrect. Heart rate would not increase in this situation. Compressing the carotid arteries can stimulate the carotid bodies and significantly decrease the patient’s heart rate and blood pressure. 2 This is correct. When assessing for a pulse using palpation of the carotid artery, it is important to palpate only one side of the neck at a time. Additionally, palpation should be light and the nurse must avoid massaging the area. Massaging the carotid can create a Valsalva response, causing a decrease in

heart rate and blood pressure. This is incorrect. Blood pressure would suddenly drop if the correct technique is not used. Compressing the carotid arteries can stimulate the carotid bodies and significantly decrease the patient’s heart rate and blood pressure. This is incorrect. The patient’s heart rate could decrease if the correct technique is not used. Pressure on the carotid can stimulate the vagus nerve, causing the pulse and blood pressure to drop suddenly and perhaps fainting or circulatory arrest. It can also decrease circulation to the brain.

PTS: 1 CON: Perfusion 36. ANS: 2 Chapter: Chapter 20 Measuring Vital Signs Objective: Discuss expected normal vital signs findings for various age groups. Page: 433 (V1) Heading: What Factors Influence Respiration? > Developmental Level Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 This is incorrect. Placing the infant on oxygen is not warranted because this is a normal respiratory rate and there are no other issues warranting the need for oxygen. 2 This is correct. The developmental level of the newborn infant is consistent with the respiratory rate obtained, so the nurse would continue the assessment. A newborn’s respiratory rate usually ranges from 40 to 60 breaths/min. Some references give an upper limit of 90 breaths/min. 3 This is incorrect. A call to the obstetrician is not needed because the respiratory rate reading is normal. 4 This is incorrect. The nurse should not need to compare the finding with those of other infants because the nurse knows the norms for the developmental stage. Furthermore, the other infants may or may not have respirations within normal limits, so the comparison would not be helpful. PTS:

CON: Oxygenation

MULTIPLE RESPONSE 37. ANS: 1, 2, 3 Chapter: Chapter 20 Measuring Vital Signs

Objective: Demonstrate correct technique and procedures for measuring temperature, pulse, respiration, and blood pressure. Page: 204 (V2) Heading: Procedure 20-1F Taking a Skin Temperature Using a Chemical Strip Thermometer > Documentation Integrated Processes: Communication and Documentation Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Communication Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is correct. The nurse should record the correct temperature and route. This is correct. The nurse should document notifying the provider. This is correct. The nurse should document interventions taken for the elevated temperature. This is incorrect. The order was for acetaminophen, not aspirin. This is incorrect. The route was oral, not rectal.

PTS: 1 CON: Communication 38. ANS: 3, 4 Chapter: Chapter 20 Measuring Vital Signs Objective: Demonstrate correct technique and procedures for measuring temperature, pulse, respiration, and blood pressure. Page: 438 (V1) Heading: Blood Pressure > Pulse Pressure Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Perfusion Difficulty: Moderate

Feedback This is incorrect. Pulse pressure is systolic blood pressure (SBP) minus diastolic blood pressure (DBP). Pulse pressure is usually approximately one-third of SBP Thus, 104 – 50 = 54; one-third of 104 = 34.7; 54 and 34.7 are not within normal limits. This is incorrect. Pulse pressure is SBP minus DBP. Pulse pressure is usually approximately one-third of SBP. Thus, 120 – 62 = 58; one-third of 120 = 40; 58 and 40 are not within normal limits. This is correct. Pulse pressure is SBP minus DBP. Pulse pressure is usually approximately one-third of SBP. Thus, 120 – 80 = 40; one-third of 120 = 40. Both

4. 5.

indicate a normal pulse pressure. This is correct. Pulse pressure is SBP minus DBP. Pulse pressure is usually approximately one-third of SBP. Thus, 130 – 86 = 44; one-third of 130 = 43. This is incorrect. Pulse pressure is SBP) minus DBP. Pulse pressure is usually approximately one-third of SBP. Thus, 180 – 70 = 110; one-third of 180 = 60; 110 and 60 are not within normal limits.

PTS: 1 CON: Perfusion 39. ANS: 1, 3 Chapter: Chapter 20 Measuring Vital Signs Objective: Describe nursing interventions for the client (1) with temperature alterations; (2) with impaired respiratory status; (3) diagnosed with high blood pressure (hypertension); and (4) with alterations in pulse parameters. Page: 421 (V1) Heading: Example Problem: Hyperthermia/Heat Stroke > Interventions Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Thermo-regulation Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is correct. If ice packs are used, they are applied to the groin, neck, or axillae. This is incorrect. Instruct the client to use minimal bed covers. This is correct. A fever increases metabolic needs, so fluids are necessary to prevent dehydration. This is incorrect. A tympanic thermometer is prone to errors and is not appropriate when an accurate temperature is needed, as when a client has a fever. This is incorrect. Caffeinated drinks are to be avoided during a fever.

PTS: 1 CON: Thermo-regulation 40. ANS: 3, 4 Chapter: Chapter 20 Measuring Vital Signs Objective: Discuss expected normal vital signs findings for various age groups. Page: 416 (V1) Heading: What Factors Influence Body Temperature? > Gero Icon and What Factors Influence the Pulse Rate? > Developmental level and What Factors Influence Respirations? > Developmental level and What Factors Influence Blood Pressure? > Developmental Stage and Gender Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Evidence-Based Practice

Difficulty: Moderate

1. 2. 3.

4. 5.

Feedback This is incorrect. Blood pressure increases as one ages, but heart rate and respirations decline. Resting heart rate increases with age. This is incorrect. Respirations change from 40 to 60 breaths/min to 12 to 20 breaths/minutes. This is not a fairly constant rate. This is correct. Heart rate and respiratory rate tend to decrease as people age, whereas blood pressure increases because of increased vascular resistance. However, resting heart rate can increase in the older adult. This is correct. Men’s blood pressure tends to be higher than that of women’s until after menopause, when women’s blood pressure typically increases. This is incorrect. The nurse can think of the average normal temperature for older adults as about 95°F to 96.8°F (35°C to 36°C). Older adults have difficulty maintaining body heat because of slower metabolism, decreased vasomotor control, and loss of subcutaneous tissue.

PTS: 1 CON: Evidence-Based Practice 41. ANS: 2, 4 Chapter: Chapter 20 Measuring Vital Signs Objective: Demonstrate correct technique and procedures for measuring temperature, pulse, respiration, and blood pressure. Page: 438 (V1) Heading: Procedure 20-6 Measuring Blood Pressure Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Comprehension [Understanding] Concept: Perfusion Difficulty: Moderate

1. 2. 3.

4. 5.

Feedback This is incorrect. The bladder length should encircle 80% of the arm. The cuff width is 40% of the arm circumference. This is correct. The cuff should be wrapped snugly around the client’s arm. This is incorrect. Holding the arm out can cause an erroneously higher blood pressure measurement; the arm should be supported at heart level with palm facing upward. This is correct. Crossed legs or dangling legs can increase blood pressure, so feet should be flat on the floor. This is incorrect. The client is identified with two identifiers, not one.

PTS:

CON: Perfusion

42. ANS: 2, 3 Chapter: Chapter 20 Measuring Vital Signs Objective: Demonstrate correct technique and procedures for measuring temperature, pulse, respiration, and blood pressure. Page: 431 (V1) Heading: Pulse Quality Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Knowledge [Remembering] Concept: Perfusion Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is incorrect. Rhythm of the pulses refers to rhythm, not quality. This is correct. The quality of a pulse refers to the pulse volume (strength). This is correct. The quality of a pulse refers to the bilateral equality of the pulses. This is incorrect. The rate compared with apical pulse is the apical–radial pulse, not quality. This is incorrect. Intervals between heartbeats indicate rhythm.

PTS: 1 CON: Perfusion 43. ANS: 1, 2 Chapter: Chapter 20 Measuring Vital Signs Objective: Describe nursing interventions for the client (1) with temperature alterations; (2) with impaired respiratory status; (3) diagnosed with high blood pressure (hypertension); and (4) with alterations in pulse parameters. Page: 421 (V1) Heading: Example Problem: Hyperthermia/Heat Stroke Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Fluid and Electrolyte Balance Difficulty: Difficult

Feedback This is correct. An elevated temperature can be expected in a patient with dehydration. A temperature of 101.5°F (38.6°C) in an adult will require fluids to replace those lost through diaphoresis. This is correct. A temperature of 101.5°F (38.6°C) in an adult will require monitoring of vital signs at least every 2 hours. The frequency of measuring vital signs may increase if the patient’s temperature continues to increase. This is incorrect. The provider should not be notified for respirations of 18 (normal

4. 5.

rate). An increase in respirations is expected with an elevated temperature (respiratory rate increases by up to four breaths/min for every 1°F [0.6°C] increase in temperature). This is incorrect. The nurse should encourage the patient to drink fluids, not place the patient as NPO. This is incorrect. Physical activity is limited, not increased.

PTS: 1 CON: Fluid and Electrolyte Balance 44. ANS: 1, 2, 4, 5 Chapter: Chapter 20 Measuring Vital Signs Objective: Describe nursing interventions for the client (1) with temperature alterations; (2) with impaired respiratory status; (3) diagnosed with high blood pressure (hypertension); and (4) with alterations in pulse parameters. Page: 421 (V1) Heading: Example Problem: Hyperthermia/Heat Stroke > Signs of Heat Stroke Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Thermo-regulation Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is correct. Heat stroke occurs when the body’s temperature regulation fails, usually when the hyperthermia progresses to a temperature above 103°F (39.4°C). This is correct. Throbbing headache is a symptom of heat stroke. This is incorrect. Diaphoresis occurs in heat exhaustion. In heat stroke, the body is unable to sweat. This is correct. Confusion is a manifestation of heat stroke. This is correct. Red, hot, dry skin is a sign of heat stroke.

PTS:

CON: Thermo-regulation

Chapter 21. Communication & Therapeutic Relationships Multiple Choice Identify the choice that best completes the statement or answers the question. 1. Which form of communication is the nurse using when interviewing the patient during the admission health history and physical assessment? 1. Small group 2. Interpersonal 3. Group 4. Intrapersonal 2. During admission to the unit, a patient states, “I’m not worried about the results of my tests. I’m sure I’ll be all right.” As the nurse observes the patient, the nurse notes that the patient is shaky, tearful, and does not make eye contact. Unfortunately, the nurse is called away to an emergency before completing this discussion. Which goal is most appropriate for the nurse to establish when returning to the patient? The patient will: 1. Explain the reason for the incongruent statements 2. Engage in diversional activities to cope with stress 3. Express concerns to the primary care provider 4. Discuss concerns and fears with the nurse 3. The nurse is preparing a patient for a computed tomography (CT) scan of the abdomen. Patients must be NPO (nothing by mouth) for 8 hours and void several minutes before the test. Which statement by the nurse is best to help prepare the patient? 1. “You are to remain NPO for the 8 hours prior to your CT scan.” 2. “You cannot have anything to eat or drink for 8 hours before your test.” 3. “You will need to be NPO and drink this contrast medium before your test.” 4. “You may need to void before you go to the department for your CT scan.” 4. The nurse is assigned to care for the following patients. In planning nursing care, the nurse knows touch should be used cautiously when communicating with which patient? 1. A middle-aged woman just diagnosed with terminal lung cancer 2. A middle-aged man experiencing the acute phase of myocardial infarction 3. An older adult admitted with dehydration with a history of dementia 4. A young adult recovering from surgery for a ruptured appendix who will be discharged tomorrow 5. The nurse manager of the medical intensive care unit formed a group to help the staff cope with stress more effectively. Which comment by a group member will lead the manager to evaluate the group as successful? 1. “This was a good idea to form a group; I’ve been wanting to get to know some of the people from the other shifts.” 2. “It really helps me to share feelings about how hard it is to see pain and suffering

every day.” 3. “I now have a group to help me when I need to work through situations at home causing personal stress.” 4. “It’s nice to have a chance to get away from the unit and talk on a regular basis.” 6. A patient who speaks little English is admitted to the hospital after experiencing severe abdominal pain. Which nursing diagnosis is preferred for this patient? 1. Impaired Communication 2. Readiness for Enhanced Communication 3. Impaired Verbal Communication 4. Sensory Alteration 7. A young adult with a severe episode of asthma-related bronchoconstriction comes to the emergency department with signs of respiratory distress. When the nurse performs the orientation assessment, the nurse notes that the patient cannot identify the place/location or the time. Which nursing diagnosis is most suitable for this patient? 1. Chronic Confusion 2. Acute Confusion 3. Impaired Verbal Communication 4. Readiness for Enhanced Communication 8. A patient experiences expressive aphasia after a stroke. Which expected outcome is appropriate for this patient? 1. Uses alternative methods of communication 2. Communicates effectively using an interpreter 3. Interprets messages accurately 4. Follows commands when asked 9. Which intervention by the nurse helps to establish a trusting nurse–patient relationship? 1. Avoiding topics that may provoke emotional responses from the patient 2. Listening to the patient while performing care activities 3. Performing care interventions quietly without explanation 4. Greeting the patient by name whenever entering the patient’s room 10. A physician tells a female patient that she has cancer and that she should have surgery as soon as possible. The patient is not certain she wants to pursue this treatment approach, but responds by saying, “I’ll do whatever you think I should do.” Which communication style is this patient using? 1. Assertive 2. Aggressive 3. Passive aggressive 4. Passive 11. Which statement or question by the nurse manager demonstrates an assertive approach? 1. “Pain status must be assessed and documented for every patient.” 2. “Why haven’t you been assessing and documenting pain for every patient?”

3. “Will you please assess and document pain status for every patient?” 4. “Explain why you haven’t been assessing and documenting pain for every patient.” 12. A patient with severe substernal chest pain comes to the emergency department. The patient is restless and anxious. Which statement by the nurse appropriately offers reassurance? 1. “I’ll give you some medication to help relieve the pain.” 2. “If you lie still and relax, you’ll be fine in a little while.” 3. “Please try not to think about the pain as best as you can.” 4. “Don’t worry; we’re going to take good care of you.” 13. Which statement or question by the nurse indicates that the nurse–patient relationship is entering the termination phase? 1. “I’ll be admitting you to our nursing unit as soon as I obtain your health history.” 2. “You seem upset today. Would you like to talk about whatever is bothering you?” 3. “I’m leaving for the day. Is there anything I can do for you before I leave?” 4. “Hello. My name is Leslie, and I’m going to be your nurse today.” 14. A hospital that is interested in purchasing intravascular infusion pumps organizes a group of nurses to evaluate pumps provided by a variety of vendors. Which type of group has been organized? 1. Short-term 2. Ongoing 3. Self-help 4. Work-related social support 15. The nurse must insert a nasogastric (NG) tube into a patient with a bowel obstruction. After inserting the NG tube, the nurse thinks about the interaction to improve communication skills. Which attribute is the nurse exhibiting? 1. Respect 2. Genuineness 3. Empathy 4. Confrontation 16. A male patient had surgery 6 hours ago. When the nurse enters the room to turn him, the nurse notes that he is restless and grimacing. Considering the patient’s nonverbal communication, what action should the nurse take first? 1. Administer pain medication to the patient. 2. Turn and reposition the patient. 3. Share observations about the behaviors. 4. Leave the room so that the patient can rest quietly. 17. A patient who speaks only French was admitted to the hospital after a motor vehicle accident. Since the nurse does not speak French, what is the best way to communicate with this patient? 1. Use sign language for communicating. 2. Ask a family member to serve as an interpreter. 3. Request the services of a hospital translator.

4. Speak in English, but speak very slowly. 18. After a physician discusses cancer treatment options with a patient, the patient asks the nurse which treatment should be used. Which response by the nurse is best? 1. “If I were you, I’d go with chemotherapy.” 2. “What do you think about radiation therapy?” 3. “Why don’t you see what your spouse thinks?” 4. “I’ll give you some information about each option.” 19. Which action by the nurse is a nonverbal behavior that enhances communication? 1. Keeping a neutral expression on the face 2. Maintaining a distance of 6 to 12 inches 3. Sitting down to speak with the patient 4. Asking mostly open-ended questions 20. A male patient being admitted in hypertensive crisis informs the nurse that he stopped taking his blood pressure medication 3 weeks ago. Which response by the nurse is best? 1. “You’re lucky you didn’t have a stroke; you really need to take your medication.” 2. “Tell me more about your experience with your high blood pressure medication.” 3. “Why did you stop taking your high blood pressure medication?” 4. “It’s very important to take your blood pressure medication.” 21. The wife of an elderly patient begins crying after she is informed that the patient has a terminal illness. Which intervention by the nurse is best? 1. Sit quietly with the patient’s wife while she composes her thoughts. 2. Inform the wife that a chaplain is available if she would like to speak to him. 3. Remind the wife that her husband has lived a long and good life. 4. Tell the wife there are always options and suggest she not give up hope. 22. A patient newly diagnosed with breast cancer tells the nurse, “I’m worried I won’t survive to see my children grow up.” Which response by the nurse best conveys concern and active listening? 1. “There have been many advances in breast cancer treatment; hope for the best.” 2. “Breast cancer is a serious disease; I can understand why you’re worried.” 3. “You’re strong and have youth on your side to fight the breast cancer.” 4. “I’d be worried too; I’ve seen a lot of patients die of breast cancer.” 23. A nurse has sound, scientific evidence to support changing a procedure that would reduce catheterrelated infections on the unit. The unit manager, nevertheless, is unwilling to make the change because it would be too costly. Which response by the nurse represents assertive communication? 1. “This is a widely used practice. If you read more research, you’d probably wonder why we aren’t already doing it.” 2. “There is extensive evidence to support the new method, but I understand this change would be too difficult.” 3. “Is the budget more important to the hospital than reducing infections and patient suffering?”

4. “I’d like to help gather information regarding cost of new materials versus the savings in treating infections.” 24. When using the SBAR model to communicate with a physician, what information does the nurse offer first? 1. Statement of the problem and its probable cause 2. Nurse’s name, patient’s name, and reason for the communication 3. History of information related to and leading up to the reason for the communication 4. What the nurse thinks will correct the problem or what is needed from the physician 25. The nurse is caring for an elderly woman with dementia who is frightened in the hospital room. Which is the best action by the nurse to communicate empathy and compassion? 1. Use the bedside intercom to inform her that the nurse will be entering the room. 2. Lightly touch the patient’s arm or shoulder before greeting her. 3. Shut the patient’s door in the hallway if there is noise or loud talking. 4. Firmly but kindly insist the patient accepts reality as the nurse has presented it. 26. During patient rounds with the multidisciplinary team, the nurse expresses disagreement with the type of medication prescribed for the patient hospitalized for renal failure. What is the likely result of the nurse’s speaking up? 1. Reduces the opportunity for inadvertent error in clinical judgment 2. Increases the risk for medical liability when pointing out possible error 3. Interferes with the good working relationship among the healthcare team 4. Compromises the nurse’s reputation as a collaborative team member 27. The nurse caring for a patient with recurrent abdominal pain of unknown origin addresses the patient by name and puts a hand on the patient’s shoulder and offers reassuring words: “You’ll be okay. Try not to think about things too much, if you can.” How would another nurse most likely evaluate this nurse’s verbal and nonverbal communication? 1. Words offer hope and consolation 2. Nurse’s interaction is comforting 3. Response builds nurse–patient trust 4. Message provides false reassurance 28. What is the primary purpose of communication? 1. Exchange information 2. Form relationships 3. Establish therapeutic rapport 4. Meet primarily psychosocial needs 29. The nurse is caring for a patient with a fluid and electrolyte imbalance. The nurse asks the certified nursing assistant (CNA) to obtain the intake and output. Which statement below best describes the most appropriate communication to the CNA in delegating this task?

1. “Can you please place a sign on the door for room 3 and start obtaining I&O?” 2. “Please record all food and fluid the patient takes in and the amount of all urine, stool, and emesis for the next 48 hours.” 3. “The patient is starting to have some problems so we’ll have to watch the patient’s fluids for the entire shift.” 4. “What is the intake and output on the patient in room 3?” 30. The nurse is caring for a patient after abdominal surgery and notices that the urine is blood tinged. The nurse places a call to the physician regarding the color of the urine. When communicating to the physician using the SBAR format, which statement by the nurse below best describes the “R” in SBAR? 1. “Hello, my name is Susan, and I’m calling about your patient who just had abdominal surgery.” 2. “Your patient just had surgery, and I’ve noticed some blood-tinged urine in the Foley catheter.” 3. “Your patient has blood-tinged urine after surgery. I suggest that we obtain a urinalysis for this patient.” 4. “I’m calling to let you know I ordered and sent a urinalysis for this patient.” 31. The nursing student is assigned to care for a patient who has just been diagnosed with advancedstage cancer. The patient is very upset and crying. The nursing student states to the instructor, “I don’t know what to do. My patient just can’t stop crying.” What is the best response from the instructor? 1. “Sometimes just sitting with patient and remaining silent can be the best care.” 2. “You will need to wait patiently until your patient stops crying to complete your care.” 3. “You will not be effective while the patient is crying. Tell the patient you will come back later.” 4. “Try to distract the patient from crying by trying to change the conversation.” 32. The nurse is caring for a patient with severe arthritis and notices a written pain medication order that appears to have an extremely high dose. The nurse places a call to the physician to question the prescription dose. Which statement below best describes an assertive communication style by the nurse in interacting with the physician regarding the pain medication order? 1. “I’m calling about the pain medication prescription for Mrs. Garcia. The dose is too high.” 2. “Sorry to bother you but I’m not sure about the dose of pain medication you prescribed for Mrs. Garcia.” 3. “I’m concerned about the medication dose that was prescribed for Mrs. Garcia.” 4. “You may disagree with me, but the dose for Mrs. Garcia is too high.” 33. The nurse is caring for a patient who suffered a stroke and now has expressive aphasia. The nurse is having a difficult time communicating and the patient is becoming angry and frustrated. In developing the plan of care, what is the most appropriate outcome for this patient?

1. 2. 3. 4.

Patient will use alternative methods of communication. Patient will understand the reason for the frustration. Patient will learn sign language to communicate effectively. Patient will have family members present for communication.

Multiple Response Identify one or more choices that best complete the statement or answer the question. 34. Which elements of the communication process are accurately matched? Select all that apply. 1. Receiver—decodes the message 2. Message—process of selecting the words and gestures 3. Channel—method in which message is conveyed 4. Encoding—verbal and/or nonverbal information sent 5. Sender—provides feedback 35. Which statements by the nurse demonstrate that active listening has occurred? Select all that apply. 1. “I listened to my patient while I was changing the intravenous (IV) site.” 2. “I made eye contact and listened to my patient to find out concerns.” 3. “I took detailed notes when I listened to my patient describe symptoms.” 4. “I sat with my patient, and the patient’s spouse to talk about their fears before surgery.” 5. “I did not interrupt while the patient was expressing anxiety about the diagnostic tests.” 36. A patient tells the nurse, “I’m having a lot of pain in my hip.” Which responses by the nurse most likely would stimulate the patient to provide the most complete data? Select all that apply. 1. “Is your pain severe?” 2. “Tell me about your pain.” 3. “Do you need pain medicine?” 4. “How would you describe your pain?” 5. “Is your pain better or worse than it was this morning?” 37. In the communication process, which characteristics best describe an effective verbal message? Select all that apply. 1. Clear and long 2. Developmental level appropriate 3. Situation appropriate 4. Delivered at an appropriate time 5. Organized information 38. The nurse is conducting an assessment while admitting a female Chinese patient to the medical unit. Which actions will best enhance communication between the nurse and patient during the assessment? Select all that apply. 1. Interacting in a causal manner

2. 3. 4. 5.

Keeping 18 inches to 4 feet between nurse and the patient Assessing for any language barrier Including family members in the assessment process Changing the subject during the assessment

39. Which statements are reflective of barriers to communication? Select all that apply. 1. “I see you had a heart attack. Why are you still smoking?” 2. “I know you are having pain in your knee. I will check your vital signs before getting your pain medications.” 3. “The nursing assistant told me you are having back pain. I’ll get your pain medication now.” 4. “Tell me a little more about the chest pain you were having at home.” 5. “Let’s talk about all the possible causes and treatments for chest pain.” 40. Which actions by the nurse are best for communicating with an unconscious patient? Select all that apply. 1. Speak loudly and clearly. 2. Explain all procedures. 3. Use touch appropriately. 4. Talk calmly and slowly. 5. Introduce yourself.

Chapter 21. Communication & Therapeutic Relationships Answer Section MULTIPLE CHOICE 1. ANS: 2 Chapter: Chapter 21 Communication & Therapeutic Relationships Objective: Discuss the three basic levels of communication. Page: 452 (V1) Heading: Communication Occurs on Many Levels > Interpersonal Communication Integrated Processes: Communication and Documentation Client Need: Psychosocial Integrity Cognitive Level: Comprehension [Understanding] Concept: Communication Difficulty: Moderate Feedback 1 This is incorrect. Small group communication occurs when a person engages in an exchange of ideas with two or more people at the same time. 2 This is correct. The nurse uses interpersonal communication when interviewing the patient about the health history during the admission assessment. 3 This is incorrect. Group communication is interaction that occurs among several people. 4 This is incorrect. Intrapersonal communication is conscious internal dialogue with self. PTS: 1 CON: Communication 2. ANS: 4 Chapter: Chapter 21 Communication & Therapeutic Relationships Objective: Analyze factors that influence the communication process. Page: 464 (V1) Heading: Planning Outcomes/Evaluation and Enhancing Therapeutic Communication Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Communication Difficulty: Moderate Feedback 1 This is incorrect. It is inappropriate to ask the patient to explain why the verbal message did not match the nonverbal message because this will inhibit further conversation. 2 This is incorrect. It is not appropriate to suggest diversional activities until the reason for the mismatch between the words and behavior is identified.

This is incorrect. While having the patient discuss concerns with the primary care provider may be appropriate, there is not enough information to suggest this course of action. This is correct. The nurse has observed a mismatch between verbal and nonverbal communication. Unfortunately, an emergency has required the nurse to leave the patient. To resolve this mismatch, the nurse will set a goal to have the patient discuss concerns and fears at their next interaction.

PTS: 1 CON: Communication 3. ANS: 2 Chapter: Chapter 21 Communication & Therapeutic Relationships Objective: List the characteristics of verbal and nonverbal communication. Page: 454 (V1) Heading: Verbal Communication > Vocabulary Integrated Processes: Communication and Documentation Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Communication Difficulty: Moderate Feedback 1 This is incorrect. This option uses medical jargon (NPO and CT scan) that many patients may not understand. 2 This is correct. Telling the patient that he or she cannot have anything to eat or drink for a specific time before the test is the best statement. It uses terms that the patient can understand. 3 This is incorrect. NPO and contrast medium are medical terms that many patients may not understand. 4 This is incorrect. This option uses medical jargon (void, department, and CT scan) that many patients find confusing. PTS: 1 CON: Communication 4. ANS: 3 Chapter: Chapter 21 Communication & Therapeutic Relationships Objective: Compare and contrast techniques that enhance communication with techniques that hinder communication. Page: 456 (V1) Heading: Touch Integrated Processes: Communication and Documentation Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Communication Difficulty: Moderate

1 2 3

Feedback This is incorrect. In general, touch can be used with most patients, such as patients with cancer. This is incorrect. Touch can be reassuring to patients with acute conditions, such as patients with an acute myocardial infarction (MI). This is correct. The nurse should use touch cautiously when communicating with a person who suffers from impaired mental health (mentally disturbed), such as dementia, because the patient may have difficulty interpreting the meaning of touch. This is incorrect. In general, touch can be used with most patients, such as patients recovering from surgery for a ruptured appendix, and with all age groups.

PTS: 1 CON: Communication 5. ANS: 2 Chapter: Chapter 21 Communication & Therapeutic Relationships Objective: Describe the elements of collaborative professional communication. Page: 463 (V1) Heading: Work-Related Social Support Groups and Box 21-3 Characteristics of a Successful Group Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Professionalism Difficulty: Moderate Feedback 1 This is incorrect. This statement does not indicate success. Although this may also be an opportunity to meet other staff members, this is not the primary focus of the group. 2 This is correct. A statement about sharing feelings about how hard it is to see pain and suffering indicates the group was successful. Work-related social support groups assist members of a profession to cope with the stress associated with their work. The focus of the group is to share feelings about the stress of the work environment. 3 This is incorrect. This statement does not indicate success. Although sharing personal and family problems may be helpful, this is not the primary focus of the group. 4 This is incorrect. This statement does not indicate success. Although this may also be an opportunity to get away from the unit, this is not the primary focus of the group. PTS:

CON: Professionalism

6. ANS: 1 Chapter: Chapter 21 Communication & Therapeutic Relationships Objective: Plan nursing care for a client experiencing impaired communication. Page: 464 (V1) Heading: Analysis/Nursing Diagnosis Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is correct. Impaired Communication is the preferred nursing diagnosis when the patient is unfamiliar with the dominant language. 2 This is incorrect. Readiness for Enhanced Communication is an appropriate diagnosis when the patient expresses willingness to enhance communication. 3 This is incorrect. Impaired Verbal Communication is an appropriate diagnosis for the patient with expressive or receptive aphasia. 4 This is incorrect. Sensory Alteration is an appropriate diagnosis when there is a change in the characteristics of the patient’s incoming stimuli. PTS: 1 CON: Patient-Centered Care 7. ANS: 2 Chapter: Chapter 21 Communication & Therapeutic Relationships Objective: Plan nursing care for a client experiencing impaired communication. Page: 464 (V1) Heading: Analysis/Nursing Diagnosis > Etiologies of Communication Diagnoses Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment > Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is incorrect. As a young adult with an acute episode of asthma, this patient would not likely have a history of confusion; therefore, without more data, Chronic Confusion is not an appropriate diagnosis for this patient. 2 This is correct. This patient is experiencing Acute Confusion caused by lack of oxygen related to the respiratory distress. 3 This is incorrect. Impaired Verbal Communication is an appropriate diagnosis for the patient with expressive or receptive aphasia, but not with confusion. 4 This is incorrect. Readiness for Enhanced Communication is an appropriate diagnosis when the patient expresses willingness to enhance communication, but not for confusion.

PTS: 1 CON: Patient-Centered Care 8. ANS: 1 Chapter: Chapter 21 Communication & Therapeutic Relationships Objective: Plan nursing care for a client experiencing impaired communication. Page: 464 (V1) Heading: Analysis/Nursing Diagnosis and Planning Outcomes/Evaluation and Focused Assessment > Aphasia Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is correct. Expressive aphasia means the patient cannot verbalize the intended message and alternative methods of communication are needed. 2 This is incorrect. “Communicates effectively using an interpreter” is an appropriate outcome for a patient who is unfamiliar with the dominant language. 3 This is incorrect. “Interprets messages accurately” is an appropriate outcome for the patient with receptive, not expressive, aphasia. 4 This is incorrect. A patient with receptive, not expressive, aphasia would have an outcome of “Follows commands when asked.” PTS: 1 CON: Patient-Centered Care 9. ANS: 4 Chapter: Chapter 21 Communication & Therapeutic Relationships Objective: Describe the role of communication in each of the four phases of the therapeutic relationship. Page: 465 (V1) Heading: Establishing Trust Integrated Processes: Caring Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Communication Difficulty: Moderate Feedback 1 This is incorrect. Avoiding topics that may provoke emotional responses will not establish trust. Patients need to be heard. 2 This is incorrect. Listening to the patient while performing care activities is not active listening and will not develop trust. The nurse should focus attention on the patient, not on the tasks. 3 This is incorrect. Explaining care helps establish trust.

This is correct. The nurse can establish a trusting nurse–patient relationship by always greeting the patient by name, listening actively, responding honestly to the patient’s concern, providing explanations for care interventions, and providing care competently and consistently.

PTS: 1 CON: Communication 10. ANS: 4 Chapter: Chapter 21 Communication & Therapeutic Relationships Objective: Analyze factors that influence the communication process. Page: 459 (V1) Heading: Communication Styles > Passive Integrated Processes: Communication and Documentation Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Communication Difficulty: Moderate Feedback 1 This is incorrect. With assertive communication, the person expresses beliefs or feelings without infringing on another’s rights. 2 This is incorrect. An aggressive approach forces others to relinquish control. The goal of the aggressive approach is to win and be in control. 3 This is incorrect. The passive–aggressive approach uses the passive and aggressive–submissive style of communication, but is aggressive in the sense that it manipulates the receiver to help the sender win. This allows the sender to be in control without conflict. 4 This is correct. This patient is using a passive communication style. The passive approach avoids conflict with others and allows the other person to be in control. PTS: 1 CON: Communication 11. ANS: 1 Chapter: Chapter 21 Communication & Therapeutic Relationships Objective: Describe the elements of collaborative professional communication. Page: 459 (V1) Heading: Communicating Assertively Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Leadership and Management Difficulty: Moderate Feedback 1 This is correct. By stating that pain must be assessed and documented for every

2 3

patient, the nurse manager is using an assertive approach. An assertive approach uses the statement of facts, not judgments. This is incorrect. Asking why the nurse has not been assessing and documenting pain is judgmental and aggressive. This is incorrect. Asking the nurses whether they will assess and document pain for every patient invites a negative response and does not use an assertive approach. This is incorrect. Using the phrases, “Explain why you haven’t” is aggressive. Asking the nurse to explain why pain assessments haven’t been done is also judgmental.

PTS: 1 CON: Leadership and Management 12. ANS: 1 Chapter: Chapter 21 Communication & Therapeutic Relationships Objective: Compare and contrast techniques that enhance communication to techniques that hinder communication. Page: 468 (V1) Heading: Providing False Reassurance Integrated Processes: Communication and Documentation Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Communication Difficulty: Moderate Feedback 1 This is correct. By telling the patient that medication will be given to relieve the pain, the nurse is offering the patient realistic reassurance. Providing realistic reassurance helps ease concerns, offers comfort, and communicates empathy. 2 This is incorrect. Saying, “You’ll be fine in a little while” indicates false reassurance. Such a response is uninformed and inaccurate, and may feel dismissive and even condescending. 3 This is incorrect. Saying, “Please try not to think about the pain” dismisses and minimizes the patient’s concerns, all of which decrease rapport. 4 This is incorrect. Saying, “Don’t worry” is false reassurance and negates the patient’s feelings and concerns. PTS: 1 CON: Communication 13. ANS: 3 Chapter: Chapter 21 Communication & Therapeutic Relationships Objective: Describe the role of communication in each of the four phases of the therapeutic relationship. Page: 462 (V1)

Heading: Communication Is Essential to All Phases of the Therapeutic Relationship > Termination Phase Integrated Processes: Communication and Documentation Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Communication Difficulty: Moderate Feedback 1 This is incorrect. The preinteraction phase occurs before the nurse meets the patient. The statement “I’ll be admitting you to our floor as soon as I obtain your history” demonstrates the preinteraction phase of the nurse–patient relationship. 2 This is incorrect. During the working phase of the nurse–patient relationship, feelings are explored. This phase is demonstrated when the nurse says, “You seem upset today. Would you like to talk about whatever is bothering you?” 3 This is correct. When the nurse says, “I’m leaving for the day. Is there anything I can do for you before I leave?” the nurse–patient relationship is entering the termination phase. The termination phase is the conclusion of the relationship, which can occur at the end of a nurse’s shift or on the patient’s discharge from the unit or facility. 4 This is incorrect. The nurse introduces self to the patient during the orientation phase. PTS: 1 CON: Communication 14. ANS: 1 Chapter: Chapter 21 Communication & Therapeutic Relationships Objective: Describe the elements of collaborative professional communication. Page: 462 (V1) Heading: Communication Is Important in Group Helping Relationships > Task Groups Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Quality Improvement Difficulty: Moderate Feedback 1 This is correct. The organized group is a short-term group. Short-term groups focus on the task at hand, which in this case is evaluating infusion pumps. 2 This is incorrect. Ongoing groups address issues that are recurrent. This group is not recurrent. 3 This is incorrect. Self-help groups are voluntary organizations composed of people with a common need. 4 This is incorrect. Work-related social support groups assist members of a profession to cope with the stress associated with their work.

PTS: 1 CON: Quality Improvement 15. ANS: 2 Chapter: Chapter 21 Communication & Therapeutic Relationships Objective: List the characteristics of verbal and nonverbal communication. Page: 462 (V1) Heading: Therapeutic Communication Has Five Key Characteristics > Genuineness Integrated Processes: Communication and Documentation Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Professionalism Difficulty: Moderate Feedback 1 This is incorrect. In the therapeutic relationship, the nurse communicates respect by valuing the patient, by being flexible to meet needs, by the way the nurse addresses the patient, and by the words and intonation the nurse chooses. 2 This is correct. Genuineness requires two qualities: honesty and willingness to self-evaluate. The nurse is self-evaluating communication skills after a patient interaction. 3 This is incorrect. The desire to understand and be sensitive to the feelings, beliefs, and situation of another person is called empathy. 4 This is incorrect. If the patient is unable to express thoughts clearly, the nurse must be willing to confront the patient to request clarification. Similarly, the nurse must be willing to be confronted if message is unclear. PTS: 1 CON: Professionalism 16. ANS: 3 Chapter: Chapter 21 Communication & Therapeutic Relationships Objective: Compare and contrast techniques that enhance communication to techniques that hinder communication. Page: 465 (V1) Heading: Restating, Clarifying, and Validating Messages and Interpreting Body Language and Sharing Observations Integrated Processes: Communication and Documentation Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Communication Difficulty: Moderate Feedback 1 This is incorrect. The nurse should not assume by the patient’s nonverbal communication that the patient is in pain and administer pain medication; the nurse should validate the message being sent.

2 3

This is incorrect. The nurse should not turn and reposition the patient without validating the nonverbal behaviors. This is correct. The nurse should share observations about the behaviors to determine whether the patient is having pain. This action will validate the meaning of the nonverbal behaviors. This is incorrect. Leaving the patient without addressing the nonverbal cues is neglectful.

PTS: 1 CON: Communication 17. ANS: 3 Chapter: Chapter 21 Communication & Therapeutic Relationships Objective: Communicate with clients whose culture or language is different from yours. Page: 229 (V1) Heading: Clinical Insight 21-3 Communicating With Clients From Another Culture Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Culture Difficulty: Moderate Feedback 1 This is incorrect. Using sign language can be an effective strategy for communicating with hearing-impaired persons. 2 This is incorrect. A family member should not be used as an interpreter unless there are no other options because it is often culturally unacceptable to have a family member ask personal questions. Also, considering the patient’s right to confidentiality, it is not appropriate to share private information about the patient with family members unless permission is obtained. 3 This is correct. The nurse should request the services of a hospital translator to communicate with the patient who does not speak English. 4 This is incorrect. Speaking slowly in English is not useful if the patient does not understand the language. PTS: 1 CON: Culture 18. ANS: 4 Chapter: Chapter 21 Communication & Therapeutic Relationships Objective: Compare and contrast techniques that enhance communication to techniques that hinder communication. Page: 466 (V1) Heading: Barriers to Therapeutic Communication > Offering Advice Integrated Processes: Communication and Documentation Client Need: Psychosocial Integrity Cognitive Level: Application [Applying]

Concept: Communication Difficulty: Easy Feedback 1 This is incorrect. A response such as, “If I were you, I’d go with chemotherapy,” is nontherapeutic. The nurse should avoid giving a personal opinion. 2 This is incorrect. “What do you think about radiation therapy,” is leading the patient without exploring other options. 3 This is incorrect. “Why don’t you see what your spouse thinks?” does not respect the patient’s right to make his or her own decisions. 4 This is correct. If the patient asks, “What should I do?” help clarify the options and provide the patient with information about choices. The nurse should avoid giving a personal opinion; instead, offer the patient more information so the patient can make an informed decision. PTS: 1 CON: Communication 19. ANS: 3 Chapter: Chapter 21 Communication & Therapeutic Relationships Objective: Compare and contrast techniques that enhance communication to techniques that hinder communication. Page: 455 (V1) Heading: Nonverbal Communication Integrated Processes: Communication and Documentation Client Need: Psychosocial Integrity Cognitive Level: Comprehension [Understanding] Concept: Communication Difficulty: Moderate Feedback 1 This is incorrect. A concerned expression, not a neutral one, demonstrates interest and attention. 2 This is incorrect. Maintaining a distance of 18 inches to 4 feet, not 6 to 12 inches, while speaking allows most patients to feel comfortable, thereby enhancing communication. 3 This is correct. When speaking to a patient who is sitting or lying in bed, it is helpful to crouch or kneel down to be at eye level, rather than speaking from an elevated, standing position. This can put the patient at ease and help form a genuine connection. 4 This is incorrect. Asking open-ended questions is a verbal communication strategy, not a nonverbal behavior. PTS: 1 CON: Communication 20. ANS: 2 Chapter: Chapter 21 Communication & Therapeutic Relationships

Objective: Compare and contrast techniques that enhance communication to techniques that hinder communication. Page: 464 (V1) Heading: Enhancing Therapeutic Communication > Exploring Issues Integrated Processes: Communication and Documentation Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Communication Difficulty: Moderate Feedback 1 This is incorrect. Telling the patient that he is lucky he did not have a stroke suggests criticism. 2 This is correct. The nurse can gather more information about the patient’s reasons for stopping the blood pressure medication by asking him to explore the issue by stating, “Tell me.” 3 This is incorrect. Asking the patient “why” he stopped taking the high blood pressure medication may cause the patient to become defensive and halt further communication. 4 This is incorrect. Telling the patient that it is very important to take the blood pressure medication is patronizing and also suggests criticism; at the very least, it fails to elicit more communication from the patient. PTS: 1 CON: Communication 21. ANS: 1 Chapter: Chapter 21 Communication & Therapeutic Relationships Objective: Compare and contrast techniques that enhance communication to techniques that hinder communication. Page: 464 (V1) Heading: Enhancing Therapeutic Communication > Using Silence Integrated Processes: Caring Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Communication Difficulty: Difficult Feedback 1 This is correct. The nurse can intervene best by sitting quietly with the patient’s wife, allowing her to compose her thoughts. Silence communicates acceptance. 2 This is incorrect. After processing the bad news, the wife can provide the nurse with further information, such as whether she would like to consult with a chaplain. 3 This is incorrect. Saying that he lived a long and good life indicates an insensitivity on the nurse’s part.

This is incorrect. Telling the wife there are always options offers false reassurance and would probably discourage her from further communication.

PTS: 1 CON: Communication 22. ANS: 2 Chapter: Chapter 21 Communication & Therapeutic Relationships Objective: Compare and contrast techniques that enhance communication to techniques that hinder communication. Page: 464 (V1) Heading: Active Listening and Establishing Trust Integrated Processes: Communication and Documentation Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Communication Difficulty: Moderate Feedback 1 This is incorrect. Stating that there have been many advances in breast cancer treatment minimizes the patient’s concern. 2 This is correct. Restating the patient’s concern by saying, “Breast cancer is a serious disease; I can understand why you’re worried” conveys concern and active listening. Responding honestly to the patient’s concerns establishes trust. 3 This is incorrect. Stating that the patient is young and should have no trouble surviving breast cancer minimizes the patient’s concern and offers false reassurance. 4 This is incorrect. Stating that the nurse has seen a lot of patients die of breast cancer could frighten the patient and cause emotional harm. PTS: 1 CON: Communication 23. ANS: 4 Chapter: Chapter 21 Communication & Therapeutic Relationships Objective: Explain how relationships and roles influence communication. Page: 454 (V1) Heading: Communication Styles > Communicating Assertively Integrated Processes: Communication and Documentation Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Collaboration Difficulty: Moderate Feedback 1 This is incorrect. The statement beginning with “This is a widely used practice …” is aggressive and implies criticism and a judgment that the nurse manager does not read as much as needed.

3 4

This is incorrect. The statement ending with “… would be too difficult” is submissive and reflects a lack of confidence in the nurse’s professional role as patient advocate and change agent. This is incorrect. The statement beginning with “Is the budget more important …” is aggressive and judgmental. This is correct. The statement pertaining to helping to gather information about of the cost of materials is an assertive response that advocates for improved patient outcomes. This approach does not threaten the authority of the nurse manager. It states the nurse’s position and wishes clearly with an “I” statement, and it does not invite negative responses.

PTS: 1 CON: Collaboration 24. ANS: 2 Chapter: Chapter 21 Communication & Therapeutic Relationships Objective: Describe the elements of collaborative professional communication. Page: 460 (V1) Heading: Clinical Insight 21-2 Communicating With SBARQ Integrated Processes: Communication and Documentation Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Collaboration Difficulty: Moderate Feedback 1 This is incorrect. Statement of the problem and cause make up the Assessment. 2 This is correct. SBAR is an acronym for Situation, Background, Assessment, and Recommendation. The nurse’s name and so forth are part of the Situation. 3 This is incorrect. History of the factors leading up to the current situation makes up the Background. 4 This is incorrect. What the nurse thinks will correct the problem is categorized under Recommendation. PTS: 1 CON: Collaboration 25. ANS: 3 Chapter: Chapter 21 Communication & Therapeutic Relationships Objective: Communicate with clients with impaired hearing, speech, or cognition. Page: 457 (V1) Heading: What Factors Affect Communication? > Environment Integrated Processes: Caring Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Communication Difficulty: Moderate

Feedback This is incorrect. A voice sounding from the intercom on the bedside call system might frighten the patient with confusion, delirium, or other cognitive impairments. It is better to talk face-to-face. This is incorrect. Talk to the patient first; touch second. Touching a patient before establishing a basic trust might frighten the confused or cognitively impaired patient. This is correct. Close the door to reduce environmental distractions. Extraneous noises, lights, and even smells can compete for attention when talking with or providing instructions to the patient, especially if she is confused or cognitively impaired. This is incorrect. Do not argue or insist the patient agree with you. The patient with altered perception or cognition might not have the capacity to understand or accept reality. Pushing her to agree with the nurse can create anxiety or hostility.

PTS: 1 CON: Communication 26. ANS: 1 Chapter: Chapter 21 Communication & Therapeutic Relationships Objective: Describe the elements of collaborative professional communication. Page: 459 (V1) Heading: Communication Styles > Communicating Assertively Integrated Processes: Communication and Documentation Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Analysis [Analyzing] Concept: Collaboration Difficulty: Moderate Feedback 1 This is correct. Effective communication and teamwork are essential for the delivery of high-quality, safe patient care. To avoid communication failures that can lead to unanticipated adverse events in patients, nurses must speak up when they have concerns and take the necessary steps to communicate assertively and collaboratively with the healthcare team. Open communication leads to better patient care, improved safety, and better staff satisfaction. 2 This is incorrect. The risk is decreased (not increased) when nurses speak up. 3 This is incorrect. The working relationship is strengthened; speaking up does not interfere with the good working relationship. 4 This is incorrect. The nurse’s value is increased when safety measures can be taken. PTS: 1 27. ANS: 4

CON: Collaboration

Chapter: Chapter 21 Communication & Therapeutic Relationships Objective: Compare and contrast techniques that enhance communication to techniques that hinder communication. Page: 468 (V1) Heading: Providing False Reassurance Integrated Processes: Communication and Documentation Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Professionalism Difficulty: Moderate Feedback 1 This is incorrect. Such a response by the nurse is uninformed, inaccurate, and may feel dismissive—even condescending—to the patient and acts as a barrier to therapeutic communication. 2 This is incorrect. The nurse is using false reassurance that does not indicate the interaction is comforting. 3 This is incorrect. These well-meaning words are actually false reassurance, and can sabotage a trusting nurse-patient relationship. 4 This is correct. Although addressing the patient by the preferred name and using nonthreatening, therapeutic touch (light hand on the shoulder) both convey caring and comfort and contribute to a therapeutic and trusting nurse–patient relationship, the nurse telling the patient that everything will be fine is inappropriate (false reassurance) when the situation is unknown. PTS: 1 CON: Professionalism 28. ANS: 1 Chapter: Chapter 21 Communication & Therapeutic Relationships Objective: Describe the process of the communication process between sender and receiver; include all five elements. Page: 452 (V1) Heading: What Is Communication? Integrated Processes: Communication and Documentation Client Need: Psychosocial Integrity Cognitive Level: Comprehension [Understanding] Concept: Communication Difficulty: Moderate Feedback 1 This is correct. Communication is a dynamic, two-way process of sending and receiving messages. Communication is an interactive exchange of information. 2 This is incorrect. Forming relationships are not the primary purpose of communication; it is secondary to the exchange of a message. 3 This is incorrect. Establishing therapeutic rapport is not the primary purpose of

communication; it is secondary to the exchange of a message. This is incorrect. Communication is necessary for meeting physical, psychosocial, emotional, and spiritual needs, not just psychosocial.

PTS: 1 CON: Communication 29. ANS: 2 Chapter: Chapter 21 Communication & Therapeutic Relationships Objective: Describe the process of the communication process between sender and receiver; include all five elements. Page: 453 (V1) Heading: Communication Is a Process Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Leadership and Management Difficulty: Moderate Feedback 1 This is incorrect. Placing a sign on the door and starting I&O do not provide enough direction and are vague and unclear. 2 This is correct. Effective messages are complete, clear, concise, organized, timely, and expressed in a manner that the receiver can understand. Telling the CNA what is needed is the correct response. 3 This is incorrect. Stating that the patient has problems and watch fluid intake is vague and unclear. Output must also be obtained. 4 This is incorrect. “What is the intake and output on patient in 3” is inaccurate. This just asks for the results but does not tell the CNA the process. PTS: 1 CON: Leadership and Management 30. ANS: 3 Chapter: Chapter 21 Communication & Therapeutic Relationships Objective: Describe the elements of collaborative professional communication. Page: 229 (V2) Heading: Clinical Insight 21-2 Communicating With SBARQ Integrated Processes: Communication and Documentation Client need: Safe and Effective Care Environment: Management of Care Concept: Collaboration Cognitive Level: Application [Applying] Difficulty: Moderate Feedback 1 This is incorrect. The nurse’s introduction to the physician reflects the situation (S) of SBAR. 2 This is incorrect. Informing the physician of the blood-tinged urine reflects the

background (B) of SBAR. This is correct. The “R” is SBAR represents the “recommendation.” In this item, the best response is for the nurse to suggest obtaining a urinalysis. This is the recommendation. This is incorrect. Calling the physician to inform him or her of the ordering of the urinalysis is not a part of SBAR and not within the nurse’s scope of practice.

PTS: 1 CON: Collaboration 31. ANS: 1 Chapter: Chapter 21 Communication & Therapeutic Relationships Objective: Compare and contrast techniques that enhance communication to techniques that hinder communication. Page: 466 (V1) Heading: Using Silence Integrated Processes: Teaching and Learning Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Communication Difficulty: Moderate Feedback 1 This is correct. One of the most effective and useful tools in enhancing therapeutic communication is the use of silence. Using silence demonstrates acceptance and allows the patient to compose thoughts and perhaps provide other information. It is especially effective when the patient is emotionally upset. 2 This is incorrect. Waiting for the patient to stop crying to complete care is a missed opportunity for the nurse to support the patient’s emotional needs and show caring during a difficult time. 3 This is incorrect. Telling the patient that the nurse will come back later denies the patient the opportunity to express feelings, fears, and other emotions. 4 This is incorrect. Distracting patients or changing the topic of the conversation is actually a barrier to communication. This may make the patient feel that feelings are not accepted or warranted, or that the nurse is uninterested. PTS: 1 CON: Communication 32. ANS: 3 Chapter: Chapter 21 Communication & Therapeutic Relationships Objective: Describe the elements of collaborative professional communication. Page: 465 (V1) Heading: Communicating Assertively > How Do I Communicate Assertively? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care

Cognitive Level: Analysis [Analyzing] Concept: Collaboration Difficulty: Moderate Feedback 1 This is incorrect. Stating to the physician that the dose is too high may be offensive, as it is too direct, challenging, and aggressive. In fact, the dose may be acceptable. 2 This is incorrect. The response “Sorry to bother you” is ineffective because it is self-effacing, apologetic, and inappropriate in a professional role. 3 This is correct. The nurse used “critical language” to advocate for the patient. Nurses must question care decisions that do not seem right and assertively discuss errors or poor clinical judgment. In this item, the most appropriate and assertive communication is to state that there is a concern regarding the dose of the medication. This will lead to collaborative dialogue between the nurse and the physician. This is an open and honest response. 4 This is incorrect. Stating, “You may disagree with me but …” is self-effacing and timid rather than taking credit for contributions to safe care. PTS: 1 CON: Collaboration 33. ANS: 1 Chapter: Chapter 21 Communication & Therapeutic Relationships Objective: Plan nursing care for a client experiencing impaired communication. Page: 464 (V1) Heading: Planning Outcomes/Evaluation Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is correct. In planning care, the best outcome is for the patient to develop other strategies and mechanisms for communication. Using alternative methods, such as writing and magnet boards, picture boards, or gestures, is an effective means of communication. Using these methods will assist in decreasing the frustration on the part of the patient and enhance communication between the nurse and the patient. 2 This is incorrect. The goal to use for frustration would be to demonstrate minimal frustration with communication difficulties and specify a time frame, not to understand the reason for the frustration. 3 This is incorrect. The patient is not deaf, so sign language is not needed. 4 This is incorrect. Having a family member present is not an effective outcome, may not even be practical, and breaks confidentiality. The goal should focus on

the patient, not the family. PTS:

CON: Patient-Centered Care

MULTIPLE RESPONSE 34. ANS: 1, 3 Chapter: Chapter 21 Communication & Therapeutic Relationships Objective: Describe the process of the communication process between sender and receiver; include all five elements. Page: 453 (V1) Heading: Communication Is a Process Integrated Processes: Communication and Documentation Client Need: Psychosocial Integrity Cognitive Level: Comprehension [Understanding] Concept: Communication Difficulty: Moderate

2. 3. 4. 5.

Feedback This is correct. The receiver is the observer, listener, and interpreter of the message. The receiver interprets (decodes) by relating the message to past experiences to understand the sender’s meaning. This is incorrect. The process of selecting the words and gestures is encoding, not message. This is correct. The channel is the method in which the message is conveyed. Faceto-face communication is a commonly used channel. This is incorrect. Verbal or nonverbal information sent is the message, not encoding. This is incorrect. Feedback is provided by the receiver, not the sender.

PTS: 1 CON: Communication 35. ANS: 2, 4, 5 Chapter: Chapter 21 Communication & Therapeutic Relationships Objective: Compare and contrast techniques that enhance communication to techniques that hinder communication. Page: 465 (V1) Heading: Active Listening and Care Box Caring Using Active Listening Integrated Processes: Communication and Documentation Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Communication Difficulty: Moderate

2. 3.

4. 5.

Feedback This is incorrect. Listening to the patient while performing activities, such as hanging an IV infusion or bathing the patient, distracts the nurse from active listening. This is correct. The nurse demonstrated active listening by facing the patient, making eye contact, and listening while the patient expressed concerns. This is incorrect. Although taking detailed notes can help the nurse to accurately acknowledge the patient’s words, doing this activity while listening to the patient speak can also be a distraction and could reduce eye contact and nonverbal cues of care and concern. This is correct. Arranging time to sit with the patient and the patient’s spouse to discuss fears about an upcoming surgery also indicates active listening. This is correct. Active listening includes not interrupting the patient when he or she is discussing concerns and fears.

PTS: 1 CON: Communication 36. ANS: 2, 4 Chapter: Chapter 21 Communication & Therapeutic Relationships Objective: Compare and contrast techniques that enhance communication to techniques that hinder communication. Page: 466 (V1) Heading: Exploring Issues Integrated Processes: Communication and Documentation Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Communication Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is incorrect. Although it is important information, the question “Is your pain severe?” prompts a “yes” or “no” response. This is correct. The response, “Tell me about your pain” is an open-ended response that stimulates conversation. This is incorrect. The response, “Do you need pain medicine?” is a closed-ended question which will stimulate a brief “yes” or “no” response. This is correct. The response, “How would you describe your pain?” is an openended response that stimulates conversation. This is incorrect. The question “Is your pain better or worse …?” is closed-ended and would likely elicit a short response that might not be descriptive. Such questions allow the nurse to control the patient’s response. Limiting the response might lead to an incomplete assessment.

PTS: 1 CON: Communication 37. ANS: 2, 3, 4, 5 Chapter: Chapter 21 Communication & Therapeutic Relationships Objective: Compare and contrast techniques that enhance communication to techniques that hinder communication. Page: 453 (V1) Heading: Communication Is a Process Integrated Processes: Communication and Documentation Client Need: Psychosocial Integrity Cognitive Level: Knowledge [Remembering] Concept: Communication Difficulty: Easy

1. 2. 3. 4. 5.

Feedback This is incorrect. Effective messages are clear and concise, not long. This is correct. The effective message must be appropriate for the developmental level. This is correct. The effective message is appropriate for the situation. This is correct. The effective message is delivered at the appropriate time. This is correct. The information is organized in an effective message.

PTS: 1 CON: Communication 38. ANS: 2, 3 Chapter: Chapter 21 Communication & Therapeutic Relationships Objective: Communicate with clients whose culture or language is different from yours. Page: 229 (V1) Heading: Personal Distance and Assessment and Clinical Insight 21-3 Communicating With Clients From Another Culture Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Comprehension [Understanding] Concept: Culture Difficulty: Moderate

1. 2.

Feedback This is incorrect. To provide culturally sensitive care, smile and be polite, but not overfriendly or casual. This is correct. When communicating with the patient, the nurse should maintain a comfortable personal distance, which is typically 18 inches to 4 feet. This distance facilitates sharing of feelings or personal thoughts and communicating caring or concern. This is correct. The nurse would also carefully assess verbal and nonverbal cues for

indications of a language barrier. Although patients might not understand all that the nurse is saying, those having lower language comprehension or fluency might indicate understanding with nods or words of affirmation. This is incorrect. During the assessment period, the nurse must consider the presence of others and patient privacy. Do not assume that family members are privy to confidential patient information just from their being present. Patients typically are most comfortable in a private setting. This is incorrect. Abruptly changing the topic of discussion makes the nurse seem uninterested and unfeeling.

PTS: 1 CON: Culture 39. ANS: 1, 2, 3, 5 Chapter: Chapter 21 Communication & Therapeutic Relationships Objective: Compare and contrast techniques that enhance communication to techniques that hinder communication. Page: 466 (V1) Heading: Barriers to Therapeutic Communication Integrated Processes: Communication and Documentation Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Communication Difficulty: Moderate

Feedback This is correct. In this item, it is inappropriate for the nurse to ask the patient why he or she hasn’t stopped smoking. This may make the patient feel the nurse does not approve of him/her or the patient may become defensive and stop talking. This is correct. In the response in which the nurse asks to obtain vital sign measurements and then provide pain medication, the nurse is changing the subject, which is a barrier to communication. If patients are in pain, they may not be receptive to having vital signs measured and recorded. This can also make patients feel that the nurse’s tasks are more important than the patients’ needs. This is correct. The nurse must further assess the patient’s pain before administering pain medications. The nurse cannot rely solely on a statement by the unlicensed assistive personnel (UAP). This is incorrect. The only appropriate statement in this item is to request and further investigate the chest pain the patient was experiencing at home. This is an openended question and will lead to more dialogue between the patient and nurse. This is correct. Talking about all the possible causes of chest pain is an example of “fire-hosing” information, which is delivering an overwhelming amount of information all at once. This barrier to communication can lead the patient or family to feel stunned, confused, intimidated, and helpless.

PTS: 1 CON: Communication 40. ANS: 2, 3, 4, 5 Chapter: Chapter 21 Communication & Therapeutic Relationships Objective: Communicate with clients with impaired hearing, speech, or cognition. Page: 231 (V1) Heading: Clinical Insight 21-4 Communicating With Clients Who Have Impaired Cognition or Consciousness > Patients Who Are Unconscious Integrated Processes: Communication and Documentation Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Communication Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is incorrect. While speaking clearly is appropriate, address the patient slowly (not more loudly). This is correct. Other methods to enhance communication with the unconscious patient include explaining all procedures. Never assume they cannot hear! This is correct. Use touch appropriately for unconscious patients when providing care. This is correct. Speak calmly and slowly, even if the patient doesn’t seem to be alert and oriented. This is correct. Out of respect for the patient, always introduce yourself before beginning care.

PTS:

CON: Communication

Chapter 22. Health Assessment Multiple Choice Identify the choice that best completes the statement or answers the question. 1. A mother brings her 6-month-old infant to the clinic for a well-baby checkup. How should the nurse proceed when weighing the infant? 1. Have the mother remain outside the room. 2. Ask the mother to remove the infant’s clothing and diaper. 3. Weigh the infant with the diaper only. 4. Place the infant supine on the scale with knees extended. 2. A client has noticed a decrease in taste sensation. Which cranial nerve (CN) is most likely involved? 1. CN V and CN VII 2. CN VII and CN IX 3. CN V and CN VIII 4. CN VI and CN X 3. While the nurse assesses a newborn of African American descent, the mother points out a blueblack Mongolian spot on the newborn’s back and asks, “What’s that? Is something wrong with my baby?” Which response by the nurse is best? 1. “I’ll ask the physician to look at the spot.” 2. “Those spots are quite common and typically fade with time.” 3. “You may want a plastic surgeon to look at that.” 4. “That spot is benign so it’s nothing you need to worry about.” 4. An older adult comes to the clinic reporting pain in the left foot. While assessing the client, the nurse notes smooth, shiny skin with no hair on the client’s lower legs. Which condition does this finding suggest? 1. Venous insufficiency 2. Hyperthyroidism 3. Arterial insufficiency 4. Dehydration 5. Which skin assessment finding would cause the nurse to suspect dehydration in a middle-aged patient admitted to the hospital with traveler’s diarrhea? 1. Edema 2. Hyperhidrosis 3. Pallor 4. Tenting 6. A female patient has excessive facial hair. The nurse should document this finding using which term?

1. 2. 3. 4.

Alopecia Albinism Hirsutism Milia

7. The nurse is concerned that an African American client is experiencing cyanosis. Which sign of cyanosis would the nurse look for in this client? 1. The presence of excessive interstitial fluid, with decreased skin elasticity 2. A bluish tinge in the skin, tongue, and mucous membranes 3. Redness and a variety of rashes over the entire body 4. An absence of underlying red tones in the skin 8. A 6-week-old infant is brought to the pediatrician’s office for a well-baby checkup. The nurse notes flattening of the skull. Flattening of the skull in the infant might suggest which finding? 1. Lying in the same position for several hours a day 2. A disorder associated with excessive growth hormone 3. An accumulation of excessive cerebrospinal fluid 4. Temporomandibular joint (TMJ) syndrome 9. The nurse notes ptosis in a patient who just arrived in the emergency department. The nurse quickly triages the patient because the nurse knows that this finding, along with other symptoms, might suggest the patient is experiencing which condition? 1. Hyperthyroidism 2. Stroke 3. Glaucoma 4. Macular degeneration 10. Small hemorrhages are noted under the nailbed of a patient with a history of intravenous drug abuse. This finding is associated with which condition? 1. Low albumin levels 2. Zinc deficiency 3. Renal disease 4. Bacterial endocarditis 11. Which abnormal laboratory value is associated with an icteric sclera? 1. Occult blood 2. Bilirubin 3. Hemoglobin 4. Glucose 12. The left pupil of a patient fails to accommodate. This finding may reflect an abnormality in which cranial nerve (CN)? 1. CN III 2. CN V 3. CN VIII

4. CN X 13. When testing near vision, the nurse should position printed text how many inches away from the patient? 1. 20 (50.8 cm) 2. 18 (45.7 cm) 3. 16 (40.4 cm) 4. 14 (35.5 cm) 14. A 48-year-old patient comes to the physician’s office complaining of diminished near vision, which the nurse confirms with testing. The nurse should document this finding using which term? 1. Myopia 2. Hyperopia 3. Presbyopia 4. Mydriasis 15. Which situation indicates that the nurse is conducting a focused assessment? 1. The nurse performs a head-to-toe assessment that includes every body system. 2. The nurse performs the Romberg test on a patient who reports problems with balance. 3. The nurse evaluates the patient during every interaction to determine nursing care needs. 4. The nurse evaluates the patient’s overall health status. 16. Which statement best describes the procedure used to assess capillary refill? 1. Briefly press the tip of the nail with firm, steady pressure, then release and observe for changes in color. 2. Press firmly with your fingertip for 5 seconds over a bony area, release pressure, and observe the skin for the reaction. 3. Tap on the skin with short strokes using middle fingers. 4. Lift a fold of skin, and allow it to return to its normal position. 17. Which abnormal capillary refill finding would the nurse report? 1. 1 second 2. 2 seconds 3. 3 seconds 4. 4 seconds 18. Which length of time accurately describes when the infant’s anterior fontanel (soft spot) typically fuses? 1. At about 8 weeks 2. At about 18 months 3. By 6 months of age 4. Before 1 year of age

19. The 4-year-old child’s vision is not 20/20. What does this result indicate? 1. Strabismus 2. Anisocoria 3. Normal finding 4. Presbyopia 20. Which test should the patient undergo when the Weber test result is positive? 1. Romberg test 2. Rinne test 3. Snellen test 4. Whisper test 21. The nurse is performing an otoscopic examination on an adult patient. The nurse has the patient tilt head to the side not being examined. Which step should the nurse perform next? 1. Straighten the ear canal by pulling the pinna up and back. 2. Insert the speculum into the ear canal slowly. 3. Test the mobility of the tympanic membrane. 4. Gently pull the pinna down and back. 22. An 85-year-old patient is brought to the emergency department with lethargy and hypotension. As the nurse assesses the patient’s tongue, it appears dry and furry. Which condition would the nurse suspect the patient is experiencing? 1. Fungal infection 2. Dehydration 3. Allergy 4. Iron deficiency 23. Which assessment should the nurse perform if the patient has a palpable thyroid gland? 1. Illuminate the thyroid gland for the presence of fluid. 2. Auscultate the thyroid gland for bruits. 3. Percuss the thyroid gland for mass size. 4. Measure the thyroid gland to assess change. 24. While palpating the anterior chest, the nurse notes crackling in the skin around the patient’s chest tube insertion site. Which term would the nurse use to document this finding? 1. Tactile fremitus 2. Egophony 3. Bronchophony 4. Crepitus 25. Bronchovesicular breath sounds are best heard over which area? 1. Midline over the trachea just below the larynx 2. Fifth intercostal space, in the midclavicular line 3. First and second intercostal spaces next to the sternum 4. At the base of the lungs near the diaphragm

26. High-pitched breath sounds produced by airway narrowing are known as: 1. Rales 2. Crackles 3. Rhonchi 4. Wheezing 27. The nurse finds a small pulsation at the patient’s fifth intercostal space midclavicular line. This should be documented as a: 1. Thrill 2. Murmur 3. Normal finding 4. Heave 28. The nurse notes an S3 heart sound while performing an assessment on a patient admitted with an acute myocardial infarction. The nurse notifies the physician of the finding, which most likely suggests: 1. Heart failure 2. Coronary artery disease 3. Hypertension 4. Pulmonic stenosis 29. The admission assessment form indicates that the patient has pedal pulses that are rated 1 in amplitude. This documentation indicates that the patient’s pulses are: 1. Bounding 2. Normal 3. Full 4. Diminished 30. A patient’s jugular venous pressure measures 5 cm. What should this finding indicate to the nurse? 1. A normal finding 2. Hypovolemia 3. Heart failure 4. Dehydration 31. The nurse is caring for a patient who underwent abdominal surgery 24 hours ago and has a nasogastric tube for intermittent suction. How should the nurse proceed when performing an abdominal assessment on this patient? 1. Avoid palpating the patient’s abdomen. 2. Turn off the suction before auscultating bowel sounds. 3. Listen for bowel sounds for 2 minutes in each quadrant. 4. Percuss the abdomen before auscultating bowel sounds. 32. Abdominal palpation should be avoided in a child who has which disorder? 1. Appendicitis

2. Wilms’ tumor 3. Crohn’s disease 4. Small bowel obstruction 33. A father brings his 18-month-old child to the pediatric clinic for a well-baby checkup. The father tells the nurse that he is concerned because the child’s legs are bowed. Which response by the nurse is appropriate? 1. “Your child will most likely require physical therapy.” 2. “You should consider having your child seen by an orthopedic surgeon.” 3. “This is a normal finding in children for 1 year after they begin walking.” 4. “Your child is walking fine, so you don’t need to worry.” 34. The nurse asks the patient to spread the fingers and then bring them together again. Which type of movement is the nurse testing when asking the patient to bring the fingers together? 1. Abduction 2. Adduction 3. Flexion 4. Extension 35. An adult admitted to the hospital after a stroke does not respond to verbal stimuli. What should the nurse do next to try to provoke a response? 1. Apply pressure to the mandible at the jaw. 2. Rub the patient’s sternum. 3. Squeeze the trapezius muscle. 4. Gently shake the patient’s shoulder. 36. Which assessment question helps assess immediate memory? 1. “How did you get to the hospital today?” 2. “Can you repeat the numbers 2, 7, 9 for me?” 3. “Do you remember the three items I mentioned earlier?” 4. “What is your birth date including the year?” 37. Which documentation about a patient’s level of consciousness is best? 1. Patient is lethargic and slept when undisturbed. 2. Patient responds to tactile stimulation; falls back to sleep immediately after tactile and verbal stimulation are stopped. 3. Patient slept throughout the day, missing meals and bath. 4. Patient appears to be tired and slept throughout the day except when bathed. 38. Based on developmental stage, how should the nurse modify the comprehensive physical examination of an older adult? 1. Work rapidly to finish as quickly as possible. 2. Sequence the examination to limit position changes. 3. Demonstrate equipment before using it. 4. Omit portions of the examination that may be tiring.

39. The nurse applies resistance to the top of a male client’s foot and asks him to pull his toes toward his knee. The nurse observes active motion against some resistance, but not against full resistance. How should the nurse document this finding? 1. 5: Normal 2. 4: Slight weakness 3. 3: Weakness 4. 2: Poor range of motion (ROM) 40. The nurse is bathing a newborn infant in the nursery and notices scaly white patches over the infant’s scalp. What is the most appropriate action by the nurse? 1. Wash the scalp, and apply gentle scrubbing. 2. Notify the primary care provider. 3. Obtain a computed tomography (CT) scan of the infant’s head. 4. Assess for patches on the infant’s lower torso. 41. The nurse is working in an outpatient clinic in the community. Late in the afternoon, three clients come in with suspected pediculosis. Which assessment will the nurse perform? 1. Integumentary assessment for head lice 2. Oral assessment for bad breath and caries 3. Musculoskeletal assessment for spine alignment 4. Lower extremity assessment for athlete’s foot 42. An older adult’s fingernails appear concave and spoon shaped. The nurse associates this observation with which condition? 1. A normal finding in older adults 2. Chronic lung disease 3. Iron deficiency 4. Chronic heart disease 43. The mother of a 1-month-old infant states to the examining nurse, “There is something wrong with my baby’s eyes. She seems to be cross-eyed.” What is the most appropriate response by the nurse? 1. “I will need to perform a thorough eye examination.” 2. “This is not uncommon in infants in their first 2 months of life.” 3. “Please try not to overreact. You are new parents, and there is much for you to learn.” 4. “I will report your concerns to the pediatrician.” 44. The nurse is planning a breast examination class for a group of women at a community health fair. In planning the class, what is most important for the nurse to consider in preparation for the class? 1. Women who perform breast self-examinations should be trained in proper technique to avoid false-negative findings. 2. Breast examinations should be performed yearly for all women over the age of 25 years. 3. Clinical breast exams are recommended for average-risk women at any age.

4. A breast examination that includes assessment of the breast and axillae is indicated only if the woman is at high risk for breast cancer. Multiple Response Identify one or more choices that best complete the statement or answer the question. 45. The nurse obtains vital signs for a 56-year-old patient who underwent surgery yesterday. Which findings require further assessment? Select all that apply. 1. Blood pressure 110/64 mm Hg 2. Pulse rate 118 beats/min 3. Respiratory rate 35 breaths/min 4. Oral temperature 98.6°F (37°C) 5. Blood pressure 118/78 mm Hg 46. Which disorders might limit a patient’s visual field? Select all that apply. 1. Poorly controlled diabetes 2. Advanced glaucoma 3. Peripheral vascular disease 4. Cataracts 5. Macular degeneration 47. The nurse is assessing the level of consciousness of a client who suffered a head injury. The nurse uses the Glasgow Coma Scale and determines that the client’s score is 15. Which responses did the nurse assess in this client? Select all that apply. 1. Opens eyes spontaneously 2. Assumes flexor posture 3. Has unequal pupil size 4. Is orientated to person, place, and time 5. Obeys verbal commands for movement 48. Which statements describe the proper technique for auscultating heart sounds? Select all that apply. 1. Auscultate in an orderly fashion, starting at the aortic area and proceeding to pulmonic, tricuspid, and mitral areas. 2. Listen for S1 first in all landmark areas, and then proceed to listening for S2 in all landmark areas. 3. Use the diaphragm of the stethoscope for normal sounds and the bell of the stethoscope to detect any extra sounds. 4. Rotate the starting point of landmarks at each patient assessment to detect any changes. 5. Perform cardiac auscultation from the patient’s left side, whenever possible. 49. Which information describes the nurse’s general survey? Select all that apply. 1. Consists of an overall impression of the patient

2. 3. 4. 5.

Assists in identifying deviations that need further exploration Includes obtaining a full set of vital signs Includes the comprehensive physical assessment Focuses solely on the physical

50. The nurse on a medical unit notes fluid accumulation in the feet and ankles of a 75-year-old patient. What are the rationales for the nurse performing a physical examination? Select all that apply. 1. Obtain baseline data. 2. Determine health problems. 3. Address needs of the patient. 4. Receive reimbursement for care. 5. Provide discretion and privacy. 51. When performing a skin assessment, the nurse notices a mole on the patient’s upper back. Which actions would the nurse take to further investigate the mole? Select all that apply. 1. Ask the patient about any new moles or changes in moles. 2. Do not alarm the patient by asking questions about the mole. 3. Measure the mole’s diameter and elevation. 4. Assess for any exudate on or around the mole. 5. Avoid palpating the mole. 52. The nurse is performing a vision examination. In assessing for color blindness, the nurse applies which knowledge? Select all that apply. 1. It may be genetically inherited. 2. It is more common in males. 3. It may be the result of macular degeneration. 4. It may be the result of a lens defect of the eye. 5. It can be tested by using the letters on the Snellen chart. 53. The nurse is performing an otoscopic examination on the patient. In assessing the tympanic membrane, the nurse assesses for which normal findings in appearance? Select all that apply. 1. Light red 2. Pearly gray 3. Shiny 4. Translucent 5. Retracted 54. Which principles apply when performing a focused assessment of the abdomen? Select all that apply. 1. Ask the patient to empty bladder prior to the assessment. 2. Follow the assessment sequence of inspection, palpation, percussion, and auscultation. 3. Position the patient in the supine position, with knees slightly flexed. 4. Begin palpating with light pressure to detect surface characteristics, and move to

deep palpation. 5. Examine painful areas first to minimize discomfort. 55. Which statements regarding common neurological changes in older adults are true? Select all that apply. 1. Older adults have slower reactions and decreased ability for rapid problem solving. 2. With advanced age, the number of functioning neurons decreases. 3. Neurological deficits may be attributed to medications or medication interactions. 4. With normal aging, memory and the ability to discriminate decrease. 5. Intelligence decreases during the normal aging process. 56. The nurse has completed an external genital examination on several female clients in the women’s health clinic. Which clients would require an internal genital examination? Select all that apply. 1. A client on hormone therapy 2. A client who has had more than three pregnancies 3. A client with an abnormal finding on the external examination 4. A 15-year-old client who is not sexually active 5. A 32-year-old client with pelvic pain and pressure 57. The nurse is performing a comprehensive health assessment on several clients in the community clinic. Which clients are most at risk for developing hemorrhoids? Select all that apply. 1. A client with a history of constipation 2. A client with a history of prostate cancer 3. A woman who has had four children 4. A woman younger than 25 years of age 5. A woman 7 months pregnant

Chapter 22. Health Assessment Answer Section MULTIPLE CHOICE 1. ANS: 2 Chapter: Chapter 22 Health Assessment Objective: Explain adaptations that may be required when you examine clients of various ages. Page: 239 (V2) Heading: Procedure 22-1 Performing the General Survey > Infants and children Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate Feedback 1 This is incorrect. Infants are typically more comfortable with the parent close by, so the mother should remain in the room. 2 This is correct. The nurse should ask the mother to remove the infant’s clothing and diaper before weighing and measuring the infant. An older child can be examined in underwear; infants should be fully undressed. 3 This is incorrect. The infant needs to be naked. 4 This is incorrect. The infant should be supine with knees extended on the examination table when being measured, not when being weighed. PTS: 1 CON: Health Promotion 2. ANS: 2 Chapter: Chapter 22 Health Assessment Objective: Discuss the expected findings of a physical examination. Page: 256 (V2) Heading: Table 22-4 Cranial Nerves Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Sensory Perception Difficulty: Moderate Feedback 1 This is incorrect. While CN VII does supply sensations for taste, cranial nerve V supplies sensation to the eyes, face, and mouth. 2 This is correct. Cranial nerves VII and IX supply sensation to the tongue. 3 This is incorrect. CN V supplies sensory and motor movement to the eyes, scalp, teeth, facial sensations, and jaw movement, and CN VIII provides sensations to

the ear. This is incorrect. CN VI provides motor movement to the eyes, while CN X supplies sensations to the pharynx and larynx; motor activity of swallowing and vocal cords; sensory in cardiac, respiratory, and blood pressure reflexes; peristalsis; and digestive secretions.

PTS: 1 CON: Sensory Perception 3. ANS: 2 Chapter: Chapter 22 Health Assessment Objective: Explain adaptations that may be required when you examine clients of various ages. Page: 481 (V1) Heading: Skin Color Integrated Processes: Culture and Spirituality Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate Feedback 1 This is incorrect. The nurse should report the finding in the newborn’s health record, but there is no need to notify the physician. 2 This is correct. The best response by the nurse is to explain that Mongolian spots are common in dark-skinned newborns and typically fade over time. 3 This is incorrect. It is inappropriate for the nurse to recommend that the mother take her newborn to a plastic surgeon. Mongolian spots do not require treatment. 4 This is incorrect. Although it contains correct information, “… nothing you need to worry about” ignores the mother’s concerns and is providing false reassurance, a nontherapeutic communication technique. PTS: 1 CON: Health Promotion 4. ANS: 3 Chapter: Chapter 22 Health Assessment Objective: Discuss the expected findings of a physical examination. Page: 481 (V1) Heading: Skin Texture Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback 1 This is incorrect. Venous insufficiency leads to thick, rough skin that is commonly hyperpigmented.

2 3 4

This is incorrect. Hyperthyroidism is associated with coarse, thick, dry skin. This is correct. Peripheral arterial insufficiency is associated with smooth, thin, shiny skin with little or no hair. This is incorrect. Decreased turgor would be seen in dehydration.

PTS: 1 CON: Perfusion 5. ANS: 4 Chapter: Chapter 22 Health Assessment Objective: Discuss the expected findings of a physical examination. Page: 252 (V1) Heading: Procedure 22-2 Assessing the Skin > Developmental Variations Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 This is incorrect. Edema, an excessive amount of fluid in the tissues, may be a sign of heart failure, kidney disease, peripheral vascular disease, or low albumin levels. 2 This is incorrect. Hyperhidrosis is a term for excessive sweating, which may be a sign of hyperthermia, thyroid hyperactivity, or anxiety. 3 This is incorrect. Pallor, abnormal loss of skin color, may be a sign of anemia or blood loss. 4 This is correct. Tenting, skin that takes several seconds to return to normal after lifting up a skinfold, may be a sign of dehydration. PTS: 1 CON: Fluid and Electrolyte Balance 6. ANS: 3 Chapter: Chapter 22 Health Assessment Objective: Document the findings of a physical examination. Page: 483 (V1) Heading: The Hair Integrated Processes: Communication and Documentation Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Hair loss should be documented as alopecia. 2 This is incorrect. Albinism is a condition caused by lack of pigment in which the patient has white hair and very pale skin.

3 4

This is correct. The nurse should document this finding as hirsutism, excessive facial or trunk hair. This is incorrect. Milia refers to white, raised areas on the nose, chin, and forehead of newborns.

PTS: 1 CON: Patient-Centered Care 7. ANS: 2 Chapter: Chapter 22 Health Assessment Objective: Discuss the expected findings of a physical examination. Page: 482 (V1) Heading: Table 22-2 Common Skin Color Variations > Cyanosis Integrated Processes: Culture and Spirituality Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Perfusion Difficulty: Easy Feedback 1 This is incorrect. Edema is the presence of excessive interstitial fluid. 2 This is correct. Cyanosis is a bluish tinge most evident in the skin, tongue, and mucous membranes. It is important to note that pallor, cyanosis, and erythema may appear differently in clients with brown or black skin, and the nurse must take care not to overlook abnormal findings. 3 This is incorrect. Erythema is redness associated with a variety of rashes, skin infections, or prolonged pressure on the skin. 4 This is incorrect. Pallor occurs when there is too little circulating blood or hemoglobin and is characterized by the absence of underlying red tones in darkskinned clients. PTS: 1 CON: Perfusion 8. ANS: 1 Chapter: Chapter 22 Health Assessment Objective: Explain adaptations that may be required when you examine clients of various ages. Page: 484 (V1) Heading: The Head > The Skull and Face Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Health Promotion Difficulty: Moderate Feedback 1 This is correct. Abnormal flattening of the skull in infants may result from the baby placed in the same position for several hours every day.

2 3

This is incorrect. A large head in an adolescent or adult may be associated with acromegaly, a disorder associated with excessive growth hormone. This is incorrect. In infants and children, a head that is growing disproportionately faster than the body may be a sign of hydrocephalus, which is fluid collection in the cavity within the brain. This is incorrect. Irregular jaw movement and cracking of the jaw in adults may indicate TMJ syndrome.

PTS: 1 CON: Health Promotion 9. ANS: 2 Chapter: Chapter 22 Health Assessment Objective: Identify the components of the general survey. Page: 479 (V1) Heading: The General Survey Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Neurologic Regulation Difficulty: Moderate Feedback 1 This is incorrect. Exophthalmos is associated with hyperthyroidism. 2 This is correct. Ptosis, or drooping of the eyelid, may be seen in a patient who experienced Bell’s palsy or a stroke. 3 This is incorrect. Mydriasis may be seen with glaucoma. 4 This is incorrect. Macular degeneration has no outward signs. PTS: 1 CON: Neurologic Regulation 10. ANS: 4 Chapter: Chapter 22 Health Assessment Objective: Discuss the expected findings of a physical examination. Page: 483 (V1) Heading: The Nails Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Infection Difficulty: Difficult Feedback 1 This is incorrect. A distal band of reddish-pink covering 20% to 60% of the nail (“half-and-half nails”) is seen in patients with low albumin levels. 2 This is incorrect. White spots may indicate zinc deficiency. 3 This is incorrect. A patient with renal disease may have a distal band of reddish-

pink covering 20% to 60% of the nail (“half-and-half nails”). This is correct. Small hemorrhages under the nailbed, known as splinter hemorrhages, are associated with bacterial endocarditis.

PTS: 1 CON: Infection 11. ANS: 2 Chapter: Chapter 22 Health Assessment Objective: Discuss the expected findings of a physical examination. Page: 485 (V1) Heading: External Structures > Sclera and Conjunctiva Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Knowledge [Remembering] Concept: Metabolism Difficulty: Moderate Feedback 1 This is incorrect. Positive occult blood indicates bleeding in the GI tract. 2 This is correct. An icteric sclera is associated with elevated bilirubin levels. 3 This is incorrect. Low hemoglobin would indicate anemia. High hemoglobin is polycythemia, which is like thick blood. 4 This is incorrect. Low glucose is hypoglycemia, and high sugar is hyperglycemia. PTS: 1 CON: Metabolism 12. ANS: 1 Chapter: Chapter 22 Health Assessment Objective: Identify the components of the general survey. Page: 485 (V1) Heading: External Structures > Pupils Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Comprehension [Understanding] Concept: Neurologic Regulation Difficulty: Moderate Feedback 1 This is correct. CN III, the oculomotor nerve, is responsible for accommodation. Failure of a pupil to accommodate reflects an abnormality in CN III. 2 This is incorrect. CN V, the trigeminal nerve, controls the corneal reflex, chewing, and biting. 3 This is incorrect. CN VIII, the acoustic nerve, plays a role in hearing and the sense of balance. 4 This is incorrect. CN X, the vagus nerve, affects heart rate, peristalsis,

swallowing, and the gag reflex. PTS: 1 CON: Neurologic Regulation 13. ANS: 4 Chapter: Chapter 22 Health Assessment Objective: Demonstrate the skills used in physical examination. Page: 259 (V2) Heading: Highlights of Procedures 22-1 Through 22-20 > Procedure 22-6: Assessing the Eyes and Procedure 22-6 Assessing the Eyes Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Knowledge [Remembering] Concept: Sensory Perception Difficulty: Moderate Feedback 1 This is incorrect. Twenty inches (50.8 cm) is too long a distance to test near vision. 2 This is incorrect. To test near vision, the distance needs to be shorter than 18 inches (45.7 cm). 3 This is incorrect. Sixteen inches (40.4 cm) is too long a distance. 4 This is correct. Test near vision by having the client read text from a distance of 14 inches (35.5 cm). PTS: 1 CON: Sensory Perception 14. ANS: 3 Chapter: Chapter 22 Health Assessment Objective: Explain adaptations that may be required when you examine clients of various ages. Page: 259 (V2) Heading: Procedure 22-6 Assessing the Eyes > Test near vision > Developmental Variations Integrated Processes: Communication and Documentation Client Need: Health Promotion and Maintenance Cognitive Level: Knowledge [Remembering] Concept: Sensory Perception Difficulty: Moderate Feedback 1 This is incorrect. Diminished distant vision is known as myopia. 2 This is incorrect. Hyperopia refers to diminished near vision. 3 This is correct. Diminished near vision in a patient over age 45 years is known as presbyopia. 4 This is incorrect. Mydriasis, or enlarged pupils, may be seen with glaucoma. PTS:

CON: Sensory Perception

15. ANS: 2 Chapter: Chapter 22 Health Assessment Objective: Discuss the differences among comprehensive, focused, and ongoing physical examinations. Page: 473 (V1) Heading: Types of Physical Examinations Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Performing a head-to-toe assessment including every body system is a comprehensive assessment, not a focused assessment. 2 This is correct. The patient reported problems with balance and the nurse conducted the Romberg test; this indicates a focused assessment. 3 This is incorrect. Evaluating the patient at every interaction is an ongoing assessment, not a focused assessment. 4 This is incorrect. Evaluating the overall health status is a comprehensive assessment, not a focused assessment. PTS: 1 CON: Patient-Centered Care 16. ANS: 1 Chapter: Chapter 22 Health Assessment Objective: Demonstrate the skills used in physical examination. Page: 256 (V2) Heading: Procedure 22-4 Assessing the Nails > Assess capillary refill Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Knowledge [Remembering] Concept: Perfusion Difficulty: Moderate Feedback 1 This is correct. To assess capillary refill, the nurse should briefly press the tip of the nail with firm, steady pressure, then release and observe for changes in skin color. 2 This is incorrect. The nurse should press firmly with fingertip for 5 seconds over a bony area, then release the finger and observe the skin for the reaction to grade edema. 3 This is incorrect. Tapping the skin describes the procedure for performing percussion. 4 This is incorrect. Lifting a fold of skin demonstrates the procedure for checking

skin turgor and monitoring for tenting. PTS: 1 CON: Perfusion 17. ANS: 4 Chapter: Chapter 22 Health Assessment Objective: Discuss the expected findings of a physical examination. Page: 256 (V2) Heading: Procedure 22-4 Assessing the Nails > Assess capillary refill Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Knowledge [Remembering] Concept: Collaboration Difficulty: Easy Feedback 1 This is incorrect. This is a normal finding. 2 This is incorrect. Expected findings for capillary refill is less than 2 to 3 seconds. 3 This is incorrect. Normal capillary refill is less than 2 to 3 seconds. 4 This is correct. Normal capillary refill is less than 3 seconds; therefore, the nurse should report a capillary refill of 4 seconds. PTS: 1 CON: Collaboration 18. ANS: 2 Chapter: Chapter 22 Health Assessment Objective: Explain adaptations that may be required when you examine clients of various ages. Page: 257 (V2) Heading: Procedure 22-5 Assessing the Head and Face Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Growth and Development Difficulty: Moderate Feedback 1 This is incorrect. The posterior (not anterior) fontanel fuses at about 8 weeks of age. 2 This is correct. The large soft spot on the top of the head, known as the anterior fontanel, typically fuses at about 18 months. 3 This is incorrect. The infant should be able to hold the head up by age 6 months. 4 This is incorrect. The anterior fontanel fuses after (not before) 1 year of age. PTS: 1 19. ANS: 3

CON: Growth and Development

Chapter: Chapter 22 Health Assessment Objective: Explain adaptations that may be required when you examine clients of various ages. Page: 259 (V2) Heading: Procedure 22-6 Assessing the Eyes Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Sensory Perception Difficulty: Moderate Feedback 1 This is incorrect. Strabismus refers to crossed eye, in which one or both eyes deviate from the object they are looking at. 2 This is incorrect. Unequal pupils (anisocoria) can be a normal variation if the difference is less the 0.5 mm. 3 This is correct. Children typically do not have 20/20 vision until age 6 or 7 years. This finding would be considered normal in a 4-year-old child. 4 This is incorrect. Hyperopia is diminished near vision and is represented by a large fraction, such as 20/15; when found in people over age 45 years, it is known as presbyopia. PTS: 1 CON: Sensory Perception 20. ANS: 2 Chapter: Chapter 22 Health Assessment Objective: Demonstrate the skills used in physical examination. Page: 486 (V1) Heading: Assessing Hearing Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Knowledge [Remembering] Concept: Sensory Perception Difficulty: Moderate Feedback 1 This is incorrect. The Romberg test is performed to test equilibrium. 2 This is correct. If the Weber test is positive, the patient should undergo the Rinne test to assess the type of hearing loss. 3 This is incorrect. The Snellen test is for assessment of vision, not hearing. 4 This is incorrect. The whisper test is for assessment of gross hearing, not a test to be performed if the Weber test is positive. PTS: 1 CON: Sensory Perception 21. ANS: 1 Chapter: Chapter 22 Health Assessment

Objective: Explain the adaptations that may be required when you examine clients of various ages. Page: 266 (V2) Heading: Procedure 22-7 Assessing the Ears and Hearing Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate Feedback 1 This is correct. Next, the nurse should straighten the ear canal by pulling the pinna up and back. 2 This is incorrect. After straightening the ear canal, the nurse should slowly insert the speculum and observe the ear canal. 3 This is incorrect. Mobility of the tympanic membranes occurs after observing the tympanic membrane. 4 This is incorrect. In a preschool child, the nurse should straighten the ear canal by pulling the pinna down and back. PTS: 1 CON: Health Promotion 22. ANS: 2 Chapter: Chapter 22 Health Assessment Objective: Discuss the expected findings of a physical examination. Page: 273 (V2) Heading: Procedure 22-9 Assessing the Mouth and Oropharynx Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 This is incorrect. A black, hairy tongue is characteristic of a fungal infection. 2 This is correct. A dry, furry tongue is associated with dehydration. 3 This is incorrect. Absence of papillae, reddened mucosa, and ulcerations may indicate allergy or inflammation. 4 This is incorrect. Patients who have a deficiency of iron may have a smooth, red tongue. PTS: 1 CON: Fluid and Electrolyte Balance 23. ANS: 2 Chapter: Chapter 22 Health Assessment Objective: Demonstrate the skills used in physical examination. Page: 278 (V2)

Heading: Procedure 22-10 Assessing the Neck > What if … Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Metabolism Difficulty: Moderate Feedback 1 This is incorrect. It is not necessary to illuminate the thyroid gland. 2 This is correct. Normally, the thyroid gland is smooth, firm, and nontender. It is often nonpalpable. If the thyroid gland is palpable, the nurse should auscultate it for bruits. 3 This is incorrect. The thyroid gland should not be percussed, it is palpated. 4 This is incorrect. The thyroid gland is not measured. PTS: 1 CON: Metabolism 24. ANS: 4 Chapter: Chapter 22 Health Assessment Objective: Document the findings of a physical examination. Page: 283 (V2) Heading: Procedure 22-12 Assessing the Chest and Lungs Integrated Processes: Communication and Documentation Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Easy Feedback 1 This is incorrect. Tactile fremitus involves palpating for vibrations as the patient says “99,” which indicates the presence of fluid in the chest. 2 This is incorrect. Egophony is present if the sound heard is “ay” when the nurse listens over the lung fields as the patient says “eee.” 3 This is incorrect. Bronchophony is present if the words “1, 2, 3” are clearly heard over the lungs as the nurse listens while the patient says those words. 4 This is correct. The nurse should document this finding as “crepitus,” crackling skin caused by air leaking into the subcutaneous tissues. PTS: 1 CON: Oxygenation 25. ANS: 3 Chapter: Chapter 22 Health Assessment Objective: Discuss the expected findings of a physical examination. Page: 283 (V2) Heading: Procedure 22-12 Assessing the Chest and Lungs and unnumbered table 22-P12.1 Normal Lung Sounds

Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Knowledge [Remembering] Concept: Oxygenation Difficulty: Moderate Feedback 1 This is incorrect. Bronchial (not bronchovesicular) breath sounds are heard over the trachea. 2 This is incorrect. The fifth intercostal space midclavicular line is known as the point of maximal impulse for the heart. 3 This is correct. Bronchovesicular breath sounds are best heard over the first and second intercostal spaces adjacent to the sternum on the anterior chest. 4 This is incorrect. Base of the lungs is not the best place to hear bronchovesicular breath sounds. PTS: 1 CON: Oxygenation 26. ANS: 4 Chapter: Chapter 22 Health Assessment Objective: Discuss the expected findings of a physical examination. Page: 288 (V2) Heading: unnumbered table 22-P12.2 Abnormal Lung Sounds Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Knowledge [Remembering] Concept: Oxygenation Difficulty: Easy Feedback 1 This is incorrect. Even though rales are high-pitched, rales are not produced by narrowing airways. Rales, also called crackles, are crackling, bubbling sounds that indicate emphysema or pneumonia. 2 This is incorrect. Even though crackles are high-pitched, crackles are not produced by narrowing airways. Crackles are crackling, bubbling sounds that indicate emphysema or pneumonia. 3 This is incorrect. Rhonchi are low-pitched snoring or rumbling sounds that result from mucous secretions in the large airways. 4 This is correct. Wheezing is a high-pitched sound produced by narrowing of an airway. PTS: 1 CON: Oxygenation 27. ANS: 3 Chapter: Chapter 22 Health Assessment Objective: Document the findings of a physical examination.

Page: 290 (V2) Heading: Inspecting and Palpating the Heart and Procedure 22-13 Assessing the Heart and Vascular System Integrated Processes: Communication and Documentation Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback 1 This is incorrect. A thrill is a vibration palpated in any area except the point of maximum impulse, indicating turbulent blood flow. 2 This is incorrect. A murmur (additional heart sound) occurs when structural defects in the heart’s chambers or valves cause turbulent blood flow. 3 This is correct. A small pulsation at the fifth intercostal space midclavicular line is known as the point of maximal impulse and is considered a normal finding. 4 This is incorrect. A heave, which is a visible palpation, is associated with an enlarged ventricle. PTS: 1 CON: Perfusion 28. ANS: 1 Chapter: Chapter 22 Health Assessment Objective: Discuss the expected findings of a physical examination. Page: 290 (V2) Heading: Procedure 22-13 Assessing the Heart and Vascular System Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Perfusion Difficulty: Difficult Feedback 1 This is correct. A third heart sound, commonly referred to as S3, is heard with heart failure or volume overload. 2 This is incorrect. The S4 heart sound (not S3) may be auscultated with coronary artery disease. 3 This is incorrect. The S4 heart sound (not S3) may be auscultated with hypertension. 4 This is incorrect. The S4 heart sound (not S3) may be auscultated with pulmonic stenosis. PTS: 1 CON: Perfusion 29. ANS: 4 Chapter: Chapter 22 Health Assessment

Objective: Document the findings of a physical examination. Page: 290 (V2) Heading: Procedure 22-13 Assessing the Heart and Vascular System Integrated Processes: Communication and Documentation Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Comprehension [Understanding] Concept: Perfusion Difficulty: Moderate Feedback 1 This is incorrect. A pulse amplitude of 4 indicates a bounding pulse. 2 This is incorrect. Pulses documented as a 2 indicates a normal pulse. 3 This is incorrect. A pulse documented as a 3 indicates a full pulse. 4 This is correct. Pulses documented as 1 are diminished and barely palpable (weak). PTS: 1 CON: Perfusion 30. ANS: 3 Chapter: Chapter 22 Health Assessment Objective: Discuss the expected findings of a physical examination. Page: 290 (V2) Heading: Procedure 22-13 Assessing the Heart and Vascular System Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Comprehension [Understanding] Concept: Perfusion Difficulty: Moderate Feedback 1 This is incorrect. Normal jugular venous pressure is less than 3 cm. 2 This is incorrect. A low jugular venous pressure (not elevated) indicates hypovolemia. 3 This is correct. A jugular venous pressure of 5 cm indicates elevated pressure and suggests heart failure or constricted flow into the right side of the heart. 4 This is incorrect. Dehydration would lead to low jugular venous pressure, not high. PTS: 1 CON: Perfusion 31. ANS: 2 Chapter: Chapter 22 Health Assessment Objective: Demonstrate the skills used in physical examination. Page: 296 (V2) Heading: Procedure 22-14 Assessing the Abdomen > What if … Integrated Processes: Nursing Process

Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Light palpation can be performed in the postoperative patient. 2 This is correct. The sound of suction attached to a nasogastric tube can be mistaken for bowel sounds; therefore, the nurse should discontinue the suction or clamp off the tube while auscultating bowel sounds. 3 This is incorrect. The nurse should listen for bowel sounds for at least 5 minutes before determining that they are absent. 4 This is incorrect. Auscultation should be performed before percussion in examining the abdomen. PTS: 1 CON: Patient-Centered Care 32. ANS: 2 Chapter: Chapter 22 Health Assessment Objective: Explain adaptations that may be required when you examine clients of various ages. Page: 296 (V2) Heading: Procedure 22-14 Assessing the Abdomen Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Knowledge [Remembering] Concept: Cellular Regulation Difficulty: Moderate Feedback 1 This is incorrect. Abdominal palpation can be performed on a patient with appendicitis. 2 This is correct. Abdominal palpation should be avoided in the child who has Wilms’ tumor, large diffuse pulsation, or a history of organ transplant. 3 This is incorrect. Palpation can be performed on a patient with Crohn’s disease. 4 This is incorrect. Abdominal palpation can be performed on a patient with small bowel obstruction. PTS: 1 CON: Cellular Regulation 33. ANS: 3 Chapter: Chapter 22 Health Assessment Objective: Explain the adaptations that may be required when you examine clients of various ages. Page: 301 (V2) Heading: Procedure 22-15 Assessing the Musculoskeletal System Integrated Processes: Communication and Documentation Client Need: Health Promotion and Maintenance

Cognitive Level: Application [Applying] Concept: Growth and Development Difficulty: Moderate Feedback 1 This is incorrect. The child shows no signs, in the scenario, that physical therapy is needed. 2 This is incorrect. Referrals are not needed when the finding is normal. It is not appropriate for the nurse to recommend an orthopedic surgeon; physician referrals are given by the physician or the advanced practice nurse, when appropriate. 3 This is correct. Genu varum, or bowlegs, is a normal finding in children for 1 year after they begin walking and the bones of the legs become more ossified with development and weight-bearing. However, assessment over time is important to be sure the gait and positioning develop normally. The nurse should allay the father’s concerns by providing him with this information. 4 This is incorrect. “Your child is walking fine …” is condescending, is providing false reassurance, and does not appropriately address the father’s concerns. PTS: 1 CON: Growth and Development 34. ANS: 2 Chapter: Chapter 22 Health Assessment Objective: Demonstrate the skills used in physical examination. Page: 301 (V2) Heading: Procedure 22-15 Assessing the Musculoskeletal System Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Knowledge [Remembering] Concept: Mobility Difficulty: Moderate Feedback 1 This is incorrect. Asking the patient to spread fingers tests abduction. 2 This is correct. Asking the patient to bring fingers together assesses adduction. 3 This is incorrect. Asking the patient to make a fist tests flexion. 4 This is incorrect. Asking the patient to extend the hand tests extension. PTS: 1 CON: Mobility 35. ANS: 4 Chapter: Chapter 22 Health Assessment Objective: Demonstrate the skills used in physical examination. Page: 310 (V2) Heading: Procedure 22-16 Assessing the Sensory–Neurological System Integrated Processes: Nursing Process

Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Neurologic Regulation Difficulty: Moderate Feedback 1 This is incorrect. Apply pressure on the mandible at the angle of the jaw only after the patient does not respond to tactile stimuli. 2 This is incorrect. Rubbing the sternum is not performed unless the patient does not respond to tactile stimuli. 3 This is incorrect. If the patient does not respond to tactile stimuli, the nurse should try painful stimuli by squeezing the trapezius muscle. 4 This is correct. If the patient does not respond to verbal stimuli, the nurse should try tactile stimuli by gently shaking the patient’s shoulder. PTS: 1 CON: Neurologic Regulation 36. ANS: 2 Chapter: Chapter 22 Health Assessment Objective: Demonstrate the skills used in physical examination. Page: 311 (V2) Heading: Procedure 22-16 Assessing the Sensory–Neurological System Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Neurologic Regulation Difficulty: Moderate Feedback 1 This is incorrect. The nurse can assess recent (not immediate) memory by asking the patient how he or she got to the hospital. 2 This is correct. The nurse can assess immediate memory by asking the patient to repeat a series of three numbers and gradually increasing the length of the series until the patient cannot repeat the series correctly. 3 This is incorrect. The nurse can assess recent (not immediate) memory by asking the patient to repeat three items what the nurse had mentioned earlier in the examination. 4 This is incorrect. The nurse can assess remote (not immediate) memory by asking the patient his or her birth date or the date of a significant historical event. PTS: 1 CON: Neurologic Regulation 37. ANS: 2 Chapter: Chapter 22 Health Assessment Objective: Document the findings of a physical examination.

Page: 496 (V1) Heading: Documenting Cerebral Function > Documenting Responses Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Communication Difficulty: Moderate Feedback 1 This is incorrect. While correctly written, this charting entry provides little information about the level of consciousness. From this description, the patient might have a decreased level of consciousness or could simply be exhausted. 2 This is correct. This charting entry provides more objective information than the rest. The option that includes the most detailed information provides the most accurate description of the patient’s level of consciousness. 3 This is incorrect. While correctly written, this chart entry is not the best. It provides little details about the patient’s level of consciousness. 4 This is incorrect. “Appears to be tired” is not objective. The nurse should provide objective data rather than an opinion or judgment. PTS: 1 CON: Communication 38. ANS: 2 Chapter: Chapter 22 Health Assessment Objective: Explain adaptations that may be required when you examine clients of various ages. Page: 478 (V1) Heading: Modifications for Different Age-Groups > Gero Feature: Older Adults Integrated Processes: Caring Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. The nurse should work efficiently; however, speed is not the goal, and the nurse should observe the patient’s energy level and stop for periods of rest as needed. 2 This is correct. Because older adults may tire easily and because they may have stiff muscles and arthritic joints, the nurse should arrange the sequence of the examination to limit position changes. 3 This is incorrect. It is appropriate to demonstrate equipment for school-age children but is not usually necessary for older adults, who have probably experienced other physical examinations. 4 This is incorrect. Because this is a comprehensive examination, it is not appropriate to omit portions of it because they may be tiring. As discussed, the

patient should rest and then the nurse should return to the examination. PTS: 1 CON: Patient-Centered Care 39. ANS: 2 Chapter: Chapter 22 Health Assessment Objective: Document the findings of a physical examination. Page: 310 (V2) Heading: unnumbered table 22-P15T1 Muscle Strength Rating Scale Integrated Processes: Communication and Documentation Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Mobility Difficulty: Difficult

1 2 3 4

Feedback This is incorrect. A rating of 5 indicates active motion against full resistance and is normal. This is correct. The nurse should document “4: Slight weakness, active motion against some resistance.” This is incorrect. Weakness or active motion against gravity but none against resistance is documented as a “3: Weakness.” This is incorrect. If passive ROM is performed, the client has poor ROM and the rating is a “2: Poor ROM.”

PTS: 1 CON: Mobility 40. ANS: 1 Chapter: Chapter 22 Health Assessment Objective: Explain adaptations that may be required when you examine clients of various ages. Page: 254 (V2) Heading: Procedure 22-3 Assessing the Hair Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Ante/Intra/Post-partum Difficulty: Moderate Feedback 1 This is correct. In newborns, cradle cap—scaly white patches over the scalp due to secretion of sebum—is common. It can be removed with washing and gentle scrubbing. 2 This is incorrect. Notification of the primary care provider is not needed since this is a normal finding. 3 This is incorrect. A CT scan is not needed since this is a normal finding. The

newborn is experiencing cradle cap. This is incorrect. It is not necessary to assess for these patches over the torso, as this is common to the scalp.

PTS: 1 CON: Ante/Intra/Post-partum 41. ANS: 1 Chapter: Chapter 22 Health Assessment Objective: Demonstrate the skills used in physical examination. Page: 253 (V2) Heading: The Hair > Pediculosis and Procedure 22-3 Assessing the Hair Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 This is correct. When assessing the hair, inspect and palpate for color, texture, and distribution, as well as the condition of the scalp. In addition, the hair should be free of debris and pediculosis, which are indicative of a head lice infestation. Pediculosis is unrelated to oral, musculoskeletal, or lower extremity assessments. 2 This is incorrect. Pediculosis is unrelated to an oral assessment. 3 This is incorrect. A musculoskeletal assessment is related to abnormalities of the spine symmetry, not for pediculosis. 4 This is incorrect. Pediculosis is not athlete’s foot. PTS: 1 CON: Infection 42. ANS: 3 Chapter: Chapter 22 Health Assessment Objective: Discuss the expected findings of a physical examination. Page: 255 (V2) Heading: Procedure 22-4 Assessing the Nails Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Perfusion Difficulty: Easy Feedback 1 This is incorrect. Spoon-shaped nails are not part of a normal aging process and should be evaluated in the older adult. 2 This is incorrect. In chronic lung disease, clubbing of the nails may be present due to chronic hypoxia.

3 4

This is correct. A change in nail shape may indicate underlying disease. Spoonshaped nails may result from iron deficiency. This is incorrect. In heart disease, changes occur with delayed capillary refill time, not spoon-shaped nails.

PTS: 1 CON: Perfusion 43. ANS: 2 Chapter: Chapter 22 Health Assessment Objective: Explain adaptations that may be required when you examine clients of various ages. Page: 259 (V2) Heading: Procedure 22-6 Assessing the Eyes Integrated Processes: Communication and Documentation Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Growth and Development Difficulty: Moderate Feedback 1 This is incorrect. The nurse does not need to perform a thorough eye exam since this is a normal finding. 2 This is correct. The most appropriate response by the nurse is to first reassure the parents that this may be normal. Strabismus (crossed-eye) is a condition in which one or both eyes deviate from the object they are looking at. It is normal during the first 1 to 2 months of life. After that, it may be caused by weak intraocular muscles or a lesion on the oculomotor nerve. 3 This is incorrect. It is inappropriate to tell new parents not to overreact, as this may make them reluctant to report future findings. 4 This is incorrect. It is not necessary to report a normal finding to the pediatrician. PTS: 1 CON: Growth and Development 44. ANS: 1 Chapter: Chapter 22 Health Assessment Objective: Describe how to prepare for a physical examination. Page: 279 (V2) Heading: The Breasts and Axillae > Breast Self-Exam and Procedure 22-11 Assessing the Breasts and Axillae Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Health Promotion Difficulty: Moderate Feedback

This is correct. Researchers agree that women who perform breast selfexaminations should be trained in proper technique to avoid false-negative findings. This is incorrect. Breast exams should be done annually for women aged 40 and older, and every 1 to 3 years for women aged 20 to 39. This is incorrect. Clinical breast exams are not recommended for average-risk women at any age. This is incorrect. The majority of breast tumors are found in the tail of Spence, in the axilla. A breast exam for all women (not just high risk) always includes an exam of the axillae.

2 3 4

PTS:

CON: Health Promotion

MULTIPLE RESPONSE 45. ANS: 2, 3 Chapter: Chapter 22 Health Assessment Objective: Identify the components of the general survey. Page: 244 (V2) Heading: Procedure 22-1 Performing the General Survey Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Easy

1. 2. 3. 4. 5.

Feedback This is incorrect. Blood pressure of 110/64 mm Hg is considered normal and does not require further assessment. This is correct. Pulse rate of 118 beats/min is abnormally elevated and requires further assessment. This is correct. Respiratory rate of 35 breaths/min is abnormally elevated and require further assessment. This is incorrect. Oral temperature of 98.6°F (37°C) is considered normal and does not require further assessment. This is incorrect. Blood pressure of 118/78 mm Hg is within the normal range (less than 120/80 mm Hg) and does not require further assessment.

PTS: 1 CON: Patient-Centered Care 46. ANS: 1, 2, 4, 5 Chapter: Chapter 22 Health Assessment Objective: Discuss the expected findings of a physical examination.

Page: 261 (V2) Heading: Visual Acuity > Visual Field Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Knowledge [Remembering] Concept: Sensory Perception Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is correct. Poorly controlled diabetes may limit the visual field. This is correct. The visual field may be limited by advanced glaucoma. This is incorrect. Peripheral vascular disease may be associated with diabetes, but it occurs in the extremities, not in the eyes. This is correct. The patient’s visual field may be limited by cataracts. This is correct. Macular degeneration may limit the visual field.

PTS: 1 CON: Sensory Perception 47. ANS: 1, 4, 5 Chapter: Chapter 22 Health Assessment Objective: Discuss the expected findings of a physical examination. Page: 312 (V2) Heading: Procedure 22-16 Assessing the Sensory-Neurological System Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Neurologic Regulation Difficulty: Difficult

2. 3. 4.

Feedback This is correct. The Glasgow Coma Scale assesses the level of consciousness by testing and scoring three observations: eye opening, motor response, and verbal stimuli response. Clients are scored on their best responses, and these scores are totaled. The highest score is 15. The highest responses in these three categories are spontaneous eye opening, obeying motor commands, and orientation to time, place, and person. This is incorrect. Pupil size is not a parameter assessed in the Glasgow Coma Scale. Eye opening is assessed. This is incorrect. Assumes flexor posture is worth 3 points, and combining this score with those of the other two parameters would not add up to 15. This is correct. The Glasgow Coma Scale assesses the level of consciousness by testing and scoring three observations: eye opening, motor response, and verbal stimuli response. Clients are scored on their best responses, and these scores are

totaled. The highest score is 15. The highest responses in these three categories are spontaneous eye opening, obeying motor commands, and orientation to time, place, and person. This is correct. The Glasgow Coma Scale assesses the level of consciousness by testing and scoring three observations: eye opening, motor response, and verbal stimuli response. Clients are scored on their best responses, and these scores are totaled. The highest score is 15. The highest responses in these three categories are spontaneous eye opening, obeying motor commands, and orientation to time, place, and person.

PTS: 1 CON: Neurologic Regulation 48. ANS: 1, 3 Chapter: Chapter 22 Health Assessment Objective: Demonstrate the skills used in physical examination. Page: 294 (V2) Heading: Procedure 22-13 Assessing the Heart and Vascular System and Clinical Insight 22-2 Performing Auscultation Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Perfusion Difficulty: Moderate

2. 3.

4. 5.

Feedback This is correct. Auscultate in an orderly fashion, starting in the aortic area and moving gradually through each landmark. The mnemonic of A-P-T-M (aortic– pulmonic–tricuspid–mitral) can be used. The nurse should listen carefully at each site to each component of the heart sound. This is incorrect. The nurse listens for S1 and then S2 in each landmark before moving to the next site. This is correct. The diaphragm is used to auscultate high-pitched sounds that normally occur in the heart, lungs, and abdomen. The bell is used to auscultate lowpitched sounds, such as extra heart sounds, murmurs, or bruits. This is incorrect. The nurse should be systematic. To keep from missing important parts of the examination, always auscultate in the same order through all the areas. This is incorrect. Perform cardiac palpation and auscultation from the patient’s right (not the left) side, whenever possible.

PTS: 1 CON: Perfusion 49. ANS: 1, 2, 3 Chapter: Chapter 22 Health Assessment Objective: Identify the components of the general survey.

Page: 239 (V2) Heading: The General Survey and Procedure 22-1 Performing the General Survey Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Health Promotion Difficulty: Moderate

1. 2.

3. 4.

Feedback This is correct. The general survey is the nurse’s overall impression of the patient. It begins at first contact and continues throughout the examination. This is correct. If a deviation from normal is discovered during the general survey, the nurse can then explore the finding further during a focused assessment of that body system. This is correct. The general survey includes obtaining a full set of vital signs. This is incorrect. The general survey does not include a comprehensive physical assessment (CPA), as the CPA includes the health history interview and a complete head-to-toe examination of every body system. This is incorrect. The general survey focuses on both emotional and physical aspects, not just solely on the physical.

PTS: 1 CON: Health Promotion 50. ANS: 1, 2, 3 Chapter: Chapter 22 Health Assessment Objective: Identify the purposes and components of a physical examination. Page: 473 (V1) Heading: Purposes of a Physical Examination Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate

2. 3. 4.

Feedback This is correct. To obtain baseline data: data about the patient’s physical status and functional abilities serve as a baseline for comparison as the patient’s health status changes. This is correct. To screen for health problems: a physical examination helps identify health problems at early stages. This is correct. A physical examination helps address the patient’s needs. This is incorrect. Reimbursement of care is not a rationale for performing a physical assessment.

This is incorrect. While providing discretion and privacy is important during the performance of a physical examination, it is not the rationale for performing a physical exam.

PTS: 1 CON: Patient-Centered Care 51. ANS: 1, 3, 4 Chapter: Chapter 22 Health Assessment Objective: Demonstrate the skills used in physical examination. Page: 245 (V2) Heading: Procedure 22-2 Assessing the Skin Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Cellular Regulation Difficulty: Moderate

3. 4. 5.

Feedback This is correct. Ask the patient if there has been any newly developed moles or skin lesions or whether there has been any change in the appearance of existing lesions. The nurse will further assess for asymmetry, border irregularity, color variation, diameter, and elevation above the skin surface, exudate, itching, or pain. This is incorrect. The nurse should ask questions about the moles. Evaluate all skin lesions for the possibility of malignancy, especially those located in a site exposed to chronic rubbing or other trauma. This is correct. The nurse will further assess the mole by measuring the diameter, and elevation of the mole. This is correct. The nurse will further assess for exudate (drainage) on or around the mole. This is incorrect. The nurse should palpate the mole to determine softness or hardness of the mole.

PTS: 1 CON: Cellular Regulation 52. ANS: 1, 2, 3 Chapter: Chapter 22 Health Assessment Objective: Demonstrate the skills used in physical examination. Page: 260 (V2) Heading: Visual Acuity > Color Vision Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Comprehension [Understanding] Concept: Sensory Perception Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is correct. Color vision is the ability to detect color. Color blindness may be genetically inherited. This is correct. Color blindness is more common in males. This is correct. Macular degeneration can lead to color blindness. This is incorrect. The cones of the eye are part of the retina that are affected by color blindness and are unrelated to the lens of the eye. This is incorrect. It may be tested by using the color bars at the base of the Snellen chart or with Ishihara cards.

PTS: 1 CON: Sensory Perception 53. ANS: 2, 3, 4 Chapter: Chapter 22 Health Assessment Objective: Demonstrate the skills used in physical examination. Page: 268 (V2) Heading: Examining the External and Middle Ear > Otoscopic Examination and Procedure and 227 Assessing the Ears and Hearing Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Knowledge [Remembering] Concept: Sensory Perception Difficulty: Easy

1. 2. 3. 4. 5.

Feedback This is incorrect. A red, bulging membrane is not normal and may indicate otitis media, an infection in the middle ear. This is correct. Normally, the tympanic membrane is pearly gray. This is correct. Normally, the tympanic membrane is shiny. This is correct. Normally, the tympanic membrane is translucent. This is incorrect. There should be no bulging or retraction of the tympanic membrane. If bulging or retraction is present, it is abnormal.

PTS: 1 CON: Sensory Perception 54. ANS: 1, 3, 4 Chapter: Chapter 22 Health Assessment Objective: Demonstrate the skills used in physical examination. Page: 296 (V2) Heading: The Abdomen and Procedure 22-14 Assessing the Abdomen Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying]

Concept: Nutrition Difficulty: Moderate

3. 4. 5.

Feedback This is correct. The nurse should ask the patient to empty bladder prior to the examination to promote comfort and make sure the nurse does not mistake a full bladder for a mass. This is incorrect. The skills used in physical examination include inspection, palpation, percussion, auscultation, and sometimes olfaction. These skills are performed in the above order, with one exception: When performing an abdominal assessment, perform auscultation before percussion and palpation to avoid disturbing the abdominal sounds. This is correct. The patient is also positioned supine with flexed knees, further promoting comfort and relaxing the abdominal muscles. This is correct. Begin with light pressure to detect surface characteristics. Then move to deep palpation to assess the underlying structures. This is incorrect. If the patient has a painful area, examine that area last to minimize discomfort during the rest of the exam.

PTS: 1 CON: Nutrition 55. ANS: 1, 2, 3 Chapter: Chapter 22 Health Assessment Objective: Explain adaptations that may be required when you examine clients of various ages. Page: 479 (V1) Heading: Developmental Considerations > Gero Feature: Older Adults Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Neurologic Regulation Difficulty: Moderate

1. 2. 3.

4. 5.

Feedback This is correct. With advanced age, changes commonly observed are slower reaction time, decreased ability for rapid problem solving, and slower voluntary movement. This is correct. The number of functioning neurons decreases with age. This is correct. Neurological deficits in older adults are usually the result of adverse effects of medication or medication interactions, nutritional deficits, dehydration, cardiovascular changes that alter cerebral blood flow, diabetes, degenerative neurological condition, alcohol or drug use, depression, or abuse. This is incorrect. With normal aging, memory and the ability to discriminate do not change. This is incorrect. Intelligence, memory, and discrimination do not change with

normal aging. PTS: 1 CON: Neurologic Regulation 56. ANS: 1, 2, 3, 5 Chapter: Chapter 22 Health Assessment Objective: Describe how to prepare for a physical examination. Page: 498 (V1) Heading: Internal Examination Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Health Promotion Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is correct. Women who are sexually active need an internal examination. This is correct. Women who are sexually active need an internal examination. Having had more than three pregnancies indicates sexual activity. This is correct. Women who have abnormal findings on external examinations should receive an internal examination. This is incorrect. A person who is not sexually active does not require an internal examination. This is correct. Women who have a history of pelvic complaints should receive an internal examination.

PTS: 1 CON: Health Promotion 57. ANS: 1, 3, 5 Chapter: Chapter 22 Health Assessment Objective: Discuss the expected findings of a physical examination. Page: 332 (V2) Heading: The Anus, Rectum, and Prostate > Procedure 22-19 Assessing the Anus and Rectum Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Knowledge [Remembering] Concept: Elimination Difficulty: Moderate

1. 2. 3.

Feedback This is correct. Hemorrhoids may be seen in clients with a history of constipation. This is incorrect. Although an enlarged prostate causes urinary problems, there is no indication that this causes hemorrhoids. This is correct. Many women develop hemorrhoids with pregnancy and childbirth.

4. 5.

This is incorrect. Young adults are not prone to hemorrhoids. This is correct. Pregnancy makes women prone to hemorrhoids.

PTS:

CON: Elimination

Chapter 23. Promoting Asepsis & Preventing Infection Multiple Choice Identify the choice that best completes the statement or answers the question. 1. Which behavior by the nurse indicates the highest potential for spreading infections among clients? 1. Disinfects dirty hands with antibacterial soap 2. Rubs alcohol-based hand gel for 20–30 seconds 3. Washes hands primarily after leaving each room 4. Uses warm water for medical asepsis 2. What is the most effective method to prevent the spread of infection among institutionalized patients? 1. Place patient on airborne precautions. 2. Prevent contact with contaminated equipment. 3. Perform hand hygiene routinely. 4. Decrease exposure to infections from family members. 3. Which term should the nurse use to describe a patient infected with a virus but who does not have any outward signs of the disease? 1. Pathogen 2. Fomite 3. Vector 4. Carrier 4. A patient with tuberculosis is admitted to the hospital. Which precautions must the nurse institute when caring for this patient? 1. Droplet transmission 2. Airborne transmission 3. Direct contact 4. Indirect contact 5. A patient becomes infected with oral candidiasis (thrush) while receiving intravenous antibiotics to treat a systemic infection. Which type of infection has the patient developed? 1. Endogenous healthcare-related infection 2. Exogenous healthcare-related infection 3. Latent infection 4. Primary infection 6. A patient admitted to the hospital with pneumonia has been receiving antibiotics for 2 days. The patient’s condition has stabilized, and the temperature has returned to normal. Which stage of infection is the patient most likely experiencing? 1. Incubation 2. Prodromal

3. Decline 4. Illness 7. The nurse assists a surgeon with central venous catheter insertion. Which action is necessary to help maintain sterile technique? 1. Closing the patient’s door to limit room traffic while preparing the sterile field 2. Using clean procedure gloves to handle sterile equipment 3. Placing the nonsterile syringes containing flush solution on the sterile field 4. Remaining 6 inches away from the sterile field during the procedure 8. A patient develops localized heat and erythema over an area on the lower leg. These findings are primarily indicative of which secondary defense against infection? 1. Phagocytosis 2. Lysozyme 3. Inflammation 4. Immunity 9. The patient is just beginning to feel symptoms after being exposed to an upper respiratory infection. Which initial antibody would most likely be elevated in a test of immunoglobulin (Ig) levels? 1. IgA 2. IgE 3. IgG 4. IgM 10. What type of immunity is provided by intravenous (IV) administration of immunoglobulin G (IgG)? 1. Cell-mediated 2. Passive 3. Secondary defense 4. Active 11. A patient asks the nurse why there is no vaccine available for the common cold. Which response by the nurse is correct?” 1. “The virus changes too rapidly to develop a vaccine.” 2. “Vaccines are developed only for very serious illnesses.” 3. “Researchers are focusing their efforts on an HIV vaccine.” 4. “The virus for the common cold has not been identified.” 12. A patient who has a temperature of 100°F (37.8°C) most likely requires: 1. Acetaminophen 2. Increased fluids 3. Bedrest 4. A hot bath

13. The nurse is caring for a client with Clostridium difficile infection. The nurse is caring for which client? 1. A neonate just born to a mother with a sinus infection 2. A young adult with vancomycin-resistant enterococci 3. A 78-year-old male taking antibiotics for cellulitis 4. A 45-year-old female taking hormonal medications 14. How should the nurse remove the disposable breakfast tray of a patient who requires airborne isolation? 1. Move the tray to a specially marked trashcan inside the patient’s room. 2. Place the tray in a special isolation bag held by a second healthcare worker at the patient’s door. 3. Return the tray with a note to dietary services so that it can be cleaned and reused for the next meal. 4. Carry the tray to an isolation trash receptacle located in the dirty utility room, and dispose of it there. 15. As a general rule, what is the minimum amount of liquid antiseptic solution in milliliters (mL) the nurse would use for effective handwashing? 1. 2 2. 3 3. 6 4. 7 16. To ensure effectiveness, when should the nurse stop rubbing antiseptic hand gel over all surfaces of the hands? 1. When fingers feel sticky 2. After 5 to 10 seconds 3. Before leaving the client’s room 4. Once fingers and hands feel dry 17. While donning sterile gloves, the nurse notices the edges of the glove package are slightly yellow. The yellow area is more than 1 inch away from the gloves and only appears to be on the outside of the glove package. What is the best action for the nurse to take at this point? 1. Continue using the gloves inside the package because the package is intact. 2. Remove the gloves from the sterile field, and use a new pair of sterile gloves. 3. Throw away all supplies that were to be used, and begin again. 4. Use the gloves and make sure the yellow edges of the package do not touch the client. 18. The nurse is removing personal protective equipment (PPE). Which item should be removed first? 1. Gown 2. Gloves 3. Face shield 4. Hair covering

19. The patient in the intensive care unit has developed a urinary tract infection related to the indwelling urinary catheter. Which type of infection does this best describe? 1. Nosocomial infection 2. Healthcare-associated infection (HAI) 3. Multidrug-resistant organisms (MDROs) 4. Unavoidable occurrence 20. The mother of a 6-year-old child says to the pediatric nurse, “My son had such a bad case of the measles. I hope he doesn’t get them again.” What is the most appropriate response by the nurse? 1. “It sounds like he was very sick. Let’s hope he doesn’t get them again.” 2. “Measles is a disease that once you’ve had it, you won’t get it again. The body has learned to make cells that will fight off any future exposures.” 3. “Would you like me to prepare a plan for you with ways you can prevent future episodes of measles?” 4. “It will be important for you to keep your son away from other children with measles, as he is now more susceptible.” 21. The nurse has just administered a subcutaneous insulin injection to a diabetic patient. What is the next immediate action by the nurse? 1. Dispose of the needle/syringe uncapped into a disposable sharps container. 2. Recap the syringe with needle and dispose into a sharps container. 3. Place the needle/syringe into a biohazard bag inside the patient’s room. 4. Separate the needle and syringe and place them into a sharps container. 22. Should a bioterrorism event occur; what factor is most important in minimizing the effects of such an event? 1. Rapidly recognize unusual disease patterns, and detect the presence of unusual infectious diseases. 2. Communicate any extraordinary events to the organization’s safety officer. 3. Report any suspicious findings to the Centers for Disease Control and Prevention. 4. Institute a community-wide education program for standard precautions and handwashing. 23. The nurse is caring for a patient who has hepatitis B and accidentally sticks self with a contaminated needle after administering an injection. Which action should the nurse take first? 1. Thoroughly flush the area with water. 2. Immediately notify the supervisor. 3. Complete an incident report using objective data. 4. Obtain baseline lab work as quickly as possible. Multiple Response Identify one or more choices that best complete the statement or answer the question.

24. In which situation would using standard precautions be adequate? Select all that apply. 1. While interviewing a client with a contagious productive cough 2. While helping a client perform his or her own hygiene care 3. While taking vital signs for a client who has smallpox 4. While inserting a peripheral intravenous catheter 5. While assessing sutures in an abdominal incision 25. Which factors protect the body against infection? Select all that apply. 1. Eating a healthy well-balanced diet 2. Being an older adult or an infant 3. Engaging in stress reduction activities 4. Exercising regularly 5. Taking chemotherapeutic agents 26. The nurse is teaching a group of newly hired unlicensed assistive personnel (UAP) about proper handwashing with soap and water. The nurse will know that the teaching was effective if a UAP demonstrates which behaviors? Select all that apply. 1. Uses a dry paper towel to turn off the faucet 2. Holds fingertips above the wrists while rinsing off the soap 3. Removes all rings and watch before washing hands 4. Cleans underneath each fingernail 5. Vigorously rubs hands together for at least 15 seconds 27. Alcohol-based solutions for hand hygiene can be used to combat which types of organisms? Select all that apply. 1. Viruses 2. Bacterial spores 3. Yeasts 4. Molds 5. Organic material 28. A patient with tuberculosis is scheduled for computed tomography (CT). How should the nurse proceed? Select all that apply. 1. Question the order because the patient must remain in isolation. 2. Place an N-95 respirator mask on the patient, and transport to the test. 3. Place a surgical mask on the patient and transport to CT lab. 4. Notify the computed tomography department about precautions prior to transport. 5. Apply a sterile gown and face shield over the patient before leaving the room. 29. The Centers for Disease Control and Prevention (CDC) is a federal agency devoted to infection control and prevention in healthcare settings. What are the goals of the CDC? Select all that apply. 1. Reduce catheter-associated urinary tract infections 2. Reduce targeted antimicrobial-resistant bacterial infections 3. Decrease ventilator-associated pneumonia 4. Establish competencies to improve quality and safety for nursing education

5. Develop the National Patient Safety Goals 30. Which information would the nurse include in a health promotion class about the association between smoking and pulmonary infections? Select all that apply. 1. Smoking interferes with respiratory functions, including the ability to move the chest, cough, and sneeze. 2. Smoking increases alveolar elasticity, leading to overproduction of mucus that leads to pulmonary infections. 3. Smoking decreases movement of the cilia in the lower airways, creating a favorable environment for bacterial growth. 4. Nonsmokers chronically exposed to secondhand smoke have minimal risk for pulmonary infections. 5. Smoking increases the production of abnormal red blood cells, leading to ineffective protection against infections. 31. The community health nurse is preparing a teaching plan for infection control in the home. Which instructions will the nurse include in the plan for the home setting? Select all that apply. 1. Keep a supply of broad-spectrum antibiotics. 2. Use clean technique for urinary catheterization. 3. Wash hands before preparing food. 4. Share personal items routinely. 5. Mix 10-part bleach to 25-parts water for a cleaning solution. 32. The hospital nurse educator is preparing an orientation class for those newly hired on the surgical suite. Which information will the educator include in the orientation curriculum regarding hand and fingernail care? Select all that apply. 1. Healthcare staff must routinely inspect their hands for breaks in the skin. 2. Artificial nails are permitted if properly secured to the nailbed. 3. Wristwatches be may be worn as long as they are all metal. 4. Healthcare staff are to avoid wearing nail polish. 5. Fingernail length should be kept to half inch or less. 33. The nurse is obtaining a patient’s health history related to infections. Which are the appropriate questions the nurse will ask the patient? Select all that apply. 1. “Have you recently traveled out of the country?” 2. “How would you describe your current stress level?” 3. “Do you like fruits and vegetables?” 4. “What is your normal heart rate?” 5. “What types of herbal products do you use?”

Chapter 23. Promoting Asepsis & Preventing Infection Answer Section MULTIPLE CHOICE 1. ANS: 3 Chapter: Chapter 23 Promoting Asepsis & Preventing Infection Objective: Use standard precautions to prevent transmission of infection through blood and body fluids. Page: 341 (V2) Heading: Protective Environment in Special Situations > Follow Standard Precautions and Clinical Insight 23-1 Guidelines for Hand Hygiene Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Comprehension [Understanding] Concept: Safety Difficulty: Easy Feedback 1 This is incorrect. Disinfecting dirty hands with antibacterial soap would decrease infections. When the hands are soiled, healthcare staff should use antibacterial soap with warm water to remove dirt and debris from the skin surface. 2 This is incorrect. Using alcohol-based hand gels for 20–30 seconds would decrease infections. When no visible dirt is present, alcohol-based hand gels are used until hands are completely dry. 3 This is correct. Washing hands primarily after leaving each room would increase the spread of infection. Clients acquire infection by contact with other clients, family members, and healthcare equipment. But most infection among clients is spread through the hands of healthcare workers. Handwashing interrupts the transmission and should be done before and after all contact with clients, regardless of the diagnosis. 4 This is incorrect. Using warm water for medical asepsis would decrease the spread of infection. Warm water opens pores and helps remove microorganisms without removing skin oils. It also reduces chapping. Hot water increases the risk for skin breakdown. PTS: 1 CON: Safety 2. ANS: 3 Chapter: Chapter 23 Promoting Asepsis & Preventing Infection Objective: Implement measures to prevent healthcare-related infections. Page: 522 (V1) Heading: Practicing Medical Asepsis > Maintaining Clean Hands

Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Knowledge [Remembering] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. Airborne transmission is not the most effective method to prevent the spread of infection in institutionalized patients. 2 This is incorrect. While contact with contaminated equipment can be a cause of infections, preventing its occurrence is not the most effective measure. 3 This is correct. Hand hygiene is the single most important activity for preventing and controlling infection. 4 This is incorrect. Exposure from family members is not the most common cause for the spread of infection. Thus, decreasing exposure from family members is not the most effective method. PTS: 1 CON: Safety 3. ANS: 4 Chapter: Chapter 23 Promoting Asepsis & Preventing Infection Objective: Discuss the six links in the chain of infection. Page: 506 (V1) Heading: Infections Develop in Response to a Chain of Factors > Reservoir Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Comprehension [Understanding] Concept: Infection Difficulty: Moderate Feedback 1 This is incorrect. A pathogen is an organism capable of causing disease. 2 This is incorrect. A fomite is a contaminated object that transfers a pathogen, such as pens, stethoscopes, and contaminated needles. 3 This is incorrect. A vector is an organism that carries a pathogen to a susceptible host through a portal for entry into the body. An example of a vector is a mosquito or tick that bites or stings. 4 This is correct. Some people might harbor a pathogenic organism, such as HIV, within their body and yet do not acquire the disease/infection. These individuals, called carriers, have no outward sign of active disease, yet they can pass the infection to others. PTS: 1 CON: Infection 4. ANS: 2 Chapter: Chapter 23 Promoting Asepsis & Preventing Infection

Objective: Describe additional precautions that must be taken when there is concern about contact, droplet, or airborne disease transmission. Page: 347 (V2) Heading: Mode of Transmission and Clinical Insight 23-4 Following Transmission-Based Precautions > Airborne Precautions Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Comprehension [Understanding] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. Droplet transmission occurs when the pathogen travels in water droplets expelled as an infected person exhales, coughs, sneezes, or talks, or during suctioning and oral care. 2 This is correct. Common airborne pathogens are the agents of measles and tuberculosis, and many fungal infections. 3 This is incorrect. Direct contact usually involves physical contact, sexual intercourse, and contact with wound drainage, but it can involve scratching and biting. 4 This is incorrect. Indirect contact involves contact with a fomite, a contaminated object that transfers a pathogen. PTS: 1 CON: Safety 5. ANS: 1 Chapter: Chapter 23 Promoting Asepsis & Preventing Infection Objective: Discuss the six links in the chain of infection. Page: 509 (V1) Heading: Infections Can Be Classified by Location and Duration > Exogenous or Endogenous Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Infection Difficulty: Difficult Feedback 1 This is correct. Thrush in this patient is an example of an endogenous healthcare-related infection. This type of infection arises from suppression of the patient’s normal flora as a result of some form of treatment, such as antibiotics. Normal flora usually keeps yeast from growing in the mouth. 2 This is incorrect. In exogenous nosocomial infection, the pathogen arises from the healthcare environment, like a staph infection. 3 This is incorrect. A latent infection causes no symptoms for long periods of time, even years. An example of a latent infection is HIV infection.

This is incorrect. A primary infection is the first infection that occurs in a patient. This scenario describes a secondary infection.

PTS: 1 CON: Infection 6. ANS: 3 Chapter: Chapter 23 Promoting Asepsis & Preventing Infection Objective: Describe the stages of a typical infectious process. Page: 509 (V1) Heading: Infections Follow Predictable Stages > Decline Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Infection Difficulty: Moderate Feedback 1 This is incorrect. Incubation is the stage between the invasion by the organism and the onset of symptoms. During the incubation stage, the patient does not know he or she is infected and is capable of infecting others. 2 This is incorrect. The prodromal stage is characterized by the first appearance of vague symptoms. 3 This is correct. The stage of decline occurs when the patient’s immune defenses, along with any medical therapies (in this case antibiotics), are successfully reducing the number of pathogenic microbes. As a result, the signs and symptoms of infection begin to fade (temperature returns to normal). 4 This is incorrect. The illness stage begins when the patient becomes ill, and signs and symptoms of the disease occur. PTS: 1 CON: Infection 7. ANS: 1 Chapter: Chapter 23 Promoting Asepsis & Preventing Infection Objective: Use medical asepsis and sterile technique, when appropriate. Page: 355 (V2) Heading: Using Sterile Technique in Nursing Care and Procedure 23-8 Sterile Fields Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 This is correct. To maintain sterile technique, the nurse should close the patient’s door and limit the number of persons entering and exiting the room because air currents can carry dust and microorganisms.

2 3 4

This is incorrect. Sterile gloves, not clean gloves, should be used to handle sterile equipment. This is incorrect. Placing nonsterile syringes on the sterile field contaminates the field. This is incorrect. Six inches is not required between people and the sterile field to prevent contamination.

PTS: 1 CON: Safety 8. ANS: 3 Chapter: Chapter 23 Promoting Asepsis & Preventing Infection Objective: Describe four processes involved in primary, secondary, and tertiary defenses. Page: 511 (V1) Heading: Secondary Defenses Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Immunity Difficulty: Difficult Feedback 1 This is incorrect. The secondary defenses of phagocytosis (process by which white blood cells engulf and destroy pathogens) does not produce visible findings. 2 This is incorrect. Lysozyme is an antimicrobial enzyme that is a primary defense, not secondary. Saliva and tears contain lysozymes. 3 This is correct. The classic signs of inflammation, a secondary defense against infection, are erythema (redness) and localized heat. 4 This is incorrect. Immunity is a tertiary defense that protects the body from future infection. PTS: 1 CON: Immunity 9. ANS: 4 Chapter: Chapter 23 Promoting Asepsis & Preventing Infection Objective: Describe four processes involved in primary, secondary, and tertiary defenses. Page: 511 (V1) Heading: Tertiary Defenses > Humoral Immunity and Box 23-2 Immunoglobulin (Ig) Classes Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Immunity Difficulty: Moderate Feedback 1 This is incorrect. IgA is found in mucous membranes in the intestines,

2 3 4

respiratory and urinary tracts, saliva, tears, and breast milk. IgA provides additional immune protection by secreting around the body openings. This is incorrect. IgE is the antibody primarily responsible for an allergic response. This is incorrect. IgG antibodies appear later— perhaps up to 10 days later. This is correct. IgM antibodies are the first to be made in response to infection.

PTS: 1 CON: Immunity 10. ANS: 2 Chapter: Chapter 23 Promoting Asepsis & Preventing Infection Objective: Identify activities that promote immune function. Page: 511 (V1) Heading: Tertiary Defenses and Box 23-1 Four Types of Immunity Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Comprehension [Understanding] Concept: Immunity Difficulty: Difficult Feedback 1 This is incorrect. IgG does not provide cell-mediated immunity; it is an antibody. Cellular (cell-mediated) immune response acts directly to destroy pathogens without using antibodies. The humoral immune response (or antibody-mediated response) protects the body by circulating antibodies to fight against pathogens (e.g., bacteria). 2 This is correct. IV administration of IgG provides the patient with passive immunity. Passive immunity occurs when antibodies are transferred by antibodies from an immune host, such as from the placenta to the fetus or from another person or animal. 3 This is incorrect. IgG is not a secondary defense mechanism (phagocytosis, complement cascade, fever, and inflammation). IgG is an antibody from the humoral immune response. 4 This is incorrect. IgG does not provide active immunity, when the body makes its own antibodies. The patient received antibodies from someone else through an IV infusion. PTS: 1 CON: Immunity 11. ANS: 1 Chapter: Chapter 23 Promoting Asepsis & Preventing Infection Objective: Identify activities that promote immune function. Page: 520 (V1) Heading: Promoting Wellness to Support Host Defenses > Immunizations Integrated Processes: Communication and Documentation

Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 This is correct. Common cold viruses mutate (change) too rapidly to develop a vaccine. 2 This is incorrect. Vaccines are developed for common infectious diseases as well as very serious illnesses. 3 This is incorrect. Information about research focusing on a vaccine for HIV does not answer the patient’s question. 4 This is incorrect. Stating that the common cold virus has not been identified is not an answer to the patient’s question. PTS: 1 CON: Infection 12. ANS: 2 Chapter: Chapter 23 Promoting Asepsis & Preventing Infection Objective: Identify activities that promote immune function. Page: 520 (V1) Heading: Promoting Wellness to Support Host Defenses > Nutrition Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Analysis [Analyzing] Concept: Infection Difficulty: Difficult Feedback 1 This is incorrect. Acetaminophen is not necessary for this low-grade fever because fever is beneficial in fighting infection. 2 This is correct. Fever, a common defense against infection, increases water loss; therefore, additional fluid is needed to supplement this loss. 3 This is incorrect. Adequate rest, not necessarily bedrest, is necessary with a fever. 4 This is incorrect. A hot bath would make the fever worse. PTS: 1 CON: Infection 13. ANS: 3 Chapter: Chapter 23 Promoting Asepsis & Preventing Infection Objective: Explain why multidrug-resistant pathogens are of special concern in healthcare. Page: 512 (V1) Heading: Healthcare-Associated Infections and Example Problem: Multidrug-Resistant Organism (MDRO) Infections Integrated Processes: Caring

Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis [Analyzing] Concept: Infection Difficulty: Moderate Feedback 1 This is incorrect. A neonate just born to a mother with a sinus infection is not prone to Clostridium difficile infection. 2 This is incorrect. While vancomycin-resistant enterococci is a type of multidrugresistant organism infection, it does not lead to Clostridium difficile infection. 3 This is correct. Elderly, the immunocompromised, and people who have had prolonged treatment with antibiotics are at greater risk for developing Clostridium difficile infection. 4 This is incorrect. A female taking hormonal medications is not prone to Clostridium difficile infection. PTS: 1 CON: Infection 14. ANS: 2 Chapter: Chapter 23 Promoting Asepsis & Preventing Infection Objective: Describe additional precautions that must be taken when there is concern about contact, droplet, or airborne disease transmission. Page: 525 (V1) Heading: Control of Potentially Contaminated Equipment and Supplies > Disposing of Used Isolation Supplies Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. The tray must be removed from the patient’s room. 2 This is correct. Patients who require airborne isolation are served meals on disposable dishes and trays. To dispose of the tray, the nurse inside the room must wear protective garb and place the tray and its contents inside a special isolation bag that is held by a second healthcare worker at the patient’s door. The items must be placed on the inside of the bag without touching the outside of the bag. 3 This is incorrect. Returning the tray to the dietary services would spread the infection. 4 This is incorrect. Disposing of the tray in the dirty utility room would spread the infection and possibly contaminate other healthcare workers. PTS:

CON: Safety

15. ANS: 2 Chapter: Chapter 23 Promoting Asepsis & Preventing Infection Objective: Use medical asepsis and sterile technique, when appropriate. Page: 341 (V2) Heading: Procedure 23-1 Hand Hygiene > Procedure 23-1B Using Alcohol-Based Handrubs Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Knowledge [Remembering] Concept: Safety Difficulty: Easy Feedback 1 This is incorrect. Two milliliters of solution is not enough for effective handwashing. 2 This is correct. Apply antiseptic solution in a quantity sufficient (at least 3–5 mL) to cover the hands and wrists. 3 This is incorrect. This amount (6 mL) of solution is too much for effective handwashing. 4 This is incorrect. Seven milliliters of solution is not the minimum amount for effective handwashing. PTS: 1 CON: Safety 16. ANS: 4 Chapter: Chapter 23 Promoting Asepsis & Preventing Infection Objective: Use standard precautions to prevent transmission of infection through blood and body fluids. Page: 341 (V1) Heading: Procedure 23-1 Hand Hygiene > Procedure 23-1B Using Alcohol-Based Handrubs Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Knowledge [Remembering] Concept: Safety Difficulty: Easy Feedback 1 This is incorrect. “When fingers feel sticky” is not the time to stop rubbing antiseptic gel over the hands. 2 This is incorrect. The nurse should rub hands for 20 to 30 seconds, not 5 to 10 seconds. 3 This is incorrect. The nurse should wash hands upon entering and when leaving clients’ rooms, not just when leaving. 4 This is correct. If using antimicrobial hand gels, apply and rub hands until dry. Cover all surfaces of the hands: interlacing fingers, rubbing around each finger and thumb, and rubbing the backs and palms of the hands in a circular motion,

including under the nails, until the solution is completely dry. PTS: 1 CON: Safety 17. ANS: 2 Chapter: Chapter 23 Promoting Asepsis & Preventing Infection Objective: Use medical asepsis and sterile technique, when appropriate. Page: 357 (V2) Heading: Adding Supplies to a Sterile Field > Key Point and Procedure 23-7 Sterile Gloves (Open Method) Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. Because of the yellow area, the gloves are considered contaminated. Never assume an item is sterile. If there is any doubt about its sterility, consider it contaminated. 2 This is correct. The gloves should be thrown away because the gloves are likely to be contaminated from an outside source. 3 This is incorrect. The other supplies do not have to be thrown away because they have not been contaminated. 4 This is incorrect. The gloves cannot be used since the sterility is in question from the yellow area. The gloves are considered contaminated. PTS: 1 CON: Safety 18. ANS: 2 Chapter: Chapter 23 Promoting Asepsis & Preventing Infection Objective: Use standard precautions to prevent transmission of infection through blood and body fluids. Page: 346 (V2) Heading: Procedure 23-3 Removing Personal Protective Equipment (PPE) Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Knowledge [Remembering] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. The gown is removed second. 2 This is correct. The gloves are removed first because they are usually the most contaminated PPE and must be removed to avoid contamination of clean areas of the other PPE during their removal.

3 4

This is incorrect. The mask or face shield is removed after the gown. This is incorrect. The hair covering, if used, is removed after the face shield.

PTS: 1 CON: Safety 19. ANS: 1 Chapter: Chapter 23 Promoting Asepsis & Preventing Infection Objective: Implement measures to prevent healthcare-related infections. Page: 505 (V1) Heading: Healthcare-Associated Infections Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Comprehension [Understanding] Concept: Infection Difficulty: Easy Feedback 1 This is correct. The term nosocomial infections refers specifically to hospitalacquired infections. 2 This is incorrect. The term healthcare-associated infections (HAIs) refer to infections associated with healthcare given in any setting (hospitals, long-term care facilities); however, another term is more specific. 3 This is incorrect. An MDRO is a bacterium that is resistant to many antibiotics. Examples of MDROs include methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE). 4 This is incorrect. Indwelling urinary catheters are needed in many circumstances and might be unavoidable in that sense. However, the infection itself is not unavoidable because it can be prevented, in most instances, with meticulous nursing care. Therefore, “unavoidable occurrence” is an incorrect option. PTS: 1 CON: Infection 20. ANS: 2 Chapter: Chapter 23 Promoting Asepsis & Preventing Infection Objective: Describe four processes involved in primary, secondary, and tertiary defenses. Page: 511 (V1) Heading: Tertiary Defenses Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Immunity Difficulty: Easy Feedback 1 This is incorrect. The child will never get the disease again so the nurse saying, “Let’s hope he doesn’t get them again” is incorrect.

3 4

This is correct. People who recover from some infectious diseases, such as measles, never get the disease again, even if they are repeatedly exposed to the virus. The reason is “specific immunity”: the process by which the body’s immune cells learn to recognize and destroy pathogens they have encountered before. This is incorrect. Once a child has measles, the child will never get the disease again. Therefore, the nurse should not say, “prevent future episodes.” This is incorrect. Keeping a child who has had measles away from a child who currently has measles will have no effect on the child getting measles.

PTS: 1 CON: Immunity 21. ANS: 1 Chapter: Chapter 23 Promoting Asepsis & Preventing Infection Objective: Use standard precautions to prevent transmission of infection through blood and body fluids. Page: 525 (V1) Heading: Control of Potentially Contaminated Equipment and Supplies > Disposing of Used Isolation Supplies > Safety Feature Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Moderate Feedback 1 This is correct. Always place disposable needles, syringes, and other sharp items such as broken glass in a special disposable, sharps container immediately after their use. Never recap or handle any contaminated needle. 2 This is incorrect. Never recap a contaminated needle. 3 This is incorrect. The needle/syringe could puncture the biohazard bag. Needles are placed in a sharps container immediately after use. 4 This is incorrect. The needle is not separated from the syringe. This increases the risk for a needlestick injury. PTS: 1 CON: Safety 22. ANS: 1 Chapter: Chapter 23 Promoting Asepsis & Preventing Infection Objective: Discuss the nurse’s role in recognizing, preventing, and helping to contain the spread of a biological epidemic. Page: 530 (V1) Heading: How Can I Minimize the Effects of Bioterrorism and Epidemics? > Recognize an Outbreak Integrated Processes: Nursing Process

Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 This is correct. Should a biological event occur, either as a result of bioterrorism or a naturally occurring epidemic, a key factor in minimizing its effects is the ability to quickly recognize unusual disease patterns and detect the presence of infectious diseases. 2 This is incorrect. While the nurse should communicate to the organization’s safety officer, this is not the most important. 3 This is incorrect. While the nurse would report any suspicious findings to the Centers for Disease Control and Prevention, it is not the most important. 4 This is incorrect. Instituting a community-wide program for standard precautions and handwashing would not minimize a bioterrorist attack. PTS: 1 CON: Safety 23. ANS: 1 Chapter: Chapter 23 Promoting Asepsis & Preventing Infection Objective: Implement measures to prevent healthcare-related infections. Page: 529 (V1) Heading: What Should I Do If I Am Exposed to Bloodborne Pathogens? and Box 23-4 If You Are Exposed to Blood or Other Body Fluids Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Safety Difficulty: Easy Feedback 1 This is correct. The nurse should immediately flush the exposed areas with water and clean any wound with soap and water or a skin disinfectant, if available. 2 This is incorrect. Reporting to the supervisor is the second action the nurse should take. 3 This is incorrect. Out of the actions listed, completing an incident report is the last step the nurse should take. 4 This is incorrect. Seeking immediate medical attention and baseline lab work is the third step. PTS:

MULTIPLE RESPONSE

CON: Safety

24. ANS: 2, 4, 5 Chapter: Chapter 23 Promoting Asepsis & Preventing Infection Objective: Use standard precautions to prevent transmission of infection through blood and body fluids. Page: 524 (V1) Heading: Table 23-2 Comparison of CDC Standard and Transmission-Based Precautions Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Difficult

2. 3. 4.

Feedback This is incorrect. Since the disease is contagious, it is spread by air or droplets. Therefore, droplet or airborne precautions would be needed in addition to standard precautions. This is correct. If giving a complete bed bath or performing oral hygiene, the nurse would need to use standard precautions (gloves). This is incorrect. Taking vital signs for a client who has smallpox would require airborne precautions in addition to standard precautions. This is correct. Standard precautions should be instituted with all clients whenever there is a possibility of coming in contact with blood, body fluids (except sweat), excretions, secretions, mucous membranes, and breaks in the skin (e.g., while inserting a peripheral IV). This is correct. Assessing sutures in an abdominal wound would require standard precautions.

PTS: 1 CON: Safety 25. ANS: 1, 3, 4 Chapter: Chapter 23 Promoting Asepsis & Preventing Infection Objective: Identify activities that promote immune function. Page: 520 (V1) Heading: Promoting Wellness to Support Host Defenses Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Infection Difficulty: Moderate

Feedback This is correct. A lifestyle factor that strengthens host defenses and helps break the

4. 5.

chain of infection is healthful nutrition (well-balanced diet). This is incorrect. Older adults are also susceptible hosts because the immune response declines with aging. Skin, a primary defense, becomes less elastic and more prone to breakdown with aging. Elders also tend to be less active, and their nutrition may be inadequate. Young children are vulnerable because their immune systems are immature and have had limited exposure to pathogens. Children frequently begin to have more infections when they start interacting with people outside their family (e.g., when they begin day care or start school). This is correct. Inform clients of the need to reduce stress. Laughing increases immune responses, improves oxygenation, and promotes body movement. In contrast, physical or mental stress decreases the body’s immune defenses. This is correct. Regular exercise helps protect the body against infections. This is incorrect. As a side effect, some medications, such as chemotherapeutic agents, decrease the production of white blood cells or cause the cells produced to be abnormal, increasing the risk for infections.

PTS: 1 CON: Infection 26. ANS: 1, 3, 4, 5 Chapter: Chapter 23 Promoting Asepsis & Preventing Infection Objective: Use medical asepsis and sterile technique, when appropriate. Page: 341 (V2) Heading: Maintaining Clean Hands and Procedure 23-1 Hand Hygiene > Procedure 23-1A Using Soap and Water Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate

1. 2. 3.

4. 5.

Feedback This is correct. If the faucet is not hands-free, use a dry paper towel to turn it off. This is incorrect. The fingers should be held lower than the wrists. Hands and finger tips should be below (not above) the wrists and forearms. This is correct. The UAP should bare hands and forearms by removing wristwatch and rings. Jewelry harbors bacteria and creates a moist area on the skin, which facilitates bacterial growth. This is correct. The UAP should clean underneath each fingernail. Areas under the nails harbor high concentrations of microorganisms. This is correct. The UAP should vigorously rub hands together for at least 15 seconds. It takes at least 15 seconds for mechanical removal of microorganisms and for antimicrobial products to be effective.

PTS: 1 CON: Safety 27. ANS: 1, 3, 4 Chapter: Chapter 23 Promoting Asepsis & Preventing Infection Objective: Compare and contrast methods of preventing infection by breaking the chain of infection. Page: 341 (V2) Heading: Procedure 23-1 Hand Hygiene > Procedure 23-1B Using Alcohol-Based Handrubs Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Comprehension [Understanding] Concept: Safety Difficulty: Moderate

1. 2.

3. 4. 5.

Feedback This is correct. Alcohol-based solutions are effective against viruses. This is incorrect. If there is potential for contact with bacterial spores, hands must be washed with soap and water; alcohol-based solutions are ineffective against bacterial spores. This is correct. Alcohol-based gels are effective against yeast. This is correct. Alcohol-based gels are effective against mold. This is incorrect. Alcohol-based solutions are to be avoided if there is organic material or visible dirt on hands. Soap and water should be used when hands are visibly soiled.

PTS: 1 CON: Safety 28. ANS: 3, 4 Chapter: Chapter 23 Promoting Asepsis & Preventing Infection Objective: Describe additional precautions that must be taken when there is concern about contact, droplet, or airborne disease transmission. Page: 347 (V2) Heading: Clinical Insight 23-4 Following Transmission-Based Precautions > Airborne Precautions Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Safety Difficulty: Difficult

1. 2.

Feedback This is incorrect. The patient is allowed to go to different departments so the nurse should not question the order. However, transporting should be limited. This is incorrect. The patient does not need to wear an N-95 respirator mask when being transported to different areas.

4. 5.

This is correct. Transporting a patient who requires airborne precautions should be limited; however, when necessary, the patient should wear a surgical mask that covers the mouth and nose to prevent the spread of infection. This is correct. The department to which the patient is being transported should be notified about the precautions before transport. This is incorrect. A sterile gown is not needed, and a mask should be placed on the patient when transporting a patient with tuberculosis.

PTS: 1 CON: Safety 29. ANS: 1, 2, 3 Chapter: Chapter 23 Promoting Asepsis & Preventing Infection Objective: Implement measures to prevent healthcare-related infections. Page: 524 (V1) Heading: Professional Standards and Guidelines > The Centers for Disease Control and Prevention (CDC) Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Knowledge [Remembering] Concept: Evidence-Based Practice Difficulty: Moderate

Feedback This is correct. The CDC is a federal agency devoted to infection control and prevention in healthcare settings. Many healthcare facilities’ policies and procedures are based on the CDC guidelines. Among its many goals for healthcare facilities, the CDC is advocating for a reduction in catheter-associated urinary tract infections. This is correct. The CDC is a federal agency devoted to infection control and prevention in healthcare settings. Many healthcare facilities’ policies and procedures are based on the CDC guidelines. Among its many goals for healthcare facilities, the CDC is advocating for a reduction of targeted antimicrobial-resistant bacterial infections. This is correct. The CDC is a federal agency devoted to infection control and prevention in healthcare settings. Many healthcare facilities’ policies and procedures are based on the CDC guidelines. Among its many goals for healthcare facilities, the CDC is advocating for a decrease in ventilator-associated pneumonia. This is incorrect. Quality and Safety Education for Nurses (QSEN) is a group of educators that was formed to address the challenge of preparing nurses with the competencies necessary to improve the quality and safety of their places of work. This is incorrect. The Joint Commission is a quality oversight agency and develops the National Patient Safety Goals each year.

PTS:

CON: Evidence-Based Practice

30. ANS: 1, 3 Chapter: Chapter 23 Promoting Asepsis & Preventing Infection Objective: Discuss the factors that place an individual at increased risk for infection. Page: 516 (V1) Heading: What Factors Increase Host Susceptibility? > Tobacco Use Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Health Promotion Difficulty: Moderate

2. 3. 4.

Feedback This is correct. Smoking is a major risk factor for pulmonary infections. Smoking interferes with normal respiratory functioning, including the ability to move the chest, cough, sneeze, or have full air exchange. This is incorrect. Smoking does not increase alveolar elasticity. This is correct. Chemicals in tobacco paralyze cilia; thus, secretions pool in the lower airways, creating a hospitable environment for bacterial growth. This is incorrect. Although tobacco users are most profoundly affected by these changes, people chronically exposed (bartenders, children of smokers) are also affected by these changes and are at increased risk for infection. This is incorrect. Smoking does not increase the production of abnormal red blood cells. White blood cells, not red blood cells, protect against infections.

PTS: 1 CON: Health Promotion 31. ANS: 2, 3 Chapter: Chapter 23 Promoting Asepsis & Preventing Infection Objective: Discuss infection prevention and control measures in the home and in the community. Page: 521 (V1) Heading: Home care box side bar > Home Care > Preventing Infection in the Home and Community Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate

Feedback This is incorrect. There is no recommendation to have a supply of a broad-spectrum antibiotics on hand. In fact, there is growing concern regarding the overuse and overprescribing of antibiotics because this has now been shown to contribute to the rise of microbial-resistant diseases.

2. 3.

4. 5.

This is correct. Procedures performed using sterile technique in the hospital (e.g., urinary catheterization) are often performed by using clean technique in the home. This is correct. Always wash hands before preparing food, before eating, before putting the hands near the face, after going to the bathroom, or after blowing the nose. This is incorrect. Do not share personal care items (e.g., towels, washcloths, toothbrushes, combs). This is incorrect. To disinfect the home environment, mix a solution of 1 part regular-strength bleach to 50 parts water. The mixture may be stored for a month in an opaque container.

PTS: 1 CON: Health Promotion 32. ANS: 1, 4 Chapter: Chapter 23 Promoting Asepsis & Preventing Infection Objective: Use medical asepsis and sterile technique, when appropriate. Page: 342 (V2) Heading: Procedure 23-1 Hand Hygiene > Pre-procedure Assessments and Clinical Insight 23-1 Guidelines for Hand Hygiene > Fingernails Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate

2. 3. 4. 5.

Feedback This is correct. Infection control and prevention measures regarding hands and nails in the surgical suite and in all areas of most healthcare facilities include checking the skin condition of the hands for breaks in the skin. This is incorrect. Artificial nails are to be avoided, regardless of how they are attached to the nail. This is incorrect. Wristwatches being all metal is not a requirement for hand and nail hygiene. This is correct. Nail polish should be avoided as chipped polish acts as a reservoir for microorganisms. This is incorrect. Nails should be no longer than fingertips.

inch (not

inch) from the

PTS: 1 CON: Safety 33. ANS: 1, 2, 5 Chapter: Chapter 23 Promoting Asepsis & Preventing Infection Objective: Discuss the factors that place an individual at increased risk for infection. Page: 518 (V1)

Heading: Nursing History Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Infection Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is correct. To elicit information related to infection, the nurse should ask the patient about any recent travel outside the country. This is correct. Asking about current stress level will provide important data for information related to infection. This is incorrect. Asking the patient about liking fruits and vegetables is related more to nutrition than to infection. This is incorrect. Asking the patient about heart rate is important information regarding the cardiac system, but not infection. This is correct. Asking about the use of herbal products is important information related to infection.

PTS:

CON: Infection

Chapter 24. Promoting Safety Multiple Choice Identify the choice that best completes the statement or answers the question. 1. Physiological changes associated with aging place the older adult especially at risk for which nursing diagnosis? 1. Risk for Falls 2. Risk for Ineffective Airway Clearance (choking) 3. Risk for Poisoning 4. Risk for Suffocation (drowning) 2. The nurse will teach the client that the most common cause(s) of death related to a house fire is/are: 1. Explosions 2. Falls from second-story windows 3. Thermal damage to skin and body surfaces 4. Smoke inhalation injury 3. The nurse instructing a new parent on the proper positioning of the infant car seat will explain that the child may be positioned forward facing in an automobile at which age? 1. 2 years 2. 3 years 3. 4 years 4. 5 years 4. While eating in the hospital cafeteria, the nurse sees a visitor display the “universal sign of choking.” Which action should the nurse take first? 1. Page a “Code Blue” emergency. 2. Immediately perform five abdominal thrusts. 3. Assess the situation by asking, “Are you choking?” 4. Deliver four sharp back blows between the scapulae. 5. A nurse is teaching a group of mothers about first aid. If mercury comes in contact with their child’s clothing and skin, which action should the nurse instruct the mothers to take first? 1. Remove the contaminated clothing immediately. 2. Flood the contaminated area with lukewarm water. 3. Wash the contaminated area with soap and water and rinse. 4. Call the nearest poison control center immediately. 6. Which instruction is most important for the nurse to include when teaching a mother of a 3-yearold about protecting her child against accidental poisoning? 1. Store medications on countertops out of the child’s reach. 2. Purchase medication in child-resistant containers.

3. Take medications in front of the child, and explain that they are for adults only. 4. Never leave the child unattended around medications or cleaning solutions. 7. A patient is brought to the emergency department after inhaling mercury. The nurse should be alert for which acute adverse effects associated with mercury inhalation? 1. Chest pain, pneumonitis, and inflammation of the mouth 2. Intestinal obstruction and numbness of hands 3. Hypotension, oliguria, and tingling of feet 4. Tachycardia, hematuria, and diaphoresis 8. Which aspect of restraint use can the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Assessing the patient’s status 2. Determining the need for restraint 3. Evaluating the patient’s response to restraints 4. Applying and removing the restraints 9. The nurse suspects a 3-year-old child who is coughing vigorously has aspirated a small object. Which action should the nurse take first? 1. Encourage the child to continue coughing. 2. Deliver upward abdominal thrusts with a fisted hand. 3. Complete five rapid back blows between the shoulder blades. 4. Perform a blind finger sweep of the child’s mouth. 10. Which is the most commonly reported incident in hospitals? 1. Equipment malfunction 2. Patient falls 3. Laboratory specimen errors 4. Treatment delays 11. The nurse is working in a doctor’s office. Which annual assessment test would the nurse schedule for a 75-year-old patient? 1. Timed Up and Go 2. Get Up and Go 3. Morse Fall Scale 4. Safety Assessment Scale 12. A male patient in the emergency department is angry, yelling, cursing, and waving both arms when the nurse comes to the treatment cubicle. Which action by the nurse is advisable? 1. Reassure the patient by entering the room alone. 2. Ask the patient whether he is carrying any weapons. 3. Stay between the patient and the door while keeping the door open. 4. Stand close to the patient to establish rapport and trust. 13. While teaching a safety session at the local library, the nurse emphasizes that according to the National Weather Service, the leading cause of weather-related fatalities is:

1. 2. 3. 4.

Floods Heat Hurricanes Tornadoes

14. The quality and risk nurse in the local hospital is performing a hospital survey on sentinel events. Which statement would the nurse use to best describe a sentinel event? 1. An event that can cause serious injury to a patient that should never happen in a hospital 2. Specific events that enable a hospital to maximize reimbursement 3. An unexpected event involving death or serious physical or psychological injury 4. Operating room event involving the use of unsafe equipment 15. The nurse is caring for a group of patients on the medical-surgical unit. What is the most important action the nurse can take in preventing falls? 1. Raise the two siderails for each patient’s bed. 2. Place a fall risk sign on the front of the patient’s door. 3. Identify those patients who are at risk for falls. 4. Use bed alarms for patients prone to falls. 16. The nurse is invited to a childcare center for a safety class. An employee comes running into the class and says to the nurse, “I think one of the children swallowed a poisonous chemical from our storage area.” What is the first action by the nurse? 1. Identify the poison then call 911 or the local emergency number. 2. Assess for signs and symptoms then call 911 or the local emergency number. 3. Call 911 immediately, even if the child has no symptoms. 4. Induce vomiting in the child then call 911. Multiple Response Identify one or more choices that best complete the statement or answer the question. 17. Which points should the nurse include when teaching safety precautions to the mother of a toddler? Select all that apply. 1. Make sure the child sleeps supine (on the back) at night. 2. Keep the telephone number of the poison control center accessible. 3. Use a rear-facing car seat placed in the back seat of the car. 4. Keep syrup of ipecac on hand in case of accidental poisoning. 5. Remove philodendron and English ivy plants from the house. 18. During a thermometer exchange program at a local hospital, a person drops a mercury thermometer on the floor. How should the trained nurse intervene? Select all that apply. 1. Use a flashlight to search for beads of mercury on hard surfaces. 2. Notify the hazardous material management team immediately. 3. Evacuate the area immediately.

4. After putting on a gown, gloves, and a mask, clean up the mercury. 5. Ventilate the area well. 19. The community health nurse is making a presentation on carbon monoxide (CO) poisoning at the neighborhood health fair. Which information will the nurse include in the presentation? Select all that apply. 1. Carbon monoxide is a colorless, odorless, and tasteless gas. 2. Home-installed carbon dioxide detectors are shown to be ineffective. 3. Carbon monoxide poisoning causes many older adult deaths in cold weather months. 4. During rainy weather, a home fireplace with charcoal may be used for barbequing. 5. Occasionally using a kerosene heater to heat the house is recommended. 20. The nurse on the pediatric unit is preparing a teaching plan related to small children and drowning. Which sources of drowning will the nurse include in the plan? Select all that apply. 1. Empty bathtub 2. Water-filled wading pool 3. Toilet 4. Mop bucket filled with water 5. Unfilled hot tub 21. The community health nurse is preparing a teaching plan on motor vehicle accidents. Which information will the nurse include in the plan? Select all that apply. 1. The risk of being injured or killed in a car crash increases for older adult drivers. 2. Young children should be placed in the front seat of a motor vehicle so that the driver can watch them. 3. Air bags have no effect on injury or death related to motor vehicle accidents. 4. Cell phone use while driving is directly correlated with an increase in motor vehicle accidents. 5. Failure to use seat belts is a major contributing factor for injury and death with regard to motor vehicle accidents. 22. While working with an unlicensed assistive personnel (UAP) in a local nursing home, the nurse knows which fall risk and prevention measures may be delegated to the UAP? Select all that apply. 1. Remove clutter and spills in patient rooms. 2. Place nonskid slippers on patients. 3. Lock beds and wheelchairs. 4. Assess each patient for fall risk. 5. Monitor for injuries if the patient falls. 23. The mother of 6-year-old twins says to the pediatric nurse, “My husband and I keep a gun in our home. Do you have any safety tips for us?” The most appropriate responses by the nurse are which of the following? Select all that apply. 1. “I do not recommend owning a firearm when children are living in the home.” 2. “Be careful not to allow your children into the homes of others who own firearms.”

3. “Be sure to keep your gun unloaded and in a secure and locked cabinet.” 4. “Ammunition for your gun should be stored in a different location from the gun.” 5. “I can’t believe your family owns a gun, especially when you have twins.” 24. The nurse is preparing to write the nursing progress notes for a patient who has wrist restraints. Which chart entries will the nurse include in the progress notes? Select all that apply. 1. Family teaching initiated regarding the need for patient restraint 2. Restraint removed once per shift to assess skin color, sensation, and movement of extremity 3. Prescription for wrist restraint received from the primary care provider 4. Wrist restraints applied because of the patient’s increasing confusion 5. Double knot used to tie restraints to bed frame 25. The nurse is teaching a safety class for campers. Which statements by the participants indicate understanding of the safety measures against ticks? Select all that apply. 1. “I will wash the tick repellent off the next morning.” 2. “I will apply sunscreen first and then the tick repellent.” 3. “I will wear a long-sleeved shirt, tucked in.” 4. “I will look over my whole body, even my hair, for ticks.” 5. “I will not stay around old tires filled with water.” 26. The home health nurse is performing an initial assessment in the home of an 80-year-old client. Which instructions will the nurse provide to minimize and prevent bathroom accidents? Select all that apply. 1. Install grab bars in the bathtub or shower. 2. Avoid handheld shower attachments. 3. Use a nonskid mat in the bathtub. 4. Install a raised toilet seat. 5. Avoid shower chairs.

Chapter 24. Promoting Safety Answer Section MULTIPLE CHOICE 1. ANS: 1 Chapter: Chapter 24 Promoting Safety Objective: Discuss developmental and individual factors that create safety risks. Page: 536 (V1) Heading: Developmental Factors > Adult > Gero Feature: Older Adult and Example Problem: Falls > Gero Feature Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Safety Difficulty: Easy Feedback 1 This is correct. Loss of muscle strength and joint mobility place older adults at risk for falls. 2 This is incorrect. Choking is a primary safety concern for infants and toddlers. 3 This is incorrect. Ingesting poisons is a critical safety concern for infants and toddlers. 4 This is incorrect. Drowning is a safety concern for infants, toddlers, and adolescents. PTS: 1 CON: Safety 2. ANS: 4 Chapter: Chapter 24 Promoting Safety Objective: Identify at least five safety hazards in the home environment and interventions to prevent injury from them. Page: 538 (V1) Heading: Safety Hazards in the Home > Fires Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Comprehension [Understanding] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. Explosions are not the most common cause of death in a house fire. 2 This is incorrect. The most common cause of death in a house fire is not due to falling from a second-story window.

3 4

This is incorrect. Thermal damage to skin and body surfaces is not the most common cause of death in a house fire. This is correct. Most fire-related deaths occur from smoke inhalation.

PTS: 1 CON: Safety 3. ANS: 4 Chapter: Chapter 24 Promoting Safety Objective: Describe the four main physical hazards that are found in the community and the interventions to prevent injury from them. Page: 556 (V1) Heading: Table 24-4 Types of Car Safety Seats Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. Use rear-facing seats from birth to ages 2–4 years old. 2 This is incorrect. Three years of age is too young to position a child in a forward-facing car seat. 3 This is incorrect. From ages 2–4 years old, rear-facing seats should be used. 4 This is correct. Rear-facing seats are safer for toddlers up to age 4 years of age. Thus, 5 years of age is appropriate for forward-facing car seats. PTS: 1 CON: Safety 4. ANS: 3 Chapter: Chapter 24 Promoting Safety Objective: Describe the choking rescue maneuver, and identify instances when it is appropriate to use it. Page: 556 (V1) Heading: Clinical Insight 24-1 Choking Rescue Maneuver Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. A “Code Blue” is called when the patient has no pulse and/or no respirations. 2 This is incorrect. The choking rescue maneuver is implemented after the person has indicated he or she is choking. 3 This is correct. The nurse’s first response is to assess that the person is actually

choking by asking, “Are you choking?” This is incorrect. The American Red Cross (2015) recommends alternating five back blows with five abdominal thrusts until the blockage is dislodged. However, choking must be established before implementing this procedure.

PTS: 1 CON: Safety 5. ANS: 1 Chapter: Chapter 24 Promoting Safety Objective: Describe the four main physical hazards that are found in the community and the interventions to prevent injury from them. Page: 544 (V1) Heading: Box 24-3 What to Do If There Is a Mercury Spill Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Moderate Feedback 1 This is correct. The nurse should tell the mother to first remove the contaminated clothing as quickly as possible. Additionally, it is most important to remove contact between the skin and the poison before doing anything. 2 This is incorrect. Flooding the area with water may come later in the process. 3 This is incorrect. Washing the area with soap with water comes later in the process. 4 This is incorrect. Call the National Poison Control Center (it does not have to be a local poison control center). PTS: 1 CON: Safety 6. ANS: 4 Chapter: Chapter 24 Promoting Safety Objective: Discuss the steps to follow when you suspect that a client has ingested a poisonous substance. Page: 553 (V1) Heading: Home Care box side bar > Home Care > Preventing Poisoning in the Home Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. Medications should never be stored on kitchen counters or bathroom surfaces because children love to explore and climb and can get into

3 4

them. This is incorrect. The nurse should reinforce that although child-resistant containers are a deterrent, they are not foolproof because many toddlers and preschoolers can open them. This is incorrect. The nurse should explain that medications should not be taken in front of the child because children imitate adult behavior. This is correct. The nurse should instruct the mother to avoid leaving her child unattended around medications or cleaners, even for a moment.

PTS: 1 CON: Safety 7. ANS: 1 Chapter: Chapter 24 Promoting Safety Objective: Discuss the steps to follow when you suspect that a client has ingested a poisonous substance. Page: 544 (V1) Heading: Table 24-3 Potential Health Effects of Mercury Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Difficult Feedback 1 This is correct. Acute adverse effects of mercury inhalation include chest pain, inflammation of mouth, pneumonitis, respiratory damage, wakefulness, muscle weakness, anorexia, headache, and ringing in the ears. 2 This is incorrect. While intestinal obstruction is an acute effect of mercury ingestion, numbness of the hands is a chronic effect. Chronic effects include numbness or tingling of the hands, lips, and feet and personality changes. 3 This is incorrect. Hypotension and oliguria are not an acute effect of mercury inhalation. Tingling of the feet is a chronic effect. 4 This is incorrect. Tachycardia, hematuria, and diaphoresis are not acute effects of mercury inhalation. PTS: 1 CON: Safety 8. ANS: 4 Chapter: Chapter 24 Promoting Safety Objective: Properly apply restraints, and discuss measures to prevent injury in clients who are restrained. Page: 563 (V1) Heading: Which Safety Interventions Can I Delegate? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care

Cognitive Level: Knowledge [Remembering] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. The nurse responsible for care of the patient must assess the patient’s status. 2 This is incorrect. The nurse, not the UAP, must determine the need for restraints. 3 This is incorrect. The nurse, not the UAP, must evaluate the patient’s response to restraints. 4 This is correct. The nurse can delegate applying and removing the restraints, skin care, and checking for skin breakdown. PTS: 1 CON: Safety 9. ANS: 1 Chapter: Chapter 24 Promoting Safety Objective: Describe the choking rescue maneuver, and identify instances when it is appropriate to use it. Page: 555 (V1) Heading: Clinical Insight 24-1 Choking Rescue Maneuver Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Moderate Feedback 1 This is correct. If the nurse suspects aspiration in a child who is coughing vigorously, the nurse should encourage the child to continue coughing. 2 This is incorrect. Choking rescue maneuver is implemented only if the airway is blocked completely. Coughing indicates the child is not choking. 3 This is incorrect. Back blows are only used when the child is choking, not just coughing. Coughing indicates the airway is not totally blocked. 4 This is incorrect. A blind finger sweep should never be performed because it could push the foreign object into the airway. PTS: 1 CON: Safety 10. ANS: 2 Chapter: Chapter 24 Promoting Safety Objective: Describe and give examples of hazards that we encounter in the healthcare agency. Page: 546 (V1) Heading: Example Problem: Falls Integrated Processes: Caring Client Need: Safe and Effective Care Environment: Safety and Infection Control

Cognitive Level: Comprehension [Understanding] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. Although equipment (e.g., infusion pump) malfunctions may occur, they are not the most common. 2 This is correct. Patient falls are by far the most common incident reported in hospitals and long-term care facilities. 3 This is incorrect. Laboratory specimen errors are not the most commonly reported incident in hospitals. 4 This is incorrect. Treatment delays do not occur as commonly as falls do. PTS: 1 CON: Safety 11. ANS: 1 Chapter: Chapter 24 Promoting Safety Objective: Discuss at least one data collection instrument that is used to assess the client who is at risk for falls. Page: 550 (V1) Heading: Assessment > Gero Feature > Assessing Older Adults for Falls > Timed Get Up and Go Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Safety Difficulty: Moderate Feedback 1 This is correct. Primary care providers should annually perform a Timed Up & Go test for fall risk assessment for all patients over age 65. The scenario asks for an annual assessment for a 75-year-old. 2 This is incorrect. Get Up & Go is performed if a patient or caregiver reports a single fall or risk factors. There is no indication that the patient has fallen. 3 This is incorrect. The Morse Fall Scale is typically used on a nursing unit, not in a doctor’s office. 4 This is incorrect. The Safety Assessment Scale is an objective way to evaluate the dangers faced by people with memory and cognitive deficits who live alone at home. There is no indication of memory or cognitive deficits in this scenario. PTS: 1 CON: Safety 12. ANS: 3 Chapter: Chapter 24 Promoting Safety Objective: Describe and give examples of hazards that we encounter in the healthcare agency. Page: 563 (V1) Heading: Coping With Violence

Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Violence Difficulty: Difficult Feedback 1 This is incorrect. The nurse should not enter a room with an angry patient by himself or herself. 2 This is incorrect. The nurse should avoid being threatening or aggressive (asking if the patient is carrying a weapon). The nurse must be calm and reassuring. 3 This is correct. The nurse should keep the door open and position self such that the patient cannot block the exit from the room (stay between the patient and the door). 4 This is incorrect. Remain at least an arm’s length away from the angry patient. PTS: 1 CON: Violence 13. ANS: 2 Chapter: Chapter 24 Promoting Safety Objective: Describe the four main physical hazards that are found in the community and interventions to prevent injury from them. Page: 559 (V1) Heading: Weather Hazards Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Knowledge [Remembering] Concept: Thermo-regulation Difficulty: Moderate Feedback 1 This is incorrect. Deaths related to floods have declined only recently mostly because of advances in technology and warning systems. 2 This is correct. More than 1000 people die each year in the United States due to weather hazards. The most likely killer is heat. 3 This is incorrect. The number of deaths due to hurricanes has fallen steadily in the 21st century. 4 This is incorrect. Tornadoes are not the leading cause of weather-related deaths. PTS: 1 CON: Thermo-regulation 14. ANS: 3 Chapter: Chapter 24 Promoting Safety Objective: Describe and give examples of hazards that we encounter in the healthcare agency. Page: 541 (V1) Heading: Understanding Errors in Healthcare—Root Cause Analysis

Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. This is an example of a never event, not a sentinel event. Never events, also known as serious reportable events (SREs), are healthcare-acquired complications that (1) can cause serious injury or death to a patient and (2) should never happen in a hospital. A list of never events include foreign objects left in patients after surgery, air embolism, administration of the wrong blood type, and severe pressure injuries. 2 This is incorrect. Reimbursement is maximized when complications are prevented, not when complications occur. 3 This is correct. A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury. The Joint Commission requires all healthcare agencies to perform a root cause analysis of such events. 4 This is incorrect. Operating room event using unsafe equipment is a never event, not a sentinel event. PTS: 1 CON: Safety 15. ANS: 3 Chapter: Chapter 24 Promoting Safety Objective: Identify the four interventions to prevent falls in the healthcare agency. Page: 550 (V1) Heading: Interventions for Example Problem: Falls Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. The use of siderails has not been shown to prevent falls because patients often climb over them. Siderails can increase injury and falls. 2 This is incorrect. Although placing a fall risk sign on the front of the patient’s door is appropriate, it is not the most important measure. 3 This is correct. Perhaps the single-most important thing a nurse can do to prevent falls is to identify those who are at risk for falls. This should be done on the initial admitting assessment and throughout the patient’s hospitalization. 4 This is incorrect. Understand that bed alarms do not prevent falls by themselves; they are used to improve the timeliness of staff response. Patients who are at risk for falls require increased observation and surveillance.

PTS: 1 CON: Safety 16. ANS: 3 Chapter: Chapter 24 Promoting Safety Objective: Discuss the steps to follow when you suspect that a client has ingested a poisonous substance. Page: 552 (V1) Heading: Home Care Safety Interventions > Prevent Poisoning in the Home Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. The phone number should be called first. Identifying the poison may take too much time. 2 This is incorrect. The poison control center should be called first. 3 This is correct. In all cases of suspected poisoning, call 911 or the local emergency number first. Even if the person is having no symptoms, call as soon as possible. 4 This is incorrect. Never induce vomiting when the ingested material is acidic or caustic to the esophagus. PTS:

CON: Safety

MULTIPLE RESPONSE 17. ANS: 2, 3, 5 Chapter: Chapter 24 Promoting Safety Objective: Identify at least five safety hazards in the home environment and interventions to prevent injury from them. Page: 552 (V1) Heading: Home Care Safety Interventions > Prevent Poisoning in the Home and Table 24-4 Types of Care Safety Seats and Home Care box side bar > Home Care > Preventing Poisoning in the Home Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback

1. 2.

4. 5.

This is incorrect. Infants, not toddlers, should sleep on their backs to prevent sudden infant death syndrome. This is correct. The nurse should teach the mother of a toddler to keep the telephone number of the poison control center accessible because toddlers are at risk for accidental poisonings. This is correct. Toddlers should have rear-facing car seats for as long as possible (until they reach the height and weight maximum specified by the seat manufacturer). This is incorrect. Syrup of ipecac is no longer recommended to induce emesis after poisonings. This is correct. Toxic plants should be removed from the house. Examples of toxic plants are rhododendron, philodendron, English ivy, holly, mistletoe, and lily of the valley.

PTS: 1 CON: Safety 18. ANS: 1, 5 Chapter: Chapter 24 Promoting Safety Objective: Describe and give examples of hazards that we encounter in the healthcare agency. Page: 562 (V1) Heading: Box 24-3 What to Do If There Is a Mercury Spill Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Safety Difficulty: Difficult

1. 2. 3. 4. 5.

Feedback This is correct. The nurse should use a flashlight to search for beads of mercury on hard surfaces. This is incorrect. It is not necessary to notify the hazardous material management team since the nurse is trained to handle this situation. This is incorrect. The area does not have to be evacuated but people and animals must be kept away from the area. This is incorrect. The nurse should wear gloves and protective glasses. This is correct. Ventilate the area well to reduce the concentration of mercury vapors. Promote exhaust ventilation, if possible.

PTS: 1 CON: Safety 19. ANS: 1, 3 Chapter: Chapter 24 Promoting Safety Objective: Identify at least five safety hazards in the home environment and interventions to prevent injury from them.

Page: 552 (V1) Heading: Carbon Monoxide Exposure and Prevent Carbon Monoxide Poisoning Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is correct. Carbon monoxide (CO) is a colorless, tasteless, and odorless gas. This is incorrect. Carbon monoxide detectors are effective and should be used and installed. This is correct. Many carbon monoxide deaths occur during cold weather among older adults and the poor who seek nonconventional heating sources. This is incorrect. Never burn charcoal inside a home, cabin, recreational vehicle, or tent—not even in a fireplace. This is incorrect. Do not use a kerosene heater, gas oven, or gas range to heat a house, even for a short time.

PTS: 1 CON: Safety 20. ANS: 2, 3, 4 Chapter: Chapter 24 Promoting Safety Objective: Discuss developmental and individual factors that create safety risks. Page: 555 (V1) Heading: Prevent Drowning Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is incorrect. An empty bathtub is not a drowning hazard. This is correct. Even a wading pool can hold enough water to drown a small child. This is correct. A toilet is a drowning hazard. This is correct. A small child can drown in a mop bucket filled with water. This is incorrect. An unfilled hot tub is not a drowning hazard.

PTS: 1 CON: Safety 21. ANS: 1, 4, 5 Chapter: Chapter 24 Promoting Safety

Objective: Describe the four main physical hazards that are found in the community and the interventions to prevent injury from them. Page: 555 (V1) Heading: Motor Vehicle Accidents Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is correct. The risk of being injured or killed in a car crash increases for older drivers. This is incorrect. Children should be properly buckled in age-appropriate safety seats in the back seat of the car, not in the front seat of the car. This is incorrect. Severe injuries and death occur from air bag deployment when young children are improperly placed in the front passenger seat. This is correct. Driver distraction, or driver inattention, is thought to be mostly due to cell phone use and texting, which are banned or curtailed in most states. This is correct. Failure to use seat belts and proper child car seats is the major contributing factor for motor vehicle injuries and death.

PTS: 1 CON: Safety 22. ANS: 1, 2, 3 Chapter: Chapter 24 Promoting Safety Objective: Plan and implement nursing care to promote safety and prevent injury in clients who are at risk for falls. Page: 563 (V1) Heading: Which Safety Interventions Can I Delegate? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate

2. 3.

Feedback This is correct. The nurse should be sure that the UAP is aware of and follow all safety measures and institutional procedures. The nurse can expect that a UAP can remove clutter and spills from a patient room. This is correct. The nurse can expect that a UAP can provide patients with nonskid slippers. This is correct. The nurse can expect that a UAP can lock beds and wheelchairs.

This is incorrect. The assessment of a patient for fall risk cannot be delegated to a UAP. This is the responsibility of the nurse and is performed at the time of admission and throughout the length of stay. This is incorrect. It is the nurse’s responsibility to monitor for injuries if the patient falls.

PTS: 1 CON: Safety 23. ANS: 3, 4 Chapter: Chapter 24 Promoting Safety Objective: Identify at least five safety hazards in the home environment and interventions to prevent injury from them. Page: 554 (V1) Heading: Prevent Firearm Injuries Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate

1. 2.

4. 5.

Feedback This is incorrect. It is not the nurse’s responsibility to give advice. The nurse should educate the parents on safety issues with regard to having a gun in the home. This is incorrect. Even if parents do not have guns in their own home, it is possible that children will encounter them in other places. The nurse should urge parents to teach their children safe behavior around firearms and ensure that the children know what to do if they see a gun in a friend’s home or in school. This is correct. In teaching regarding firearms, a key safety rule to include is the following: Always keep the gun unloaded until ready to use, and store firearms unloaded in a secure and locked container. This is correct. To prevent firearm injury, store ammunition in a different location from the firearm. This is incorrect. This statement should be avoided because it is judgmental and nontherapeutic.

PTS: 1 CON: Safety 24. ANS: 1, 3 Chapter: Chapter 24 Promoting Safety Objective: Properly apply restraints, and discuss measures to prevent injury in clients who are restrained. Page: 560 (V1) Heading: Procedure 24-2 Using Restraints Integrated Processes: Communication and Documentation

Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Safety Difficulty: Difficult

1. 2.

4. 5.

Feedback This is correct. Notify the family of the change in patient status and the need for restraints. Obtain patient and family consent when clinically feasible. This is incorrect. Release restraints to provide skin care, passive and active range of motion (ROM), ambulation, toileting, hydration, and nutrition at least every 2 hours, not once a shift. This is correct. Restraints can be used only with a physician’s or advanced practice nurse’s order for a specified and limited time. Document the primary care provider’s orders. This is incorrect. The reason for the restraint should be documented; however, in this item, confusion alone is not enough information to warrant the need for the restraint. This is incorrect. Use a quick-release knot, such as the half-bow, when tying restraints to the bed frame or wheelchair. A double knot is not used.

PTS: 1 CON: Safety 25. ANS: 2, 3, 4 Chapter: Chapter 24 Promoting Safety Objective: Describe the four main physical hazards that are found in the community, and the interventions to prevent injury from them. Page: 559 (V1) Heading: Fighting Vector-Borne Pathogens > Ticks Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is incorrect. Wash off repellent at night before going to bed, not the next morning. This is correct. When wearing sunscreen, apply sunscreen first and then repellent. This is correct. Wear long-sleeved shirts, tucked in. This is correct. After walking in wooded areas, inspect your body, especially in the hair. This is incorrect. While this is a correct statement, it relates to mosquitoes, not ticks.

PTS:

CON: Safety

26. ANS: 1, 3, 4 Chapter: Chapter 24 Promoting Safety Objective: Identify at least five safety hazards in the home environment and interventions to prevent injury from them. Page: 546 (V1) Heading: Example Problem: Falls > Interventions for Preventing Falls in the Home > Minimize Bathroom Hazards Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate

1. 2.

3. 4. 5.

Feedback This is correct. The nurse would instruct the older adult client to install grab bars in the shower or tub. This is incorrect. The nurse would instruct the older adult client to install (not avoid) handheld shower attachments to make it easier to sit while showering and minimize the need to move and turn. This is correct. Using a nonskid mat in the bathtub is appropriate. This is correct. Installing a raised toilet seat can help minimize bathroom hazards. This is incorrect. The nurse would encourage (not avoid) the use of shower chairs to minimize falls in the bathroom.

PTS:

CON: Safety

Chapter 25. Facilitating Hygiene Multiple Choice Identify the choice that best completes the statement or answers the question. 1. During morning care, the male patient asks the nurse to shave him with a disposable razor. Before shaving him, the nurse should take which action? 1. Have him sign a permission form. 2. Check to see whether he is taking anticoagulants. 3. Tell him that only a family member may shave a patient. 4. Position him flat in bed. 2. The nurse is caring for a patient admitted with dementia. Which action by the nurse is appropriate when providing hygiene care for this patient? 1. Bathe the patient quickly. 2. Use cool water for bathing. 3. Provide care in short intervals. 4. Turn up the brightness of the lights. 3. During the bath, the nurse observed that the patient has dry skin. The best action by the nurse is to: 1. Bathe the patient more frequently. 2. Use an emollient. 3. Massage the skin with warm water. 4. Discourage fluid intake. 4. The nurse is about to bathe a female patient who has an intravenous (IV) line with no two-way, needlefree connector and needs to remove the patient’s gown. The nurse should take which action? 1. Temporarily disconnect the IV tubing at a point close to the patient and thread it through the gown. 2. Cut the gown with scissors to allow the patient’s arm to be easily removed from the gown. 3. Thread the bag and tubing through the gown sleeve, keeping the line intact. 4. Disconnect the tubing, thread it through the gown, and reconnect the tubing. 5. For which patient can the nurse safely delegate morning care to an experienced unlicensed assistive personnel (UAP)? 1. A 32-year-old just admitted with a closed head injury 2. A 76-year-old admitted with septic shock 3. A 62-year-old who underwent surgical repair of a bowel obstruction 2 days ago 4. A 23-year-old recently admitted with an exacerbation of asthma with dyspnea on exertion 6. A client’s epidermis has insufficient melanin. Which nursing diagnosis is appropriate? 1. Risk for Infection

2. Risk for Impaired Skin Integrity 3. Risk for Deficient Fluid Volume 4. Impaired Skin Integrity 7. When making an occupied bed, which action is most important for the nurse to do? 1. Keep the bed in the low position. 2. Raise the siderails on both sides of the bed. 3. Move back and forth between the sides of the bed when adjusting linens. 4. Use a bath blanket or sheet to maintain patient warmth and privacy. 8. Which intervention would be appropriate for a patient who has an eye infection with a moderate amount of discharge? 1. Cleansing the eye with hydrogen peroxide 2. Wiping from the outer canthus to the inner canthus 3. Positioning the patient on the same side as the eye to be cleansed 4. Using a different wipe to cleanse each eye 9. A patient with diarrhea is incontinent of liquid stool. The nurse documents that the patient now has excoriated skin on the buttocks. Which finding by the nurse led to this documentation? 1. The skin was softened from prolonged exposure to moisture. 2. The superficial layers of the skin were absent. 3. The epidermal layer of the skin was rubbed away. 4. A lesion caused by tissue compression was present. 10. For which patient is it most important to provide frequent perineal care? The patient: 1. With active lower gastrointestinal bleeding 2. Who is continent of urine 3. Who has a circumcised penis 4. With a history of acute asthma 11. A female patient with dementia becomes belligerent when the nurse attempts to give her a tub bath. How should the nurse proceed? 1. Call for assistance to help the patient into the bathtub. 2. Wait for the patient to calm down, and then give her a towel bath. 3. Allow the patient to go without bathing for about a week. 4. Ask another staff member to attempt the tub bath. 12. The nurse is teaching an unlicensed assistive personnel (UAP) how to give a complete bed bath. Which instruction should the nurse include? 1. “Cleanse only those areas likely to cause odor.” 2. “Provide the patient with warm water for washing the perineum.” 3. “Wash the patient’s back, buttocks, and perineum first.” 4. “Bathe the patient from head to toe, cleanest areas first.” 13. Which action should the nurse take when scanning the patient’s environment?

1. 2. 3. 4.

Check to make sure the nurse call device is within reach. Place the bed in the high position. Keep food tray in the patient’s room for later snacking. Allow the linens to have a few wrinkles.

14. A patient admitted with an acute exacerbation of chronic obstructive pulmonary disease has a nursing diagnosis of Activity Intolerance. Which type of bath is preferred for this patient? 1. Tub bath 2. Complete bed bath 3. Towel bath 4. Therapeutic 15. The school nurse is teaching a group of middle-school students how to prevent tinea pedis. Which remark by a student provides evidence of learning? 1. “I can contract the infection by walking barefoot in the gymnasium’s showers.” 2. “The best way to avoid contracting the infection is to use good handwashing.” 3. “Wearing unventilated shoes prevents the fungus from gaining contact with my feet.” 4. “There is really no way to prevent its spread; it’s a highly contagious scalp infection.” 16. The nurse is delegating the foot care of a patient with congestive heart failure to the unlicensed assistive personnel (UAP). At which temperature would the nurse tell the UAP to prepare the water? 1. 99°F (37.2°C) 2. 102°F (38.9°C) 3. 103°F (39.4°C) 4. 105°F (40.6°C) 17. While assessing a patient, the nurse notes that the patient’s nails are excessively brittle. What does this finding suggest? 1. Inadequate dietary intake 2. Normal aging process 3. Periodontal disease 4. Pallor 18. A patient with a history of seizures who takes phenytoin is at risk for which oral problem? 1. Dryness of the mouth 2. Brownish pigmentation of the gums 3. Demineralization of the tooth enamel 4. Gingival hyperplasia 19. The nurse has been teaching a student how to perform mouth care in an unconscious patient. The student will show evidence of learning if the student places the patient in which position for this care?

1. 2. 3. 4.

Supine Prone Semi-Fowler’s Side-lying

20. After receiving a course of chemotherapy, a patient begins losing hair. This adverse effect of chemotherapy should be documented as: 1. Pediculosis 2. Alopecia 3. Dandruff 4. Vellus hair 21. Which action would the nurse take when removing and cleaning a hearing aid? 1. Wash only the external surfaces, not the canal portion. 2. Clean the top part of the canal portion of the device. 3. Insert a wax loop or toothpick into the hearing aid itself. 4. Gently submerge the hearing aid in warm water. 22. The male patient is sitting in a chair at the bedside. The nurse is preparing to remove the patient’s artificial eye. What should the nurse ask the patient to do to best position him for this procedure? 1. Lean forward, and rest the arms on the overbed table. 2. Sit back in the chair, and tilt the head back. 3. Move to the bed, and lie down. 4. Stand up, and lean over the bed. Multiple Response Identify one or more choices that best complete the statement or answer the question. 23. Which areas should the nurse inspect when assessing for cyanosis in a dark-skinned patient? Select all that apply. 1. Buccal mucosa 2. Around the lips 3. Palms 4. Tongue 5. Sclera 24. Which of the following are the benefits of bathing? Select all that apply. 1. Constricts blood vessels 2. Increases depth of respirations 3. Provides opportunity for assessments 4. Reduces sensory input 5. Prevents buildup of plaque 25. For which patients should the nurse avoid using back massage? Select all that apply.

1. 2. 3. 4. 5.

One who underwent heart surgery 2 days ago One who sustained rib fractures from a fall One who has heartburn One who sustained a leg fracture in a sledding accident One who has a backache

Chapter 25. Facilitating Hygiene Answer Section MULTIPLE CHOICE 1. ANS: 2 Chapter: Chapter 25 Facilitating Hygiene Objective: Identify factors influencing personal hygiene practices. Page: 589 (V1) Heading: Shaving Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Perfusion Difficulty: Easy Feedback 1 This is incorrect. A permission form is not needed for shaving. 2 This is correct. If the patient has a bleeding disorder or is taking anticoagulant medication, the nurse should use an electric razor, not a disposable razor. 3 This is incorrect. Staff or family can shave a patient. 4 This is incorrect. The patient does not have to be flat; in fact, most like to be upright or sitting. PTS: 1 CON: Perfusion 2. ANS: 3 Chapter: Chapter 25 Facilitating Hygiene Objective: Demonstrate nursing skills to promote patient hygiene (such as bathing, foot care, and bed making). Page: 577 (V1) Heading: Bathing Patients Who Have Dementia and iCare Box 25-2 Caring tips for bathing a patient with dementia and Procedure 25-1 Bathing: Providing a Complete Bed Bath Using a Prepackaged Bathing Product > What If You Are Bathing a Patient With Dementia? Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is incorrect. Bathe the patient slowly. Do not rush as this may cause the patient to feel tension and become agitated. 2 This is incorrect. Using cool water to bathe the patient may cause shivering. The patient should be kept warm, using warm water.

3 4

This is correct. The nurse should provide care in short intervals to avoid overstimulating the patient. This is incorrect. Avoid sensory overload by keeping the lights turned down.

PTS: 1 CON: Patient-Centered Care 3. ANS: 2 Chapter: Chapter 25 Facilitating Hygiene Objective: Apply the nursing process to common hygiene-related problems of the skin, feet, nails, mouth, hair, eyes, ears, and nose. Page: 576 (V1) Heading: Box 25-1 Guidelines for Bathing the Adult Patient Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Analysis [Analyzing] Concept: Tissue Integrity Difficulty: Easy Feedback 1 This is incorrect. Frequent bathing will increase dryness. 2 This is correct. Using an emollient will aid in soothing dry skin. 3 This is incorrect. Massaging skin with water will not play a role in improving dry skin. 4 This is incorrect. Discouraging fluid intake will increase dry skin. PTS: 1 CON: Tissue Integrity 4. ANS: 3 Chapter: Chapter 25 Facilitating Hygiene Objective: Demonstrate nursing skills to promote patient hygiene (such as bathing, foot care, and bed making). Page: 576 (V1) Heading: Procedure 25-1 Bathing: Providing a Complete Bed Bath Using a Prepackaged Bathing Product > Patient With an IV Line Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Infection Difficulty: Moderate

1 2

Feedback This is incorrect. Never disconnect this type of IV tubing connection; this breaks the sterile system and provides a portal of entry for pathogens. This is incorrect. The nurse does not cut the gown. There are gowns with snapopen sleeves can be used for this patient.

This is correct. If there is no two-way, needlefree connector on the tubing, the bag should be threaded through the gown sleeve, keeping the line intact to prevent contamination and infection. This is incorrect. If the patient has a needlefree two-way connector, this technique may be used. However, this patient does not have a two-way connector.

PTS: 1 CON: Infection 5. ANS: 3 Chapter: Chapter 25 Facilitating Hygiene Objective: Discuss delegation of hygiene activities to unlicensed assistive personnel (UAP). Page: 568 (V1) Heading: Delegating Hygiene Care Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Leadership and Management Difficulty: Difficult Feedback 1 This is incorrect. The patient who sustained a closed head injury is unstable. Therefore, care of this patient should not be delegated to the UAP. 2 This is incorrect. The patient admitted with septic shock may easily become unstable during care; therefore, a registered nurse is required to provide morning care safely. 3 This is correct. Morning care for the patient who underwent surgical repair of a bowel 2 days ago can be safely delegated to the UAP because the patient is stable. 4 This is incorrect. The patient who was admitted with exacerbation of asthma and becomes short of breath with activity requires the critical-thinking skills of a registered nurse to detect respiratory compromise quickly. PTS: 1 CON: Leadership and Management 6. ANS: 2 Chapter: Chapter 25 Facilitating Hygiene Objective: Identify the nursing diagnoses related to self-care ability and hygiene practices. Page: 569 (V1) Heading: Anatomy and Physiology of the Skin and Analysis/Nursing Diagnosis (Skin) Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Tissue Integrity Difficulty: Moderate

1 2

Feedback This is incorrect. Fibroblasts (not melanin), also found in the dermis, produce new cells and assist in wound healing, thereby helping to prevent infection. This is correct. The epidermis contains melanin, a pigment that protects against the sun’s ultraviolet rays; therefore, a person with insufficient melanin is at risk for Impaired Skin Integrity, such as a sunburn. This is incorrect. The dermis contains blood and lymphatic vessels, nerves, bases of hair follicles, and sebaceous and sweat glands; melanin does not prevent fluid loss. This is incorrect. There are no symptoms to indicate that the client has a break or injury to the skin, only that a risk factor is present.

PTS: 1 CON: Tissue Integrity 7. ANS: 4 Chapter: Chapter 25 Facilitating Hygiene Objective: Demonstrate nursing skills to promote patient hygiene (such as bathing, foot care, and bed making). Page: 422 (V2) Heading: Procedure 25-16 Making an Occupied Bed Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Analysis [Analyzing] Concept: Comfort Difficulty: Moderate Feedback 1 This is incorrect. Keeping the bed in the low position may strain the nurse’s back. 2 This is incorrect. Working over raised siderails may strain the nurse’s back. 3 This is incorrect. Continually moving from side to side is disorganized and time consuming. 4 This is correct. When making an occupied bed, the nurse should cover the patient with a bath blanket, if available, or leave the top sheet over the patient. Covering the patient prevents chilling and preserves modesty. PTS: 1 CON: Comfort 8. ANS: 4 Chapter: Chapter 25 Facilitating Hygiene Objective: Demonstrate care of the eyes, ears, and teeth, including glasses, contacts, hearing aids, and dentures. Page: 589 (V1) Heading: Care of the Eyes Integrated Processes: Nursing Process

Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 This is incorrect. Agency-approved water or normal saline (not hydrogen peroxide) should be used for cleansing the eye of any discharge. 2 This is incorrect. Always cleanse from the inner canthus to the outer canthus to avoid forcing debris into the nasolacrimal duct. The inner canthus is considered “clean.” 3 This is incorrect. The patient does not have to be lying on the side to clean the eye. The patient can be supine. 4 This is correct. To prevent cross-contamination if there is drainage or crusting, a different wipe should be used for each eye. PTS: 1 CON: Infection 9. ANS: 2 Chapter: Chapter 25 Facilitating Hygiene Objective: Describe assessments to make when providing hygiene care of the skin, feet, nails, mouth, hair, eyes, ears, and nose. Page: 572 (V1) Heading: Common Skin Problems Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Tissue Integrity Difficulty: Moderate Feedback 1 This is incorrect. Maceration is the term for softening of skin from exposure to moisture. 2 This is correct. Excoriation refers to loss of the superficial layers of the skin caused by the digestive enzymes in feces. 3 This is incorrect. Abrasion, rubbing away of the epidermal layer of the skin, especially over bony areas, is often caused by friction or shearing forces that occur when a patient moves in bed. 4 This is incorrect. Pressure injuries, which are lesions caused by tissue compression and inadequate perfusion, are the result of immobility, not moving in bed. PTS: 1 CON: Tissue Integrity 10. ANS: 1 Chapter: Chapter 25 Facilitating Hygiene

Objective: Identify the factors influencing personal hygiene practices. Page: 577 (V1) Heading: Perineal Care Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is correct. The patient admitted with active lower gastrointestinal bleeding will require frequent perineal care because of the irritating effect of the enzymes in stools. 2 This is incorrect. A patient who is incontinent (not continent) of urine would require more frequent perineal care. 3 This is incorrect. The uncircumcised patient, not the circumcised patient, may require frequent perineal care. 4 This is incorrect. Patients who have a history of acute asthma do not require frequent perineal care. PTS: 1 CON: Patient-Centered Care 11. ANS: 2 Chapter: Chapter 25 Facilitating Hygiene Objective: Demonstrate the nursing skills to promote patient hygiene (such as bathing, foot care, and bed making). Page: 577 (V1) Heading: Bathing Patients Who Have Dementia and What if You Are Bathing a Patient with Dementia? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. The patient should not be helped into the tub with assistance as this could increase the agitation and belligerence. 2 This is correct. Nurses need to individualize bathing to meet the needs of the patient. If the patient becomes belligerent, the nurse should wait until the patient calms down and then attempt a towel bath. Towel baths have been shown to reduce agitation significantly. 3 This is incorrect. While a patient does not have to bathe every day, a week may be too long. There is a better option for a belligerent patient who has dementia. 4 This is incorrect. Having another staff member attempt the tub bath will most

likely increase the patient’s agitation, as consistency of caregivers is important for patients with dementia. PTS: 1 CON: Safety 12. ANS: 4 Chapter: Chapter 25 Facilitating Hygiene Objective: Describe the following types of baths: complete, assist, partial, towel, bag, shower, tub, and therapeutic. Page: 574 (V1) Heading: Highlights of Procedures 25-1 to 25-16 Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Collaboration Difficulty: Moderate Feedback 1 This is incorrect. During a partial bath, the UAP should cleanse only the areas that may cause odor or discomfort. 2 This is incorrect. The UAP should provide the patient with a basin of warm water and allow him or her to wash the perineum when giving an assisted bath or bed bath (the question concerns a complete bed bath). 3 This is incorrect. The UAP should never begin the bath with the back, buttocks, and perineum because this violates the principle of “clean to dirty.” 4 This is correct. The nurse should instruct the UAP to give a complete bed bath (a bath for patients who must remain in bed but who are unable to bathe themselves), in a head-to-toe fashion, beginning with the cleanest part of the body and ending with the dirtiest. PTS: 1 CON: Collaboration 13. ANS: 1 Chapter: Chapter 25 Facilitating Hygiene Objective: Discuss the relationship between a patient’s overall well-being and the immediate environment. Page: 567 (V1) Heading: Assessment (Scanning the Environment) Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Safety Difficulty: Easy Feedback 1 This is correct. When scanning the environment, the nurse should make sure the

2 3 4

nurse call device is within reach. This is incorrect. The bed should be in the low position, not the high position. This is incorrect. All odors should be avoided. The food tray should be removed to decrease unpleasant odors. This is incorrect. The bed linens should be clean and free of wrinkles.

PTS: 1 CON: Safety 14. ANS: 3 Chapter: Chapter 25 Facilitating Hygiene Objective: Describe the following types of baths: complete, assist, partial, towel, bag, shower, tub, and therapeutic. Page: 575 (V1) Heading: Bed Baths and Modified Bed Baths > Towel Bath Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. A tub bath may deplete this patient’s energy. 2 This is incorrect. While a complete bed bath can be used, it is not the best method for a patient who is experiencing an acute exacerbation of respiratory problems. 3 This is correct. A towel bath is a modification of the bed bath, in which a large towel and a bath blanket are placed in a plastic bag and saturated with a commercially prepared mixture of moisturizer, nonrinse cleaning agent, and water. The bag and its contents are then placed in the microwave, and they are used to bathe the patient. This bathing method is preferred for patients who have Activity Intolerance. 4 This is incorrect. Therapeutic baths (sitz, oatmeal, coal tar) are given for a specific purpose, for example, to relax muscles or to removes scales and crust from the skin. PTS: 1 CON: Patient-Centered Care 15. ANS: 1 Chapter: Chapter 25 Facilitating Hygiene Objective: Apply the nursing process to common hygiene-related problems of the skin, feet, nails, mouth, hair, eyes, ears, and nose. Page: 579 (V1) Heading: Common Foot Problems Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance

Cognitive Level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 This is correct. One can contract the infection by walking barefoot in public showers, such as those in the school’s gymnasium. 2 This is incorrect. Good handwashing does not prevent a person from contracting tinea pedis. 3 This is incorrect. Wearing unventilated shoes may actually aggravate the infection by allowing moisture to accumulate in the shoes. 4 This is incorrect. Tinea pedis, also called athlete’s foot, is not a scalp infection. Pediculosis is the term for infestation by head lice. PTS: 1 CON: Infection 16. ANS: 4 Chapter: Chapter 25 Facilitating Hygiene Objective: Demonstrate the nursing skills to promote patient hygiene (such as bathing, foot care, and bed making). Page: 396 (V2) Heading: Procedure 25-5 Providing Foot Care Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Knowledge [Remembering] Concept: Tissue Integrity Difficulty: Moderate Feedback 1 This is incorrect. This temperature, 99°F (37.2°C), is too cold. 2 This is incorrect. A temperature of 102°F (38.9°C) is too cold. 3 This is incorrect. The water at 103°F (39.4°C) is too cold. 4 This is correct. Fill the basin halfway with warm water (approximately 105°F to 110°F [40°C to 43°C]). Warm water promotes circulation. PTS: 1 CON: Tissue Integrity 17. ANS: 1 Chapter: Chapter 25 Facilitating Hygiene Objective: Describe the assessments to make when providing hygiene care of the skin, feet, nails, mouth, hair, eyes, ears, and nose. Page: 580 (V1) Heading: Care of the Nails Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Analysis [Analyzing]

Concept: Nutrition Difficulty: Moderate Feedback 1 This is correct. Inadequate dietary intake or metabolic changes can cause the nails to become brittle. 2 This is incorrect. As a person ages, nails thicken, become ridged, and may yellow or become concave in shape. 3 This is incorrect. Periodontal disease (pyorrhea) is the major cause of tooth loss in adults 35 years of age and older. It is an inflammation characterized by bleeding and receding gums and destruction of the surrounding bone structure. It does not cause brittle nails. 4 This is incorrect. Pallor in a light-skinned person may appear as pale skin without underlying pink tones. In a dark-skinned person, the nurse should observe for an ashen gray or yellow color. Pallor does not make nails brittle. PTS: 1 CON: Nutrition 18. ANS: 4 Chapter: Chapter 25 Facilitating Hygiene Objective: Describe assessments to make when providing hygiene care of the skin, feet, nails, mouth, hair, eyes, ears, and nose. Page: 582 (V1) Heading: Risk Factors for Oral Problems Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Comprehension [Understanding] Concept: Tissue Integrity Difficulty: Moderate Feedback 1 This is incorrect. Medications such as nifedipine cause dry mouth. 2 This is incorrect. Older adult patients can develop brownish pigmentation of the gums from the aging process, not from phenytoin. 3 This is incorrect. Phenytoin does not cause demineralization of the tooth enamel. Carbohydrates, like milk, and fruit juice in a baby bottle can lead to demineralization of the tooth enamel, causing “baby-bottle tooth decay.” 4 This is correct. Phenytoin causes gingival hyperplasia. PTS: 1 CON: Tissue Integrity 19. ANS: 4 Chapter: Chapter 25 Facilitating Hygiene Objective: Apply the nursing process to common hygiene-related problems of the skin, feet, nails, mouth, hair, eyes, ears, and nose. Page: 404 (V2)

Heading: Procedure 25-8 Providing Oral Care for an Unconscious Patient Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. The supine position can cause the patient to aspirate. 2 This is incorrect. The prone position does not allow for easy access to the mouth. 3 This is incorrect. The semi-Fowler’s position can lead to aspiration. 4 This is correct. The nurse should position an unconscious patient in the sidelying position to prevent aspiration while providing mouth care. PTS: 1 CON: Safety 20. ANS: 2 Chapter: Chapter 25 Facilitating Hygiene Objective: Describe the assessments to make when providing hygiene care of the skin, feet, nails, mouth, hair, eyes, ears, and nose. Page: 588 (V1) Heading: Analysis/Nursing Diagnosis (Hair) Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Comprehension [Understanding] Concept: Cellular Regulation Difficulty: Moderate Feedback 1 This is incorrect. Pediculosis is infestation of head lice. 2 This is correct. Alopecia is abnormal hair loss that can occur as a result of chemotherapy. 3 This is incorrect. Dandruff is a condition in which there is excessive shedding of the epidermal layer of the scalp. 4 This is incorrect. Vellus hair is the short, fine hair present over much of the body. PTS: 1 CON: Cellular Regulation 21. ANS: 2 Chapter: Chapter 25 Facilitating Hygiene Objective: Demonstrate care of the eyes, ears, and teeth, including glasses, contacts, hearing aids, and dentures. Page: 415 (V2) Heading: Procedure 25-14 Caring for Hearing Aids

Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Basic Care and Comfort Cognitive Level: Comprehension [Understanding] Concept: Sensory Perception Difficulty: Difficult Feedback 1 This is incorrect. The external surfaces are cleaned with a damp cloth, not washed, and the canal portion should be cleaned. 2 This is correct. The nurse should clean the top part of the canal portion of the hearing aid by using the wax loop and wax brush, cotton-tipped applicator, pipe cleaner, or toothpick. 3 This is incorrect. Nothing should be inserted into the hearing aid. 4 This is incorrect. The hearing aid should never be placed in water. PTS: 1 CON: Sensory Perception 22. ANS: 3 Chapter: Chapter 25 Facilitating Hygiene Objective: Demonstrate care of the eyes, ears, and teeth, including glasses, contacts, hearing aids, and dentures. Page: 414 (V2) Heading: Procedure 25-13 Caring for Artificial Eyes Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Sensory Perception Difficulty: Moderate Feedback 1 This is incorrect. Leaning forward and resting the arms on an overbed table would not provide the nurse access to the eye to remove the prosthesis. 2 This is incorrect. Sitting back in the chair would allow access to the eye but would not protect the artificial eye from falling to the floor. 3 This is correct. The nurse should have the patient lie down so that if the eye is dropped when removing it, it will fall on the bed instead of the floor. 4 This is incorrect. Standing up and leaning over the bed would not provide the nurse access to the eye to remove the prosthesis. PTS:

CON: Sensory Perception

MULTIPLE RESPONSE 23. ANS: 1, 3, 4 Chapter: Chapter 25 Facilitating Hygiene

Objective: Describe the assessments to make when providing hygiene care of the skin, feet, nails, mouth, hair, eyes, ears, and nose. Page: 573 (V1) Heading: Assessment (Skin) > Objective Data Integrated Processes: Culture and Spirituality Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Difficult

1. 2. 3. 4. 5.

Feedback This is correct. In dark-skinned people, cyanosis can be best assessed by examining the buccal mucosa. This is incorrect. In light-skinned people, the area around the lips can be inspected. This is correct. In dark-skinned people, the palms of the hands or the soles of the feet can be used to assess for cyanosis. This is correct. The tongue can be used in dark-skinned people to assess for cyanosis. This is incorrect. Jaundice, not cyanosis, can be detected in the sclera of the eyes.

PTS: 1 CON: Oxygenation 24. ANS: 2, 3 Chapter: Chapter 25 Facilitating Hygiene Objective: Explain how personal hygiene relates to health and well-being. Page: 574 (V1) Heading: Planning Interventions/Implementation (Skin) > Bathing Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Knowledge [Remembering] Concept: Tissue Integrity Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is incorrect. Bathing dilates (not constricts) blood vessels near the skin’s surface, increasing circulation. This is correct. Bathing stimulates the depth of respirations. This is correct. Bathing presents an opportunity to perform a variety of assessments. This is incorrect. Bathing provides (not reduces) sensory input. This is incorrect. Plaque, an invisible bacterial film that builds up on teeth, eventually leads to destruction of the tooth enamel and is decreased with brushing teeth, not bathing.

PTS: 1 CON: Tissue Integrity 25. ANS: 1, 2 Chapter: Chapter 25 Facilitating Hygiene Objective: Identify the factors influencing personal hygiene practices. Page: 574 (V1) Heading: Planning Interventions/Implementation (Skin) > Back Massage Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is correct. The nurse would avoid a back massage in this patient. Back massage is contraindicated in a patient who underwent heart surgery 2 days ago. This is correct. The nurse would avoid performing a back massage on this patient. Back massages are contraindicated in a patient with fractured ribs. This is incorrect. A back massage is allowed on a patient who has heartburn. This is incorrect. Massage is acceptable for the patient with a leg fracture. This is incorrect. The nurse would provide a massage to a patient who has a backache.

PTS:

CON: Patient-Centered Care

Chapter 26. Administering Medications Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse administered the narcotic meperidine, 50 mg orally (PO) at 1400 to a patient with nausea, vomiting, and pain rated as 9 on a 0-to-10 scale. At 1430, the patient stated that the medication was not working and requested to have intravenous (IV) morphine, which the provider had prescribed for severe pain. What is the nurse’s best evaluation of this situation? 1. The patient needs to understand that it takes time for the medication to reduce pain. 2. Administering meperidine PO was not the best nursing intervention in this situation. 3. The provider should be notified if the patient’s pain is not relieved in 2 hours. 4. Meperidine PO was the best intervention because morphine IV can cause drug addiction. 2. An insulin-dependent diabetic female patient tells the nurse that she has been giving herself injections in the same location in her right thigh for the past several months because it is easier. What is the nurse’s best action? 1. Provide patient teaching on rotating injection sites. 2. Tell the patient to make sure the dose is in milliliters. 3. Check the type of insulin the patient receives to ensure that it is compatible with the vastus lateralis site. 4. Document the patient’s comments, as the patient understands the treatment regimen. 3. A surgeon prescribes heparin 2,500 mEq intramuscularly (IM) every 12 hours (q12hr). What is the nurse’s best action? 1. Administer the medication as prescribed. 2. Clarify the medication dose with the surgeon. 3. Administer the medication subcutaneously. 4. Clarify the dose and route with the surgeon. 4. The nurse is preparing to administer a medication for a client with cystic fibrosis. The nurse is not familiar with the drug. Which is the best action that the nurse should take? 1. Administer the drug. 2. Ask another nurse. 3. Refer to the Physician’s Desk Reference. 4. Review a nursing care plan textbook. 5. Which term refers to the movement of a drug from the site of administration to the bloodstream? 1. Absorption 2. Distribution 3. Metabolism

4. Excretion 6. A patient who just returned from the postanesthesia care unit is reporting severe incision pain. Which drug contained in the medication administration record will offer the patient the fastest relief? 1. Liquid acetaminophen with codeine 2. Intravenous morphine sulfate 3. Intramuscular meperidine 4. Oral oxycodone tablets 7. A nurse is preparing a medication that is supplied in ounces but the prescription is in milliliters. How many milliliters equal 1 ounce? 1. 5 2. 15 3. 30 4. 45 8. A patient is given furosemide 40 mg orally at 0900. The duration of action for this drug is approximately 6 hours after oral administration. At which time in military hours should the nurse no longer expect to see the effects of this drug? 1. 0930 2. 1000 3. 1100 4. 1500 9. Which factor in a patient’s medical history is most likely to prolong the half-life of certain drugs? 1. Heart disease 2. Liver disease 3. Rheumatoid arthritis 4. Osteoarthritis 10. The nurse receives a laboratory report that states the patient’s digoxin level is 1.2 mg/mL; therapeutic range for this drug is 0.5 to 2.0 mg/mL. Which action should the nurse take? 1. Notify the prescriber to reduce the dose. 2. Withhold the next dose of digoxin. 3. Administer the next dose as prescribed. 4. Ask the prescribing healthcare provider to increase the dose. 11. The primary care provider orders peak and trough levels for a patient who is receiving intravenous vancomycin every 12 hours. When should the nurse obtain a blood specimen to measure the trough? 1. With the morning routine laboratory studies 2. Approximately 30 minutes before the next dose 3. Two hours after the next dose infuses 4. While the drug is infusing

12. Teratogenic drugs should be avoided in which patient population? 1. Pregnant women 2. Elderly 3. Children 4. Adolescents 13. A patient with end-stage cancer is prescribed morphine sulfate to reduce pain. For which effect is this medication prescribed? 1. Supportive 2. Restorative 3. Substitutive 4. Palliative 14. After receiving diphenhydramine, a patient reports experiencing a very dry mouth. This is not uncommon in patients taking this medication. Which drug effect is this patient experiencing? 1. Side effect 2. Adverse reaction 3. Toxic reaction 4. Supportive effect 15. While receiving an intravenous dose of an antibiotic, levofloxacin, a patient develops severe shortness of breath, wheezing, and severe hypotension. Which action should the nurse take first? 1. Administer epinephrine intramuscularly (IM). 2. Give a bolus dose of intravenous fluids. 3. Stop the infusion of medication. 4. Prepare for endotracheal intubation. 16. A patient develops urticaria and pruritus 5 days after beginning phenytoin for treatment of seizures. Which type of reaction is the patient most likely experiencing? 1. Mild allergic reaction 2. Dose-related adverse reaction 3. Toxic reaction 4. Anaphylactic reaction 17. Laboratory test results indicate that warfarin anticoagulant therapy is suddenly ineffective in a patient who has been taking the drug for an extended period of time. The nurse suspects an interaction with herbal medications. What type of interaction does the nurse suspect? 1. Antagonistic drug interaction 2. Synergistic drug interaction 3. Idiosyncratic reaction 4. Drug incompatibility 18. A patient with terminal cancer requires increasing doses of an opioid pain medication to obtain relief from pain. This patient is exhibiting signs of drug:

1. 2. 3. 4.

Abuse Misuse Tolerance Dependence

19. Before administering a medication, the nurse must verify the six rights of medication administration, which are: 1. Right patient, right room, right drug, right route, right dose, and right time 2. Right drug, right dose, right route, right time, right physician, and right documentation 3. Right patient, right drug, right route, right time, right documentation, and right equipment 4. Right patient, right drug, right dose, right route, right time, and right documentation 20. Which expected outcome is best for a patient with a nursing diagnosis of Deficient Knowledge related to new drug treatment regimen? 1. After an explanation and written materials, verbalizes the expected actions and adverse reactions of the medication 2. In 1 week after instructional session, describes the expected actions and adverse reactions of the medications 3. Follows the treatment plan as prescribed 4. Experiences no adverse effect from the prescribed treatment plan 21. When the nurse enters a male patient’s room to administer a medication, he calls out from the bathroom, telling the nurse to leave his medication on the bedside table. He reassures the nurse that he will take the medication as soon as he is finished. How should the nurse proceed? 1. Inform the patient that the nurse will return when he is finished in the bathroom. 2. Wait outside the bathroom door until the patient is ready for the dose. 3. Withhold the dose until the next administration time later in the day. 4. Leave the medication at the bedside so that the patient can take it later. 22. Which documentation entry related to prn (as needed) medication administration is complete? 1. 6/5/20 0900 morphine 4 mg IV given in right antecubital fossa for pain rated 8 on a 1–10 scale, J. Williams RN 2. 0600 famotidine 20 mg IV given in right hand, S. Abraham RN 3. 9/2/20 0900 levothyroxine 50 mcg PO given 4. 1/16/20 furosemide 40 mg PO given, J. Smith RN 23. A patient has difficulty taking liquid medications from a cup. How should the nurse administer the medications? 1. Request that the physician change the order to the intravenous (IV) route. 2. Administer the medication by the intramuscular (IM) route. 3. Use a needleless syringe to place the medication in the side of the mouth. 4. Add the whole capsule to a small amount of food or beverage to facilitate

swallowing. 24. The primary care provider prescribes nitroglycerin 1/150 grains sublingually for a patient experiencing chest pain. How should the nurse administer the drug? 1. Put the drug in the cheek area, and allow it to dissolve. 2. Place the drug under the tongue, and allow it to dissolve. 3. Inject the drug superficially into the subcutaneous tissue. 4. Have the patient swallow the pill with water. 25. Which action should the nurse take immediately after administering a medication through a nasogastric tube? 1. Verify correct nasogastric tube placement in the stomach. 2. Auscultate the abdomen for presence of bowel sounds. 3. Immediately administer the next prescribed medication. 4. Flush the tube with water using a needleless syringe. 26. How should the nurse dispose of a contaminated needle after administering an injection? 1. Place the needle in a specially marked, puncture-proof container. 2. Recap the needle, and carefully place it in the trashcan. 3. Recap the needle, and place it in a puncture-proof container. 4. Place the needle in a biohazard bag with other contaminated supplies. 27. The nurse must administer hepatitis B (HB) immunoglobulin 0.5 mL intramuscularly to a newly born infant of a hepatitis B antigen (HB Ag)–positive mother. Which injection site should the nurse choose to administer this injection? 1. Ventrogluteal 2. Vastus lateralis 3. Deltoid 4. Dorsogluteal 28. Which action should the nurse take to relax the vastus lateralis muscle before administering an intramuscular injection into the site? 1. Apply a warm compress. 2. Massage the site in a circular motion. 3. Apply a soothing lotion. 4. Have the client assume a sitting position. 29. The physician prescribes warfarin 5 mg orally (PO) at 1800 for a patient. After administering the medication, the female nurse realizes that she administered a 10 mg tablet instead of the prescribed 5 mg PO. Which action by the nurse is appropriate? 1. No action is necessary because an extra 5 mg of warfarin is not harmful. 2. Call the prescriber and ask the order to be changed to 10 mg. 3. Document on the chart that the drug was given, and indicate the drug was given in error. 4. Complete an incident report according to the facility’s policy.

30. The nurse must administer ear drops to an infant. How should the nurse proceed? 1. Pull the pinna down and back before instilling the drops. 2. Position the pinna upward and outward before instilling the drops. 3. Instill the drops directly; no special positioning is necessary. 4. Position the patient supine with the head of the bed elevated 30°. 31. The nurse is teaching parents ways to give oral medication to their child. Which action would the parents implement to improve compliance? 1. Crush time-release capsules to put in their child’s favorite food. 2. Give medication quickly before the child knows what is happening. 3. Allow the child to eat a frozen pop before receiving the medication. 4. Mask the flavor of medication in a toddler cup with orange juice. 32. An adult patient admitted with lower gastrointestinal bleeding is prescribed a unit of packed red blood cells. Which gauge needle should be inserted to administer this blood product? 1. 18 2. 22 3. 24 4. 26 33. What is the most essential action by the nurse prior to delegating the administration of an intravenous (IV) medication to a licensed practical nurse (LPN)? 1. Review the state’s nurse practice act for LPN scope of practice. 2. Examine the unit policy and procedure for IV medication administration. 3. Determine whether the LPN has previously performed this procedure. 4. Demonstrate the procedure; then allow the LPN to administer the IV medication. 34. Which body organ is primarily responsible for the metabolism of medications? 1. Kidney 2. Skin 3. Liver 4. Large intestine 35. Which body organ is primarily responsible for medication excretion? 1. Liver 2. Kidney 3. Lungs 4. Exocrine glands 36. The nursing student is preparing to administer an intramuscular (IM) injection to the patient. The student states to the instructor, “I’m going to administer this medication in my patient’s buttocks at the dorsogluteal site.” What is the most appropriate response by the instructor? 1. “Okay. Explain the procedure to me and you are good to go.” 2. “This may not be the best site owing to proximity of the sciatic nerve.”

3. “I agree this is a good site for thin patients such as this one.” 4. “Okay, but first be sure to locate the bony landmarks carefully.” 37. The nursing student is preparing to administer lisinopril to the patient but does not know what lisinopril is used for. What is the most appropriate action by the student to obtain the information? 1. Consult the pharmacist. 2. Ask the primary nurse. 3. Question the nursing instructor. 4. Look up the drug in a medication reference text. 38. The nurse mixes two medications together in one syringe and is preparing to administer the mixture to the patient. On entering the patient’s room, the nurse notices that the medication looks cloudy and there are some particles floating in the mixture. What is the most appropriate action by the nurse? 1. Notify the pharmacist before proceeding. 2. Check for medication compatibility. 3. Discard the medications and syringe. 4. Remix the medications in a different syringe. 39. The nursing student has registered for a class on pharmacokinetics. Which phrase reflects the student’s accurate understanding of what the focus in this class will be? 1. The study of drug actions and their various side effects 2. A classification system for organizing brand names and generic names of drugs 3. The absorption, distribution, metabolism, and excretion of drugs 4. The study of how medications achieve their effects at various sites in the body Multiple Response Identify one or more choices that best complete the statement or answer the question. 40. What are the primary roles of the Food and Drug Administration (FDA)? Select all that apply. 1. Regulate the testing, manufacture, and sale of all medications 2. Monitor safety and effectiveness of medications available to consumers 3. Manage the storage and handling of controlled substances 4. Manage the sale and regulation of all herbal remedies 5. Regulate the administration and disposal of controlled substances 41. The new nurse is beginning orientation on a medical-surgical unit. What is most important for the nurse to know regarding hospital policies concerning controlled substances? Select all that apply. 1. Controlled substances are stored in a double-locked area. 2. A count of all controlled substances is performed at specific times, usually monthly. 3. The facility must keep a record of every dose of a controlled substance that is administered. 4. Schedule 1 are drugs used commonly in the healthcare field.

5. RNs can prescribe controlled substances to clients in the nursing home, but not in the hospital. 42. The nurse is preparing to administer a subcutaneous dose of insulin to a patient with diabetes. Which two sites might the nurse use that would provide the fastest absorption of the injection? Select all that apply. 1. Arm 2. Abdomen 3. Thigh 4. Upper buttocks 5. Ventral forearm 43. The nurse is preparing to administer ophthalmic eye drops to the patient. What are the most appropriate actions for administering eye drops? Select all that apply. 1. Place the patient in the high-Fowler’s position. 2. Administer the ointment from the inner to the outer canthus of the eye. 3. Position the eyedropper 1 to 2 inches above the eye. 4. Apply the medication into the conjunctival sac. 5. Allow the medication to drop gently on the cornea. 44. The nurse is preparing to administer otic medications to a 35-year-old patient. What are the most appropriate actions by the nurse? Select all that apply. 1. Pull the pinna up and back. 2. Position the pinna down and back. 3. Place the patient in the side-lying position with the appropriate ear up. 4. Instruct the patient to remain in the side-lying position for at least 20 minutes. 5. Cool the solution to slightly below body temperature. 45. The home health nurse is caring for a 75-year-old patient with severe arthritis of the hands and fingers. The patient states, “I can’t use these childproof safety lock caps because I can’t open them.” What are the most appropriate responses by the nurse? Select all that apply. 1. “I see this is difficult for you. Do you have any family members or friends who can help you?” 2. “We can ask the pharmacist not to put childproof caps on your medications; you may need to sign a form.” 3. “You can transfer your medications to different containers that are easier for you to open.” 4. “All medications come in childproof containers, so there isn’t much we can do about this.” 5. “Why can’t you open those types of medication containers? You should be able to.” 46. The nurse educator in the local hospital is preparing a teaching plan for staff nurses on using medication abbreviations in nursing documentation. What is most important for the nurse to include in the teaching plan concerning acceptable abbreviations? Select all that apply.

1. 2. 3. 4. 5.

They are based on The Joint Commission recommendations. They are commonly used by the pharmacy department. They are most commonly used by nurses. They are based on policies of the facility. They are determined by the individual nurse who is charting.

Chapter 26. Administering Medications Answer Section MULTIPLE CHOICE 1. ANS: 2 Chapter: Chapter 26 Administering Medications Objective: Demonstrate the correct procedure for administering medications by the oral, enteral, inhalant, and parenteral routes. Page: 602 (V1) Heading: Route of Administration and Special Situations and Administering Parenteral Medications Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Comfort Difficulty: Difficult Feedback 1 This is incorrect. While it does take time for medication to reduce pain, the issue is the severe pain, nausea and vomiting, which indicates oral medication is not effective. 2 This is correct. Administering meperidine PO was not the best nursing intervention in this situation because the patient was in severe pain (9/10) with nausea and vomiting. The patient needed immediate pain relief, which would not occur with PO pain medication. The nurse should have administered morphine IV. 3 This is incorrect. Waiting 2 hours to notify the physician does not provide patient comfort. 4 This is incorrect. The nurse should focus on pain relief and not worry about the patient becoming “addicted” to the morphine. PTS: 1 CON: Comfort 2. ANS: 1 Chapter: Chapter 26 Administering Medications Objective: Demonstrate the correct procedure for administering medications by the oral, enteral, inhalant, and parenteral routes. Page: 470 (V1) Heading: Choosing a Subcutaneous Site and Procedure 26-12 Administering Subcutaneous Medication Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying]

Concept: Tissue Integrity Difficulty: Moderate Feedback 1 This is correct. Administering medications in the same site over prolonged periods of time can cause fat deposits and skin lumps, which will interfere with absorption and thus hinder the effectiveness of the medication. 2 This is incorrect. Insulin is prescribed in units (not milliliters or milligrams). 3 This is incorrect. Insulin is administered subcutaneously, not intramuscularly. 4 This is incorrect. The patient does not understand the treatment regimen as the sites should be rotated. PTS: 1 CON: Tissue Integrity 3. ANS: 4 Chapter: Chapter 26 Administering Medications Objective: List the five steps to incorporate in your practice to ensure safe medication administration and prevent a medication error. Page: 615 (V1) Heading: Medication Measurements Systems > Units and Administering Heparin Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Collaboration Difficulty: Moderate Feedback 1 This is incorrect. The nurse should not administer the medication. The order is written incorrectly. 2 This is incorrect. While the nurse would clarify the dose with the surgeon, there is another aspect of the order the nurse should address. 3 This is incorrect. While heparin can be administered subcutaneously, that is not how the order is written. The nurse should contact the surgeon who prescribed the order. 4 This is correct. The nurse should contact the surgeon to clarify the dosage and route of administration. Heparin is measured in units and administered either subcutaneously or intravenously. PTS: 1 CON: Collaboration 4. ANS: 3 Chapter: Chapter 26 Administering Medications Objective: Name at least five sources of medication information. Page: 598 (V1) Heading: Drug Listings and Directories Integrated Processes: Nursing Process

Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. If the nurse is in doubt about a medication, the nurse should look it up before administering. 2 This is incorrect. While asking another nurse is acceptable, it is not the best answer because the other nurse may not be familiar with the drug either. 3 This is correct. The Physician’s Desk Reference is a book commercially compiled by the pharmaceutical companies and is a standard resource for professionals prescribing and administering medication. 4 This is incorrect. A pharmacology or drug handbook can be used, but not a nursing care plan book. PTS: 1 CON: Safety 5. ANS: 1 Chapter: Chapter 26 Administering Medications Objective: Discuss the concepts and processes of pharmacokinetics, including drug absorption, distribution, metabolism, and excretion. Page: 601 (V1) Heading: What Factors Affect Drug Absorption? Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Knowledge [Remembering] Concept: Evidence-Based Practice Difficulty: Moderate Feedback 1 This is correct. Absorption refers to the movement of drug from the site of administration into the bloodstream. 2 This is incorrect. Distribution involves the transport of the drug in body fluids, such as blood, to the tissues and organs. 3 This is incorrect. Metabolism is the biotransformation of the drug into a more water-soluble form or into metabolites that can be excreted from the body. 4 This is incorrect. Excretion, or the removal of drugs from the body, takes place in the kidneys, liver, gastrointestinal tract, lungs, and exocrine glands. PTS: 1 CON: Evidence-Based Practice 6. ANS: 2 Chapter: Chapter 26 Administering Medications Objective: Demonstrate the correct procedure for administering medications by the oral, enteral, inhalant, and parenteral routes.

Page: 645 (V1) Heading: Intravenous Medications Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Evidence-Based Practice Difficulty: Moderate Feedback 1 This is incorrect. This is not the fastest. Liquid medication has a faster onset than oral tablets but slower than intramuscular. 2 This is correct. This is the fastest. The onset of medication action takes place within seconds, so intravenous administration is especially useful in emergencies. 3 This is incorrect. This is not the fastest. This is fast, but not as fast as intravenous. 4 This is incorrect. This is not the fastest. Oral medications have the slowest onset of action when compared to other routes. PTS: 1 CON: Evidence-Based Practice 7. ANS: 3 Chapter: Chapter 26 Administering Medications Objective: Correctly calculate drug dosages, including (1) conversion among the metric, apothecary, and household measurement systems and (2) working with units and milliequivalents (mEq). Page: 623 (V1) Heading: Medication Measurement Systems > Household Measurements Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Safety Difficulty: Difficult Feedback 1 This is incorrect. One teaspoon equals 5 milliliters. 2 This is incorrect. One tablespoon or 3 teaspoons equals 15 milliliters. 3 This is correct. One ounce equals 30 milliliters. 4 This is incorrect. One ounce does not equal 45 milliliters. PTS: 1 CON: Safety 8. ANS: 4 Chapter: Chapter 26 Administering Medications Objective: Define onset, peak, and duration of drug action; therapeutic level, peak level, and trough level; and biological half-life.

Page: 615 (V1) Heading: Onset, Peak, and Duration of Action Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. The effects of oral furosemide should be seen 30 to 60 minutes after administration, which is 0900 (9:30 a.m. in this case). 2 This is incorrect. Peak effect (diuresis) should occur in 1 to 2 hours, which is 1000 hours (10:00 a.m.). 3 This is incorrect. In this scenario peak effect (diuresis) should occur in 1 to 2 hours which is 1100 hours (11:00 a.m.). 4 This is correct. The nurse should no longer see the effects of furosemide at around 1500 hours (3:00 p.m.). PTS: 1 CON: Safety 9. ANS: 2 Chapter: Chapter 26 Administering Medications Objective: Define onset, peak, and duration of drug action; therapeutic level, peak level, and trough level; and biological half-life. Page: 611 (V1) Heading: Other Concepts Relevant to Drug Effectiveness > Biological Half-Life Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Comprehension [Understanding] Concept: Safety Difficulty: Difficult Feedback 1 This is incorrect. Liver and kidney diseases, not heart disease, prolong half-life. 2 This is correct. Metabolism takes place largely in the liver. If there is a decrease in liver function (e.g., because of liver disease), the drug will be eliminated more slowly, prolonging the drug’s half-life. 3 This is incorrect. Rheumatoid arthritis will not prolong half-life; however, liver and kidney diseases can prolong half-life. 4 This is incorrect. Osteoarthritis will not prolong half-life because it does not affect the metabolism or excretion of the drug. PTS: 1 CON: Safety 10. ANS: 3 Chapter: Chapter 26 Administering Medications

Objective: Define onset, peak, and duration of drug action; therapeutic level, peak level, and trough level; and biological half-life. Page: 611 (V1) Heading: Other Concepts Relevant to Drug Effectiveness > Therapeutic Range Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Safety Difficulty: Difficult Feedback 1 This is incorrect. The prescriber does not need to be notified because the results are in the therapeutic range. 2 This is incorrect. The dose should not be withheld; this action could result in detrimental cardiac effects for the patient. 3 This is correct. Therapeutic range is a range whereby the medication is at a concentration to produce the desired effect. This patient’s level is within the therapeutic range, so the nurse should administer the next dose as prescribed because repeated doses of the medication are given to achieve and maintain a constant therapeutic concentration. 4 This is incorrect. The dose should not be increased because the prescribed dose is producing a level within the therapeutic range. PTS: 1 CON: Safety 11. ANS: 2 Chapter: Chapter 26 Administering Medications Objective: Define onset, peak, and duration of drug action; therapeutic level, peak level, and trough level; and biological half-life. Page: 611 (V1) Heading: Other Concepts Relevant to Drug Effectiveness > Therapeutic Range Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Safety Difficulty: Difficult Feedback 1 This is incorrect. Trough levels cannot be collected with the morning routine laboratory studies. 2 This is correct. Trough levels are typically obtained approximately 30 minutes before administering the next dose of the drug. 3 This is incorrect. Peak level must be measured when absorption is complete. This depends on all the factors that affect absorption. 4 This is incorrect. Trough levels would be inaccurate if the specimen is obtained

while the drug infuses. PTS: 1 CON: Safety 12. ANS: 1 Chapter: Chapter 26 Administering Medications Objective: Discuss the concepts and processes of pharmacokinetics, including drug absorption, distribution, metabolism, and excretion. Page: 609 (V1) Heading: What Factors Affect Pharmacokinetics? Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Comprehension [Understanding] Concept: Safety Difficulty: Easy Feedback 1 This is correct. Drugs that are known to cause developmental defects are termed teratogenic. These drugs are contraindicated during pregnancy because of the likelihood of adverse effects in the embryo or fetus. 2 This is incorrect. Elderly patients are not affected by teratogenic drugs. 3 This is incorrect. Teratogenic drugs do not affect children. 4 This is incorrect. Teratogenic drugs do not have to be avoided in adolescents. PTS: 1 CON: Safety 13. ANS: 4 Chapter: Chapter 26 Administering Medications Objective: Compare and contrast primary, secondary, cumulative, and side effects; and adverse, toxic, allergic, anaphylactic, and idiosyncratic reactions. Page: 611 (V1) Heading: What Are Primary Effects? Integrated Processes: Caring Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Comfort Difficulty: Moderate Feedback 1 This is incorrect. Supportive effects support the integrity of body functions until other medications or treatments become effective—for example, giving acetaminophen to control the fever until the antibiotic is at therapeutic level. 2 This is incorrect. Restorative effects return the body to or maintain the body at optimal levels of health—for example, giving vitamins and minerals to patients recovering from surgery. 3 This is incorrect. Substitutive effects replace either body fluids or a chemical

required by the body for improved functioning—for example, giving insulin to a diabetic patient. This is correct. Morphine is prescribed for its palliative effects—to relieve pain, a symptom of cancer. Palliative effects relieve the signs and symptoms of a disease but have no effect on the disease itself. For example, morphine sulfate may be given to a patient with cancer to manage pain, but it does not destroy cancer cells.

PTS: 1 CON: Comfort 14. ANS: 1 Chapter: Chapter 26 Administering Medications Objective: Compare and contrast primary, secondary, cumulative, and side effects; and adverse, toxic, allergic, anaphylactic, and idiosyncratic reactions. Page: 611 (V1) Heading: What Are Secondary Effects? > Side Effects Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Easy Feedback 1 This is correct. Dry mouth is a side effect of diphenhydramine. Side effects are unintended, often predictable, physiological effects that are well tolerated by patients. 2 This is incorrect. Adverse reactions are harmful, unintended, usually unexpected reactions to a drug administered at a normal dosage. They are commonly more severe compared with side effects. 3 This is incorrect. Toxic reactions are dangerous, damaging effects to an organ or tissue. 4 This is incorrect. Supportive effects are intended effects that support the integrity of body functions. PTS: 1 CON: Safety 15. ANS: 3 Chapter: Chapter 26 Administering Medications Objective: Compare and contrast primary, secondary, cumulative, and side effects; and adverse, toxic, allergic, anaphylactic, and idiosyncratic reactions. Page: 611 (V1) Heading: What Are Secondary Effects? > Allergic Reactions Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing]

Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. Administering epinephrine is not the first action to take. 2 This is incorrect. Starting a bolus of intravenous fluids is not the first action to take. 3 This is correct. The patient is experiencing an anaphylactic reaction (severe shortness of breath, wheezing, and severe hypotension), a life-threatening allergic reaction. Therefore, the nurse should immediately discontinue the medication. 4 This is incorrect. Respiratory support ranging from oxygen administration to endotracheal intubation and mechanical ventilation may be necessary, but it is not the first action to take. PTS: 1 CON: Safety 16. ANS: 1 Chapter: Chapter 26 Administering Medications Objective: Compare and contrast primary, secondary, cumulative, and side effects; and adverse, toxic, allergic, anaphylactic, and idiosyncratic reactions. Page: 611 (V1) Heading: What Are Secondary Effects? > Allergic Reactions Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 This is correct. Urticaria and pruritus are considered mild allergic reactions. 2 This is incorrect. Dose-related adverse reactions are undesired effects that result from the known pharmacological effects of a medication. 3 This is incorrect. Toxic reactions are dangerous, damaging effects to an organ or tissue. 4 This is incorrect. Anaphylactic reaction is a life-threatening allergic reaction that occurs during or immediately after administration. PTS: 1 CON: Safety 17. ANS: 1 Chapter: Chapter 26 Administering Medications Objective: Define drug–drug interaction, antagonistic drug relationship, synergistic drug relationship, drug incompatibility, and medication contraindications. Page: 615 (V1) Heading: How Do Medications Interact?

Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Comprehension [Understanding] Concept: Safety Difficulty: Moderate Feedback 1 This is correct. In an antagonistic drug interaction, one drug interferes with the actions of another and decreases the resultant drug effect. 2 This is incorrect. In a synergistic drug interaction, there is an additive effect; that is, the effects of both drugs combined are greater than the individual effects. 3 This is incorrect. An idiosyncratic reaction is an unexpected, abnormal, or peculiar response to a medication. 4 This is incorrect. Drug incompatibilities occur when drugs are physically mixed together, causing a chemical deterioration of one or both drugs. PTS: 1 CON: Safety 18. ANS: 3 Chapter: Chapter 26 Administering Medications Objective: Describe nursing assessment before, during, and following the administration of a drug. Page: 615 (V1) Heading: What Should I Know About Drug Abuse or Misuse? Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Comprehension [Understanding] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. Drug abuse is the inappropriate intake of a substance continually or periodically. 2 This is incorrect. Drug misuse is the nonspecific, indiscriminate, or improper use of drugs, including alcohol, over-the-counter preparations, and prescription drugs. 3 This is correct. Patients in the terminal stages of cancer commonly exhibit drug tolerance, a decreasing response to repeated doses of a medication. Therefore, pain management must be carefully planned to promote patient comfort. 4 This is incorrect. Drug dependence occurs when a person relies on or needs a drug. Dependence leads to lifestyle changes that focus on obtaining and administering the drug. PTS: 1 CON: Safety 19. ANS: 4 Chapter: Chapter 26 Administering Medications

Objective: Administer medications using the “three checks” and “rights of medication.” Page: 623 (V1) Heading: Rights of Medication Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. Right room is not one of the six rights. 2 This is incorrect. Right physician is not one of the six rights. 3 This is incorrect. Right equipment is not one of the six rights. 4 This is correct. The six rights of medication administration are the right patient, right drug, right dose, right route, right time, and right documentation. PTS: 1 CON: Safety 20. ANS: 2 Chapter: Chapter 26 Administering Medications Objective: Demonstrate the correct procedure for administering medications by the oral, enteral, inhalant, and parenteral routes. Page: 621 (V1) Heading: Planning Outcomes/Evaluation Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. While measurable behaviors are present, there is no time frame. 2 This is correct. The best phrasing for the expected outcome is the one with a specific, measurable time frame (1 week) and details for how to resolve the patient’s knowledge deficit. 3 This is incorrect. While following the treatment plan is measurable, there is no time frame listed. 4 This is incorrect. “Experiences no adverse effect” does not relate to the nursing diagnosis of Deficient Knowledge. PTS: 1 CON: Safety 21. ANS: 1 Chapter: Chapter 26 Administering Medications

Objective: Demonstrate the correct procedure for administering medications by the oral, enteral, inhalant, and parenteral routes. Page: 623 (V1) Heading: Rights of Medication > Right Patient and Medication Guidelines: Steps to Follow for All Medications (Regardless of Type or Route) Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 This is correct. The nurse should inform the patient that he or she will return with the medication when the patient is finished in the bathroom. 2 This is incorrect. The nurse likely would not have time to stand outside the door and wait for the patient to finish in the bathroom. 3 This is incorrect. Withholding the dose until the next administration time may compromise the patient’s condition and is not appropriate nursing action. 4 This is incorrect. The nurse should not leave medications at the bedside. If the medication is left at the bedside for the patient, the nurse cannot be sure that the patient actually took the medication. PTS: 1 CON: Safety 22. ANS: 1 Chapter: Chapter 26 Administering Medications Objective: Administer medications using the “three checks” and “rights of medication.” Page: 624 (V1) Heading: Right Documentation Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Communication Difficulty: Moderate Feedback 1 This is correct. The option, signed by J. Williams, is complete because it contains the date and time the medication was administered, the name of the medication, the route of administration and injection site, and the name of the nurse administering the medication. Because the medication administered was a prn order, the nurse also included the reason the medication was administered. 2 This is incorrect. Date and reason for administering the prn medication are omitted in the documentation, making the entry incomplete. 3 This is incorrect. The reason for administering the prn medication and the nurse’s signature are omitted, making the entry incomplete.

This is incorrect. Time and reason for administering the prn medication are omitted in the documentation, making the entry incomplete.

PTS: 1 CON: Communication 23. ANS: 3 Chapter: Chapter 26 Administering Medications Objective: Demonstrate the correct procedure for administering medications by the oral, enteral, inhalant, and parenteral routes. Page: 434 (V2) Heading: Procedure 26-1 Administering Oral Medications > What If … My Patient Has Difficulty Drinking From a Cup? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Comprehension [Understanding] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. It is not necessary to ask the prescriber to change the order to the IV route; it is preferable to use the least invasive route. 2 This is incorrect. The nurse cannot administer a drug by another route without a prescription to do so. Dosing might not necessarily be the same in the oral versus the IM route; thus, a prescription is needed to change the route. 3 This is correct. When a patient has difficulty taking liquid medications from a cup, the nurse should use a syringe without a needle to place the medication in the side of the patient’s mouth. After placing the syringe between the gum and cheek, the nurse should push the plunger to administer the medication slowly. 4 This is incorrect. Crush (do not place whole) soluble tablets and place them in liquids or in a small amount of applesauce or pudding. Remember that some forms (e.g., time-released tablets) should not be crushed, so check the drug reference sources to be certain. PTS: 1 CON: Safety 24. ANS: 2 Chapter: Chapter 26 Administering Medications Objective: Demonstrate the correct procedure for administering medications by the oral, enteral, inhalant, and parenteral routes. Page: 626 (V1) Heading: Buccal and Sublingual Medications Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Safety

Difficulty: Moderate Feedback 1 This is incorrect. Drugs administered by the buccal route are placed in the cheek and allowed to dissolve. 2 This is correct. Drugs administered by the sublingual route should be placed under the patient’s tongue and allowed to dissolve. 3 This is incorrect. A subcutaneous injection is administered into the subcutaneous tissue. 4 This is incorrect. Placing the drug into the patient’s mouth, giving him or her water, and instructing the patient to swallow the tablet describes oral administration. PTS: 1 CON: Safety 25. ANS: 4 Chapter: Chapter 26 Administering Medications Objective: Demonstrate the correct procedure for administering medications by the oral, enteral, inhalant, and parenteral routes. Page: 434 (V2) Heading: Procedure 26-1A Administering Medication Through an Enteral Tube Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Comprehension [Understanding] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. The nurse should verify nasogastric tube placement before administering the drug. 2 This is incorrect. The nurse should auscultate the abdomen for bowel sounds before administering the medication. 3 This is incorrect. If there is more than one medication, give each separately, flushing after each. Some medications are less effective when given in combination with others. 4 This is correct. The nurse should flush the nasogastric tube with water using a needleless syringe after administering each medication. PTS: 1 CON: Safety 26. ANS: 1 Chapter: Chapter 26 Administering Medications Objective: Demonstrate the correct procedure for administering medications by the oral, enteral, inhalant, and parenteral routes. Page: 637 (V1) Heading: Preventing Needlestick Injuries

Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Comprehension [Understanding] Concept: Safety Difficulty: Moderate Feedback 1 This is correct. To avoid needlestick injuries, the nurse should place the uncapped needle and syringe directly into a specially marked, puncture-proof container without capping, bending, or breaking the needle. 2 This is incorrect. The trashcan is an unacceptable receptacle for a used syringe and needle. 3 This is incorrect. Recapping a used needle is not advised. 4 This is incorrect. Placing the needle in an improper container (biohazard bag) that could be punctured by the contaminated needle places other staff members at risk. PTS: 1 CON: Safety 27. ANS: 2 Chapter: Chapter 26 Administering Medications Objective: Demonstrate the intramuscular injection procedure at the following sites: ventrogluteal, deltoid, and vastus lateralis. Page: 643 (V1) Heading: Choosing an Intramuscular Site > Vastus Lateralis Site Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 This is incorrect. For children who are walking, the site of choice is the ventrogluteal muscle. 2 This is correct. The preferred site for intramuscular injections for infants who are not yet walking is the vastus lateralis muscle because there are no major blood vessels or nerves in the area. 3 This is incorrect. The deltoid muscle can be used for small volumes in older children and adults. 4 This is incorrect. The dorsogluteal site is not recommended for children or adults. PTS: 1 CON: Infection 28. ANS: 4 Chapter: Chapter 26 Administering Medications

Objective: Demonstrate the intramuscular injection procedure at the following sites: ventrogluteal, deltoid, and vastus lateralis. Page: 476 (V2) Heading: Procedure 26-14A Intramuscular Injection: Traditional Method and Procedure 26-14B Intramuscular Injection: Z-Track Method Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Comprehension [Understanding] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. Using a warm compress is not a recommended technique for a vastus lateralis injection. 2 This is incorrect. Massaging or rubbing the site will alter the rate of absorption of the medication. Thus, massaging is avoided. 3 This is incorrect. Applying a soothing lotion is not recommended practice. An adhesive bandage may be applied. 4 This is correct. To relax the vastus lateralis for injection, the nurse should have the client assume a sitting position or lie flat. PTS: 1 CON: Safety 29. ANS: 4 Chapter: Chapter 26 Administering Medications Objective: Describe the appropriate steps to take when communicating a medication error. Page: 619 (V1) Heading: What Should I Do If I Commit a Medication Error? and Clinical Insight 26-1 Taking Action After a Medication Error Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. Action is necessary when any error is made, especially a medication error. Giving an extra 5 mg of warfarin can be harmful. 2 This is incorrect. While the prescriber should be notified, it is not to ask that the dose be changed but to notify the prescriber of the error. 3 This is incorrect. Document the drug, the dose, site, route, date, and time in the patient’s healthcare record but do not document that the drug was given in error. 4 This is correct. Complete an incident report according to the facility’s policy; submit the signed report to the nurse manager.

PTS: 1 CON: Safety 30. ANS: 1 Chapter: Chapter 26 Administering Medications Objective: List the five steps to incorporate in your practice to ensure safe medication administration and prevent a medication error. Page: 434 (V2) Heading: Highlights of Procedures 26-1 Through 26-18 and Procedure 26-3 Administering Otic Medication Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Comprehension [Understanding] Concept: Safety Difficulty: Moderate Feedback 1 This is correct. For a child younger than 3 years of age, the nurse should pull the pinna down and back. This straightens the ear canal for proper channeling of the medication. 2 This is incorrect. For older children and adults, the nurse should pull the pinna upward and outward. 3 This is incorrect. The nurse should not instill the drops directly. The nurse should instill the prescribed number of drops along the side of the ear canal. 4 This is incorrect. The patient should be assisted into a side-lying position with appropriate ear facing up before instillation. PTS: 1 CON: Safety 31. ANS: 3 Chapter: Chapter 26 Administering Medications Objective: Demonstrate the correct procedure for administering medications by the oral, enteral, inhalant, and parenteral routes. Page: 628 (V1) Heading: Self-Care box side bar > Self-Care > Teaching Parents About Medicating Children Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Growth and Development Difficulty: Moderate Feedback 1 This is incorrect. Time-released capsules should not be crushed and favorite foods should not be used to mask unpleasant medication taste. 2 This is incorrect. Parents should take their time when giving medications to children. Rushing the child can be frustrating and lead to struggles with the child.

This is correct. The parent can give the child a frozen fruit bar or frozen flavored ice pop just before the medication. This helps to numb the taste buds to weaken the taste of the medication. This is incorrect. Do not use essential foods in the child’s diet (e.g., milk or orange juice) to mask the taste of medications. The child may later refuse a food he or she associates with the medicine.

PTS: 1 CON: Growth and Development 32. ANS: 1 Chapter: Chapter 26 Administering Medications Objective: Demonstrate the correct procedure for administering medications by the oral, enteral, inhalant, and parenteral routes. Page: 633 (V1) Heading: Needles > Gauge Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Knowledge [Remembering] Concept: Safety Difficulty: Easy Feedback 1 This is correct. Large-gauge needles, 14- to 18-gauge needles, are used for blood products in adults because the bore is large enough to allow transfusion without cell damage (lysis). 2 This is incorrect. This gauge (22) is too small for blood transfusions. 3 This is incorrect. A 24-gauge needle is too small for blood transfusions. 4 This is incorrect. Smaller needles, such as a 26-gauge needle, cause less pain and trauma to the tissue but it is not large enough for blood. PTS: 1 CON: Safety 33. ANS: 1 Chapter: Chapter 26 Administering Medications Objective: Discuss the agencies and legislation that help to ensure drug quality and safety. Page: 619 (V1) Heading: Legal Considerations > Nurse Practice Acts Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Legal Difficulty: Difficult Feedback 1 This is correct. The State Board of Nursing regulates the types and routes of medications that can be administered by the various levels of nurses. For

2 3 4

example, LPNs in some states cannot administer IV medications, whereas other states require additional education and experience before LPNs can perform this action. This is incorrect. Once scope of practice is identified, the nurse can proceed with reviewing the unit policies. This is incorrect. There is an action that is more important than assessing the experience level of the LPN. This is incorrect. If state regulations do not allow LPNs to administer IV medications, there is no reason for the nurse to demonstrate the procedure.

PTS: 1 CON: Legal 34. ANS: 3 Chapter: Chapter 26 Administering Medications Objective: Discuss the concepts and processes of pharmacokinetics, including drug absorption, distribution, metabolism, and excretion. Page: 607 (V1) Heading: How Are Drugs Metabolized in the Body? Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Knowledge [Remembering] Concept: Metabolism Difficulty: Easy Feedback 1 This is incorrect. Medications can be detoxified in the kidneys, but it is not the primary organ. The kidneys are the primary organ for excretion of drugs. 2 This is incorrect. The skin is not the primary organ for metabolism of medications. 3 This is correct. Drug metabolism takes place mainly in the liver. If liver function is impaired due to liver disease, medications will be eliminated more slowly, and toxic levels may accumulate. 4 This is incorrect. The gastrointestinal tract can help excrete some drugs in the feces, but it does not metabolize medications. PTS: 1 CON: Metabolism 35. ANS: 2 Chapter: Chapter 26 Administering Medications Objective: Discuss the concepts and processes of pharmacokinetics, including drug absorption, distribution, metabolism, and excretion. Page: 608 (V1) Heading: How Are Drugs Excreted From the Body? Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

Cognitive Level: Knowledge [Remembering] Concept: Elimination Difficulty: Easy Feedback 1 This is incorrect. The liver is the primary site for metabolism, not excretion. 2 This is correct. The kidneys are the primary site of excretion. If the patient has decreased renal function, the nurse should closely monitor for medication toxicity. 3 This is incorrect. While the lungs can excrete some drugs, it is not the primary organ. 4 This is incorrect. While exocrine glands can help eliminate some drugs, it is not the primary site. PTS: 1 CON: Elimination 36. ANS: 2 Chapter: Chapter 26 Administering Medications Objective: Explain the disadvantages of using the dorsogluteal site for intramuscular injections. Page: 643 (V1) Heading: Choosing an Intramuscular Site and Dorsogluteal Site—Site to Avoid Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. The dorsogluteal site should be avoided; the site is not recommended. 2 This is correct. The dorsogluteal site consists of the gluteal muscles of the buttocks. Avoid using the dorsogluteal site for IM injections because its close proximity to the sciatic nerve and superior gluteal artery increases the risk of injection into a major blood vessel and damage to the sciatic nerve. Furthermore, the site is difficult to identify accurately in older adults or people with flabby skin. The instructor should advise the student that this is not the appropriate site and elicit another site from the student. 3 This is incorrect. This is not a good site for intramuscular injections. 4 This is incorrect. The nursing instructor should not encourage the nursing student to use this site. It is no longer recommended. PTS: 1 CON: Safety 37. ANS: 4 Chapter: Chapter 26 Administering Medications Objective: Name at least five sources of medication information.

Page: 598 (V1) Heading: Drug Listings and Directories Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Safety Difficulty: Easy Feedback 1 This is incorrect. While the pharmacist is a good reference, this action is not the most appropriate. 2 This is incorrect. Asking the primary nurse is not the best action to take in this situation. 3 This is incorrect. Questioning the nursing instructor is not the most appropriate action for the student nurse to take. 4 This is correct. Look it up! As a nurse, one is professionally, ethically, legally, and personally responsible for every dose of medication administered to a patient. Always use current information when researching a medication. PTS: 1 CON: Safety 38. ANS: 3 Chapter: Chapter 26 Administering Medications Objective: Define drug–drug interaction, antagonistic drug relationship, synergistic drug relationship, drug incompatibility, and medication contraindications. Page: 607 (V1) Heading: How Do Medications Interact? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. The pharmacist could have been consulted before mixing the drugs, but not afterward. The reaction has already taken place and should not be administered. 2 This is incorrect. The nurse should always consult a medication resource and compatibility chart before mixing medications. 3 This is correct. Drug incompatibilities occur when multiple drugs are mixed together, causing a chemical deterioration of one or more of the drugs. The result is an incompatible solution that should not be administered. The nurse can usually recognize an incompatibility when the mixed solution takes on a changed appearance. If the contents of the syringe become discolored or there are particles in the solution, do not administer the medication.

This is incorrect. Remixing the medications using a different syringe is inappropriate, as because this will only elicit the same result.

PTS: 1 CON: Safety 39. ANS: 3 Chapter: Chapter 26 Administering Medications Objective: Discuss the concepts and processes of pharmacokinetics, including drug absorption, distribution, metabolism, and excretion. Page: 601 (V1) Heading: What Is Pharmacokinetics? Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Comprehension [Understanding] Concept: Evidence-Based Practice Difficulty: Moderate Feedback 1 This is incorrect. Pharmacology is the science of drug effects. It deals with all drugs used in society, legal and illegal, prescription and nonprescription. 2 This is incorrect. Drug classification is a system for making inferences about the drug’s basic characteristics. Drug names refer to chemical names, generic names, official names, and brand/trade names. 3 This is correct. Pharmacokinetics refers to the absorption, distribution, metabolism, and exertion of a drug. These four processes determine the intensity and duration of a drug’s action. Each drug has unique pharmacokinetics characteristics. 4 This is incorrect. Pharmacodynamics, another subconcept of pharmacology, is the study of how medications achieve their effects at various sites in the body, how specific drug molecules interact with target cells, and how biological responses occur. PTS:

CON: Evidence-Based Practice

MULTIPLE RESPONSE 40. ANS: 1, 2 Chapter: Chapter 26 Administering Medications Objective: Discuss the agencies and legislation that help to ensure drug quality and safety. Page: 599 (V1) Heading: Legal Considerations Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding]

Concept: Legal Difficulty: Moderate

2. 3. 4.

Feedback This is correct. The FDA of the U.S. Department of Health and Human Services regulates the testing, manufacturing, and sale of all medications. This process helps to ensure that ineffective or unsafe drugs are not marketed or are recalled, if later found unsafe. This is correct. This agency also monitors the safety and effectiveness of medications available to consumers. This is incorrect. The management of controlled substances is under the auspices of the Drug Enforcement Agency (DEA). This is incorrect. Many medicinal products are not regulated by the FDA. For example, herbal remedies and some naturopathic supplements are considered “food products” and are not regulated, even though they are advertised as having health benefits. This is incorrect. The DEA regulates the administration and disposal of controlled substances, not the FDA.

PTS: 1 CON: Legal 41. ANS: 1, 3 Chapter: Chapter 26 Administering Medications Objective: Discuss the agencies and legislation that help to ensure drug quality and safety. Page: 599 (V1) Heading: Regulation of Controlled Substances Integrated Processes: Teaching and Learning Client need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Legal Difficulty: Moderate

1. 2. 3. 4.

Feedback This is correct. Controlled substances must be stored in locked drawers with a second locked area. This process is known as double-locking. This is incorrect. A count of all controlled substances is performed at specified times, usually at change of shift (not monthly). This is correct. The facility must also keep a record of every dose administered. This is incorrect. Schedule I identifies drugs that have a high potential for abuse and no acceptable medical use (e.g., heroin, lysergic acid diethylamide [LSD], ecstasy, peyote, mescaline). This is incorrect. Only prescribers with a national provider identification number have the authority to prescribe controlled substances. RNs do not prescribe any type

of medications. PTS: 1 CON: Legal 42. ANS: 1, 2 Chapter: Chapter 26 Administering Medications Objective: Demonstrate the correct procedure for administering medications by the oral, enteral, inhalant, and parenteral routes. Page: 639 (V1) Heading: Subcutaneous Injections Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate

3. 4. 5.

Feedback This is correct. Absorption is fastest in the arms. Subcutaneous injections are given into the subcutaneous tissue, the layer of fat located below the dermis and above the muscle tissue. This is correct. Absorption is faster in the abdomen. Medication is absorbed more evenly from the abdomen than from the thighs and buttocks because it is affected less by activity. This is incorrect. Absorption is slower in the thighs. This is incorrect. Absorption is slower in the upper buttocks. This is incorrect. The ventral forearm is used for the intradermal site, not for insulin injections.

PTS: 1 CON: Safety 43. ANS: 1, 2, 4 Chapter: Chapter 26 Administering Medications Objective: List the five steps to incorporate in your practice to ensure safe medication administration and prevent a medication error. Page: 434 (V2) Heading: Highlights of Procedures 26-1 Through 26-18 > Procedure 26-2 Administering Ophthalmic Medication and Procedure 26-2 Administering Ophthalmic Medication Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback

1. 2. 3. 4. 5.

This is correct. When administering ophthalmic medications, use a high-Fowler’s position. This is correct. Work from the inner canthus to the outer canthus when applying eye ointment. This is incorrect. Position the eyedropper about 1.5 to 2.0 cm ( to in.) above the eye; 1 to 2 inches is too high. This is correct. Apply the medication into the conjunctival sac. This is incorrect. Do not apply the medication to the cornea and do not allow the dropper to touch the eye.

PTS: 1 CON: Safety 44. ANS: 1, 3 Chapter: Chapter 26 Administering Medications Objective: Demonstrate the correct procedure for administering medications by the oral, enteral, inhalant, and parenteral routes. Page: 434 (V2) Heading: Highlights of Procedures 26-1 Through 26-18 > Procedure 26-3 Administering Otic Medication and Procedure 26-3 Administering Otic Medication Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is correct. Straighten the ear and pull the pinna up and back for an adult patient. This is incorrect. Position the pinna down and back for a child, not for an adult. This is correct. Assist the patient to a side-lying position, with the appropriate ear facing up when instilling otic medication. This is incorrect. Instruct the patient to remain on his or her side for 5 to 10 minutes after the procedure, not 20. This is incorrect. When administering otic medications, warm the solution to be instilled to body temperature; it should not be cooled.

PTS: 1 CON: Safety 45. ANS: 1, 2 Chapter: Chapter 26 Administering Medications Objective: List the five steps to incorporate in your practice to ensure safe medication administration and prevent a medication error. Page: 622 (V1) Heading: Teaching Patients About Medication Self-Administration > Administer Your Drugs Correctly

Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate

4. 5.

Feedback This is correct. If a patient has difficulty opening containers and administering medications owing to pain or stiffness in the hands and fingers, family members and friends can be asked to help. This is correct. Additionally, the nurse or patient can ask the pharmacy and the primary care provider not to put childproof safety lids on containers for easier handling. Older adults are allowed to sign a release with their pharmacy to be able to do this. This is incorrect. Do not store a drug in a container that is different from the one it came in. The medication may lose its strength, or the patient may take the wrong medication. This is incorrect. This is an inaccurate statement and does not address the patient’s issue. All medications do not come with childproof lids. This is incorrect. This disregards the patient’s concerns and places the blame on the patient, which is nontherapeutic. Using “why” should be avoided.

PTS: 1 CON: Safety 46. ANS: 1, 4 Chapter: Chapter 26 Administering Medications Objective: List the five steps to incorporate in your practice to ensure safe medication administration and prevent a medication error. Page: 616 (V1) Heading: What Abbreviations Are Used in Medication Prescriptions? Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Communication Difficulty: Moderate

1. 2. 3.

Feedback This is correct. The Joint Commission has an official Do Not Use list of abbreviations, which should be included in the teaching presentation. This is incorrect. While abbreviations can be used by the pharmacy department, The Joint Commission and the facility determine the acceptable abbreviations. This is incorrect. The nurse should write out drug names and dosages in full. All healthcare team members, not just nurses, must follow the approved abbreviation

4. 5.

list. This is correct. The nurse must be familiar with the facility’s approved list of abbreviations, and this is correct information to include in the teaching presentation. This is incorrect. An individual nurse cannot determine which abbreviations to use in charting.

PTS:

CON: Communication

Chapter 27. Nutrition Multiple Choice Identify the choice that best completes the statement or answers the question. 1. Which food item provides the body with no usable glucose? 1. Wheat germ 2. Potatoes 3. Honey 4. Brown rice 2. In a patient with type 1 diabetes mellitus admitted with hyperglycemia, fats are being broken down for energy. Which alternative fuel does the breakdown of fats produce? 1. Glycogen 2. Insulin 3. Ketones 4. Proteins 3. Which patient is most likely experiencing positive nitrogen balance? A patient admitted: 1. With third-degree burns of the legs 2. In the sixth month of a healthy pregnancy 3. From a nursing home who has been refusing to eat 4. For acute pancreatitis 4. Which substance is stored in the liver? 1. Insulin 2. Ketones 3. Glycogen 4. Vitamin C 5. While addressing a community group, the nurse explains the importance of replacing saturated fats in the diet with mono- and polyunsaturated fats. The nurse emphasizes that doing so greatly reduces the risk of which complication? 1. Kidney failure 2. Asthma 3. Stroke 4. Lung cancer 6. Which nutrient deficiency increases the risk for tissue breakdown? 1. Potassium 2. Protein 3. Fluoride 4. Vitamin D

7. The patient is irritable, temperature is elevated, and mucous membranes are dry. Based on these findings, the patient most likely has excess levels of which mineral? 1. Sodium 2. Potassium 3. Phosphorus 4. Magnesium 8. A patient who was prescribed furosemide is deficient in potassium. Which nutritional goal is appropriate for this patient? The patient will increase consumption of: 1. Avocados, peaches, molasses, and potatoes 2. Eggs, celery, baking soda, and baking powder 3. Wheat bran, chocolate, eggs, and sardines 4. Egg yolks, nuts, broccoli, and sardines 9. During the day shift, a patient’s temperature measures 97F (36.1C) orally. At 2000, the patient’s temperature measures 102F (38.9C). What effect does this rise in temperature have on the patient’s basal metabolic rate? 1. Increases the rate by 7% 2. Decreases the rate by 14% 3. Increases the rate by 35% 4. Decreases the rate by 28% 10. A mother brings her 4-month-old infant for a well-baby checkup. The mother tells the nurse that she would like to start bottle feeding her baby because she cannot keep up with the demands of breastfeeding since returning to work. Which response by the nurse is appropriate? 1. “Make sure you give your baby an iron-fortified formula to supplement any stored breast milk you have.” 2. “You really need to continue breastfeeding your baby.” 3. “Give your baby formula until he is 6 months old; then you can introduce whole milk.” 4. “Your baby weighs 14 pounds, so he will require about 36 ounces of formula a day.” 11. After instructing a mother about nutrition for a preschool-age child, which statement by the mother indicates correct understanding of the topic? 1. “I usually use dessert only as a reward for eating other foods.” 2. “I will make sure my child gets at least 2,000 kcal/day.” 3. “I do not give my child snacks; they simply spoil the appetite for meals.” 4. “I know that lifelong food habits are developed during this stage of life.” 12. The nurse is providing nutrition counseling for a patient planning pregnancy. The nurse should emphasize the importance of consuming which nutrient to prevent neural tube defects? 1. Folic acid 2. Calcium 3. Protein

4. Vitamin D 13. A middle-aged patient with a history of alcohol abuse is admitted with acute pancreatitis. Which nutrient level will most likely be the lowest? 1. Iron 2. B vitamins 3. Calcium 4. Phosphorus 14. A patient who underwent surgery 24 hours ago is prescribed a clear liquid diet. The patient asks for something to drink. Which item may the nurse provide for the patient? 1. Vanilla shake 2. Orange juice 3. Grape juice 4. Skim milk 15. A patient with trigeminal neuralgia is prescribed a mechanical soft diet. This diet places the patient at risk for which complication? 1. Dehydration 2. Constipation 3. Hyperglycemia 4. Diarrhea 16. Which nutritional goal is appropriate for a patient newly diagnosed with hypertension? The patient will: 1. Limit intake of protein 2. Avoid foods containing gluten 3. Restrict use of sodium 4. Reduce intake of potassium-rich foods 17. The nurse notices that a patient has spoon-shaped, brittle nails. This suggests that the patient is experiencing Imbalanced Nutrition: Less Than Body Requirements related to deficiency of which nutrient? 1. Iron 2. Vitamin A 3. Protein 4. Vitamin C 18. Which portion of a nutritional assessment must the registered nurse complete? 1. Analyzing the data 2. Obtaining intake and output 3. Weighing the patient 4. Taking the nutritional history 19. Which laboratory test result most accurately reflects a patient’s nutritional status?

1. 2. 3. 4.

Albumin Prealbumin Creatinine Hemoglobin

20. A 52-year-old man has a body mass index of 28.9, and his weight exceeds the ideal body weight for height by 23%. Which nursing diagnosis should the nurse identify for this patient? 1. Imbalanced Nutrition: More Than Body Requirements 2. Risk for Imbalanced Nutrition: More Than Body Requirements 3. Imbalanced Nutrition: Less Than Body Requirements 4. Readiness for Enhanced Nutrition 21. A patient’s parenteral nutrition (PN) container infuses before the pharmacy prepares the next container. This places the patient at risk for which complication? 1. Sepsis 2. Aspiration 3. Hypoglycemia 4. Diarrhea 22. Which intervention would help to prevent or relieve persistent nausea? 1. Assess for signs of dehydration. 2. Provide dietary supplements. 3. Place the patient in a supine position for 30 minutes after eating. 4. Immediately remove any food that the patient cannot eat. 23. The nurse completes the nutrition assessment for a 14-year-old female with a body mass index (BMI) of 15. Which physical assessment finding would cause the nurse to suspect an eating disorder? 1. Cold intolerance 2. Hypertension 3. Excessively thick hair 4. Early development of sexual maturation 24. For an elderly client who is experiencing chronic nausea and weight loss, which laboratory result would the nurse recognize as being most consistent with a diagnosis of Imbalanced Nutrition: Less Than Body Requirements? 1. Serum glucose of 78 mg/dL 2. Serum albumin of 3.2 g/dL 3. Creatinine of 1.0 mg/dL 4. Hemoglobin of 12.8 g/dL 25. Which statement made by a client whose body mass index (BMI) is 34 and is attempting to lose weight would indicate the need for further teaching? 1. “I should limit the number of fruit juices that I drink every day.” 2. “I need to tell my family and friends about my commitment to losing weight.”

3. “An online food diary is unlikely to help me to improve my food intake.” 4. “The amount of time that I spend in front of my computer and TV should be limited.” 26. The nurse is checking the aspirate for the patient receiving gastric tube feedings. The nurse notes the 200 mL of pale yellow and cloudy fluid with a pH of 7.3. Which action should the nurse take? 1. Stop the feeding immediately; then notify the prescribing provider. 2. Hold the tube feeding for 2 hours; continue if residual is less than 200 mL. 3. Flush tube with 30 mL of sterile water; resume tube feeding at prescribed rate. 4. Administer a promotility agent as prescribed; resume feeding in 1 hour. 27. Which class of nutrients is the body’s primary source of energy? 1. Proteins 2. Carbohydrates 3. Lipids 4. Vitamins 28. The nurse is caring for a patient with a significant history of hypertension and cardiovascular disease. The nurse would be most interested in the findings of which laboratory results? 1. Lipoproteins, such as low-density and high-density lipoproteins (LDLs and HDLs) 2. Fatty acids, such as alpha-linolenic acid (omega-3) 3. B-complex vitamins 4. Vitamin K 29. The nurse is caring for a patient who states, “I have been smoking two packs of cigarettes a day for 20 years, and now my nurse practitioner wants me to take vitamins. Do you think I need to take vitamins?” What is the most appropriate response by the nurse? 1. “Smoking is bad for your health. I believe if you stop smoking, you would certainly be better off and not have to take vitamins.” 2. “Smokers use vitamin C faster than do nonsmokers, and this is linked to iron deficiency. You can either eat more foods containing vitamin C and iron or take dietary supplements.” 3. “It is probably a good idea. With your history of tobacco use, I’m sure you are lacking in vitamins and nutrients.” 4. “I really cannot answer this question. You will need to speak with a nutritionist to find out more about this.” 30. While the nurse is performing a nutritional assessment, the patient states, “I am on a vegan diet. I have been a vegan for 10 years.” What is the best response by the nurse? 1. “Is this a religious or cultural requirement for you?” 2. “It is fine; however, you may not be getting all the nutrients you need.” 3. “Can you tell me about the foods you eat along with any other supplements you take?” 4. “I think it is your right to be on whatever diet you would like to be on.”

31. A 30-year-old patient newly diagnosed with type 2 diabetes states to the nurse, “If glucose is so important, then I think as long as my blood sugar is high I must be doing well.” What is the most appropriate response by the nurse? 1. “It depends on what you mean by high blood sugar. You will need to obtain more information from your provider as diabetes is a very complicated disease process.” 2. “I understand how you are thinking; however, a high glucose level does not mean that there is more fuel available for your body’s cells. Because you have diabetes, your body cells can’t use the excess glucose.” 3. “I will be able to explain this to you a little better when we talk about diabetes. For now, I have to finish my assessment, and then we can get back to your question.” 4. “When I finish your assessment, I will teach you how to perform glucose testing. As long as your blood sugar remains somewhere in the 120-to-140 range, you will be doing well.” 32. After inserting a nasogastric feeding tube, what would be the nurse’s priority action prior to starting the first tube feeding? 1. Auscultate bowel sounds over the abdomen. 2. Aspirate gastric contents and obtain a pH reading. 3. Obtain radiographic verification (x-ray). 4. Mix the feeding with water for the first feeding only. 33. A group of pediatric nurses accepts an international assignment in an underdeveloped country. The nurses are informed that they will be caring for many children with kwashiorkor. The nurses will create a care plan focusing on which primary nutrient for these children? 1. Calories 2. Protein 3. Niacin 4. Vitamin C 34. An elderly female, adequately nourished, was admitted to the skilled nursing facility 3 months ago. Since then, she has had a significant weight loss and has become weak. Her appetite and activity level are reduced, and she has lost interest in interacting with other patients. What would the nurse suspect the reason for her condition to be? 1. Need for teaching about nutrition 2. Anxiety 3. Distaste for the food served 4. Frail elderly syndrome Multiple Response Identify one or more choices that best complete the statement or answer the question.

35. To promote wound healing, the nurse is teaching a patient about choosing foods containing protein. The nurse will evaluate that learning has occurred if the patient recognizes which foods are incomplete proteins that should be consumed with a complementary protein? Select all that apply. 1. Whole grain rice 2. Legumes 3. Poultry 4. Eggs 5. Milk 36. The nurse is teaching a male patient about the importance of reducing saturated fats in the diet. The nurse will recognize that learning has occurred if, upon questioning, the patient replies that he should read product labels to eliminate the intake of which saturated fats? Select all that apply. 1. Palm oil 2. Coconut oil 3. Canola oil 4. Peanut oil 5. Safflower oil 37. Which instructions should the nurse give to the older adult patient experiencing constipation? Select all that apply. 1. Drink at least eight glasses of water or fluid per day. 2. Obtain a minimum of four servings of meat per day. 3. Consume whole grains and fresh greens. 4. Exercise vigorously at least 60 minutes per day. 5. Include both soluble and insoluble fibers in the diet. 38. Where in the body is glucose stored? Select all that apply. 1. Brain 2. Liver 3. Skeletal muscles 4. Smooth muscles 5. Bone marrow 39. For a patient with Risk for Imbalanced Nutrition: Less Than Body Requirements related to Impaired Swallowing, which nursing interventions are appropriate? Select all that apply. 1. Check inside the mouth for pocketing of food after eating. 2. Provide a full liquid diet that is easy to swallow. 3. Remind the patient to raise the chin slightly to prepare for swallowing. 4. Keep the head of the bed elevated for 30 to 45 minutes after feeding. 5. Encourage the use of straws to drink fluids easily. 40. What should the nurse include in a plan for teaching adults about dietary trans-fatty acids? Select all that apply. 1. Trans fat increases the shelf-life of foods. 2. Trans fat decreases blood cholesterol levels and low-density lipoprotein (LDL)

levels. 3. The Food and Drug Administration (FDA) mandates that trans fat content be listed on all food labels. 4. Check for hydrogenated vegetable oils on food labels. 5. Vegetable oil sprays used for cooking are high in trans fats. 41. The pediatric nurse is preparing a teaching plan about vitamins for parents of school-age children. What vital information will the nurse include in the plan? Select all that apply. 1. Water-soluble vitamins are needed for cellular metabolism. 2. Vitamins are necessary for preventing particular deficiency diseases. 3. Because the body does not make vitamins, they must be supplied by the foods we eat. 4. The most important vitamin for children is vitamin C. 5. Vitamin E is needed to prevent night blindness. 42. The nurse admitting a new patient to the medical-surgical unit is conducting a dietary history. What information should the nurse include? Select all that apply. 1. Basic eating habits 2. Food preferences 3. Attitude toward food 4. Body mass index (BMI) 5. Cultural dietary restrictions 43. The nurse assigned to an oncology unit reports that three of the patients with cancer do not have an appetite and have eaten little during the shift. What strategies can the nurse on the next shift use to increase these patients’ appetites? Select all that apply. 1. Offer frequent, smaller meals. 2. Keep the patients’ rooms neat and clean. 3. Provide or assist with frequent oral hygiene. 4. Increase liquid intake before meals. 5. Avoid high-protein supplements. 44. The registered nurse (RN) on a medical-surgical unit is making assignments. Which tasks would the RN delegate to the licensed practical nurse (LPN)? Select all that apply. 1. Tube feeding 2. Fingerstick blood glucose 3. Nutritional history 4. Laboratory findings interpretations 5. Lipid administration

Chapter 27. Nutrition Answer Section MULTIPLE CHOICE 1. ANS: 1 Chapter: Chapter 27 Nutrition Objective: Identify the types, functions, metabolism, and major food sources of (1) the energy nutrients, (2) vitamins, (3) minerals, and (4) water. Page: 661 (V1) Heading: Carbohydrates > Types of CHOs Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Nutrition Difficulty: Moderate Feedback 1 This is correct. Dietary fiber, such as wheat germ, contains no usable glucose. Humans do not have the enzymes to digest fiber; thus, it provides no usable glucose. 2 This is incorrect. Potatoes are a carbohydrate that provides usable glucose for the body. 3 This is incorrect. Honey is a simple sugar and provides usable glucose for the body. 4 This is incorrect. Brown rice is a complex carbohydrate and provides usable glucose. PTS: 1 CON: Nutrition 2. ANS: 3 Chapter: Chapter 27 Nutrition Objective: Identify the types, functions, metabolism, and major food sources of (1) the energy nutrients, (2) vitamins, (3) minerals, and (4) water. Page: 661 (V1) Heading: Carbohydrates > Functions of CHOs Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Metabolism Difficulty: Difficult Feedback 1 This is incorrect. Glycogen is converted to glucose to meet energy needs. Glycogen is not from the breakdown of fats.

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This is incorrect. Insulin, a pancreatic hormone, promotes the movement of glucose into cells for use. This is correct. When fats are used for energy, they are converted directly into an alternative fuel called ketone. This is incorrect. Proteins would not be used for fuel as long as fats are available. Protein is not from the breakdown of fats.

PTS: 1 CON: Metabolism 3. ANS: 2 Chapter: Chapter 27 Nutrition Objective: Identify the types, functions, metabolism, and major food sources of (1) the energy nutrients, (2) vitamins, (3) minerals, and (4) water. Page: 661 (V1) Heading: Proteins > Protein Metabolism and Storage Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Metabolism Difficulty: Easy Feedback 1 This is incorrect. Patients with burns commonly experience negative nitrogen balance because tissues are lost. 2 This is correct. A positive nitrogen balance typically exists during pregnancy when new tissues are being formed and nitrogen intake exceeds output. 3 This is incorrect. This patient is experiencing negative nitrogen balance because nitrogen intake is less than nitrogen loss, which occurs in malnutrition. 4 This is incorrect. A patient with an illness is in negative nitrogen balance, not positive. PTS: 1 CON: Metabolism 4. ANS: 3 Chapter: Chapter 27 Nutrition Objective: Identify the types, functions, metabolism, and major food sources of (1) the energy nutrients, (2) vitamins, (3) minerals, and (4) water. Page: 661 (V1) Heading: Carbohydrates > Functions of CHOs Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Knowledge [Remembering] Concept: Metabolism Difficulty: Easy Feedback

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This is incorrect. Insulin is a pancreatic hormone that promotes the movement of glucose into cells. Insulin is not stored in the liver. This is incorrect. If fats must be used for energy, they are converted directly into ketones. They are not stored in the liver. This is correct. Humans store glucose in liver and skeletal muscle tissue as glycogen. Glycogen can then be converted back into glucose to meet energy needs through a process known as glycogenolysis. This is incorrect. Fat-soluble vitamins, not water-soluble vitamins (vitamin C), are stored in the liver.

PTS: 1 CON: Metabolism 5. ANS: 3 Chapter: Chapter 27 Nutrition Objective: Identify the types, functions, metabolism, and major food sources of (1) the energy nutrients, (2) vitamins, (3) minerals, and (4) water. Page: 663 (V1) Heading: Lipids > Types of Lipids > Saturated and Unsaturated Fatty Acids Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Nutrition Difficulty: Moderate Feedback 1 This is incorrect. Fats are not the cause of kidney failure. 2 This is incorrect. Asthma is not linked to intake of dietary fats. 3 This is correct. Dietary fat should mainly be polyunsaturated and unsaturated to reduce the risk of heart disease and stroke. 4 This is incorrect. Smoking, not fats, is linked to lung cancer. PTS: 1 CON: Nutrition 6. ANS: 2 Chapter: Chapter 27 Nutrition Objective: Identify the types, functions, metabolism, and major food sources of (1) the energy nutrients, (2) vitamins, (3) minerals, and (4) water. Page: 663 (V1) Heading: Proteins > Functions of Proteins Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Nutrition Difficulty: Moderate Feedback

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This is incorrect. Potassium deficiency would affect the heart, not cause tissue breakdown. This is correct. Protein is necessary for growth and maintenance of body tissues. Protein deficiency places the patient at risk for skin breakdown. This is incorrect. Fluoride deficiency leads to cavities, not tissue breakdown. This is incorrect. Vitamin D regulates blood calcium levels and helps deposit calcium into the bones. A deficiency would lead to rickets or fractures, not tissue breakdown.

PTS: 1 CON: Nutrition 7. ANS: 1 Chapter: Chapter 27 Nutrition Objective: Identify the types, functions, metabolism, and major food sources of (1) the energy nutrients, (2) vitamins, (3) minerals, and (4) water. Page: 531 (V2) Heading: Table 27-4 Minerals: Adult Dietary Reference Intakes Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Fluid and Electrolyte Balance Difficulty: Difficult Feedback 1 This is correct. Signs and symptoms associated with sodium excess include thirst, fever, dry and sticky tongue and mucous membranes, restlessness, irritability, and seizures. 2 This is incorrect. Findings associated with potassium excess include cardiac arrhythmias, weakness, abdominal cramps, diarrhea, anxiety, and paresthesia. 3 This is incorrect. Phosphorus excess leads to tetany and seizures. 4 This is incorrect. Magnesium excess causes weakness, nausea, and malaise. PTS: 1 CON: Fluid and Electrolyte Balance 8. ANS: 1 Chapter: Chapter 27 Nutrition Objective: Identify the types, functions, metabolism, and major food sources of (1) the energy nutrients, (2) vitamins, (3) minerals, and (4) water. Page: 531 (V2) Heading: Table 27-4 Minerals: Adult Dietary Reference Intakes Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Fluid and Electrolyte Balance Difficulty: Moderate

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Feedback This is correct. Foods rich in potassium include peaches, molasses, meats, avocados, milk, shellfish, dates, figs, and potatoes. This is incorrect. Eggs, celery, baking soda, and baking powder have high sodium content. This is incorrect. Dairy products, beef, pork, beans, sardines, eggs, chicken, wheat bran, and chocolate are rich in phosphorus. This is incorrect. Egg yolks, nuts, sardines, dairy products, broccoli, and legumes are rich in calcium.

PTS: 1 CON: Fluid and Electrolyte Balance 9. ANS: 3 Chapter: Chapter 27 Nutrition Objective: Calculate a client’s basal metabolic rate. Page: 671 (V1) Heading: What Factors Affect Basal Metabolic Rate? Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Metabolism Difficulty: Difficult

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Feedback This is incorrect. The answer would be “7%” if the patient’s temperature rose by only 1F, for example, if the patient’s temperature went from 97F to 98F. This is incorrect. Fever causes the basal metabolic rate to increase, not decrease. This is correct. Basal metabolic rate increases by 7% for each degree Fahrenheit (0.56C); therefore, this patient’s temperature rise is an increase of 35%: 102 – 97 = 5  7 = 35. This is incorrect. The basal metabolic rate will increase, not decrease, with a fever. If the patient’s temperature went from 97F to 101F, the basal metabolic rate would be increased by 28%.

PTS: 1 CON: Metabolism 10. ANS: 1 Chapter: Chapter 27 Nutrition Objective: Identify the primary nutritional considerations for various developmental stages. Page: 676 (V1) Heading: Infants to One Year > Infant Feedings Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying]

Concept: Nutrition Difficulty: Moderate Feedback 1 This is correct. The nurse should emphasize the importance of giving the baby iron-fortified formula because fetal iron stores become depleted by age 4 to 6 months. The mother can give it to supplement any stored breast milk she might have in supply. 2 This is incorrect. The nurse should not make the mother feel guilty about her decision to begin bottle feeding to supplement breastfeeding. Instead, she should educate the mother about best practices for bottle feeding. 3 This is incorrect. Infants younger than 1 year of age should not receive regular cow’s milk because it may place a strain on the immature kidneys. 4 This is incorrect. Because the baby weighs 14 pounds, he will require about 21 to 28 ounces of formula a day (not 36 ounces), based on the nutritional recommendations that infants require 1.5 to 2 ounces of breast milk or formula per pound of body weight per day. PTS: 1 CON: Nutrition 11. ANS: 4 Chapter: Chapter 27 Nutrition Objective: Identify the primary nutritional considerations for various developmental stages. Page: 676 (V1) Heading: Developmental Stage > Preschoolers Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Nutrition Difficulty: Moderate Feedback 1 This is incorrect. Desserts should not be used as rewards for eating other foods. Reward with attention instead of food. 2 This is incorrect. Preschool-age children need 1,200 to 1,400 kcal/day. 3 This is incorrect. Because they are active, preschoolers require nutritious between-meal snacks. 4 This is correct. Lifelong food habits are developed during the preschool stage of life. Therefore, the mother should widen the variety of foods she introduces to the child. PTS: 1 CON: Nutrition 12. ANS: 1 Chapter: Chapter 27 Nutrition Objective: Identify the primary nutritional considerations for various developmental stages.

Page: 679 (V1) Heading: Pregnant and Lactating Women Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Knowledge [Remembering] Concept: Health Promotion Difficulty: Easy Feedback 1 This is correct. The nurse should emphasize the importance of consuming folic acid even before conception to prevent neural tube defects from developing. 2 This is incorrect. Calcium needs increase during pregnancy; however, its consumption does not prevent neural tube defects. 3 This is incorrect. While protein needs increase during pregnancy, it is not needed to prevent neural tube defects. 4 This is incorrect. Vitamin D consumption does not prevent neural tube defects. PTS: 1 CON: Health Promotion 13. ANS: 2 Chapter: Chapter 27 Nutrition Objective: Discuss how each of the following affects and is affected by nutritional status: lifestyle choices, vegetarianism, dieting for weight loss, culture and religion, disease processes, functional limitations, and special diets. Page: 679 (V1) Heading: Lifestyle Choices Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Nutrition Difficulty: Moderate Feedback 1 This is incorrect. While iron may be low, it is not the lowest. 2 This is correct. Patients who regularly abuse alcohol may be deficient in many nutrients; however, they are commonly deficient in the B vitamins and folic acid. 3 This is incorrect. Calcium will not be the lowest nutrient. 4 This is incorrect. Phosphorus may be low, but it will not be the lowest. PTS: 1 CON: Nutrition 14. ANS: 3 Chapter: Chapter 27 Nutrition

Objective: Discuss how each of the following affects and is affected by nutritional status: lifestyle choices, vegetarianism, dieting for weight loss, culture and religion, disease processes, functional limitations, and special diets. Page: 533 (V1) Heading: Table 27-5 Diets Modified by Consistency Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Comprehension [Understanding] Concept: Nutrition Difficulty: Easy Feedback 1 This is incorrect. A vanilla shake is included in a full liquid diet. 2 This is incorrect. Orange juice is part of a full liquid diet, not a clear liquid diet. 3 This is correct. A clear liquid diet consists of water; tea (without dairy); coffee; broth; clear juices, such as apple, grape, or cranberry; popsicles; carbonated beverages; and gelatin. 4 This is incorrect. A patient can have skim milk on a full liquid diet, not a clear liquid diet. PTS: 1 CON: Nutrition 15. ANS: 2 Chapter: Chapter 27 Nutrition Objective: Discuss how each of the following affects and is affected by nutritional status: lifestyle choices, vegetarianism, dieting for weight loss, culture and religion, disease processes, functional limitations, and special diets. Page: 533 (V1) Heading: Table 27-5 Diets Modified by Consistency Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Comprehension [Understanding] Concept: Nutrition Difficulty: Moderate Feedback 1 This is incorrect. A mechanical soft diet can supply a full range of nutrients and fluids. Nausea and vomiting or a lack of fluids can lead to dehydration. 2 This is correct. Because of its lack of fiber, a mechanical soft diet places the patient at risk for constipation. 3 This is incorrect. Hyperglycemia is not a complication of a mechanical soft diet. It is a complication of diabetes. 4 This is incorrect. Constipation, not diarrhea, is a complication of a mechanical soft diet.

PTS: 1 CON: Nutrition 16. ANS: 3 Chapter: Chapter 27 Nutrition Objective: Discuss how each of the following affects and is affected by nutritional status: lifestyle choices, vegetarianism, dieting for weight loss, culture and religion, disease processes, functional limitations, and special diets. Page: 684 (V1) Heading: Special Diets > Diets Modified for Disease Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Nutrition Difficulty: Easy Feedback 1 This is incorrect. Those with liver and kidney diseases should control their protein intake. 2 This is incorrect. Patients with celiac disease should avoid foods containing gluten. 3 This is correct. Patients with hypertension should limit their intake of sodium. 4 This is incorrect. Patients with renal disease must limit their intake of potassium-rich foods. PTS: 1 CON: Nutrition 17. ANS: 1 Chapter: Chapter 27 Nutrition Objective: List at least five physical assessment findings that indicate nutritional imbalance. Page: 701 (V1) Heading: Focused Assessment box #4, sidebar > Focused Assessment > Integumentary System Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Nutrition Difficulty: Difficult Feedback 1 This is correct. Patients with iron deficiency may have spoon-shaped, brittle nails. 2 This is incorrect. Nails that are pale, have poor blanching, or present with mottled nails indicate a vitamin A or C deficiency. 3 This is incorrect. Abnormal nail findings include dull nails with transverse ridge for protein deficiency. Bruising or bleeding beneath the nails indicates protein or caloric deficiency. 4 This is incorrect. Splinter hemorrhages occur with a vitamin C deficiency.

PTS: 1 CON: Nutrition 18. ANS: 1 Chapter: Chapter 27 Nutrition Objective: Describe tools and techniques for gathering subjective data about nutritional status. Page: 688 (V1) Heading: May I Delegate Nutritional Assessments? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Collaboration Difficulty: Moderate Feedback 1 This is correct. The registered nurse should review and interpret (analyze) the data collected as part of a nutritional assessment. 2 This is incorrect. The registered nurse can delegate intake and output to the unlicensed assistive personnel. 3 This is incorrect. Weighing the patient can be safely delegated to the unlicensed assistive personnel. 4 This is incorrect. Nutritional history taking can be safely delegated to the licensed practical nurse. PTS: 1 CON: Collaboration 19. ANS: 2 Chapter: Chapter 27 Nutrition Objective: Identify the laboratory values that are indicators of nutritional status. Page: 687 (V1) Heading: What Laboratory Values Indicate Nutritional Status? > Serum Protein Levels and Indices Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Factors Cognitive Level: Knowledge [Remembering] Concept: Nutrition Difficulty: Moderate Feedback 1 This is incorrect. Albumin level is not as accurate because the half-life of albumin is 18 to 21 days, causing a delay in detection of nutritional problems. 2 This is correct. Prealbumin levels fluctuate daily, and is considered a better marker of acute change than albumin. 3 This is incorrect. Creatinine, an end product of skeletal muscle metabolism, is excreted through the kidneys and is an excellent indicator of renal function (not for nutritional status). 4 This is incorrect. There is another test that more accurately reflects a patient’s

nutritional status. Hemoglobin level reflects iron intake or chronic blood loss. PTS: 1 CON: Nutrition 20. ANS: 1 Chapter: Chapter 27 Nutrition Objective: List at least five physical assessment findings that indicate nutritional imbalance. Page: 673 (V1) Heading: Example Problem: Overweight and Obesity Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Nutrition Difficulty: Moderate Feedback 1 This is correct. This patient has defining characteristics for the nursing diagnosis Imbalanced Nutrition: More Than Body Requirements: body mass index is in the overweight category and weight is 20% over ideal for height and frame. 2 This is incorrect. The patient has an actual nutrition problem, not a Risk problem. 3 This is incorrect. The patient’s nursing diagnosis is More (not Less) Than Body Requirements. 4 This is incorrect. There are no defining criteria for Readiness for Enhanced Nutrition in this scenario. PTS: 1 CON: Nutrition 21. ANS: 3 Chapter: Chapter 27 Nutrition Objective: Safely provide enteral and parenteral nutrition for patients. Page: 533 (V2) Heading: Procedure 27-5 Administering Parenteral Nutrition > Safety feature Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Metabolism Difficulty: Difficult Feedback 1 This is incorrect. Sepsis is a complication that can occur if a break in aseptic technique occurs during therapy or from contamination of PN solution or supplies. 2 This is incorrect. Aspiration can occur with enteral feedings, not PN feedings. 3 This is correct. Because of the high glucose content of parenteral nutrition, any interruption in therapy places the patient at risk for hypoglycemia. PN should

not be discontinued abruptly, but rather over several (as many as 48) hours to prevent a sudden drop in blood sugar (rebound hypoglycemia). This is incorrect. Diarrhea is a complication from enteral feedings, not PN feedings.

PTS: 1 CON: Metabolism 22. ANS: 4 Chapter: Chapter 27 Nutrition Objective: Describe nursing interventions for patients with special needs: Impaired Swallowing, NPO, older adults, and Nausea. Page: 533 (V2) Heading: Box 27-5 Interventions for Patients Who Have Nausea Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Nutrition Difficulty: Difficult Feedback 1 This is incorrect. Dehydration can occur as a result of continued nausea and vomiting, so the nurse should assess for this condition. However, this intervention does not prevent nausea. 2 This is incorrect. Dietary supplements might help to prevent malnutrition. However, they do not prevent nausea; in fact, they often cause nausea. 3 This is incorrect. Having the patient sit upright (not supine) for 30 to 45 minutes may help. 4 This is correct. Odors (even pleasant ones) and even the sight and smell of hot food can cause nausea, so any uneaten food should be removed immediately from the room. PTS: 1 CON: Nutrition 23. ANS: 1 Chapter: Chapter 27 Nutrition Objective: List at least five physical assessment findings that indicate nutritional imbalance. Page: 693 (V1) Heading: Example Problem: Undernutrition and Malnutrition > Assessment Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Nutrition Difficulty: Moderate Feedback 1 This is correct. Cold intolerance is a physical sign of an eating disorder.

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This is incorrect. Low blood pressure, not hypertension, is a physical assessment finding that might suggest an eating disorder. This is incorrect. Hair loss, not thick hair, is a sign of an eating disorder. This is incorrect. A delay of sexual maturation (not early development) is a sign of an eating disorder.

PTS: 1 CON: Nutrition 24. ANS: 2 Chapter: Chapter 27 Nutrition Objective: Identify the laboratory values that are indicators of nutritional status. Page: 693 (V1) Heading: Example Problem: Undernutrition and Malnutrition > Others at risk Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Nutrition Difficulty: Moderate Feedback 1 This is incorrect. Serum glucose is normal (70 to 100 mg/dL) in this scenario. 2 This is correct. Serum albumin is a blood protein and marker for nutritional status. The value should be between 3.4 and 4.8 g/dL. This situation is consistent with undernutrition due to low nutritional intake. 3 This is incorrect. The serum creatinine is within normal limits for women (0.5 to 1.0 mg/dL). 4 This is incorrect. The hemoglobin level is within normal limits for a female (11.7 to 15.5 g/dL). PTS: 1 CON: Nutrition 25. ANS: 3 Chapter: Chapter 27 Nutrition Objective: Identify and discuss the six nursing interventions for Undernutrition/Malnutrition and six interventions for Overweight/Obesity. Page: 686 (V1) Heading: Self-Care box side bar > Self-Care > Keep a Food Diary Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Nutrition Difficulty: Easy Feedback 1 This is incorrect. Sugar-sweetened beverages (e.g., soda, fruit juices, fruit drinks, and energy drinks) have a high concentration of empty calories and

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minimal micronutrients. This is incorrect. Setting realistic, measurable goals that are shared with family members (accountability) increases the likelihood of success. This is correct. Keeping a food diary (either traditional or online), reviewing nutritional intake (both food selections and serving size), and patterns of consumption have all been shown to assist clients in decreasing dietary intake. This is incorrect. Increased exercise and reduced sedentary activities (e.g., screen time), coupled with reduced dietary intake with improved food quality, tend to result in weight loss.

PTS: 1 CON: Nutrition 26. ANS: 1 Chapter: Chapter 27 Nutrition Objective: Safely provide enteral and parenteral nutrition for patients. Page: 533 (V2) Heading: Clinical Insight 27-5 Guidelines for Checking Feeding Tube Placement > Inspecting the Aspirate and Measuring the Volume and pH of the Aspirate Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Collaboration Difficulty: Difficult Feedback 1 This is correct. Normal gastric fluid should be greenish brown or white, and acidic (pH 1 to 5.5). If the gastric aspirate has a pH of 7.3 (alkaline), the nurse must stop the tube feeding immediately and notify the prescriber of the feedings. This finding might indicate the feeding tube has migrated to the lungs, which could lead to aspiration pneumonia and become a medical emergency. 2 This is incorrect. Holding the feeding for 2 hours and continuing after that could lead to aspiration pneumonia because the quality of the fluid indicates the placement of the tube is in the lungs. 3 This is incorrect. Flushing the tube and resuming feedings when the feeding tube is in the lungs could lead to a medical emergency. 4 This is incorrect. If the gastric residual volume is 250 mL or greater after a second gastric residual check, a promotility agent may be considered in adult clients. However, the feeding tube may be in the lungs in this situation. PTS: 1 CON: Collaboration 27. ANS: 2 Chapter: Chapter 27 Nutrition Objective: Identify the types, functions, metabolism, and major food sources of (1) the energy nutrients, (2) vitamins, (3) minerals, and (4) water.

Page: 662 (V1) Heading: Carbohydrates Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Knowledge [Remembering] Concept: Metabolism Difficulty: Easy Feedback 1 This is incorrect. Proteins primarily perform the following functions: build tissue and maintain metabolism, immune systems functions, fluid balance, and acid–base balance. They are a secondary energy source. 2 This is correct. Carbohydrates are the primary energy source for the body. Carbohydrates perform several functions. They supply energy for muscle and organ function, spare protein, and enhance insulin secretion. 3 This is incorrect. The primary functions of lipids include supplying the body with essential nutrients, acting as an energy source, providing flavor and satiety, and providing insulation. It is not the body’s primary energy source. 4 This is incorrect. Although vitamins provide no energy, they are critical in regulating a variety of body functions. PTS: 1 CON: Metabolism 28. ANS: 1 Chapter: Chapter 27 Nutrition Objective: Identify the laboratory values that are indicators of nutritional status. Page: 663 (V1) Heading: Types of Lipids Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Nutrition Difficulty: Moderate Feedback 1 This is correct. LDLs transport cholesterol to body cells. Diets high in saturated fats increase LDL circulation in the bloodstream and may result in fatty deposits on vessel walls, causing cardiovascular disease. As a result, LDL is often known as the “bad cholesterol.” HDLs remove cholesterol from the bloodstream, returning it to the liver, where it is used to produce bile; thus, a high HDL is considered protective against cardiovascular disease and is often known as the “good cholesterol.” 2 This is incorrect. Linolenic acid (omega-3) helps to protect against heart disease but does not indicate cardiovascular disease. 3 This is incorrect. B-complex vitamins’ primary function is cellular metabolism.

This is incorrect. Vitamin K is involved in blood clotting.

PTS: 1 CON: Nutrition 29. ANS: 2 Chapter: Chapter 27 Nutrition Objective: Discuss the need for and advisability of vitamin and mineral supplementation. Page: 679 (V1) Heading: Lifestyle Choices and Teaching Clients About Vitamin and Mineral Supplementation Integrated Processes: Communication and Documentation Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Nutrition Difficulty: Moderate Feedback 1 This is incorrect. Telling a patient he or she would be better off not smoking may be true, but it reflects a judgmental attitude on the part of the nurse. 2 This is correct. Because vitamin C is an antioxidant, smokers metabolize vitamin C faster than do nonsmokers. The more a person uses tobacco, the more vitamin C is lost, yet, the body needs more vitamin C to counteract the damage smoking causes to cells. Additionally, because vitamin C aids in absorption of iron, a low level of vitamin C is also linked to iron deficiency. If a person cannot quit smoking, vitamin C and iron supplementation may help compensate. 3 This is incorrect. Telling the patient that he or she is lacking in many vitamins is too broad and not helpful. 4 This is incorrect. Nurses can answer these questions without having to refer the patient to a nutritionist. Encourage patients to ask their primary care provider’s advice before taking vitamins and other dietary supplements. PTS: 1 CON: Nutrition 30. ANS: 3 Chapter: Chapter 27 Nutrition Objective: Discuss how each of the following affects and is affected by nutritional status: lifestyle choices, vegetarianism, dieting for weight loss, culture and religion, disease processes, functional limitations, and special diets. Page: 680 (V1) Heading: Vegetarianism > Types of Vegetarian Diets Integrated Processes: Communication and Documentation Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Nutrition Difficulty: Moderate Feedback

This is incorrect. Asking the patient whether this is a religious or cultural requirement may be judgmental, is a closed-ended question, and will not elicit information regarding specific dietary intake. This is incorrect. While a vegan diet is lacking in some nutrients, the nurse cannot assume the patient is not getting all the nutrients needed. The nurse must gather data first. Vegans usually take supplements to obtain the needed nutrients. This is correct. The most appropriate response by the nurse is to first assess what the patient is eating and what supplements the patient uses. This will assist the nurse in identifying the patient’s knowledge level of the diet and in identifying proper supplements. This is incorrect. It is certainly an individual’s right to make his or her own choices regarding diet; however, this response will not assist the nurse in conducting a thorough nutritional assessment.

PTS: 1 CON: Nutrition 31. ANS: 2 Chapter: Chapter 27 Nutrition Objective: Discuss how each of the following affects and is affected by nutritional status: lifestyle choices, vegetarianism, dieting for weight loss, culture and religion, disease processes, functional limitations, and special diets. Page: 687 (V1) Heading: Blood Glucose > Hyperglycemia Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Metabolism Difficulty: Difficult Feedback 1 This is incorrect. Putting the patient off by telling him or her to ask the provider indicates either the nurse’s own poor understanding of the disease or an unwillingness to provide patient teaching. The nurse should clarify, explain, and teach this information to the patient in a timely manner. 2 This is correct. Diabetes, an endocrine problem, may develop as a result of either insufficient insulin production or resistance to the existing supply of insulin. A high blood glucose level does not mean that there is more fuel available for cellular energy. A characteristic of diabetes is that although there is more than enough glucose in the blood, it cannot enter and be used by the cells. 3 This is incorrect. The patient’s needs are more important than completing the task of the assessment. This type of response ignores the patient’s need for education. 4 This is incorrect. Glucose testing is important; however, a random blood sugar range of 120 to 140 mg/dL is too high for diabetic patients.

PTS: 1 CON: Metabolism 32. ANS: 3 Chapter: Chapter 27 Nutrition Objective: Safely provide enteral and parenteral nutrition for patients. Page: 533 (V2) Heading: Clinical Insight 27-5 Guidelines for Checking Feeding Tube Placement Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. Auscultating bowel sounds does not provide any reliable information related to tube placement, although it is an indicator of intestinal motility. 2 This is incorrect. Feeding tube placement can be checked by testing the pH of the aspirate in combination with other methods; however, this is not the most reliable indication of proper placement prior to a first feeding. 3 This is correct. Radiographic (x-ray) verification is the only reliable method for confirming tube placement; it must be performed before the first feeding is administered. 4 This is incorrect. While in some instances mixing water in the first tube feeding can be done, tube placement must be verified prior to feeding. PTS: 1 CON: Safety 33. ANS: 2 Chapter: Chapter 27 Nutrition Objective: Identify and discuss the six nursing interventions for Undernutrition/Malnutrition and six interventions for Overweight/Obesity. Page: 694 (V1) Heading: Example Problem: Undernutrition and Malnutrition Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Nutrition Difficulty: Moderate Feedback 1 This is incorrect. Marasmus is a severe protein and overall caloric deficit. 2 This is correct. Kwashiorkor is a severe deficiency of dietary protein. 3 This is incorrect. A lack of niacin results in pellagra, not kwashiorkor. 4 This is incorrect. A lack of vitamin C results in scurvy, not kwashiorkor.

PTS: 1 CON: Nutrition 34. ANS: 4 Chapter: Chapter 27 Nutrition Objective: Identify the primary nutritional considerations for various developmental stages. Page: 678 (V1) Heading: Gero feature > Older Adults > Frail Elderly Syndrome Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Nutrition Difficulty: Moderate Feedback 1 This is incorrect. The resident’s poor appetite is not a result of not understanding nutrition or the need to eat. Teaching would not be helpful in this instance. 2 This is incorrect. In this situation, the resident’s poor appetite is more likely related to depression and social withdrawal or even dementia, rather than to anxiety. 3 This is incorrect. There are no data in the scenario to indicate a distaste for the food served. However, the skilled nursing facility can address individual preferences. This is not the most likely reason for the resident’s condition. 4 This is correct. With advancing age, older adults face many losses. As a result, depression and social isolation are common. Both negatively affect appetite. Frail elderly syndrome is a complex disorder characterized by weight loss, lessened activity and interaction, and increasing frailty. PTS:

CON: Nutrition

MULTIPLE RESPONSE 35. ANS: 1, 2 Chapter: Chapter 27 Nutrition Objective: Identify the types, functions, metabolism, and major food sources of (1) the energy nutrients, (2) vitamins, (3) minerals, and (4) water. Page: 520 (V2) Heading: Table 27-1 Energy Nutrients > Proteins Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Nutrition Difficulty: Moderate

3. 4. 5.

Feedback This is correct. Whole grain rice is an incomplete protein. Incomplete proteins are supplied by plant sources (e.g., grains, nuts, legumes, seeds, vegetables). They can be combined to make complete proteins. This is correct. Legumes are examples of incomplete protein. Grains, nuts, legumes, seeds, and vegetables are examples of incomplete proteins. They can be combined to make complete proteins. This is incorrect. Poultry comes from an animal source and is a complete protein. This is incorrect. Eggs are a complete protein providing all of the essential amino acids necessary for protein synthesis. This is incorrect. Milk is a complete protein.

PTS: 1 CON: Nutrition 36. ANS: 1, 2 Chapter: Chapter 27 Nutrition Objective: Identify the types, functions, metabolism, and major food sources of (1) the energy nutrients, (2) vitamins, (3) minerals, and (4) water. Page: 520 (V2) Heading: Table 27-1 Energy Nutrients > Lipids and Table 27-2 Dietary Fats Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Health Promotion Difficulty: Moderate

4. 5.

Feedback This is correct. Palm oil is a source of saturated fat that are contained in many processed foods. The patient should be encouraged to read product labels to eliminate them from the diet. This is correct. Many processed foods contain coconut oils, which are sources of saturated fat. The patient should be encouraged to read product labels to eliminate them from the diet. This is incorrect. Canola oil is a monounsaturated fat that tends to lower the level of low-density lipoprotein (LDL) cholesterol (the “bad” cholesterol). These should be substituted for saturated fats in the diet. This is incorrect. Monounsaturated fats should be included in the patient’s diet. Peanut oil is a type of monounsaturated fat. This is incorrect. Safflower oil is a polyunsaturated fat and should be included in the patient’s diet.

PTS: 1 37. ANS: 1, 3, 5

CON: Health Promotion

Chapter: Chapter 27 Nutrition Objective: Describe the nursing interventions for patients with special needs: Impaired Swallowing, NPO, older adults, and Nausea. Page: 679 (V1) Heading: Gero feature > Older Adults and Impaired Digestive or Elimination Function > Constipation Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Comprehension [Understanding] Concept: Elimination Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is correct. To prevent constipation, the nurse should instruct the patient to drink at least eight glasses of water or fluid per day. This is incorrect. Four servings of meat is not a recommendation for constipation. This is correct. Whole grains and fresh greens provide the needed fiber for constipation. This is incorrect. While activity is beneficial for constipation, 60 minutes of vigorous activity is not necessary for older adults. This is correct. Soluble fiber allows more water to remain in the stool, which makes it softer and easier to pass. Insoluble fiber adds bulk to the stool for easier defecation.

PTS: 1 CON: Elimination 38. ANS: 2, 3 Chapter: Chapter 27 Nutrition Objective: Identify the types, functions, metabolism, and major food sources of (1) the energy nutrients, (2) vitamins, (3) minerals, and (4) water. Page: 661 (V1) Heading: Carbohydrates > Functions of CHOs Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Knowledge [Remembering] Concept: Metabolism Difficulty: Moderate

1. 2. 3.

Feedback This is incorrect. The brain requires glucose (carbohydrates) to function but does not store glucose. This is correct. Glucose is stored in the liver as glycogen. This is correct. The skeletal muscles store glucose.

4. 5.

This is incorrect. Skeletal muscles, not smooth muscles, store glucose. This is incorrect. Blood, not glucose, is produced in the bone marrow. Bone marrow does not store glucose.

PTS: 1 CON: Metabolism 39. ANS: 1, 4 Chapter: Chapter 27 Nutrition Objective: Describe nursing interventions for patients with special needs: Impaired Swallowing, NPO, older adults, and Nausea. Page: 526 (V2) Heading: Clinical Insight 27-3 Interventions for Patients With Impaired Swallowing Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is correct. The nurse should check for pocketing of food (storing food in cheeks) that the patient has not been able to swallow. This is incorrect. Thin liquids should be avoided unless thickeners are added. This is incorrect. The patient should flex the head forward (tuck the chin) in preparation for swallowing, not raise the chin. This is correct. Keep the head of the bed elevated for 30 to 45 minutes after feeding to help prevent aspiration. This is incorrect. Avoid the use of drinking straws for a patient with impaired swallowing.

PTS: 1 CON: Safety 40. ANS: 1, 3, 4 Chapter: Chapter 27 Nutrition Objective: Identify the types, functions, metabolism, and major food sources of (1) the energy nutrients, (2) vitamins, (3) minerals, and (4) water. Page: 663 (V1) Heading: Lipids > Saturated and Unsaturated Fatty Acids and Table 27-2 Dietary Fats Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate Feedback

2. 3. 4. 5.

This is correct. Trans-fatty acids are saturated fats created when food manufacturers add hydrogen to polyunsaturated plant oils, such as corn oil. This process solidifies the fat, improves texture and flavor, and extends the shelf-life of the food. This is incorrect. Trans fats increase (not decrease) blood cholesterol levels. Additionally, they raise LDL levels. This is correct. The FDA mandates that trans fat content be listed on all food labels. Intake of saturated and trans fat should be limited. This is correct. Trans fats are found in many margarines and other processed foods containing hydrogenated vegetable oils. This is incorrect. Vegetable oil sprays are not high in trans fats. The Centers for Disease Control and Prevention (CDC) recommends cooking and baking with vegetable oils (liquid or spray) instead of solid fats (e.g., solid shortenings, butter, lard).

PTS: 1 CON: Health Promotion 41. ANS: 1, 2, 3 Chapter: Chapter 27 Nutrition Objective: Identify the types, functions, metabolism, and major food sources of (1) the energy nutrients, (2) vitamins, (3) minerals, and (4) water. Page: 528 (V2) Heading: Vitamins and Table 27-3 Vitamins: Adult Dietary Reference Intakes (DRIs) Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is correct. Water-soluble vitamins, especially the B vitamins, are needed for cellular metabolism. This is correct. Vitamins are organic substances that are necessary for metabolism and for preventing a particular deficiency disease. This is correct. Because the body cannot make vitamins, they must be supplied by the foods we eat. This is incorrect. There is no reference that children need any other specific vitamin, such as vitamin C, more than others; all are important for healthy bodily functions. This is incorrect. Vitamin A, not E, is needed to prevent night blindness.

PTS: 1 CON: Health Promotion 42. ANS: 1, 2, 3, 5 Chapter: Chapter 27 Nutrition Objective: Describe the tools and techniques for gathering subjective data about nutritional status.

Page: 686 (V1) Heading: Dietary History and Focused Assessment > Dietary history Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Nutrition Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is correct. A nurse can obtain a dietary history during any routine assessment. The purpose is to collect baseline information about the patient’s basic eating habits. This is correct. The nurse would gather data about food preferences. A dietary history creates a picture of the patient’s food habits and eating behaviors. This is correct. Attitude toward food is a consideration when obtaining a dietary history. This is incorrect. A body mass index (BMI) is not part of the dietary history, although it is sometimes a part of a total nutritional assessment. This is correct. The nurse would collect data about dietary influences from ethnic, cultural, or religious practices.

PTS: 1 CON: Nutrition 43. ANS: 1, 2, 3 Chapter: Chapter 27 Nutrition Objective: Identify and discuss the six nursing interventions for Undernutrition/Malnutrition and six interventions for Overweight/Obesity. Page: 694 (V1) Heading: Example Problem: Undernutrition and Malnutrition > Interventions > Stimulating Appetite Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Nutrition Difficulty: Moderate

2. 3.

Feedback This is correct. Illness, with any accompanying pain, anxiety, and medications, often causes appetite loss. To improve appetite and intake and, subsequently, nutritional status, the nurse would offer frequent and smaller meals. This is correct. Keeping the patient’s environment neat and clean and free of unpleasant sights and odors would stimulate a patient’s appetite. This is correct. Providing or assisting with frequent oral hygiene is a strategy that will stimulate a patient’s appetite.

This is incorrect. Restrict liquids with meals to prevent feeling full before patient eats sufficient nutrients. Providing liquids before meals can make the patient feel full before even starting to eat a meal. This is incorrect. High-protein supplements should be offered, not avoided.

PTS: 1 CON: Nutrition 44. ANS: 1, 2, 3 Chapter: Chapter 27 Nutrition Objective: Safely provide enteral and parenteral nutrition for patients. Page: 688 (V1) Heading: May I Delegate Nutritional Assessments? and Procedure 27-1 Checking Fingerstick (Capillary) Blood Glucose Levels > Delegation and Administering Feedings Through Gastric and Enteric Tubes > Delegation Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Leadership and Management Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is correct. The registered nurse can safely delegate tube feeding to the licensed practical nurse (LPN/LVN). This is correct. An LPN/LVN can safely perform a fingerstick blood glucose reading. This is correct. Collecting a nutritional history can safely be delegated to the LPN. This is incorrect. The registered nurse is responsible for reviewing and interpreting the findings of the nutritional assessment, including laboratory values. This is incorrect. Do not delegate this skill to the LPN because administration of lipids requires advanced assessment and critical-thinking skills.

PTS:

CON: Leadership and Management

Chapter 28. Urinary Elimination Multiple Choice Identify the choice that best completes the statement or answers the question. 1. While performing a physical assessment, the female student nurse tells the instructor that she cannot palpate the patient’s bladder. Which statement by the instructor is best? 1. “Try to palpate it again; it takes practice but you will locate it.” 2. “Palpate the patient’s bladder only when it is distended by urine.” 3. “Document this abnormal finding on the patient’s chart.” 4. “Notify the nurse assigned to the care of your patient.” 2. Which urine specific gravity would be expected in a patient admitted with dehydration? 1. 1.002 2. 1.010 3. 1.021 4. 1.033 3. The nurse identifies the nursing diagnosis Urinary Incontinence in an older adult patient admitted after a stroke. Urinary Incontinence places the patient at risk for which complication? 1. Skin breakdown 2. Urinary tract infection 3. Bowel incontinence 4. Renal calculi 4. The nurse is caring for a patient who underwent a bowel resection 2 hours ago. The urine output for the past 2 hours totals 50 mL. Which action should the nurse take? 1. Do nothing; this is normal postoperative urine output. 2. Increase the infusion rate of the patient’s intravenous (IV) fluids. 3. Notify the provider about the patient’s oliguria. 4. Administer the patient’s routine diuretic dose early. 5. The nurse measures the urine output of a patient who requires a bedpan to void. Which action should the nurse take first? Put on gloves, and: 1. Have the patient void directly into the bedpan. 2. Pour the urine into a graduated container. 3. Read the volume with the container on a flat surface at eye level. 4. Observe the color and clarity of the urine in the bedpan. 6. The nurse instructs a woman about providing a clean-catch urine specimen. Which statement indicates the patient correctly understands the procedure? 1. “I will be sure to urinate into the ‘hat’ you placed on the toilet seat.” 2. “I will wipe my genital area from front to back before I collect the specimen midstream.”

3. “I will need to lie still while you put in a urinary catheter to obtain the specimen.” 4. “I will collect my urine each time I urinate for the next 24 hours.” 7. What position should the female patient assume before the nurse inserts an indwelling urinary catheter? 1. Modified Trendelenburg 2. Prone 3. Dorsal recumbent 4. Semi-Fowler’s 8. A female patient complains that she passes urine whenever she sneezes or coughs. How should the nurse document this finding in the patient’s healthcare record? 1. Transient incontinence 2. Overflow incontinence 3. Urge incontinence 4. Stress incontinence 9. Which outcome is appropriate for the patient who underwent urinary diversion surgery and creation of an ileal conduit (conventional urostomy) for invasive bladder cancer? 1. Patient will resume normal urination pattern by (target date). 2. Patient will perform urostomy self-care by (target date). 3. Patient will perform self-catheterization by (target date). 4. Patient’s urine will remain clear with sufficient volume. 10. Which intervention should the nurse take first to promote micturition in a patient who is having difficulty voiding? 1. Insert an indwelling urinary catheter. 2. Notify the healthcare provider immediately. 3. Obtain an intermittent, straight catheter. 4. Pour warm water over the patient’s perineum. 11. The student nurse asks the healthcare provider if an indwelling urinary catheter will be prescribed for a hospitalized patient who is incontinent. The healthcare provider explains that catheters should be utilized only when absolutely necessary because: 1. They are the leading cause of healthcare-associated infections. 2. They are too expensive for routine use. 3. They contain latex, increasing the risk for allergies. 4. They are painful upon insertion for most patients. 12. A patient who sustained a spinal cord injury will perform intermittent self-catheterization after discharge. After discharge teaching, which statement by the patient would indicate correct understanding of the procedure? 1. “I will need to replace the catheter monthly.” 2. “I will use clean, rather than sterile, technique at home.” 3. “I will remember to inflate the catheter balloon after insertion.”

4. “I will dispose of the catheter after use and get a new one each time.” 13. The nurse notes that a patient’s indwelling urinary catheter tubing contains sediment and crusting at the meatus. Which action should the nurse take? 1. Notify the healthcare provider immediately. 2. Flush the catheter tubing with saline solution. 3. Replace the indwelling urinary catheter. 4. Encourage fluids that increase urine acidity. 14. The nurse meets resistance when irrigating a patient’s urinary catheter. Which action would the nurse perform first? 1. Slightly turn the patient. 2. Replace the patient’s indwelling urinary catheter. 3. Force the fluid through the catheter tubing. 4. Notify the healthcare provider. 15. A patient is admitted with high blood urea nitrogen (BUN) and creatinine levels, and anuria. Based on these findings, the nurse suspects which diagnosis? 1. Urinary tract infection 2. Renal calculi 3. Enuresis 4. Renal failure 16. A mother tells the nurse at an annual well-child checkup that her 6-year-old son occasionally “wets himself” during the day. Which response by the nurse is appropriate? 1. Explain that occasional wetting is normal in children of this age. 2. Tell the mother to restrict her child’s activities to avoid wetting. 3. Suggest “time-out” to reinforce the importance of staying dry. 4. Inform the mother that medication is commonly used to control wetting. 17. The nurse is making assignments for the shift. Which assignment would the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Teaching the patient to perform the Credé’s maneuver 2. Irrigating an indwelling catheter 3. Applying a condom catheter 4. Obtaining the patient’s urinary history and physical assessment 18. Which action should the nurse take when beginning bladder training using scheduled voiding? 1. Offer the patient a bedpan every 2 hours while awake. 2. Increase the voiding interval by 30 to 60 minutes each week. 3. Frequently ask the patient if he or she has the urge to void. 4. Lengthen the time between voidings even if urine leakage occurs. 19. A patient is prescribed furosemide, a loop diuretic, for treatment of congestive heart failure. The nurse will monitor for which electrolyte loss?

1. 2. 3. 4.

Calcium Potassium Magnesium Phosphorus

20. The nurse is calculating the intake and output (I&O) for a patient. On the I&O record, the following information is noted: milk 140 mL at breakfast, voided 240 mL after breakfast, 120 mL of coffee at 1000, and urinated 300 mL at 1100. Which amount will the nurse document for the total urine output? 1. 240 mL 2. 540 mL 3. 380 mL 4. 300 mL 21. The nurse is preparing a client for a computerized tomography with contrast media. Which instruction will the nurse share with the client? 1. “You will have a pressure probe inserted into your rectum.” 2. “You will wear your rings and eyeglasses into the procedure room.” 3. “You will need to let me know if you are allergic to shellfish.” 4. “You will drink 5 to 6 glasses of fluid 90 minutes before the test.” 22. What is the best technique for obtaining a sterile urine specimen from an indwelling urinary catheter? 1. Use antiseptic wipes to cleanse the meatus prior to obtaining the sample. 2. Briefly disconnect the catheter from the drainage tube to obtain sample. 3. Withdraw urine through the port using a needleless access device. 4. Obtain the urine specimen directly from the collection bag. 23. A patient’s catheter bag is empty 2 hours after it was last drained. The nurse’s first action is to: 1. Irrigate the catheter 2. Perform a bladder scan 3. Replace the catheter 4. Check for kinks or compression 24. What type of indwelling catheter is most suitable for long-term use? 1. Silver-alloy catheter 2. Polyvinyl chloride (PVC) catheter 3. Silicone catheter 4. Triple-lumen catheter 25. The nurse is teaching a female patient with stress incontinence how to perform pelvic floor muscle exercises (PFMEs). Which statement indicates the patient understands the procedure? 1. “I will practice by stopping and starting my urine flow.” 2. “I will hold each contraction for 20 seconds.” 3. “I will perform 30 to 45 contractions each morning.”

4. “I will keep the contraction and relaxation times equal.” 26. Which urinary system structure is considered the functional unit responsible for filtration and water absorption? 1. Collecting duct 2. Ureter 3. Nephron 4. Tubular system 27. Which statement best describes how normal voluntary urination occurs? 1. The detrusor muscle relaxes to pass urine through the urethra. 2. The external urethral sphincter contracts to force urine out of the bladder. 3. Stretch receptors send sensory impulse to the voiding reflex center. 4. Voluntary control of the internal urethral sphincter leads to bladder emptying. 28. The nurse is caring for a patient who has a neobladder. Which action should the nurse take? 1. Insert an indwelling catheter. 2. Replace the collection device, as needed. 3. Inspect the color of the stoma. 4. Encourage performing Kegel exercises. 29. The nurse is inserting an indwelling urinary catheter for a female patient. Upon insertion of the catheter, the nurse accidentally touches the patient’s leg and bed sheet with the tip of the catheter. What is the most appropriate action by the nurse? 1. Wipe the tip of the catheter with povidone iodine before proceeding with the insertion. 2. Cleanse the tip of the catheter with alcohol before proceeding with the insertion. 3. Obtain a new catheter and reinsert it using sterile technique. 4. Apply more lubricant and continue to insert the catheter. 30. The nurse is caring for a patient who has had an indwelling urinary catheter inserted for the past 5 days. In reviewing and revising the plan of care, what is the most important nursing diagnosis for this patient? 1. Disturbed Body Image 2. Risk for Infection 3. Risk for Impaired Skin Integrity 4. Risk for Decreased Urine Output 31. The nurse is checking for costovertebral angle tenderness. Which technique would the nurse use? 1. Place one palm flat on the 12th rib and spine, on the back. 2. Apply the scanner above the symphysis pubis. 3. Gently percuss the bladder midline abdomen. 4. Calibrate the refractometer before using.

32. The nurse is planning care for a renal patient who is prescribed a diuretic medication. In planning care, what is the most appropriate time of day to administer this medication? 1. In the morning 2. In the afternoon 3. In the evening before bedtime 4. After meals Multiple Response Identify one or more choices that best complete the statement or answer the question. 33. Which interventions are appropriate for an older adult patient with urinary incontinence? Select all that apply. 1. Increase the intake of citrus fruits. 2. Consume high-fiber foods regularly. 3. Limit daily caffeine intake to less than 100 mg. 4. Engage in high-impact, aerobic exercise. 5. Keep fluid intake extremely low. 34. A client has just voided 50 mL and yet reports that the bladder still feels full. The nurse’s next actions should include which of the following? Select all that apply. 1. Palpating the bladder height 2. Obtaining a clean-catch urine specimen 3. Performing a bladder scan 4. Applying a heating pad to the lower abdomen 5. Inserting an incontinence pessary 35. Which tasks may be delegated to an unlicensed assistive personnel (UAP)? Select all that apply. 1. Measuring and recording intake and output 2. Performing a bedside dipstick urine test 3. Irrigating a triple lumen catheter 4. Assessing a patient’s ability to collect a urine specimen 5. Determining which type of catheter to insert 36. The nurse is caring for a patient with suspected kidney dysfunction. In reviewing the patient’s home medication list, the nurse is most alerted to which medications? Select all that apply. 1. Aspirin 2. Gentamicin 3. Estrogen 4. Ibuprofen 5. Insulin 37. The nurse is preparing a young adult, female patient for intravenous pyelogram (IVP). What are the priority actions by the nurse prior to this procedure? Select all that apply. 1. Obtain an informed consent prior to the procedure.

2. 3. 4. 5.

Ask whether the patient has an allergy to iodine. Check laboratory results for serum blood urea nitrogen (BUN) and creatinine. Encourage increased fluid intake prior to the procedure. Determine whether the patient has had a barium enema in the past 4 days.

38. Which age-related changes are considered normal processes in the urinary system that occur in older adults? Select all that apply. 1. The number of functional nephrons decreases with age. 2. The size of the kidney shrinks. 3. Increased bladder muscle tone contributes to incontinence. 4. Loss of bladder elasticity occurs. 5. Prostate enlargement causes urinary incontinence. 39. The nurse would expect which signs and symptoms for a patient with a suspected urinary tract infection (UTI)? Select all that apply. 1. Urinary frequency 2. Dysuria 3. Polyuria 4. Upper abdominal pain 5. Foul-smelling urine 40. The nurse educator is preparing a teaching plan on preventing urinary tract infections (UTIs) for a group of female college students. Which information will the nurse include in the plan? Select all that apply. 1. Empty the bladder soon after sexual intercourse. 2. Urinate when you first feel the urge to void. 3. Wear appropriate underwear, including nylon or synthetic garments. 4. Wipe perineum area from back to front after voiding. 5. Avoid tight-fitting clothes over the groin area.

Chapter 28. Urinary Elimination Answer Section MULTIPLE CHOICE 1. ANS: 2 Chapter: Chapter 28 Urinary Elimination Objective: Conduct a nursing assessment and physical examination focused on urinary elimination. Page: 707 (V1) Heading: The Urinary Bladder Stores Urine Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Elimination Difficulty: Easy Feedback 1 This is incorrect. It is not difficult to palpate the bladder when distended. The empty bladder cannot be palpated. 2 This is correct. The bladder is not palpable unless it is distended by urine. 3 This is incorrect. The nurse should document the finding, but it is not an abnormal finding. 4 This is incorrect. It is not necessary to notify the nurse assigned to the patient as this is an expected finding. PTS: 1 CON: Elimination 2. ANS: 4 Chapter: Chapter 28 Urinary Elimination Objective: Describe the diagnostic tests used to identify urinary elimination problems. Page: 707 (V1) Heading: Diagnostic Testing box #1 > Diagnostic Testing > Specific Gravity Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 This is incorrect. As fluid intake increases, urine becomes dilute and lighter in color to almost clear as it approaches a specific gravity of 1.000. 2 This is incorrect. A specific gravity of 1.010 is within the normal range and would not be expected in dehydration. 3 This is incorrect. A specific gravity of 1.021 is within the normal range and

would be higher if the patient was dehydrated. This is correct. A specific gravity of 1.033 is expected. Normal urine specific gravity ranges from 1.002 to 1.030. Specific gravity rises with dehydration (1.033).

PTS: 1 CON: Fluid and Electrolyte Balance 3. ANS: 1 Chapter: Chapter 28 Urinary Elimination Objective: Discuss common elimination problems: urinary tract infection, urinary retention, and urinary incontinence. Page: 716 (V1) Heading: Interventions for Example Problem: Urinary Incontinence and Nursing Care Plan Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Elimination Difficulty: Moderate Feedback 1 This is correct. Skin breakdown is a complication of urinary incontinence. Prolonged contact with urine causes skin breakdown and excoriation. Conscientious skin care and good hygiene will reduce the risk of skin irritation. 2 This is incorrect. Urinary tract infection can cause or worsen urinary incontinence, but it is not a complication of incontinence. 3 This is incorrect. Bowel incontinence is not a complication of urinary incontinence. However, a complication from bowel incontinence may be a urinary tract infection. 4 This is incorrect. Renal calculi is not a complication of urinary incontinence. Renal calculi may be a complication from immobility or increased consumption of high-calcium containing foods. PTS: 1 CON: Elimination 4. ANS: 3 Chapter: Chapter 28 Urinary Elimination Objective: Provide care for clients experiencing urinary problems. Page: 718 (V1) Heading: Normal Urination Patterns and Box 28-2 Terms Associated With Urination Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Elimination Difficulty: Difficult Feedback

1 2

This is incorrect. A urine output of 50 mL in 2 hours is not normal. The kidneys normally produce 60 mL of urine an hour. This is incorrect. Patients who undergo abdominal surgery commonly require increased infusions of IV fluid during the immediate postoperative period. The nurse cannot provide increased IV fluids without a provider’s order. This is correct. The amount of 50 mL in 2 hours is not normal output. The kidneys typically produce 60 mL of urine per hour. Therefore, the nurse should notify the provider when the patient shows diminished urine output (oliguria). This is incorrect. The nurse should not administer any medications before the scheduled time without a prescription.

PTS: 1 CON: Elimination 5. ANS: 1 Chapter: Chapter 28 Urinary Elimination Objective: Accurately measure urine output. Page: 718 (V1) Heading: Procedure 28-1 Measuring Urine Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Analysis [Analyzing] Concept: Elimination Difficulty: Easy Feedback 1 This is correct. First, the nurse should put on gloves and have the patient void directly into the bedpan. 2 This is incorrect. The second step is to pour the urine into a graduated container. 3 This is incorrect. The third step is to place the measuring device on a flat surface at eye level. 4 This is incorrect. The last step is to observe the urine for color, clarity, and odor. PTS: 1 CON: Elimination 6. ANS: 2 Chapter: Chapter 28 Urinary Elimination Objective: Describe procedures for collecting various types of urine specimens. Page: 560 (V2) Heading: Highlights of Procedures 28-1 Through 28-7 > Procedure 28-2A: Collecting a CleanCatch Urine Specimen Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Elimination Difficulty: Moderate

3 4

Feedback This is incorrect. The nurse should have the ambulatory patient void into a “hat” (container for collecting the urine of an ambulatory patient) when monitoring urinary output, but not when obtaining a clean-catch urine specimen. This is correct. To obtain a clean-catch urine specimen, the nurse should instruct the patient to cleanse the genital area from front to back and collect the specimen midstream. This follows the principle of going from “clean” to “dirty.” This is incorrect. A urinary catheter is required for a sterile urine specimen, not for a clean-catch specimen. This is incorrect. A 24-hour urine collection may be necessary to evaluate some disorders but a clean-catch specimen is a one-time collection.

PTS: 1 CON: Elimination 7. ANS: 3 Chapter: Chapter 28 Urinary Elimination Objective: Perform urinary catheterizations following accepted procedures. Page: 723 (V1) Heading: Urinary Catheter Insertion Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Knowledge [Remembering] Concept: Elimination Difficulty: Easy Feedback 1 This is incorrect. Modified Trendelenburg is not a position used to insert an indwelling urinary catheter. 2 This is incorrect. Prone will not allow easy access or visualization of the urinary meatus. 3 This is correct. The nurse should have the patient lie supine with knees flexed, feet flat on the bed (dorsal recumbent position). If the patient is unable to assume this position, the nurse should help the patient to a side-lying position. 4 This is incorrect. Semi-Fowler’s position is used for males when using the urinal and for females when using a bedpan. PTS: 1 CON: Elimination 8. ANS: 4 Chapter: Chapter 28 Urinary Elimination Objective: Discuss common elimination problems: urinary tract infection, urinary retention, and urinary incontinence. Page: 716 (V1) Heading: Example Problem: Adult Urinary Incontinence Integrated Processes: Communication and Documentation

Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Elimination Difficulty: Moderate Feedback 1 This is incorrect. Transient incontinence is a short-term incontinence that is expected to resolve spontaneously. It is typically caused by urinary tract infection or medications, such as diuretics. 2 This is incorrect. Overflow incontinence is the loss of urine when the bladder becomes distended; it is commonly associated with fecal impaction, enlarged prostate, and neurological conditions. 3 This is incorrect. Urge incontinence is the involuntary loss of urine associated with a strong urge to void from an overactive bladder. 4 This is correct. Stress incontinence is an involuntary loss of urine that occurs with increased intra-abdominal pressure. Activities that typically produce the symptom include sneezing, coughing, laughing, lifting, and exercise. PTS: 1 CON: Elimination 9. ANS: 2 Chapter: Chapter 28 Urinary Elimination Objective: Discuss nursing care appropriate for clients who have a urinary diversion. Page: 726 (V1) Heading: Clinical Insight 28-4 Caring for Patients With Urinary Diversion Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Elimination Difficulty: Moderate Feedback 1 This is incorrect. The patient with an ileal conduit is unable to resume a “normal” urination pattern. 2 This is correct. The most appropriate outcome for this patient is “The patient will perform urostomy self-care” by a specific date. 3 This is incorrect. The patient with a continent urostomy inserts a catheter into the stoma to drain urine. A patient with a conventional urostomy uses a drainage bag. 4 This is incorrect. Urine, along with mucus, drains continuously from the stoma site, so the urine will not be clear. Also, the phrase “sufficient volume” is too vague for an outcome statement. PTS: 1 10. ANS: 4

CON: Elimination

Chapter: Chapter 28 Urinary Elimination Objective: Provide care for clients experiencing urinary problems. Page: 726 (V1) Heading: Example Problem: Urinary Retention > Interventions Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Analysis [Analyzing] Concept: Elimination Difficulty: Moderate Feedback 1 This is incorrect. The healthcare provider may order an indwelling urinary catheter, but this is used as a last resort. 2 This is incorrect. The provider does not need to be notified immediately. If independent nursing measures fail, then the nurse should notify the healthcare provider. 3 This is incorrect. An intermittent, straight catheter may be ordered by the healthcare provider, if other measures do not work. 4 This is correct. The nurse should first perform independent nursing measures, such as pouring warm water over the patient’s perineum. Least invasive measures are tried first. PTS: 1 CON: Elimination 11. ANS: 1 Chapter: Chapter 28 Urinary Elimination Objective: Discuss common elimination problems: urinary tract infection, urinary retention, and urinary incontinence. Page: 728 (V1) Heading: TEBP box title > Toward Evidence-Based Practice Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Infection Difficulty: Easy Feedback 1 This is correct. Indwelling urinary catheters should not be routinely used for hospitalized patients with incontinence because they are the major cause of infection in hospitals. 2 This is incorrect. Cost is not the reason for using catheters only when absolutely necessary. 3 This is incorrect. Latex allergies are not the issue as there are latex-free catheters available. 4 This is incorrect. Insertion may be somewhat uncomfortable, but it should not be

painful but this is not the reason catheters are only used when necessary. PTS: 1 CON: Elimination 12. ANS: 2 Chapter: Chapter 28 Urinary Elimination Objective: Provide care for clients experiencing urinary problems. Page: 721 (V1) Heading: Clinical Insight 28-2 Teaching Clients About Clean, Intermittent Self-Catheterization Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Elimination Difficulty: Moderate Feedback 1 This is incorrect. A clean, intermittent self-catheterization catheter may be reused up to 7 days. 2 This is correct. The nurse should inform the patient that clean technique can be used after discharge. 3 This is incorrect. The patient should use a straight catheter; therefore, a balloon is not inflated after insertion. Straight catheters are removed immediately after use. 4 This is incorrect. Wash the reusable catheter in soap and water, and rinse and store it in a clean, dry place. It is not necessary for the patient to use a new catheter for each catheterization. PTS: 1 CON: Elimination 13. ANS: 3 Chapter: Chapter 28 Urinary Elimination Objective: Provide care for clients experiencing urinary problems Page: 722 (V1) Heading: Clinical Insight 28-1 Caring for a Patient With an Indwelling Catheter Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Elimination Difficulty: Moderate Feedback 1 This is incorrect. It is not necessary to notify the healthcare provider immediately. 2 This is incorrect. The nurse should not flush the catheter tubing. 3 This is correct. The catheter needs to be changed when sediment collects in the tubing or catheter and crusting at the meatus occurs.

This is incorrect. The patient should be encouraged to consume fluids that increase urine acidity to prevent urinary tract infection; however, it will not help clear the catheter tubing of sediment.

PTS: 1 CON: Elimination 14. ANS: 1 Chapter: Chapter 28 Urinary Elimination Objective: Provide care for clients experiencing urinary problems. Page: 582 (V2) Heading: Procedure 28-8 Irrigating the Bladder or Catheter > Safety feature > What if … You Meet Resistance When Irrigating? Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Elimination Difficulty: Moderate Feedback 1 This is correct. If resistance is met when irrigating, the nurse should first ask the patient to turn slightly and then attempt a second time. 2 This is incorrect. Replacing the patient’s catheter is not the first action the nurse would take. 3 This is incorrect. Do not force the fluid. If resistance continues, stop the procedure and notify the primary care provider. 4 This is incorrect. Notifying the primary care provider is not the first step. The nurse has other options to try before notifying the healthcare provider. PTS: 1 CON: Elimination 15. ANS: 4 Chapter: Chapter 28 Urinary Elimination Objective: Describe the diagnostic tests used to identify urinary elimination problems. Page: 582 (V2) Heading: Box 28-2 Terms Associated With Urination and Diagnostic Testing: Blood Studies: BUN and Creatinine Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Elimination Difficulty: Difficult Feedback 1 This is incorrect. Urinary tract infection would not result in abnormal renal function (BUN, creatinine), nor anuria. However, bacteriuria and cloudiness could be present in the urinalysis.

2 3 4

This is incorrect. Renal calculi typically produce blood in the urine but do not lead to marked renal dysfunction and failure. This is incorrect. Enuresis is involuntary urination and does not produce renal dysfunction or anuria. This is correct. Elevated BUN and creatinine, and anuria are signs of renal failure.

PTS: 1 CON: Elimination 16. ANS: 1 Chapter: Chapter 28 Urinary Elimination Objective: Discuss the factors that affect urinary elimination. Page: 709 (V1) Heading: Enuresis Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Elimination Difficulty: Moderate Feedback 1 This is correct. The nurse should explain that occasional wetting is normal in children during the early school years. 2 This is incorrect. The mother should not restrict the child’s activities; this is a normal occurrence. 3 This is incorrect. The mother should handle the situation calmly and avoid punishing the child. 4 This is incorrect. Medications are occasionally prescribed for nocturnal enuresis when the child is older and not sleeping at home, but not for occasional daytime wetting. PTS: 1 CON: Elimination 17. ANS: 3 Chapter: Chapter 28 Urinary Elimination Objective: Provide care for clients experiencing urinary problems. Page: 578 (V2) Heading: Procedure 28-6 Applying an External (Condom) Catheter > Delegation Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Elimination Difficulty: Moderate Feedback 1 This is incorrect. Teaching the patient the Credé’s maneuver involves the

2 3 4

critical-thinking skills of a professional nurse. This is incorrect. Irrigation of an indwelling catheter requires nursing assessment and clinical decision-making and should not be delegated to an UAP. This is correct. The nurse can safely delegate applying a condom catheter to an UAP. This is incorrect. Obtaining a patient’s urinary history and physical assessment is the responsibility of the nurse, not the UAP.

PTS: 1 CON: Elimination 18. ANS: 1 Chapter: Chapter 28 Urinary Elimination Objective: Provide care for clients experiencing urinary problems. Page: 566 (V2) Heading: Clinical Insight 28-3 Guidelines for Bladder Training and Pelvic Floor Exercises > Bladder Training Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Elimination Difficulty: Moderate Feedback 1 This is correct. The first step is for the nurse to offer the patient a bedpan or assist the patient to the bathroom every 2 hours while the patient is awake. 2 This is incorrect. If the patient adheres to the schedule, the voiding interval should be increased by 15 to 30 (not 30 to 60) minutes each week. 3 This is incorrect. Simply asking the patient about the urge to void does not help to manage bladder emptying. 4 This is incorrect. The patient must be able to adhere to the schedule comfortably before increasing (lengthening) the intervals. PTS: 1 CON: Elimination 19. ANS: 2 Chapter: Chapter 28 Urinary Elimination Objective: Provide care for clients experiencing urinary problems. Page: 710 (V1) Heading: Box 28-1 Common Diuretic Classes Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Comprehension [Understanding] Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback

1 2 3 4

This is incorrect. Furosemide does not cause a loss of calcium. This is correct. Furosemide is a loop diuretic, which causes potassium loss. This is incorrect. Magnesium is not lost with furosemide use. This is incorrect. Phosphorus is not lost with the loop diuretic furosemide.

PTS: 1 CON: Fluid and Electrolyte Balance 20. ANS: 2 Chapter: Chapter 28 Urinary Elimination Objective: Accurately measure urine output. Page: 714 (V1) Heading: Measuring Intake and Output Integrated Processes: Communication and Documentation Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Analysis [Analyzing] Concept: Elimination Difficulty: Moderate Feedback 1 This is incorrect. This amount (240 mL) is for one voiding only, not the total amount. 2 This is correct. The total amount of urine output is 540 mL—240 mL after breakfast and 300 mL at 1100. The total is 240 + 300 = 540 mL. 3 This is incorrect. The amount 380 mL is the sum of the milk at breakfast and the voiding after breakfast. Milk is intake, not output. 4 This is incorrect. This amount (300 mL) is for the urination at 1100; it is not the total amount of urine output. PTS: 1 CON: Elimination 21. ANS: 3 Chapter: Chapter 28 Urinary Elimination Objective: Describe the diagnostic tests used to identify urinary elimination problems. Page: 714 (V1) Heading: DT Box 3 >Diagnostic Testing > Computerized tomography Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Elimination Difficulty: Moderate Feedback 1 This is incorrect. During a cystometry (not a computerized tomography), a catheter is inserted into the bladder and a pressure probe into the rectum. 2 This is incorrect. Remove all metal objects from the client’s body (e.g., eyeglasses, rings, safety pins) when performing a computerized tomography

3 4

with contrast media. This is correct. Obtain history of allergies. This test is contraindicated for clients with allergies to shellfish or iodinated dye. This is incorrect. For a renal computerized tomography with contrast media, food and fluids are usually restricted for 2 to 4 hours prior to the procedure. However, a client undergoing bladder ultrasound may be required to drink five to six glasses of fluid 90 minutes before the procedure to ensure a full bladder.

PTS: 1 CON: Elimination 22. ANS: 3 Chapter: Chapter 28 Urinary Elimination Objective: Describe procedures for collecting various types of urine specimens. Page: 565 (V2) Heading: Procedure 28-2B Obtaining a Sterile Urine Specimen From a Catheter Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Elimination Difficulty: Moderate Feedback 1 This is incorrect. Wiping the meatus with an antiseptic material helps to minimize contamination for a clean-catch voided specimen, not a sample collected from a closed system such as an indwelling catheter system. 2 This is incorrect. Never disconnect the catheter from the drainage tube to obtain a sample. Interrupting the system creates a portal of entry for pathogens, thereby increasing the risk of contamination. 3 This is correct. To obtain a specimen from an indwelling catheter, insert the needleless access device with a 10 mL syringe into the specimen port, and aspirate to withdraw the amount of urine needed. 4 This is incorrect. Do not take the specimen from the collection bag because that urine may be several hours old. PTS: 1 CON: Elimination 23. ANS: 4 Chapter: Chapter 28 Urinary Elimination Objective: Provide care for clients experiencing urinary problems. Page: 725 (V1) Heading: Clinical Insight 28-1 Caring for a Patient With an Indwelling Catheter Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Elimination

Difficulty: Moderate Feedback 1 This is incorrect. Irrigating the catheter may be considered after a full assessment is completed and no other, simpler cause is identified. 2 This is incorrect. If there are no kinks or compression, assessment for urinary retention by performing a bladder scan may be appropriate. 3 This is incorrect. Replacing the catheter is a more invasive intervention that increases the patient’s risk for infection. This option may be considered after a full assessment is completed and no other, simpler cause is identified. 4 This is correct. The nurse should first check for kinks or compression. Kinks or compression of the catheter or tubing may impede flow of urine into the bag. PTS: 1 CON: Elimination 24. ANS: 3 Chapter: Chapter 28 Urinary Elimination Objective: Provide care for clients experiencing urinary problems. Page: 722 (V1) Heading: Types of Catheter Materials Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Elimination Difficulty: Moderate Feedback 1 This is incorrect. Silver-alloy coated catheters are used to reduce the risk of catheter-associated urinary tract infections rather than for their suitability for long-term use. 2 This is incorrect. Polyvinyl chloride (PVC) catheters are more rigid, less comfortable for indwelling use, and more commonly used for intermittent selfcatheterization. 3 This is correct. Silicone catheters are used primarily for long-term catheterization, as they cause less tissue irritation and prevent encrustation. 4 This is incorrect. A triple-lumen catheter is inserted when the patient requires continuous irrigation of the bladder. PTS: 1 CON: Elimination 25. ANS: 4 Chapter: Chapter 28 Urinary Elimination Objective: Provide care for clients experiencing urinary problems. Page: 564 (V2) Heading: Clinical Insight 28-3 Guidelines for Bladder Training and Pelvic Floor Exercises > Pelvic Floor Muscle Rehabilitation

Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Elimination Difficulty: Moderate Feedback 1 This is incorrect. The patient should be cautioned against doing pelvic floor muscle exercises (PFMEs) while actually urinating, because that can cause backflow of urine. 2 This is incorrect. Each contraction should be held for 5 to 10 seconds; 20-second contractions are too long. 3 This is incorrect. A recommended routine is to perform 10 to 15 PFMEs three times a day. The exercises should not be done all at one time. 4 This is correct. Contraction and relaxation times should be equal. For example, the patient should hold the contraction for 5 seconds, and then relax for 5 seconds. PTS: 1 CON: Elimination 26. ANS: 3 Chapter: Chapter 28 Urinary Elimination Objective: Describe the normal structures and functions of the organs in the urinary system. Page: 706 (V1) Heading: The Nephrons Form Urine Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Elimination Difficulty: Moderate Feedback 1 This is incorrect. While the collecting duct is part of the nephron, it is not considered the functional unit of the kidney. 2 This is incorrect. The ureters transport urine; they do not filter and are not the functional unit of the kidney. 3 This is correct. The nephron is the basic structural and functional unit of the kidney. Each nephron consists of a Bowman’s capsule, enclosing a glomerulus (responsible for most of filtering), a series of filtrating tubules and a collecting duct. Together, these structures act as a microscopic filter, controlling the excretion and retention of fluids and solutes according to the body’s moment-bymoment needs. 4 This is incorrect. While the series of filtrating tubules are part of the nephron, they are not considered the functional unit of the kidney.

PTS: 1 CON: Elimination 27. ANS: 3 Chapter: Chapter 28 Urinary Elimination Objective: Describe the processes of urine formation and elimination. Page: 707 (V1) Heading: How Does Urinary Elimination Occur? Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Elimination Difficulty: Difficult Feedback 1 This is incorrect. Motor impulses cause the detrusor muscle to contract, not relax. 2 This is incorrect. Voiding may be voluntarily delayed by inhibiting release of a second, external urethral sphincter. When the person is ready to urinate, the brain signals the external sphincter to relax, and urine flows through the urethra. 3 This is correct. Stretch receptors send sensory impulses to the voiding reflex center in the spinal cord. 4 This is incorrect. The internal sphincter is not under voluntary control. PTS: 1 CON: Elimination 28. ANS: 4 Chapter: Chapter 28 Urinary Elimination Objective: Discuss the nursing care appropriate for clients who have a urinary diversion. Page: 568 (V2) Heading: Clinical Insight 28-4 Caring for Patients With Urinary Diversion > Neobladder Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Elimination Difficulty: Moderate Feedback 1 This is incorrect. If the patient is unable to fully empty the bladder after using noninvasive techniques, intermittent self-catheterization may be needed. 2 This is incorrect. The patient with a neobladder does not use a collection device. 3 This is incorrect. Patients with a neobladder do not have a stoma. 4 This is correct. The patient with a neobladder will be instructed to perform Kegel exercises. PTS: 1 29. ANS: 3

CON: Elimination

Chapter: Chapter 28 Urinary Elimination Objective: Perform urinary catheterizations following accepted procedures. Page: 571 (V2) Heading: Procedure 28-5 Inserting an Indwelling Urinary Catheter > Indwelling Catheter Insertion for a Female Patient > 9. Manage the catheter Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis [Analyzing] Concept: Elimination Difficulty: Moderate Feedback 1 This is incorrect. Cleansing a catheter with povidone-iodine (Betadine) is not acceptable as this does not sterilize the catheter. 2 This is incorrect. Since this is a sterile procedure, the catheter must stay sterile. Alcohol will not sterilize a contaminated catheter tip. 3 This is correct. Insertion of an indwelling urinary catheter is a sterile procedure for all patients. If the catheter upon insertion touches the labia or vagina (female), unsterile bed linens, or any part of the patient’s body, it is contaminated. The nurse must obtain and insert a new, sterile catheter. 4 This is incorrect. The nurse should not continue the procedure without obtaining a new catheter. PTS: 1 CON: Elimination 30. ANS: 2 Chapter: Chapter 28 Urinary Elimination Objective: Identify the nursing diagnoses associated with altered urinary elimination. Page: 722 (V1) Heading: Urinary Catheterization > Urinary Catheter Insertion Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 This is incorrect. Although the patient may be embarrassed about having a catheter, a body image diagnosis (Disturbed Body Image) is rarely given priority over a basic need, such as remaining infection free. There are no data in the scenario to suggest an actual Disturbed Body Image. 2 This is correct. Anyone who has an indwelling catheter is at risk for infection. The longer the catheter remains in place, there is greater the risk for catheterassociated urinary tract infections. 3 This is incorrect. Although the catheter may be a risk factor for Impaired Skin

Integrity, that is less common and of a lower priority than Risk for Infection. This is incorrect. The patient is not at risk for decreased urine input from a catheter. Decreased urine output is primarily a problem of fluid intake or kidney function, not from insertion of a catheter.

PTS: 1 CON: Infection 31. ANS: 1 Chapter: Chapter 28 Urinary Elimination Objective: Conduct a nursing assessment and physical examination focused on urinary elimination. Page: 719 (V1) Heading: Guidelines for Physical Assessment for Urinary Elimination Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Elimination Difficulty: Moderate Feedback 1 This is correct. To check for costovertebral tenderness, the nurse places one palm flat on the costovertebral angle (junction of the 12th rib and the spine on both sides of the back) and lightly strike it with the closed fist of the other hand. 2 This is incorrect. Applying the scanner above the symphysis pubis is involved when the nurse is using a portable bladder scanner. 3 This is incorrect. Percussion is not involved in checking for costovertebral angle tenderness. A distended bladder produces a dull sound when percussed. 4 This is incorrect. A refractometer is used to check specific gravity, not costovertebral angle tenderness. PTS: 1 CON: Elimination 32. ANS: 1 Chapter: Chapter 28 Urinary Elimination Objective: Provide care for clients experiencing urinary problems. Page: 729 (V1) Heading: Example Problem: Adult Urinary Incontinence (UI) > Teaching Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Elimination Difficulty: Moderate Feedback 1 This is correct. In planning care or teaching patients about diuretic medications, the nurse should administer and teach for these medications to be taken in the morning. Diuretics increase urine output and when taken at night can cause

nocturia, leading to interrupted sleep. This is especially important for the elderly, as there may be associated safety risks with frequent arising for urination during the night. This is incorrect. Waiting until the afternoon is not the best time to administer the medication as this could lead to nocturia. This is incorrect. Giving the medication before bedtime will lead to nocturia. The medication should be given earlier. This is incorrect. Diuretic medication generally does not cause nausea or gastrointestinal upset; therefore, it is not necessary to take the medication after meals (for a full stomach).

2 3 4

PTS:

CON: Elimination

MULTIPLE RESPONSE 33. ANS: 2, 3 Chapter: Chapter 28 Urinary Elimination Objective: Provide care for clients experiencing urinary problems. Page: 729 (V1) Heading: Example Problem: Adult Urinary Incontinence (UI) > Teaching Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Elimination Difficulty: Moderate

1. 2.

3. 4. 5.

Feedback This is incorrect. Citrus is considered a bladder irritant; intake should be reduced or eliminated. This is correct. The patient should consume fiber to prevent constipation. Constipation can be associated with increased risk of urinary incontinence because it causes pressure on the urinary tract, interfering with flow. This is correct. Caffeine also irritates the bladder; intake should be limited to less than 100 mg per day. This is incorrect. High-impact exercise aggravates stress urinary incontinence, so it should not be an intervention for this patient. This is incorrect. Although fluid restriction is common, too low a fluid intake has not been shown to be useful in preventing urinary incontinence and increases the risk for urinary tract infections, constipation, and dehydration.

PTS: 1 34. ANS: 1, 3, 4

CON: Elimination

Chapter: Chapter 28 Urinary Elimination Objective: Provide care for clients experiencing urinary problems. Page: 728 (V1) Heading: Example Problem: Urinary Retention > Interventions Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Elimination Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is correct. The nurse should palpate the bladder for distention to validate the client’s statement. This is incorrect. Obtaining a clean-catch urine specimen is not necessary at this time. This is correct. A bladder scan will yield a more accurate measurement of the postvoid residual urine, so it would be appropriate at this time. This is correct. The nurse should apply a heating pad to the lower abdomen to relax the muscles near the bladder for a client with urinary retention. This is incorrect. Inserting an incontinence pessary is for urinary incontinence, not urinary retention.

PTS: 1 CON: Elimination 35. ANS: 1, 2 Chapter: Chapter 28 Urinary Elimination Objective: Provide care for clients experiencing urinary problems. Page: 558 (V2) Heading: Procedure 28-1 Measuring Urine > Delegation and Procedure 28-3 Testing Urine at the Bedside > Delegation Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Elimination Difficulty: Difficult

1. 2. 3.

Feedback This is correct. Measuring and recording intake and output is a task that can be delegated to an unlicensed assistive personnel. This is correct. The nurse can assign the task of performing a bedside dipstick urine test to the UAP. This is incorrect. Irrigation of a triple-lumen indwelling catheter requires nursing assessment and clinical decision making and should not be assigned to the UAP.

This is incorrect. The UAP cannot assess a patient’s urinary and cognitive status to determine ability to collect a specimen as this is the responsibility of the registered nurse. This is incorrect. The UAP cannot determine which catheter type is most appropriate for a patient. This judgment would be made by the registered nurse or prescribed for specific patient needs.

PTS: 1 CON: Elimination 36. ANS: 1, 2, 4 Chapter: Chapter 28 Urinary Elimination Objective: Discuss the factors that affect urinary elimination. Page: 710 (V1) Heading: Medications > Safety feature Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Elimination Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is correct. In caring for patients with kidney disease, the nurse is most alerted to medications that can be nephrotoxic. One example of a nephrotoxic drug is aspirin. This is correct. Gentamicin is nephrotoxic (damaging to the kidneys) and should cause the nurse concern. This is incorrect. Estrogen is not nephrotoxic. Estrogen is used to improve the blood flow to the urethral tissues and increase thickness of mucosal and urethral tissues. This is correct. Nonsteroidal anti-inflammatory drugs, such as ibuprofen, are nephrotoxic and should cause the nurse concern. This is incorrect. The nurse should not have concern regarding the use of insulin with respect to potential for kidney dysfunction.

PTS: 1 CON: Elimination 37. ANS: 1, 2, 3, 5 Chapter: Chapter 28 Urinary Elimination Objective: Describe the diagnostic tests used to identify urinary elimination problems. Page: 714 (V1) Heading: Diagnostic Testing box #3 > Diagnostic Testing > Intravenous Pyelogram (IVP) & Retrograde Pyelogram Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Elimination

Difficulty: Moderate

3. 4.

Feedback This is correct. The nurse must ensure that a signed consent form is on the chart because this is an invasive procedure. An intravenous pyelogram (IVP) uses radiopaque contrast medium to visualize the kidneys, ureters, bladder, and renal pelvis. This is correct. The nurse must assess for an iodine allergy. Radiopaque dyes can be highly allergenic for some patients; therefore, this test is contraindicated for patients with allergies to shellfish or iodinated dye. This is correct. Ensure baseline BUN and creatinine results are available. This test is contraindicated for patients who are in renal failure. This is incorrect. The nurse would not increase fluid intake prior to the procedure, but would instruct and maintain the patient on NPO (nothing by mouth) status for 8 hours prior to the test. This is correct. Ask whether the patient has had an x-ray test using barium contrast material (e.g., a barium enema) or have taken a medication containing bismuth (e.g., Pepto-Bismol) in the four days prior to the test. These can affect the test results.

PTS: 1 CON: Elimination 38. ANS: 1, 2, 4 Chapter: Chapter 28 Urinary Elimination Objective: Discuss the factors that affect urinary elimination. Page: 709 (V1) Heading: What Factors Affect Urinary Elimination? > Gero feature > Developmental Factors: Older Adults Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Elimination Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is correct. The size and functioning of the kidneys begin to decrease at about age 50, and by age 80 only about two-thirds of the functioning nephrons remain. This is correct. The size of the kidneys decrease (shrink) in normal aging. This is incorrect. There is a loss (not increase) of muscle tone in the bladder wall with normal aging. This is correct. Loss of bladder elasticity occurs with normal aging. This is incorrect. While the prostate gland enlarges with normal aging, it causes urinary frequency, dribbling, and hesitancy, not incontinence.

PTS: 1 CON: Elimination 39. ANS: 1, 2, 5 Chapter: Chapter 28 Urinary Elimination Objective: Conduct a nursing assessment and physical examination focused on urinary elimination. Page: 714 (V1) Heading: Example Problem: Urinary Tract Infection (UTI) > Symptoms Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Infection Difficulty: Difficult

1. 2. 3.

Feedback This is correct. Signs and symptoms of urinary tract infections include urinary frequency. This is correct. Dysuria is present with a UTI. This is incorrect. Polyuria is excessive urination and does not occur with a UTI. However, it may be caused by excessive hydration, diabetes mellitus, diabetes insipidus, or kidney disease. This is incorrect. Patients do not usually complain of upper abdominal pain with UTI but could have pain in the lower abdomen. Pain if present is flank pain when the UTI advances to a kidney infection. This is correct. Foul-smelling urine is a sign of a UTI.

PTS: 1 CON: Infection 40. ANS: 1, 2, 5 Chapter: Chapter 28 Urinary Elimination Objective: Provide care for clients experiencing urinary problems. Page: 713 (V1) Heading: Example Problem: Urinary Tract Infection (UTI) > Teaching Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Infection Difficulty: Moderate

Feedback This is correct. To reduce the risk of UTIs, the nurse would teach the college females to urinate after having intercourse to flush away bacteria that might have entered the urethra. This is correct. Because bacteria can multiply in stagnant urine, women should urinate when they feel the urge to void, and not make a habit of postponing

urination. This is incorrect. Cotton underwear is better than nylon or other synthetic fabrics, which are unbreathable fabrics. With such fabrics, moisture builds up, creating an ideal environment for microbial growth. This is incorrect. Women should always wipe from front to back (clean to dirty) after urination or defecation to help prevent transferring bacteria from the rectum and vagina to the urethra. This is correct. Avoid tight-fitting clothing in the groin area. Bacteria and other microorganisms grow well in a warm, moist environment.

PTS:

CON: Infection

Chapter 29. Bowel Elimination Multiple Choice Identify the choice that best completes the statement or answers the question. 1. When changing a diaper, the nurse observes that a 2-day-old infant has passed green-black, tarry stools. What should the nurse do? 1. Notify the provider immediately. 2. Do nothing; this is normal. 3. Give the baby sterile water until the mother’s milk comes in. 4. Apply a skin barrier cream to the buttocks to prevent irritation. 2. Considering normal developmental and physical maturation in children, for which age would a goal of “Achieves bowel control by the end of this month” be most realistic? 1. 18 months 2. 3 years 3. 4 years 4. 5 years 3. The registered nurse is working on a medical-surgical floor. Which behavior by a licensed practical nurse (LPN) would cause the nurse to intervene immediately? 1. Applies a clean ostomy appliance 2. Irrigates a newly created colostomy 3. Applies an external fecal collection system 4. Irrigates an ileostomy 4. A patient is diagnosed with an intestinal infection after traveling abroad. The nurse should encourage the intake of which food to promote healing? 1. Yogurt 2. Pasta 3. Oatmeal 4. Broccoli 5. The nurse is performing an abdominal assessment on a client with irritable bowel syndrome. The nurse has just finished inspection of the abdomen. Which action should the nurse take next? 1. Palpate for distention 2. Percuss for presence of air 3. Auscultate for bowel sounds 4. Feel for masses 6. A male patient with a skin infection is prescribed cephalexin (an antibiotic) 500 mg orally every 12 hours. The patient reports that the last time he took this medication, he had frequent episodes of loose stools. Which recommendation should the nurse make to the patient? 1. Stop taking the drug immediately if diarrhea develops.

2. Take an antidiarrheal agent, such as diphenoxylate. 3. Consume yogurt daily while taking the antibiotic. 4. Increase intake of fiber until the diarrhea stops. 7. The nurse is caring for a patient who has a continent ileostomy. Which intervention will the nurse add to the plan of care? 1. Change the ostomy appliance as needed. 2. Place a bedside commode by the patient’s bed. 3. Keep the collection device below the bladder. 4. Insert a tube into the stoma to drain the pouch. 8. The healthcare team suspects that a patient has an intestinal infection. Which action should the nurse take to help confirm the diagnosis? 1. Prepare the patient for an abdominal flat plate. 2. Collect a stool specimen that contains 20 to 30 mL of liquid stool. 3. Administer a laxative to prepare the patient for a colonoscopy. 4. Test the patient’s stool by using a fecal occult test. 9. The nurse is instructing a patient about performing home testing for fecal occult blood. The nurse should explain that ingestion of which substance may cause a false-negative fecal occult blood test? 1. Vitamin D 2. Iron 3. Vitamin C 4. Thiamine 10. Which action should the nurse tell the parent to take to assess a 2-year-old child for pinworms? 1. Press clear cellophane tape against the rectum as soon as the child wakes up. 2. Collect freshly passed stools from the diaper by using a wooden specimen blade. 3. Insert a cotton-tipped swab 2 inches (5 cm) into the rectum to look for visible worms. 4. Do not let the child eat after midnight for an x-ray in the morning. 11. A patient with cancer is started on morphine for excruciating pain. Which diagnosis should the nurse add to the patient’s care plan? 1. Risk for Constipation 2. Constipation 3. Perceived Constipation 4. Chronic Constipation 12. The nurse assesses a patient’s abdomen 4 days after abdominal surgery and notes that bowel sounds are absent. This finding most likely suggests which postoperative complication? 1. Paralytic ileus 2. Small bowel obstruction 3. Diarrhea

4. Constipation 13. A patient with severe hemorrhoids is incontinent of liquid stool. Which intervention is contraindicated? 1. Apply an indwelling fecal drainage device. 2. Apply an external fecal collection device. 3. Place an incontinence garment on the patient. 4. Place a moisture-resistant pad under the patient’s buttocks. 14. A patient has a colostomy in the descending (sigmoid) colon and wants to control bowel evacuation and possibly stop wearing an ostomy pouch. To help achieve this goal, the nurse should teach the patient to: 1. Call the primary care provider if the stoma becomes pale, dusky, or black 2. Limit the intake of gas-forming foods such as cabbage, onions, and fish 3. Irrigate the stoma to produce a bowel movement on a schedule 4. Follow the bananas, white rice, applesauce, and toast (BRAT) diet on a regular basis 15. The nurse is performing a colostomy irrigation on a male client. During the irrigation, the client begins to complain of abdominal cramps. What is the appropriate nursing action? 1. Notify the physician. 2. Stop the irrigation temporarily. 3. Increase the height of the irrigation. 4. Medicate for pain and resume the irrigation. 16. The nurse instilled 60 mL of irrigant into an indwelling fecal drainage device. The client’s output was 140 mL. What would the nurse chart as the client’s output of stool? 1. 200 mL 2. 140 mL 3. 60 mL 4. 80 mL 17. The nurse is obtaining a bowel elimination history from an 80-year-old patient. The patient states, “Sometimes when I go to the bathroom, I push real hard, hold my breath, and plug my nose.” Which action should the nurse take first? 1. Warn the patient, “You should not hold your breath while straining.” 2. Assure the patient, “This does seem to help some people to have a bowel movement.” 3. Check the patient’s medical history for heart disease or glaucoma. 4. Notify the primary care provider that the patient has reported performing this action. 18. The nurse is seeing a patient at home with a new colostomy. In formulating the plan of care, what is the priority goal for this patient? The patient will: 1. Adjust emotionally to the colostomy and lifestyle change

2. Verbalize appropriate steps in caring for the colostomy 3. Assume self-care in colostomy management 4. Experience liquid stool with minimal flatus 19. The enterostomal nurse is conducting a teaching session for patients with new colostomies. Today’s topic is self-assessment and signs and symptoms that must be immediately reported to the surgeon. Which sign/symptom should the nurse include in this teaching? 1. Constipation 2. Skin breakdown 3. A stoma that is deep pink to red in color 4. A stoma that is pale, dusky, or black in color 20. In which area is the appendix located? 1. Inside the sigmoid colon 2. Next to the rectum 3. Off of the cecum 4. Right by the internal sphincter of the anus 21. The nurse is preparing a patient for an invasive diagnostic test that will provide direct visualization of the rectum, entire large intestine, and distal small bowel. The nurse should teach and give the patient written instructions about which test? 1. Barium enema 2. Ultrasound of the abdomen 3. Sigmoidoscopy 4. Colonoscopy Multiple Response Identify one or more choices that best complete the statement or answer the question. 22. Which factors place the patient at risk for constipation? Select all that apply. 1. Sedentary lifestyle 2. High-dose calcium supplements 3. Lactose intolerance 4. Consumption of spicy food 5. Antibiotic use 23. A patient who has been immobile since sustaining injuries in a motor vehicle accident reports passing hard stools. The nurse encourages the patient to increase daily fluid intake. Which fluids should the patient avoid because of the diuretic effect? Select all that apply. 1. Cranberry juice 2. Water 3. Coffee 4. Lemonade 5. Tea

24. The nurse must administer an enema to an adult patient with constipation. Which of the following would be a safe and effective distance for the nurse to insert the tubing into the patient’s rectum? Select all that apply. 1. 2 in. (5.1 cm) 2. 3 in. (7.6 cm) 3. 4 in. (10.2 cm) 4. 5 in. (12.7 cm) 5. 6 in (15.2 cm) 25. In advising an older adult who takes laxatives regularly, the nurse would identify which of the following factors? Select all that apply. 1. Consistent use of laxatives is thought to cause, rather that cure, constipation. 2. Habitual use of laxatives may lead to the need for ever-increasing dosages until the intestine fails to work properly. 3. Chronic laxative use can lead to dependency on the medication. 4. Over-the-counter (OTC) laxatives are better than bulking agents. 5. Laxatives use is recommended, if taken regularly. 26. Which populations are considered high risk for the development of hemorrhoids? Select all that apply. 1. Pregnant women 2. School bus drivers 3. Marathon runners 4. Intensive care unit nurses 5. Desk job workers 27. The nurse is caring for a patient on the medical-surgical unit. The patient states, “I really don’t like to talk about my bowel movements, but what is considered normal for bowel movements?” What is the best response by the nurse? Select all that apply. 1. “We usually like to set an acceptable standard of at least two bowel movement per week.” 2. “We can say normal frequency is anything from several times a day to once per week. It depends on your normal pattern.” 3. “We also consider whether you have to strain with bowel movements, use laxatives, or have to rush to the toilet.” 4. “There is no such thing as normal. All people are different, so no need to worry about it.” 5. “Since there are so many different types of normal, this is an issue you should discuss with your primary care provider.” 28. The nurse is performing a focused bowel assessment on an older adult. Which physiological changes of aging should alert the nurse to an increased risk for problems associated with bowel elimination? Select all that apply. 1. Decreased sphincter control

2. 3. 4. 5.

Decreased peristalsis Increased intestinal muscle tone Decreased physical activity Increased perineal tone

29. The community health nurse is preparing a teaching plan on food choices that promote normal bowel elimination. Which foods should the nurse teach participants to be sure to include in their diet? Select all that apply. 1. Fresh fruits 2. Lean meats 3. Whole-grain cereals 4. Pastas 5. Peas 30. A client has a history of chronic constipation. Which medications prescribed for the client would alert the nurse to be especially vigilant in observing for constipation and teach the client about preventive measures? Select all that apply. 1. Naproxen 2. Iron 3. Antibiotics 4. Pain medications 5. Ibuprofen 31. The nursing instructor is teaching students how to use a fracture pan for patients. What are the most appropriate instructions for this procedure? Select all that apply. 1. Use for patients with a total hip replacement. 2. Elevate the head of the bed before placing the pan under the patient. 3. Place the wide, rounded end of the pan toward the front of the patient. 4. Assist the patient to a side-lying position prior to placing the bedpan. 5. Don sterile gloves to place the patient on the bedpan. 32. Which tasks may be delegated to an unlicensed assistive personnel (UAP)? Select all that apply. 1. Irrigating a newly created colostomy 2. Collecting and testing a stool sample for occult blood 3. Digitally removing stool as a result of a fecal impaction 4. Assisting with placing a fracture pan on an immobile patient 5. Changing a preexisting, stable ostomy appliance 33. The pediatric nurse educator is teaching a group of parents about distinguishing between food allergies and food intolerance. The nurse should teach parents that which food items are considered to be true food allergens? Select all that apply. 1. Egg whites 2. Shellfish 3. Peanuts 4. Corn

5. Asparagus 34. A day after abdominal surgery, a postoperative patient on a surgical unit says to the nurse, “I’m having a problem with a lot of gas. Maybe it’s the food I’m eating.” What is the appropriate response by the nurse? Select all that apply. 1. “If the problem continues after you go home, you’ll need to avoid gas-producing foods, such as beans.” 2. “Let’s get you out of bed and walking more. This can help with your gas.” 3. “When was your last bowel movement? You may be a bit constipated.” 4. “I understand. I’ll have to call the doctor for insertion of a rectal tube.” 5. “We may need to get you ready to go back to surgery to fix this problem.” 35. The mother of a 3-month-old infant comes to emergency department and states, “My baby has been having severe diarrhea for 4 days. She is crying all the time.” In formulating the plan of care for diarrhea, the nurse focuses outcomes on which of the following? Select all that apply. 1. Fluid management 2. Electrolyte balance 3. Skin integrity 4. Excessive crying 5. Ease of stool passage

Chapter 29. Bowel Elimination Answer Section MULTIPLE CHOICE 1. ANS: 2 Chapter: Chapter 29 Bowel Elimination Objective: Describe normal bowel elimination. Page: 742 (V1) Heading: Developmental Stage Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Elimination Difficulty: Moderate Feedback 1 This is incorrect. The provider does not need to be notified as this is a normal finding. 2 This is correct. The nurse should do nothing; this is normal. During the first few days of life, a term newborn passes green-black, tarry stools known as meconium. Stools transition to a yellow-green color over the next few days. After that, the appearance of stools depends on the feedings the newborn receives. 3 This is incorrect. Sterile water does nothing to alter this progression. 4 This is incorrect. The infant does not need a skin barrier cream at this time. PTS: 1 CON: Elimination 2. ANS: 2 Chapter: Chapter 29 Bowel Elimination Objective: Describe normal bowel elimination. Page: 742 (V1) Heading: Developmental Stage Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Growth and Development Difficulty: Moderate

Feedback This is incorrect. This is too young. Toilet training requires neural and muscular control as well as conscious effort. The child must be aware of the urge to defecate, be able to maintain closure of the external anal sphincter while getting

2 3 4

to the toilet, and be able to remove clothing. This is correct. Between ages 2 and 3 years, a child can typically control defecation, thereby making toilet training possible. This is incorrect. This is not the typical age for bowel control to be achieved. Most 4-year-olds have already achieved bowel control at an earlier age. This is incorrect. Bowel control occurs before the age of 5.

PTS: 1 CON: Growth and Development 3. ANS: 4 Chapter: Chapter 29 Bowel Elimination Objective: Discuss nursing care associated with the use of bowel diversions. Page: 763 (V1) Heading: Clinical Insight 29-2 Guidelines for Ostomy Care > Determine Whether the Ostomy Should Be Irrigated Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. The LPN can apply a clean ostomy appliance. The nurse does not need to intervene. 2 This is incorrect. While a registered nurse usually irrigates a newly created colostomy, irrigation of a newly created colostomy to the LPN is acceptable. The nurse does not need to intervene. 3 This is incorrect. Insertion of an internal fecal collection device is usually performed by a professional nurse, but may be delegated to an LPN. The nurse does not need to intervene. 4 This is correct. The nurse needs to intervene. Ileostomies should never be irrigated. Only a qualified person, such as an enterostomal therapy nurse, may perform gentle lavage to clear food blockage near the stomal outlet in an ileostomy. PTS: 1 CON: Safety 4. ANS: 1 Chapter: Chapter 29 Bowel Elimination Objective: Discuss the factors that affect bowel elimination. Page: 743 (V1) Heading: Nutrition, Hydration, and Activity Level Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying]

Concept: Infection Difficulty: Moderate Feedback 1 This is correct. The nurse would recommend yogurt. The active bacteria in yogurt stimulate peristalsis and promote healing of intestinal infections. 2 This is incorrect. Pasta is a low-fiber food that slows peristalsis. It does not promote healing of intestinal infections. 3 This is incorrect. Oatmeal stimulates peristalsis, but it does not promote healing of intestinal infections. 4 This is incorrect. Broccoli stimulates gas production; it is ineffective against intestinal infections. PTS: 1 CON: Infection 5. ANS: 3 Chapter: Chapter 29 Bowel Elimination Objective: Perform a physical examination focused on bowel elimination. Page: 747 (V1) Heading: Assessment Guidelines and Tools > Focused Assessment > Physical Assessment Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Elimination Difficulty: Moderate Feedback 1 This is incorrect. While the nurse should palpate for distention, this is not the next step after inspection. 2 This is incorrect. The nurse should percuss for the presence of air but this is not the next action to take after inspection. 3 This is correct. The nurse would auscultate next. Recall that in an abdominal assessment, the order of the exam is inspection, auscultation, percussion, and palpation. 4 This is incorrect. Feeling or palpating for masses is an acceptable practice for an abdominal assessment and should be done, but it is not the next step to take. PTS: 1 CON: Elimination 6. ANS: 3 Chapter: Chapter 29 Bowel Elimination Objective: Discuss common bowel elimination problems. Page: 754 (V1) Heading: Medications and Example Problem: Diarrhea >Interventions Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

Cognitive Level: Application [Applying] Concept: Elimination Difficulty: Moderate Feedback 1 This is incorrect. Diarrhea is a common adverse effect of antibiotics; therefore, stopping the drug is not necessary or advisable. 2 This is incorrect. The patient should not be encouraged to take an antidiarrheal agent at this time. Diphenoxylate slows peristalsis. 3 This is correct. Antibiotics given to combat infection decrease the normal flora in the colon. The result is often diarrhea. Bacterial populations can be maintained with daily consumption of yogurt. 4 This is incorrect. Increasing the intake of fiber combats constipation, not diarrhea. PTS: 1 CON: Elimination 7. ANS: 4 Chapter: Chapter 29 Bowel Elimination Objective: Discuss nursing care associated with the use of bowel diversions. Page: 745 (V1) Heading: What Is a Bowel Diversion? > Ileostomy Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Elimination Difficulty: Moderate Feedback 1 This is incorrect. A continent ileostomy avoids continuous drainage, so the patient does not need to wear an ostomy appliance. 2 This is incorrect. The patient with a continent ileostomy will not need a bedside commode. The patient who has a total colectomy with ileoanal reservoir will evacuate the bowels on the commode in the usual manner. 3 This is incorrect. The patient with a continent ileostomy does not wear a collection device. A urinary catheter is kept below the bladder level. 4 This is correct. To drain the pouch, the patient inserts a tube through the external stoma into the pouch several times per day. PTS: 1 CON: Elimination 8. ANS: 2 Chapter: Chapter 29 Bowel Elimination Objective: List and describe diagnostic tests used to identify bowel elimination problems. Page: 749 (V1) Heading: Laboratory Studies of Stool > Handling Stool Specimens

Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 This is incorrect. An intestinal infection is not confirmed by using an abdominal flat plate. 2 This is correct. To confirm the diagnosis of an infection, the nurse should collect a liquid stool specimen that contains 20 to 30 mL of liquid stool. 3 This is incorrect. The patient will not need a colonoscopy at this time. Thus, administering a laxative will not help determine the presence of an infection. 4 This is incorrect. A fecal occult blood test cannot confirm the diagnosis of an intestinal infection. PTS: 1 CON: Infection 9. ANS: 3 Chapter: Chapter 29 Bowel Elimination Objective: List and describe diagnostic tests used to identify bowel elimination problems. Page: 600 (V1) Heading: Procedure 29-1 Testing Stool for Occult Blood > Pre-Procedure Assessment Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Comprehension [Understanding] Concept: Elimination Difficulty: Moderate Feedback 1 This is incorrect. Ingestion of vitamin D does not affect the test result. 2 This is incorrect. Iron can lead to a false-positive result. The question asked about a false-negative result. 3 This is correct. Ingestion of vitamin C can produce a false-negative fecal occult blood test result. 4 This is incorrect. The patient may consume thiamine because it will not affect the test result. PTS: 1 CON: Elimination 10. ANS: 1 Chapter: Chapter 29 Bowel Elimination Objective: List and describe diagnostic tests used to identify bowel elimination problems. Page: 750 (V1) Heading: Assessing for Pinworms Integrated Processes: Teaching and Learning

Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Comprehension [Understanding] Concept: Infection Difficulty: Moderate Feedback 1 This is correct. The parent can test for the presence of the eggs with tape. In the morning, as soon as the child awakens, press clear cellophane tape against the anal opening. 2 This is incorrect. Using a wooden specimen blade is the method to collect a fresh stool specimen from a diaper. It does not test for pinworms. 3 This is incorrect. Alternatively, or in addition, insert a cotton-tipped swab gently into the rectum for not more than 2.5 cm (1 in.), not 2 inches (5 cm). Smear the specimen on a slide for microscopic inspection for parasites and eggs. 4 This is incorrect. An x-ray is not a method of assessing for pinworms. Therefore, not letting the child eat after midnight is unnecessary. PTS: 1 CON: Infection 11. ANS: 1 Chapter: Chapter 29 Bowel Elimination Objective: Formulate nursing diagnoses associated with altered bowel elimination. Page: 750 (V1) Heading: Analysis/Nursing Diagnosis Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Elimination Difficulty: Moderate Feedback 1 This is correct. Risk for Constipation is an appropriate diagnosis for patients at increased risk because of bedrest, medications such as opioids, or surgery. The nurse might use this diagnosis for a patient with a condition or taking medications known to decrease peristalsis, like morphine. 2 This is incorrect. Based upon the data in the scenario, at this time the patient does not have an actual problem of constipation. 3 This is incorrect. Perceived Constipation is an appropriate diagnosis for a patient who makes a self-diagnosis of constipation and uses laxatives, suppositories, or enemas to ensure a daily bowel movement. 4 This is incorrect. At this point in time, the patient does not have chronic constipation, constipation that typically lasts 3 months or longer and may persist for years. PTS:

CON: Elimination

12. ANS: 1 Chapter: Chapter 29 Bowel Elimination Objective: Perform a physical examination focused on bowel elimination. Page: 747 (V1) Heading: Focused Physical Assessment Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Elimination Difficulty: Moderate Feedback 1 This is correct. Absent bowel sounds on the fourth postoperative day suggests paralytic ileus, a complication associated with abdominal surgery. 2 This is incorrect. Hyperactive bowel sounds occur with a small bowel obstruction. 3 This is incorrect. Diarrhea produces hyperactive bowel sounds. 4 This is incorrect. Constipation might be associated with hypoactive bowel sounds. PTS: 1 CON: Elimination 13. ANS: 1 Chapter: Chapter 29 Bowel Elimination Objective: Provide care for clients experiencing alterations in bowel elimination. Page: 760 (V1) Heading: Example Problem: Bowel Incontinence and Procedure 29-8 Placing Fecal Drainage Devices > For Indwelling Devices > Safety Feature Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Safety Difficulty: Difficult Feedback 1 This is correct. Applying an indwelling fecal management system is contraindicated for patients with large, painful, or severe hemorrhoids. An indwelling fecal drainage device is contraindicated for children; for more than 30 consecutive days of use; and for patients who have had recent bowel, rectal, or anal surgery or an injury; rectal or anal tumors; or stricture or stenosis. 2 This is incorrect. An external device may be used for this patient. However, external devices are not typically used for patients who are ambulatory, agitated, or active in bed because the device may be dislodged, causing skin breakdown. External devices cannot be used effectively when the patient has Impaired Skin Integrity because they will not seal tightly.

3 4

This is incorrect. Absorbent products are not contraindicated for this patient unless Impaired Skin Integrity occurs. This is incorrect. A moisture-resistant pad is not contraindicated. Even with absorbent products or an external collection device, the nurse should place a moisture-resistant pad under the patient to protect the bed linens.

PTS: 1 CON: Safety 14. ANS: 3 Chapter: Chapter 29 Bowel Elimination Objective: Discuss nursing care associated with the use of bowel diversions. Page: 764 (V1) Heading: Colostomy Irrigation Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Elimination Difficulty: Moderate Feedback 1 This is incorrect. While the primary care provider should be notified if the stoma becomes pale, dusky, or black, this does not help with bowel control. The color of the stoma indicates the blood flow to the stoma. 2 This is incorrect. Limiting the intake of gas-forming foods is a good idea from a social perspective; however, it does not help achieve the goal of having regular bowel movements, thus eliminating the need to wear a pouch. 3 This is correct. Patients with an ostomy in the descending or sigmoid colon may use colostomy irrigation as a means to control and schedule bowel evacuation and possibly eliminate the need to wear an ostomy pouch. 4 This is incorrect. The Bananas, Rice (white), Applesauce, and Toast (BRAT) diet is for diarrhea, not for controlling bowel evacuation for a sigmoid ostomy. PTS: 1 CON: Elimination 15. ANS: 2 Chapter: Chapter 29 Bowel Elimination Objective: Provide care for clients experiencing alterations in bowel elimination. Page: 618 (V1) Heading: Procedure 29-7 Irrigating a Colostomy Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Elimination Difficulty: Moderate Feedback

1 2

3 4

This is incorrect. The physician does not need to be notified. This is correct. If cramping occurs during a colostomy irrigation, the irrigation flow is stopped 15 to 30 seconds and the client is asked to take deep breaths. Cramping may indicate that the bowel is ready to empty, the water is too cold, the flow is too fast, or the tube contains air. This is incorrect. Increasing the height of the irrigation will cause further discomfort. This is incorrect. Medicating the client for pain is not the appropriate action in this situation.

PTS: 1 CON: Elimination 16. ANS: 4 Chapter: Chapter 29 Bowel Elimination Objective: Discuss nursing care associated with the use of bowel diversions. Page: 618 (V1) Heading: Clinical Insight 29-1 Caring for a Patient With an Indwelling Fecal Drainage Device Integrated Processes: Communication and Documentation Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Fluid and Electrolyte Balance Difficulty: Difficult Feedback 1 This is incorrect. The amount 200 mL is too large. The nurse must subtract (not add) the irrigant from the stool volume to maintain an accurate record of intake and output. 2 This is incorrect. While this is the amount of output, it includes the amount of irrigant. The amount of the irrigant must be subtracted from this amount (140 mL). 3 This is incorrect. The amount 60 mL is the amount of irrigant used. It does not reflect the client’s stool output. 4 This is correct. The nurse must subtract the irrigant from the stool volume to find the true amount of stool output: 140 – 60 = 80. PTS: 1 CON: Fluid and Electrolyte Balance 17. ANS: 3 Chapter: Chapter 29 Bowel Elimination Objective: Discuss the factors that affect bowel elimination. Page: 742 (V1) Heading: The Process of Defecation > Valsalva Maneuver Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying]

Concept: Elimination Difficulty: Moderate Feedback 1 This is incorrect. Before deciding how to respond, the nurse should check the chart to see whether the patient has any medical conditions that contraindicate the Valsalva maneuver. Only then would it be necessary to warn the patient against the maneuver. 2 This is incorrect. The nurse should not assure the patient or further encourage the action without additional information. 3 This is correct. The patient is describing the Valsalva maneuver. Although this technique assists with the passage of stool, the nurse should caution patients with heart disease, glaucoma, increased intracranial pressure, or a new surgical wound to avoid the Valsalva maneuver because it increases pressure within the abdominal cavity, raises blood pressure, and is associated with an increased risk for cardiac arrhythmias. 4 This is incorrect. It is not necessary at this time to inform the primary care provider, although a notation should be made in the patient record. PTS: 1 CON: Elimination 18. ANS: 3 Chapter: Chapter 29 Bowel Elimination Objective: Discuss nursing care associated with the use of bowel diversions. Page: 746 (V1) Heading: Caring for Patients With Bowel Diversions and Helping Patients Adapt to the Diversion Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Elimination Difficulty: Difficult Feedback 1 This is incorrect. Although patient acceptance of his or her colostomy is important, the nurse cannot assume any patient will accept the lifestyle change. Some patients may never feel comfortable with a bowel diversion. However, if the patient has been sick before surgery and the ostomy leads to less pain or discomfort, the transition and acceptance may be easier. 2 This is incorrect. While verbalizing the steps of colostomy care is important, it is not the priority goal. Memorization is not priority. 3 This is correct. Patients experience a variety of reactions to a bowel diversion, and each person has unique physical and psychological needs. Initially, the nurse will care for the colostomy and teach the patient how to care for it. The ultimate, priority goal is for the patient to assume self-care. 4 This is incorrect. While minimal flatus is acceptable, a colostomy will have

formed stools, not liquid. An ileostomy will have liquid stools. PTS: 1 CON: Elimination 19. ANS: 4 Chapter: Chapter 29 Bowel Elimination Objective: Discuss nursing care associated with the use of bowel diversions. Page: 746 (V1) Heading: Caring for Patients With Bowel Diversions > Ongoing Assessments After Diversion Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Elimination Difficulty: Moderate Feedback 1 This is incorrect. Constipation may need to be reported to the surgeon, depending on the extent of the severity of the constipation. However, this does not need to be reported immediately. 2 This is incorrect. The patient should also pay close attention to the skin surrounding the stoma. Skin breakdown may lead to infection, pain, and leakage. However, skin breakdown does not need to be reported immediately because the nurse will provide and recommend the use of a barrier cream and other skin products. 3 This is incorrect. The surgeon does not need to be notified. A healthy stoma ranges in color from deep pink to brick red, regardless of the patient’s skin color, and is shiny and moist. This indicates adequate blood supply to the portion of the intestine that has been externalized. 4 This is correct. Immediately report to the surgeon a stoma that is pale, dusky, or black in color. Pallor or a dusky blue color indicates ischemia, and a brownblack color indicates necrosis. PTS: 1 CON: Elimination 20. ANS: 3 Chapter: Chapter 29 Bowel Elimination Objective: Identify the basic structures and functions of the gastrointestinal system. Page: 740 (V1) Heading: The Large Intestine Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Elimination Difficulty: Easy Feedback

This is incorrect. The appendix is not inside the sigmoid colon. The sigmoid colon is a final, small segment of bowel that twists medially and downward to connect with the rectum and anus. This is incorrect. The appendix is not next to the rectum. The rectum is approximately 15 cm (6 in.) long and is continuous with the anus, the last 2.5 cm (1 in.) of the colon. A highly vascular folded tube, the rectum is free of waste products until just before defecation. This is correct. The appendix is a small, fingerlike appendage off the cecum. It is believed to be a vestigial organ—one whose significance has diminished over time; however, it is lined with lymphatic tissue and may play a role in immune function. This is incorrect. The appendix is not right by the internal sphincter of the anus. The internal sphincter of the anus involuntarily relaxes and opens when stool is present in the rectum.

PTS: 1 CON: Elimination 21. ANS: 4 Chapter: Chapter 29 Bowel Elimination Objective: List and describe diagnostic tests used to identify bowel elimination problems. Page: 749 (V1) Heading: Diagnostic Testing > Direct Visualization Studies of the Gastrointestinal Tract > Fiberoptic Colonoscopy Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Elimination Difficulty: Moderate Feedback 1 This is incorrect. A barium enema is a radiological examination of the rectum, colon, and small bowel; however, this test does not provide direct visualization. Instead, it requires the use of barium and views these organ structures via x-ray. 2 This is incorrect. An ultrasound detects tissue abnormalities such as masses, cysts, edema, or stones, usually through the use of a transducer that is moved externally across the skin surface of the abdomen; it is not direct visualization. 3 This is incorrect. A sigmoidoscopy allows direct visualization of the anal canal, rectum, and sigmoid colon, but not of the entire large intestine. 4 This is correct. A colonoscopy provides direct visualization of the rectum, colon, entire large intestine, and distal small bowel. Many patients and healthcare providers choose colonoscopy for cancer screening as this procedure provides better visualization of the colon. PTS:

CON: Elimination

MULTIPLE RESPONSE 22. ANS: 1, 2 Chapter: Chapter 29 Bowel Elimination Objective: Discuss common bowel elimination problems. Page: 743 (V1) Heading: Nutrition, Hydration, and Activity Level > Dietary Supplements and Activity and Medications Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Elimination Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is correct. Physical activity stimulates peristalsis and bowel elimination. Therefore, those with a sedentary lifestyle commonly experience constipation. This is correct. High-dose calcium supplements also predispose a patient to constipation. This is incorrect. Lactose intolerance leads to diarrhea, not constipation. This is incorrect. Diarrhea, not constipation, is associated with spicy food intake. This is incorrect. Antibiotics given to combat infection decrease the normal flora in the colon. The result is often diarrhea.

PTS: 1 CON: Elimination 23. ANS: 3, 5 Chapter: Chapter 29 Bowel Elimination Objective: Discuss common bowel elimination problems. Page: 743 (V1) Heading: Support Healthful Intake of Food and Fluids Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Elimination Difficulty: Moderate

1. 2.

Feedback This is incorrect. Cranberry juice would be beneficial for this patient because it provides fluid and may help control gas or odor. This is incorrect. Water is the preferred fluid for fluid intake and should be consumed.

3. 4. 5.

This is correct. Coffee contains caffeine, which promotes diuresis. This is incorrect. Lemonade is acceptable for fluid intake. This is correct. Tea would not be beneficial for this patient because tea contains caffeine, which enhances diuresis.

PTS: 1 CON: Elimination 24. ANS: 2, 3 Chapter: Chapter 29 Bowel Elimination Objective: Describe the nursing interventions that promote normal bowel elimination. Page: 605 (V2) Heading: Procedure 29-3 Administering an Enema > Procedure 29-3A Administering a Cleansing Enema Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Knowledge [Remembering] Concept: Elimination Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is incorrect. Two inches (5.1 cm) would not be effective because it would not place the fluid high enough in the rectum. This is correct. When administering an enema, the nurse should insert the tubing about 3 to 4 inches (7.6 cm to 10.2 cm) into the patient’s rectum. This is correct. Four inches (10.2 cm) is an acceptable length to insert the tubing into the rectum. This is incorrect. Five inches (12.7 cm) is too far. This is incorrect. Six inches (15.2 cm) is too far to insert the tubing into the rectum.

PTS: 1 CON: Elimination 25. ANS: 1, 2, 3 Chapter: Chapter 29 Bowel Elimination Objective: Discuss the factors that affect bowel elimination. Page: 743 (V1) Heading: Medications and Self-Care box > Teaching Your Patient About Laxative Use Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Elimination Difficulty: Moderate

Feedback This is correct. Laxatives are used to treat constipation; however, consistent use can,

3. 4. 5.

in fact, lead to constipation. This is correct. Laxatives are frequently abused by people who self-medicate with OTC drugs, may become dependent on them, and require ever-increasing dosages until the intestine fails to work properly. This is correct. Chronic laxative use can lead to dependency on the medication. This is incorrect. Bulking agents are better than OTC laxatives. This is incorrect. Laxatives are to be used infrequently, not regularly.

PTS: 1 CON: Elimination 26. ANS: 1, 2, 5 Chapter: Chapter 29 Bowel Elimination Objective: Discuss common bowel elimination problems. Page: 741 (V1) Heading: The Rectum and Anus and Pregnancy Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Elimination Difficulty: Moderate

3. 4. 5.

Feedback This is correct. Hemorrhoids are distended blood vessels within or protruding from the anus. The anus is highly vascular. The increasing pressure of the uterus and the increased blood volume of normal pregnancy increase the woman’s risk for hemorrhoids. This is correct. School bus drivers are prone to hemorrhoids. Chronic pressure on the veins within the anal canal, as with prolonged sitting or retained feces, can cause hemorrhoids. This is incorrect. Marathon runners are active, and activity lessens the risk for hemorrhoids. This is incorrect. Intensive care unit nurses are not prone to hemorrhoids. This is correct. Hemorrhoids can develop in workers who sit at a desk all day because chronic pressure from prolonged sitting can lead to hemorrhoids.

PTS: 1 CON: Elimination 27. ANS: 2, 3 Chapter: Chapter 29 Bowel Elimination Objective: Describe normal bowel elimination. Page: 742 (V1) Heading: Normal Defecation Patterns > Normal Function Integrated Processes: Communication and Documentation Client Need: Health Promotion and Maintenance

Cognitive Level: Application [Applying] Concept: Elimination Difficulty: Difficult

1. 2.

Feedback This is incorrect. There is no acceptable standard with regard to what constitutes normal defecation patterns. Every person is different. This is correct. Part of the confusion about bowel function is that there is a wide range of “normal.” The frequency of bowel movements may range from several times per day to once a week. This is correct. As long as the person passes stools without excessive urgency (needing to rush to the toilet), with minimal effort and no straining, without blood loss, and without the use of laxative, the nurse can regard bowel function as normal. This is incorrect. While there is no such thing as normal, the nurse advises the patient not to worry about it, which is condescending and negates the patient’s concerns. The nurse should give parameters of what constitutes “normal.” This is incorrect. Telling the patient to talk to the primary provider, is ignoring the patient’s request. The nurse is able to teach patients about bowel habits and patterns.

PTS: 1 CON: Elimination 28. ANS: 1, 2 Chapter: Chapter 29 Bowel Elimination Objective: Discuss the factors that affect bowel elimination. Page: 742 (V1) Heading: Developmental Stage > Adults > Gero feature Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Elimination Difficulty: Moderate

1. 2.

3. 4.

Feedback This is correct. A physiological change of aging is a decrease in sphincter control. This is correct. Peristalsis decreases with aging and can contribute to bowel elimination problems among older adults, especially if they decrease their activity and fiber intake. This is incorrect. Increased intestinal muscle tone is not a normal physiological change of aging. A decrease occurs with aging. This is incorrect. Decreased activity level, although common in some older adults, is not a physiological change or process. In fact, some older adults may have rather high activity levels. This is incorrect. Perineal tone decreases, not increases, with normal aging.

PTS: 1 CON: Elimination 29. ANS: 1, 3, 5 Chapter: Chapter 29 Bowel Elimination Objective: Discuss the factors that affect bowel elimination. Page: 743 (V1) Heading: Nutrition, Hydration, and Activity Level and Support Healthful Intake of Food and Fluids Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is correct. Most people should have at least five servings of high-fiber foods each day. Fresh fruit is a high-fiber food. This is incorrect. Lean meat is a low-fiber food that slows peristalsis, leading to constipation. This is correct. Whole-grain cereals are high in fiber and promote normal bowel elimination. This is incorrect. Pasta, a low-fiber food, can lead to constipation. This is correct. Peas, a high-fiber food, promote normal bowel elimination.

PTS: 1 CON: Health Promotion 30. ANS: 2, 4 Chapter: Chapter 29 Bowel Elimination Objective: Discuss the factors that affect bowel elimination. Page: 743 (V1) Heading: Medications Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Elimination Difficulty: Moderate

Feedback This is incorrect. Naproxen, a nonsteroidal anti-inflammatory drug (NSAID), irritates the stomach. Repeated use of these medicines usually leads to ulceration of the stomach or the duodenum. However, NSAIDs are not usually associated with constipation. This is correct. Iron has an astringent effect on the bowel and is notorious for

3. 4. 5.

causing constipation. This is incorrect. Antibiotics, given to combat infection, decrease the normal flora in the colon. The result is often diarrhea. This is correct. Pain medications, particularly opioids (narcotics), slow peristalsis and are associated with a high incidence of constipation. This is incorrect. NSAIDs, such as ibuprofen, irritate the stomach, leading to ulceration of the stomach or the duodenum; they do not lead to constipation.

PTS: 1 CON: Elimination 31. ANS: 1, 3, 4 Chapter: Chapter 29 Bowel Elimination Objective: Describe the nursing interventions that promote normal bowel elimination. Page: 604 (V2) Heading: Procedure 29-2 Placing and Removing a Bedpan Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Elimination Difficulty: Moderate

2. 3. 4. 5.

Feedback This is correct. A fracture pan should be used for a patient with a total hip replacement. Identify factors that will necessitate the use of a fracture pan. (Examples include a fractured pelvis; total hip replacement; lower back surgery; presence of casts, splints, or braces on lower limbs; and obesity.) This is incorrect. The head of the bed is elevated after the patient is placed on the fracture pan. This is correct. Place the wide, rounded end of the fracture pan toward the front. This is correct. The patient is placed in a side-lying position, and then the fracture pan is placed. This is incorrect. Clean (not sterile) gloves are used when placing patients on a fracture pan.

PTS: 1 CON: Elimination 32. ANS: 2, 4, 5 Chapter: Chapter 29 Bowel Elimination Objective: Provide care for clients experiencing alterations in bowel elimination. Page: 602 (V2) Heading: Procedure 29-1 Testing Stool for Occult Blood > Delegation and Procedure 29-2 Placing and Removing a Bedpan > Delegation and Procedure 29-6 Changing an Ostomy Appliance > Delegation Integrated Processes: Nursing Process

Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Elimination Difficulty: Moderate

2. 3.

4. 5.

Feedback This is incorrect. Irrigating a newly created colostomy cannot be delegated. This task requires ongoing assessment of the patient by the professional nurse. Nursing judgment is necessary in determining the need to halt the procedure. This is correct. Collecting and testing a stool sample for occult blood can be delegated to a UAP. This is incorrect. The nurse cannot delegate digital removal of stool. The nurse must monitor the patient for complications, such as bleeding and vagal nerve stimulation, which requires nursing judgment. This is correct. The UAP is qualified to assist an immobile patient onto a fracture pan. This is correct. The nurse may delegate this task to a UAP if it is a pre-existing, stable stoma.

PTS: 1 CON: Elimination 33. ANS: 1, 2, 3 Chapter: Chapter 29 Bowel Elimination Objective: Discuss the factors that affect bowel elimination. Page: 745 (V1) Heading: Pathological Conditions > Food Allergies Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Immunity Difficulty: Moderate

2. 3. 4.

Feedback This is correct. Egg whites are a true food allergen. The National Institute of Allergy and Infectious Disease (NIAID) characterizes a food allergy as a true immune system reaction prompted by the presence in the body of an allergenic food. Food intolerance, in contrast to a food allergy, is specifically linked to the gastrointestinal system, but does not produce an immune reaction. This is correct. Shellfish is a true food allergen, as are dairy products and citrus fruits. This is correct. Peanuts and other nuts, gluten, and soy are all classified as true food allergens. This is incorrect. Corn is not a true food allergen.

This is incorrect. Asparagus is a vegetable that can lead to gas or odor, but it is not considered a true food allergen.

PTS: 1 CON: Immunity 34. ANS: 1, 2, 3 Chapter: Chapter 29 Bowel Elimination Objective: Provide care for clients experiencing alterations in bowel elimination. Page: 752 (V1) Heading: Manage Flatulence Integrated Processes: Communication and Documentation Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Elimination Difficulty: Moderate

Feedback This is correct. The patient is likely not eating gas-producing foods on postoperative day 1, but the nurse might want to teach the patient about this possibility. Some people develop flatulence after eating gas-producing foods, such as beans, cabbage, cauliflower, onion, or highly spiced foods. For others, flatulence occurs when fiber intake is increased. This is correct. To help patients manage flatulence, the nurse should encourage patients who have had surgery to ambulate and perform bed exercises as this helps to stimulate peristalsis and the passage of gas. This is correct. The nurse should ask about bowel movements because constipation is often accompanied by flatulence because digestive by-products undergo prolonged fermentation in the colon. This is incorrect. In severe cases, the nurse may need to obtain a prescription for a rectal tube. In this item, there is no indication that the patient’s flatulence is severe enough to indicate a rectal tube. This is incorrect. Flatulence is not treated with surgery. There are other less invasive methods to decrease flatus.

PTS: 1 CON: Elimination 35. ANS: 1, 2, 3 Chapter: Chapter 29 Bowel Elimination Objective: Provide care for clients experiencing alterations in bowel elimination. Page: 751 (V1) Heading: Analysis/Nursing Diagnosis and Example Problem: Diarrhea > Outcomes Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying]

Concept: Elimination Difficulty: Moderate

2. 3.

Feedback This is correct. Patients with diarrhea are at risk for fluid imbalance. Water loss is a primary concern. Infants, young children, and the frail elderly are most vulnerable and may require hospitalization and intravenous fluid replacement therapy. This is correct. Electrolyte imbalance, especially potassium, secondary to diarrhea is a high risk for infants, young children, and older adults. This is correct. Since the patient is an infant, skin integrity is an outcome for diarrhea, due to the irritating effects of feces in the diaper having direct contact with the infant’s skin. Because of the moisture and the activity of enzymes in the stool, infants with severe diarrhea need nursing care to prevent Skin Integrity Impairment. This is incorrect. Although crying distresses parents, managing the infant’s crying is not a priority at this time, and it will usually cease once the infant is feeling better and responding to treatment. This is incorrect. Ease of stool passage is an outcome for constipation, not diarrhea.

PTS:

CON: Elimination

Chapter 30. Sensation, Perception, & Response Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse checks a patient’s pupils using a penlight. Which receptors is the nurse stimulating? 1. Chemoreceptors 2. Photoreceptors 3. Proprioceptors 4. Mechanoreceptors 2. Which structure within the brain is responsible for consciousness and alertness? 1. Reticular activating system 2. Cerebellum 3. Thalamus 4. Hypothalamus 3. Which behavior by a parent indicates an understanding of teaching regarding stimuli used to develop the infant’s auditory nervous system? 1. Cuddling 2. Speaking 3. Feeding 4. Soothing 4. A patient reports to the nurse that since taking a medication, he has suffered from excessively dry mouth. Which term would the nurse use to document this complaint? 1. Exophthalmos 2. Anosmia 3. Insomnia 4. Xerostomia 5. Which nursing diagnosis has the highest priority for a patient with impaired tactile perception? 1. Self-Care Deficit: Dressing and Grooming 2. Impaired Adjustment 3. Risk for Injury 4. Activity Intolerance 6. Which method would the nurse plan to use to assess kinesthetic deficit in a patient? 1. Instruct the patient to read from the Snellen chart. 2. Ask the patient to close their eyes and identify common smells. 3. Have the patient perform alternating rapid movements. 4. Touch the patient using a wisp of cotton.

7. Which intervention is appropriate for the patient with a nursing diagnosis of Disturbed Sensory Perception: Gustatory? 1. Limit oral hygiene to one time a day. 2. Teach the patient to combine foods in each bite. 3. Assess for sores or open areas in the mouth. 4. Instruct the patient to avoid salt substitutes. 8. Which statement by the nurse best describes macular degeneration? 1. “The portion of the eye called the macula, which is responsible for central vision, is damaged.” 2. “The lens became cloudy, causing blurred vision. This cloudiness will increase over time.” 3. “The pressure in the anterior cavity of the eye became elevated, shifting the position of the lens.” 4. “There’s an irregular curvature of the cornea, causing blurred vision.” 9. A patient who sustained a head injury in a motor vehicle accident has damage to the temporal lobe. This injury places the patient at risk for which type of hearing loss? 1. Otosclerosis 2. Conduction deafness 3. Presbycusis 4. Central deafness 10. A patient comes to the clinic reporting a taste disturbance. Which medication is most likely responsible for this disturbance? 1. Furosemide 2. Phenytoin 3. Glyburide 4. Heparin 11. Which instruction would the nurse include when providing discharge teaching for a patient who has a serious visual deficit? 1. Install blinking lights to alert the patient about an incoming phone call. 2. Have gas appliances inspected regularly to detect gas leaks. 3. Wear properly fitting shoes and socks. 4. Avoid using throw rugs on the floors. 12. The nurse must irrigate the ear of a 4-year-old child. How would the nurse pull the pinna to straighten the child’s ear canal? 1. Up and back 2. Straight back 3. Down and back 4. Straight upward 13. Which step would the nurse take first when performing otic irrigation in an adult?

1. 2. 3. 4.

Warm the irrigation solution to room temperature. Position the patient so she is sitting with her head tilted away from the affected ear. Straighten the ear canal by pulling up and back on the pinna. Place the tip of the nozzle into the entrance of the ear canal.

14. Which essential oil might the nurse use to uplift and stimulate a patient? 1. Lavender 2. Roman chamomile 3. Rosemary 4. Ylang-ylang 15. Which assessment finding is considered an age-related change? 1. Presbycusis 2. Hyperopia 3. Increased sensitivity to touch 4. Increased sensitivity to taste 16. Which statement made by the patient indicates an understanding regarding proper ear care following removal of impacted cerumen? 1. “I will use cotton-tipped swabs to clean my ears.” 2. “I need to keep my ears moist and avoid dryness.” 3. “I will clean my ears weekly with a washcloth, soap, and water.” 4. “I need to avoid swimming in the pool until my healthcare provider says I can.” 17. A patient reports an impaired sense of smell. Which cranial nerve might have been affected? 1. Trigeminal 2. Glossopharyngeal 3. Olfactory 4. Vagus 18. Which intervention is helpful when caring for a patient with impaired vision? 1. Suggest that the patient use bright overhead lighting. 2. Advise the patient to avoid wearing sunglasses when outdoors. 3. Do not offer large-print books because this may embarrass the patient. 4. Place the patient’s eyeglasses within easy reach. 19. A patient tells the nurse that since taking a medication, he has suffered from excessively dry mouth. Which assessments would be needed to plan interventions for that symptom? 1. Asking the patient whether foods taste different now 2. Checking the patient’s sense of smell 3. Having the patient stand to check for balance 4. Assessing for a history of seizures 20. The nurse would expect to document which normal outcome following removal of impacted cerumen?

1. 2. 3. 4.

Improved hearing acuity Bloody drainage Decreased sense of smell Severe dizziness

21. The patient at the clinic says to the nurse, “My doctor checked my eyes and told me my vision was 20 over 100 [20/100]. What does that mean?” Which is the best response by the nurse? 1. “This means that your eye pressure readings are quite high and may be indicative of glaucoma.” 2. “These are numbers associated with left and right eye readings for identifying macular degeneration.” 3. “This could be nearsightedness. Your vision for seeing objects up close is better than your vision for seeing things in the distance.” 4. “This could be that you are farsighted. Your vision for seeing objects in the distance is better than it is for seeing objects up close.” 22. Which is the priority nursing diagnosis for a patient with visual impairment? 1. Self-Neglect 2. Social Isolation 3. Risk for Falls 4. Risk for Imbalanced Nutrition: Less Than Body Requirements 23. Which question will the nurse ask an elderly patient to best assess level of orientation? 1. “Will you please repeat these three words for me: glasses, rocket, truck?” 2. “Can you tell me the date of your retirement from your workplace?” 3. “What is your name and today’s date? Can you tell me where you are?” 4. “What did you eat for breakfast this morning?” 24. An 80-year-old patient on the medical-surgical unit says to the nurse, “My vision is blurry, and I see halos around lights. The glare from the sun really bothers me.” Upon assessment, the nurse notes a cloudy film over the lens of the eye. Based on the patient’s report and the nurse’s assessment, the nurse associates these findings with which of the following? 1. Strabismus 2. Cataracts 3. Glaucoma 4. Presbyopia Multiple Response Identify one or more choices that best complete the statement or answer the question. 25. For a patient with hearing loss, it is essential to minimize the risk of further damage to the auditory nerve. Which medications may need to be discontinued if the patient is taking them? Select all that apply. 1. Furosemide

2. 3. 4. 5.

Digoxin Famotidine Aspirin Penicillin

26. Which factors in a health history place a patient at risk for hearing loss? Select all that apply. 1. Being an older adult 2. Childhood chickenpox 3. Frequent otitis media 4. Diabetes mellitus 5. Congenital rubella 27. Which findings lead the nurse to suspect sensory overload in a patient in the intensive care unit? Select all that apply. 1. Disorientation 2. Restlessness 3. Hallucinations 4. Depression 5. Preoccupation with somatic complaints 28. Which actions would the nurse take to prevent sensory overload? Select all that apply. 1. Leave the television on low volume to block out other noises. 2. Minimize ambient light in the patient’s room. 3. Plan care to provide periods of sleep. 4. Speak with a moderate tone of voice. 5. Restrict caffeine intake during hospitalization. 29. Which interventions are necessary to promote patient safety in the unconscious patient? Select all that apply. 1. Talk to the patient while providing care. 2. Incorporate more touch in the plan of care. 3. Give frequent eye care if blink reflex is absent. 4. Keep the siderails up and the bed in low position. 5. Perform diligent oral care by irrigating with diluted mouthwash. 30. Which interventions are best for preventing sensory deficit for a resident in a long-term care facility? Select all that apply. 1. Talk to the patient as you provide care. 2. Incorporate touch when providing care, as appropriate. 3. Turn on bright, fluorescent light for reading. 4. Encourage waiting to drink water until after the meal. 5. Offer spicy seasoning for the resident to use on food. 31. For a patient with dementia, how might the nurse best improve orientation and clarity? Select all that apply.

1. 2. 3. 4. 5.

Place personal objects where the patient can see them. Introduce yourself each time you have contact with the patient. Encourage the patient to relax while the nurse gives the bath. Encourage the patient to participate in familiar activities. Do not offer many choices when it comes to activities of daily living (ADLs).

32. Which describes the sensory changes that occur with aging? Select all that apply. 1. Decreased number of nerve conduction fibers results in slower reflexes. 2. The lens of eye becomes less flexible and less able to focus on near objects. 3. Taste buds atrophy and decrease in number, causing decreased ability to perceive taste. 4. Impaired regulation of body temperature causes an increased risk for seizures. 5. The amount and waxiness of cerumen increases with aging. 33. Which areas would the nurse include in a mental status assessment for an adult patient? Select all that apply. 1. Behavior 2. Judgment 3. Knowledge 4. Reflexes 5. Appearance 34. The nurse in the intensive care unit enters the patient’s room and observes the patient is experiencing a seizure. Which are the most appropriate interventions by the nurse? Select all that apply. 1. Insert a padded tongue depressor in the patient’s mouth. 2. Turn the patient to his side. 3. Restrain the patient to control his jerking movements. 4. Loosen any restrictive clothing. 5. Pad the siderails of the patient’s bed. 35. Which tasks may be delegated to a certified nursing assistant (CNA)? Select all that apply. 1. Irrigating the ear of a child with impacted cerumen 2. Administering eye drops for a patient in a coma 3. Obtaining vital signs every 15 minutes after a seizure 4. Padding the sides of a bed for seizure precautions 5. Suctioning the patient’s oropharynx after a seizure 36. Which are some positive effects of pet therapy for residents in a long-term care facility? Select all that apply. 1. Increases socialization 2. Increases blood pressure 3. Decreases pain 4. Decreases loneliness 5. Decreases insomnia

37. Which populations are considered to be at high risk for sensory deprivation? Select all that apply. 1. The homebound 2. Those in prison 3. Those who are depressed 4. Those experiencing high anxiety 5. Those feeling pain 38. The pediatric nurse educator is preparing a teaching plan for seizure prevention for parents of children with seizures. Which are known to trigger seizures? Select all that apply. 1. Fever 2. Missing a dose of anticonvulsants 3. Sleep deprivation 4. Food allergens 5. Mood-altering substances 39. Which medical conditions have a direct effect on sensory function contributing to sensory deficits? Select all that apply. 1. Diabetes 2. Hypertension 3. Multiple sclerosis 4. Breast cancer 5. Zinc deficiency

Chapter 30. Sensation, Perception, & Response Answer Section MULTIPLE CHOICE 1. ANS: 2 Chapter: Chapter 30 Sensation, Perception, & Response Objective: Identify the components of the sensory experience. Page: 771 (V1) Heading: Specialized Receptors Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Comprehension [Understanding] Concept: Sensory Perception Difficulty: Easy Feedback 1 This is incorrect. Chemoreceptors are located in the taste buds and epithelium of the nasal cavity. They play a role in taste and smell. 2 This is correct. Photoreceptors located in the retina of the eyes detect visible light. 3 This is incorrect. Proprioceptors in the skin, muscles, tendons, ligaments, and joint capsules coordinate input to enable an individual to sense the position of the body in space. 4 This is incorrect. Mechanoreceptors in the skin and hair follicles detect touch, pressure, and vibration. PTS: 1 CON: Sensory Perception 2. ANS: 1 Chapter: Chapter 30 Sensation, Perception, & Response Objective: Identify the components of the sensory experience. Page: 771 (V1) Heading: Arousal Mechanism Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Knowledge [Remembering] Concept: Sensory Perception Difficulty: Easy Feedback 1 This is correct. The reticular activating system, located in the brainstem, controls consciousness and alertness. 2 This is incorrect. The cerebellum maintains muscle tone, coordinates muscle movement, and controls balance.

3 4

This is incorrect. The thalamus is a relay system for sensory stimuli. This is incorrect. The hypothalamus controls body temperature.

PTS: 1 CON: Sensory Perception 3. ANS: 2 Chapter: Chapter 30 Sensation, Perception, & Response Objective: Identify the factors that affect sensory stimulation. Page: 773 (V1) Heading: Newborns Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Sensory Perception Difficulty: Moderate Feedback 1 This is incorrect. Cuddling provides comfort and pleasure and teaches the infant about the external environment. 2 This is correct. Exposure to voices, music, and ambient sound helps develop the infant’s auditory nervous system 3 This is incorrect. Feeding provides comfort and pleasure and teaches the infant about the external environment. 4 This is incorrect. Soothing provides comfort and pleasure and teaches the infant about the external environment. PTS: 1 CON: Sensory Perception 4. ANS: 4 Chapter: Chapter 30 Sensation, Perception, & Response Objective: Assess clients for the signs and symptoms of altered sensory perception. Page: 780 (V1) Heading: Example Problem: Sensory Deficits Integrated Processes: Communication and Documentation Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Comprehension [Understanding] Concept: Sensory Perception Difficulty: Moderate Feedback 1 This is incorrect. Exophthalmos is abnormal bulging of the eyeballs that commonly occurs with thyrotoxicosis. 2 This is incorrect. Anosmia is losing the sense of smell. 3 This is incorrect. Insomnia is inability to sleep. 4 This is correct. The nurse would document excessively dry mouth as xerostomia.

PTS: 1 CON: Sensory Perception 5. ANS: 3 Chapter: Chapter 30 Sensation, Perception, & Response Objective: State the nursing diagnoses and outcomes appropriate for clients with problems of sensory perception. Page: 771 (V1) Heading: What Are the Main Points in This Chapter? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis [Analyzing] Concept: Sensory Perception Difficulty: Moderate Feedback 1 This is incorrect. Self-Care Deficit: Dressing and Grooming is also likely to be an appropriate diagnosis for this patient but is not as high a priority as Risk for Injury. 2 This is incorrect. Impaired Adjustment is also likely to be an appropriate diagnosis for this patient but is not as high a priority as Risk for Injury 3 This is correct. The patient with impaired tactile perception is unable to perceive touch, pressure, heat, cold, or pain, placing him at risk for injury. Risk for Injury is directly related to safety, which must always be a priority. 4 This is incorrect. Activity Intolerance is also likely to be an appropriate diagnosis for this patient but is not as high a priority as Risk for Injury PTS: 1 CON: Sensory Perception 6. ANS: 3 Chapter: Chapter 30 Sensation, Perception, & Response Objective: Assess clients for the signs and symptoms of altered sensory perception. Page: 787 (V1) Heading: Bedside Assessment of Sensory Function Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Sensory Perception Difficulty: Moderate Feedback 1 This is incorrect. Reading from a Snellen Chart will assess visual acuity. 2 This is incorrect. Asking a patient to close their eyes to identify smells assesses sense of smell. 3 This is correct. Asking a patient to perform alternating rapid movements, such as clapping, assesses for kinesthetic deficits.

This is incorrect. Touching a patient with a wisp of cotton assesses for tactile deficits.

PTS: 1 CON: Sensory Perception 7. ANS: 3 Chapter: Chapter 30 Sensation, Perception, & Response Objective: Plan and implement nursing interventions to meet the needs of clients with sensory deficits. Page: 774 (V1) Heading: Individualized Interventions for Gustatory Deficit Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Sensory Perception Difficulty: Moderate Feedback 1 This is incorrect. The nurse would teach the patient to provide frequent oral hygiene. 2 This is incorrect. The nurse would also teach the patient to eat foods separately to allow the taste of food to be distinguishable. 3 This is correct. The nurse would assess for sores or open areas in the mouth. 4 This is incorrect. Seasonings, salt substitutes, spices, or lemon may improve the taste of foods, so the patient should not avoid them. PTS: 1 CON: Sensory Perception 8. ANS: 1 Chapter: Chapter 30 Sensation, Perception, & Response Objective: Identify the components of the sensory experience. Page: 779 (V1) Heading: Box 30-2: Common Visual Deficits Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Sensory Perception Difficulty: Moderate Feedback 1 This is correct. Macular damage (degeneration) causes diminished central vision. 2 This is incorrect. Cataracts are caused by a cloudy lens and result in blurred vision. 3 This is incorrect. Glaucoma is pressure in the anterior cavity of the eye, which shifts the lens position.

This is incorrect. Astigmatism is irregular curvature of the cornea, resulting in blurred vision.

PTS: 1 CON: Sensory Perception 9. ANS: 4 Chapter: Chapter 30 Sensation, Perception, & Response Objective: Identify the factors that affect sensory stimulation. Page: 780 (V1) Heading: Box 30-3 Common Hearing Deficits Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Sensory Perception Difficulty: Moderate Feedback 1 This is incorrect. Otosclerosis is hardening of the bones of the middle ear, especially the stapes. 2 This is incorrect. Conduction deafness results when one of the structures that transmits vibrations is affected. 3 This is incorrect. Presbycusis is a progressive sensorineural loss associated with aging. 4 This is correct. Central deafness results from damage to the auditory areas in the temporal lobes. PTS: 1 CON: Sensory Perception 10. ANS: 2 Chapter: Chapter 30 Sensation, Perception, & Response Objective: Identify the factors that affect sensory stimulation. Page: 774 (V1) Heading: Box 30-1: Medications That Cause Smell and Taste Disturbances Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Sensory Perception Difficulty: Moderate Feedback 1 This is incorrect. Furosemide is not implicated in taste disturbances. 2 This is correct. Phenytoin is a medication that has a high incidence of associated taste disturbance. 3 This is incorrect. Glyburide is not implicated in taste disturbances. 4 This is incorrect. Heparin is not implicated in taste disturbances.

PTS: 1 CON: Sensory Perception 11. ANS: 4 Chapter: Chapter 30 Sensation, Perception, & Response Objective: Plan and implement nursing interventions to meet the needs of clients with sensory deficits. Page: 780 (V1) Heading: Sensory Deficits—Safety and Health Measures Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Sensory Perception Difficulty: Moderate Feedback 1 This is incorrect. The nurse would instruct the patient with a hearing deficit to install blinking lights to alert the patient to an incoming phone call. 2 This is incorrect. The nurse would instruct the patient with an olfactory deficit to have gas appliances inspected regularly to detect leaks. 3 This is incorrect. The patient with a tactile deficit would be instructed to use properly fitting shoes and socks. 4 This is correct. The nurse would instruct the visually impaired patient to avoid using throw rugs on the floors at home. PTS: 1 CON: Sensory Perception 12. ANS: 3 Chapter: Chapter 30 Sensation, Perception, & Response Objective: Plan and implement nursing interventions to meet the needs of clients with sensory deficits. Page: 638 (V2) Heading: Procedure 30-1 Performing Otic Irrigation Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Sensory Perception Difficulty: Moderate Feedback 1 This is incorrect. To straighten the ear canal of an adult, the nurse would pull the pinna up and outward. 2 This is incorrect. Pulling the ear straight back would not straighten the ear canal. 3 This is correct. The nurse would straighten the ear canal of a small child by pulling the pinna down and back. 4 This is incorrect. Pulling the pinna straight upward would not straighten the ear canal of a child.

PTS: 1 CON: Sensory Perception 13. ANS: 1 Chapter: Chapter 30 Sensation, Perception, & Response Objective: Plan and implement nursing interventions to meet the needs of clients with sensory deficits. Page: 638 (V2) Heading: Procedure 30-1 Performing Otic Irrigation Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Sensory Perception Difficulty: Moderate Feedback 1 This is correct. The nurse would first warm the irrigation solution to room temperature. 2 This is incorrect. In the second step, the nurse would assist the patient into a sitting position, with the head tilted away from the affected ear. 3 This is incorrect. For the third step, the nurse would straighten the ear canal by pulling up and back on the pinna. 4 This is incorrect. The last step consists of the nurse placing the tip of the nozzle into the entrance of the ear canal and directing the stream of irrigating solution gently along the top of the ear canal toward the back of the patient’s head. Irrigation should continue until the canal is clean. PTS: 1 CON: Sensory Perception 14. ANS: 3 Chapter: Chapter 30 Sensation, Perception, & Response Objective: Plan and implement nursing interventions to meet the needs of clients with sensory deficits. Page: 787 (V1) Heading: Essential Oils Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Comprehension [Understanding] Concept: Sensory Perception Difficulty: Moderate Feedback 1 This is incorrect. Lavender is used to promote relaxation. 2 This is incorrect. Roman chamomile is used to promote relaxation. 3 This is correct. Rosemary is stimulating and uplifting for many people. 4 This is incorrect. Ylang-ylang is used to promote relaxation.

PTS: 1 CON: Sensory Perception 15. ANS: 1 Chapter: Chapter 30 Sensation, Perception, & Response Objective: List the factors that place clients at risk for altered sensory perception. Page: 780 (V1) Heading: Box 30-3 Common Hearing Deficits Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Comprehension [Understanding] Concept: Sensory Perception Difficulty: Moderate Feedback 1 This is correct. Presbycusis, the loss of high-frequency tones, is an age-related change. 2 This is incorrect. Hyperopia is the ability to see distant objects well; it is not an age-related change. 3 This is incorrect. The ability to perceive touch diminishes with age; it does not increase. 4 This is incorrect. The ability to perceive taste diminishes with age; it does not increase. PTS: 1 CON: Sensory Perception 16. ANS: 4 Chapter: Chapter 30 Sensation, Perception, & Response Objective: Plan and implement nursing interventions to meet the needs of clients with sensory deficits. Page: 795 (V1) Heading: Patient Teaching Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Sensory Perception Difficulty: Difficult Feedback 1 This is incorrect. Cotton-tipped swabs should be avoided, as they can push the cerumen deeper into the ear. 2 This is incorrect. Ears should be kept dry. 3 This is incorrect. Ears should be cleaned daily with a washcloth, soap, and water. 4 This is correct. This statement indicates effective teaching because swimming pools can increase the risk for bacterial or fungal infections and should be

avoided until instructed by a healthcare provider. PTS: 1 CON: Sensory Perception 17. ANS: 3 Chapter: Chapter 30 Sensation, Perception, & Response Objective: List the factors that place clients at risk for altered sensory perception. Page: 783 (V1) Heading: Example Problem: Sensory Deficits Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Sensory Perception Difficulty: Moderate Feedback 1 This is incorrect. The trigeminal nerve transmits stimuli from the face and head. 2 This is incorrect. The glossopharyngeal nerve is responsible for taste. 3 This is correct. The olfactory nerve is responsible for the sense of smell. Damage to this nerve causes an impaired sense of smell. 4 This is incorrect. The vagus nerve is responsible for sensations of the throat, larynx, and thoracic and abdominal viscera. PTS: 1 CON: Sensory Perception 18. ANS: 4 Chapter: Chapter 30 Sensation, Perception, & Response Objective: Plan and implement nursing interventions to meet the needs of clients with sensory deficits. Page: 781 (V1) Heading: Individualized Interventions Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Sensory Perception Difficulty: Moderate Feedback 1 This is incorrect. The patient should have sufficient light but should avoid bright light, which might cause glare. Use of a magnifying lens or large-print books may be helpful. 2 This is incorrect. The patient should be encouraged to wear sunglasses, visors, or hats with brims when outdoors. 3 This is incorrect. Use of a magnifying lens or large-print books may be helpful. 4 This is correct. The nurse should place the patient’s eyeglasses within easy reach and make sure that they are clean and in good repair.

PTS: 1 CON: Sensory Perception 19. ANS: 1 Chapter: Chapter 30 Sensation, Perception, & Response Objective: Plan and implement nursing interventions to meet the needs of clients with sensory deficits. Page: 774 (V1) Heading: Table 30-1: Sensory Function Changes with Aging Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Sensory Perception Difficulty: Moderate Feedback 1 This is correct. Many medications cause xerostomia (dry mouth), which is the most common cause of impaired taste. 2 This is incorrect. Impaired sense of smell also affects the sense of taste; however, there is no reason to assume impaired sense of smell in this patient. 3 This is incorrect. Balance is related to the inner ear and to kinesthetic sense, not to taste and xerostomia. 4 This is incorrect. Xerostomia would be related to seizures only if a patient experienced dry mouth as an aura; this would be unusual. Even if this were the case, the information would allow the nurse to plan care for seizures, but not for the symptom of dry mouth. PTS: 1 CON: Sensory Perception 20. ANS: 1 Chapter: Chapter 30 Sensation, Perception, & Response Objective: State the nursing diagnoses and outcomes appropriate for clients with problems of sensory perception. Page: 778 (V1) Heading: Evaluation Integrated Processes: Communication and Documentation Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Sensory Perception Difficulty: Difficult Feedback 1 This is correct. The nurse would expect to document an improvement in hearing following removal of cerumen. Impacted cerumen can lead to diminished hearing. 2 This is incorrect. Bloody drainage is not a normal outcome following removal of

3 4

impacted cerumen. Bleeding can indicate a punctured eardrum. This is incorrect. Removing cerumen does not have an effect on sense of smell. This is incorrect. Mild dizziness is expected, but severe dizziness is not a normal finding following irrigation to remove impacted cerumen.

PTS: 1 CON: Sensory Perception 21. ANS: 3 Chapter: Chapter 30 Sensation, Perception, & Response Objective: Assess clients for the signs and symptoms of altered sensory perception. Page: 779 (V1) Heading: Box 30-2 Common Visual Deficits Integrated Processes: Communication and Documentation Client Need: Physiological Integrity: Basic Care or Comfort Cognitive Level: Application [Applying] Concept: Sensory Perception Difficulty: Moderate Feedback 1 This is incorrect. Glaucoma is a type of vision loss caused by increased pressure in the anterior cavity of the eyeball resulting in loss of peripheral vision. The fraction 20/100 is unrelated to glaucoma. 2 This is incorrect. Macular degeneration is the loss of central vision due to damage to the macula lutea, the central portion of the retina. This results in loss of central and near vision. The fraction 20/100 is unrelated to identifying macular degeneration. 3 This is correct. Myopia, or nearsightedness, means that the person is able to see close objects well but not distant objects. For example, a person with 20/100 vision can see an object from 20 feet away that a person with normal sight could see from a distance of 100 feet. 4 This is incorrect. Hyperopia, or farsightedness, implies that the eye sees distant objects well. A person with hyperopia may have 20/10 vision—he can see an object form 20 feet that a normal eye can see from 10 feet. PTS: 1 CON: Sensory Perception 22. ANS: 3 Chapter: Chapter 30 Sensation, Perception, & Response Objective: State the nursing diagnoses and outcomes appropriate for clients with problems of sensory perception. Page: 780 (V1) Heading: Visual Deficit Integrated Processes: Nursing Process Client Need: Safe and Effective Care: Safety and Infection Control Cognitive Level: Application [Applying]

Concept: Sensory Perception Difficulty: Moderate

2 3 4

Feedback This is incorrect. The patient, owing to a visual impairment, may have deficits with feeding, dressing, and social interaction; however, the highest priority is promoting safety and reducing the patient’s risk for falls. This is incorrect. The patient may have a deficit with social interaction; however, the highest priority is promoting safety and reducing risk for falls. This is correct. The priority nursing diagnosis for a patient with a visual impairment is Risk for Falls. This is incorrect. The patient may have a deficit in feeding, but the highest priority is promoting safety and reducing fall risk.

PTS: 1 CON: Sensory Perception 23. ANS: 3 Chapter: Chapter 30 Sensation, Perception, & Response Objective: Assess clients for the signs and symptoms of altered sensory perception. Page: 783 (V1) Heading: Assess Level of Consciousness Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care or Comfort Cognitive Level: Analysis [Analyzing] Concept: Sensory Perception Difficulty: Difficult

1 2

3 4

Feedback This is incorrect. Asking the patient to repeat a sequence of words (e.g., glasses, rocket, truck) assesses recall and recent memory. This is incorrect. Asking a patient for the date of retirement assesses long-term memory but does not reflect the patient’s orientation status to the present time and situation. This is correct. To assess level of orientation, the best question is to ask the patient for name, date, and current location. This is incorrect. Asking a patient what was eaten for breakfast assesses shortterm memory only.

PTS: 1 CON: Sensory Perception 24. ANS: 2 Chapter: Chapter 30 Sensation, Perception, & Response Objective: Assess clients for the signs and symptoms of altered sensory perception. Page: 779 (V1)

Heading: Box 30-2. Common Visual Deficits Integrated Processes: Communication and Documentation Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Sensory Perception Difficulty: Moderate Feedback 1 This is incorrect. Strabismus (“crossed eyes”) is the condition wherein one eye deviates from a fixed image. 2 This is correct. A cataract is a cloudy film over the lens of the eyes resulting in blurred vision, sensitivity to glare and bright light, halos around lights, fading or yellowing of colors, and image distortion. 3 This is incorrect. Glaucoma is a condition involving increasing pressure in the eyes that can lead to loss of peripheral vision and even blindness, if not treated. 4 This is incorrect. Presbyopia is a change in vision associated with aging, in which a person is less able to accommodate to near objects. PTS:

CON: Sensory Perception

MULTIPLE RESPONSE 25. ANS: 1, 4 Chapter: Chapter 30 Sensation, Perception, & Response Objective: Identify the factors that affect sensory stimulation. Page: 773 (V1) Heading: Medications Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Comprehension [Understanding] Concept: Sensory Perception Difficulty: Difficult

1. 2. 3. 4. 5.

Feedback This is correct. Furosemide may cause ototoxicity, leading to auditory nerve impairment. This is incorrect. Digoxin does not place the patient at risk for auditory nerve impairment. This is incorrect. Famotidine does not place the patient at risk for auditory nerve impairment. This is correct. Aspirin may cause ototoxicity, leading to auditory nerve impairment. This is incorrect. Penicillin does not place the patient at risk for auditory nerve damage.

PTS: 1 CON: Sensory Impairment 26. ANS: 1, 3, 5 Chapter: Chapter 30 Sensation, Perception, & Response Objective: List the factors that place clients at risk for altered sensory perception. Page: 774 (V1) Heading: Hearing Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Sensory Perception Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is correct. Older adults experience a generalized decrease in the number of nerve conduction fibers and structural changes in the ear, which cause hearing loss. This is incorrect. Chickenpox does not place the patient at risk for hearing loss. This is correct. Having had frequent ear infections (otitis media) places a patient at risk for hearing loss because of scarring that may have occurred. This is incorrect. Diabetes mellitus does not place the patient at risk for hearing loss. This is correct. Sensorineural deafness, eye abnormalities, and congenital heart disease are the classic triad that occurs with congenital rubella.

PTS: 1 CON: Sensory Perception 27. ANS: 1, 2 Chapter: Chapter 30 Sensation, Perception, & Response Objective: Compare and contrast sensory deprivation and sensory overload. Page: 778 (V1) Heading: Example Problem: Sensory Overload Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Sensory Perception Difficulty: Moderate

Feedback This is correct. The patient with sensory overload might exhibit disorientation, confusion, restlessness, decreased attention span and ability to perform tasks, anxiety, muscle tension, and difficulty sleeping. This is correct. The patient with sensory overload might exhibit disorientation, confusion, restlessness, decreased attention span and ability to perform tasks, anxiety, muscle tension, and difficulty sleeping.

3. 4. 5.

This is incorrect. Sensory deprivation leads to hallucinations. This is incorrect. Sensory deprivation causes depression. This is incorrect. Sensory deprivation can cause preoccupation with somatic complaints.

PTS: 1 CON: Sensory Perception 28. ANS: 2, 3, 4, 5 Chapter: Chapter 30 Sensation, Perception, & Response Objective: Plan and implement nursing interventions to prevent sensory deprivation and sensory overload. Page: 778 (V1) Heading: Example Problem: Sensory Overload Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Sensory Perception Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is incorrect. Television can be used to provide sensory stimuli, but not to prevent sensory overload. When used, it should not be left on indiscriminately. This is correct. To prevent sensory overload, the use of unnecessary light should be minimized. This is correct. The nurse should plan care to provide uninterrupted periods of sleep. This is correct. The nurse would speak to the patient in a moderate tone of voice. This is correct. Medications and some substances that stimulate the central nervous system, such as caffeine, may also contribute to sensory overload.

PTS: 1 CON: Sensory Perception 29. ANS: 1, 3, 4 Chapter: Chapter 30 Sensation, Perception, & Response Objective: Plan and implement nursing interventions to meet the needs of clients with sensory deficits. Page: 788 (V1) Heading: Caring for Patients With Altered Level of Consciousness Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Sensory Perception Difficulty: Difficult Feedback

1. 2. 3.

4. 5.

This is correct. It is important to talk to the patient because the sense of hearing may still be intact. This provides some stimulation and may help with reality orientation. This is incorrect. Providing touch will also help prevent sensory deficit; however, it is not a safety measure. This is correct. If the patient’s blink reflex is absent or her eyes do not totally close, you may need to give frequent eye care to keep secretions from collecting along the lid margins. The eyes may be patched to prevent corneal drying, and lubricating eye drops may be ordered. This is correct. Safety measures are a priority for unconscious clients. Keep the bed in low position when you are not at the bedside, and keep the siderails up. This is incorrect. The unconscious patient would have a minimal or absent gag reflex and lack of swallowing; therefore, you would not squirt fluid in the mouth for oral care because it could cause the patient to aspirate.

PTS: 1 CON: Sensory Perception 30. ANS: 1, 2 Chapter: Chapter 30 Sensation, Perception, & Response Objective: Plan and implement nursing interventions to prevent sensory deprivation and sensory overload. Page: 776 (V1) Heading: Example Problem: Sensory Deprivation Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Sensory Perception Difficulty: Difficult

3. 4. 5.

Feedback This is correct. Talking to the patient while providing care is not only important for personal and meaningful interaction, but also reduces social isolation and sensory deprivation. This is correct. If the patient consents, you can stimulate the sense of touch by brushing his hair or giving a back rub, for example. However, use touch carefully, considering personal and cultural preferences, while observing the patient’s reaction. This is incorrect. Provide enough light, but avoid glare; use soft, diffuse lighting, not bright, fluorescent light. This is incorrect. Teach clients to drink water between bites (not waiting until after the meal) to distinguish the taste of the food more readily. This is incorrect. Seasonings, salt substitutes, spices, or lemon may improve the taste of foods and encourage the client’s appetite. But avoid overseasoning food with excessively spicy food that overpowers the person’s sense of taste.

PTS: 1 CON: Sensory Perception 31. ANS: 1, 2, 4, 5 Chapter: Chapter 30 Sensation, Perception, & Response Objective: Plan and implement nursing interventions to meet the needs of clients with sensory deficits. Page: 792 (V1) Heading: Promote Orientation Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Sensory Perception Difficulty: Difficult

1. 2.

4. 5.

Feedback This is correct. Place personal objects, photos, and mementos in the immediate environment, and discuss them with the client. This is correct. Introduce yourself and state the client’s name each time you meet with him; wear a readable (large, plain type) nametag to reinforce your introduction. Also identify the day, date, and time as you interact. This is incorrect. While you may sometimes find it necessary to bathe the patient, that intervention wouldn’t be expected to improve orientation. Furthermore, encouraging the patient to relax would likely be ineffective in relaxing the patient, and might even elicit anger. This is correct. Encourage the patient to participate in familiar activities, such as bathing. This is correct. To promote patient orientation for a patient with confusion (e.g., dementia), use simple communication and offer few choices with ADLs to prevent from overwhelming the patient.

PTS: 1 CON: Sensory Perception 32. ANS: 1, 2, 3 Chapter: Chapter 30 Sensation, Perception, & Response Objective: Assess clients for the signs and symptoms of altered sensory perception. Page: 774 (V1) Heading: Table 30-1 Sensory Function Changes With Aging Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Comprehension [Understanding] Concept: Sensory Perception Difficulty: Moderate Feedback

1. 2. 3. 4. 5.

This is correct. A decreased number of nerve conduction fibers resulting in slower reflexes occurs with aging. This is correct. Less flexibility of the lens resulting in decreased ability to focus on near objects is an age-related change. This is correct. Atrophy of taste buds resulting in decreased ability to taste is a sensory change occurring with aging. This is incorrect. Regulation of body temperature is not a sensory deficit. This is incorrect. Cerumen is drier and more solid with aging, creating hearing loss.

PTS: 1 CON: Sensory Perception 33. ANS: 1, 2, 3, 5 Chapter: Chapter 30 Sensation, Perception, & Response Objective: Assess clients for the signs and symptoms of altered sensory perception. Page: 788 (V1) Heading: Assess Mental Status Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Sensory Perception Difficulty: Difficult

1. 2. 3. 4. 5.

Feedback This is correct. Behavior is included in the mental status assessment. This is correct. Judgment is included in the mental status assessment. This is correct. Knowledge is included in the mental status assessment. This is incorrect. Assessment of reflexes is associated with a complete and in-depth neurological assessment. This is correct. Appearance is part of the mental status assessment.

PTS: 1 CON: Sensory Perception 34. ANS: 2, 4, 5 Chapter: Chapter 30 Sensation, Perception, & Response Objective: Plan and implement nursing interventions to prevent sensory deprivation and sensory overload. Page: 793 (V1) Heading: Seizure Precautions Integrated Processes: Nursing Process Client Need: Safe and Effective Care: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Sensory Perception Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is incorrect. Do not try to open the mouth and insert a tongue depressor. This action could result in injury to the patient or injury to the nurse (biting). This is correct. When a seizure is occurring, the nurse would turn the patient to his side to prevent aspiration. This is incorrect. Do not attempt to restrain the patient, as this may result in muscle and joint injury. This is correct. In the event of a seizure, the nurse should loosen any restrictive clothing. This is correct. The nurse would pad the siderails, head, and foot of the bed to prevent injury sustained during a seizure.

PTS: 1 CON: Sensory Perception 35. ANS: 3, 4, 5 Chapter: Chapter 30 Sensation, Perception, & Response Objective: Plan and implement nursing interventions to meet the needs of clients with sensory deficits. Page: 795 (V1) Heading: After the Seizure Integrated Processes: Nursing Process Client Need: Safe and Effective Care: Management of Care Cognitive Level: Application [Applying] Concept: Legal Difficulty: Moderate

2. 3. 4. 5.

Feedback This is incorrect. A CNA may not perform ear irrigation. This requires knowledge and skill of a professional nurse. A CNA may obtain vital signs and suction the patient’s oropharynx postseizure and may perform the tasks of setting up seizure precautions, which includes padding the side of the bed to prevent injury or administer eye drops, as these interventions require knowledge, skills, and assessment of the professional nurse. This is incorrect. A CNA cannot administer eye drops, as this intervention requires skill of a professional nurse. This is correct. A CNA may obtain vital signs. This is correct. A CNA may initiate seizure precautions. This is correct. A CNA may suction a patient following a seizure.

PTS: 1 CON: Legal 36. ANS: 1, 3, 4 Chapter: Chapter 30 Sensation, Perception, & Response

Objective: Plan and implement nursing interventions to meet the needs of clients with sensory deficits. Page: 777 (V1) Heading: Pet Therapy Integrated Processes: Caring Client Need: Psychosocial Integrity Cognitive Level: Knowledge [Remembering] Concept: Sensory Perception Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is correct. Pet therapy has been shown to increase socialization in residents in long-term care facilities. This is incorrect. Pet therapy decreases blood pressure. This is correct. Pet therapy is known to decrease pain in residents of long-term care facilities. This is correct. Pet therapy is known to decrease loneliness in residents of long-term care facilities. This is incorrect. There is no evidence supporting insomnia is decreased in residents participating in pet therapy.

PTS: 1 CON: Sensory Perception 37. ANS: 1, 2, 3 Chapter: Chapter 30 Sensation, Perception, & Response Objective: Identify the factors that affect sensory stimulation. Page: 776 (V1) Heading: Example Problem: Sensory Deprivation Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Analysis [Analyzing] Concept: Sensory Perception Difficulty: Moderate

1. 2. 3.

Feedback This is correct. A nonstimulating, monotonous environment increases the risk for sensory deprivation, such as in people who are homebound. This is correct. Individuals in prison are at risk for sensory deprivation due to being in an isolated environment. This is correct. Patients with depression are at risk for sensory deprivation, as they might be withdrawn from others and activities or less apt to interact within the usual context of their lives. This is incorrect. Patients with anxiety often experience sensory overload.

This is incorrect. Pain lowers the threshold for processing sensory input, which increases the risk for sensory overload.

PTS: 1 CON: Sensory Perception 38. ANS: 1, 2, 3, 5 Chapter: Chapter 30 Sensation, Perception, & Response Objective: List the factors placing clients at risk for altered sensory perception. Page: 793 (V1) Heading: Common Triggers Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Sensory Perception Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is correct. Fever is a common trigger of seizures. This is correct. The most common reason for seizures in a person with epilepsy is failure to take the prescribed antiseizure medication. This is correct. Lack of sleep can trigger a seizure. This is incorrect. Ingesting a food allergen invokes an immunological response with reactions related to anaphylaxis. This is correct. Ingestion of a mood-altering substance can trigger a seizure.

PTS: 1 CON: Sensory Perception 39. ANS: 1, 2, 3, 5 Chapter: Chapter 30 Sensation, Perception, & Response Objective: List the factors that place clients at risk for altered sensory perception. Page: 784 (V1) Heading: Example Problem: Sensory Deficits Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Knowledge [Remembering] Concept: Sensory Perception Difficulty: Difficult

Feedback This is correct. Diseases that affect circulation may impair function of the sensory receptors and the brain, thereby altering perception and response. Some diseases affect specific sensory organs. Diabetic retinopathy is the leading cause of blindness among adults age 20 to 74. This is correct. Hypertension can damage the retina of the eye.

3. 4. 5.

This is correct. Neurological disorders, such as multiple sclerosis, slow the transmission of nerve impulses. This is incorrect. There is no indication that breast cancer leads to sensory deficits. This is correct. Zinc deficiency can cause anosmia, which is reduced sense of smell.

PTS:

CON: Sensory Perception

Chapter 31. Pain Multiple Choice Identify the choice that best completes the statement or answers the question. 1. A patient suddenly develops right-lower-quadrant pain, nausea, vomiting, and rebound tenderness. How should the nurse classify this patient’s pain? 1. Acute 2. Chronic 3. Intractable 4. Neuropathic 2. How should the nurse classify pain that a patient with lung cancer is experiencing? 1. Cutaneous 2. Deep somatic 3. Visceral 4. Neuropathic 3. A patient who underwent left above-the-knee amputation reports pain in the left foot. The nurse should document this finding as what type of pain? 1. Psychogenic 2. Phantom 3. Referred 4. Radiating 4. A nurse is working in nursery and observes an infant crying after a procedure. Which action would be appropriate for the nurse to take? 1. Nothing, newborns are not as sensitive. 2. Place the infant under a warmer. 3. Administer oral sucrose. 4. Give a pain injection. 5. In which process do peripheral nerves carry the pain message to the dorsal horn of the spinal cord? 1. Transduction 2. Transmission 3. Perception 4. Modulation 6. A patient reports using music therapy to help control the chronic pain. Music therapy works by prompting the release of endogenous opioids during which stage of the pain process? 1. Perception 2. Transduction 3. Transmission 4. Modulation

7. The nurse is assessing an intubated patient who returned from coronary artery bypass surgery 3 hours ago. Which assessment finding might indicate that this patient is experiencing pain? 1. Blood pressure 160/82 mm Hg 2. Temperature 100.6°F (38.1°C) 3. Heart rate 80 beats/min 4. Oxygen saturation 95% 8. A patient who sustained rib fractures in a motor vehicle accident is stating that the pain medication is ineffective. Inadequate pain control places this patient at risk for which complication? 1. Metabolic alkalosis 2. Overventilation 3. Pneumonia 4. Hypocarbia 9. When should the nurse assess pain? 1. With a change in the patient’s condition 2. After the nurse finishes charting 3. Every 4 hours for the first 2 days after surgery 4. Only when the patient reports pain 10. A patient who had surgery is receiving patient-controlled analgesia (PCA). Which statement by the patient indicates an understanding of PCA use? 1. “I will not push the button too many times, so I won’t get overdosed.” 2. “I will need to be careful not to roll over the button when I sleep.” 3. “I will be the only one that presses the button.” 4. “I will use this button to help me sleep better.” 11. A nurse is preparing to administer pain medications to a client. Which statement by the nurse indicates correct understanding of the guidelines for pain management? 1. “I will administer the pain medication around the clock.” 2. “I will encourage the client to wait as long as possible between doses.” 3. “I will wait to give pain medication until the client shows signs of pain.” 4. “I will assess the need for medication only if the client reports pain.” 12. The nurse administers acetaminophen 325 mg and codeine 30 mg orally to a patient reporting a severe headache. When should the nurse reassess the patient’s pain? 1. 15 minutes after administration 2. 30 minutes after administration 3. 90 minutes after administration 4. Immediately before the next dose is due 13. After receiving ibuprofen 800 mg orally for right hip pain, the patient states that the pain is 8 out of 10 on the numerical pain scale. Which action should the nurse take next? 1. Use nonpharmacological therapy while waiting 3 more hours before the next dose.

2. Administer an additional 800 mg oral dose of ibuprofen right away. 3. Do nothing because the patient’s facial expression indicates an absence of pain. 4. Notify the prescriber that the current pain management plan is ineffective. 14. The nurse is teaching a client who sustained an ankle injury about cold application. Which instruction should the nurse include in the teaching plan? 1. Place the cold pack directly on the skin over the ankle. 2. Apply the cold pack to the ankle for 30 minutes at a time. 3. Check the skin frequently for extreme redness. 4. Keep the cold pack in place for at least 24 hours. 15. The nurse plays music for a child with leukemia who is experiencing pain. Which pain management technique is this nurse using? 1. Distraction 2. Guided imagery 3. Sequential muscle relaxation 4. Hypnosis 16. The male nurse uses his hands to direct energy fields surrounding the patient’s body. After this intervention, the patient states that the pain has lessened. How should the nurse document the intervention? 1. Tactile distraction was performed and appeared effective in reducing pain. 2. Guided imagery was effective in relaxing the patient and reducing the pain. 3. Therapeutic touch was performed; patient verbalized lessening of pain after treatment. 4. Sequential muscle relaxation was performed; patient states pain is less. 17. A patient prescribed a nonsteroidal anti-inflammatory drug (NSAID), naproxen, for the treatment of arthritis reports stomach upset. What should the nurse instruct the patient to do? 1. Take the medication on an empty stomach. 2. Take the medication with food. 3. Take the medication with 8 ounces of water. 4. Take the medication before bedtime. 18. A patient is prescribed morphine sulfate 4 mg intravenously for postoperative pain. Which action should the nurse take before administering the medication? 1. Monitor the patient’s respiratory status. 2. Auscultate the patient’s heart sounds. 3. Check blood pressure with the patient in the supine and sitting positions. 4. Assess the patient for elevated temperature. 19. A client reports taking acetaminophen to control osteoarthritis. Which instruction should the nurse give the client requiring long-term acetaminophen use? 1. Caution the client against combining acetaminophen with alcohol. 2. Inform the client that acetaminophen increases the risk for bleeding.

3. Advise taking acetaminophen with meals to prevent gastric irritation. 4. Explain that physical dependence may occur with long-term oral use. 20. Which side effect associated with opioid use may improve after taking a few doses of the drug? 1. Paradoxical reaction 2. Drowsiness 3. Dry mouth 4. Difficulty with urination 21. A patient develops a respiratory rate of 6 breaths/min after receiving intravenous hydromorphone 2 mg. Which medication should the nurse anticipate administering to this patient after notifying the prescriber of this side effect? 1. Piroxicam 2. Oxycodone 3. Naloxone 4. Meperidine 22. Which pain management task can be safely delegated to the unlicensed assistive personnel (UAP)? 1. Assessing the quality and intensity of the patient’s pain 2. Evaluating the effectiveness of pain medication 3. Providing a therapeutic back massage 4. Administering oral dose of acetaminophen 23. Which expected outcome is best for the patient with a nursing diagnosis of Acute Pain related to movement and secondary to surgical resection of a ruptured spleen and possible inadequate analgesia? 1. The patient will verbalize reduction in pain after receiving pain medication and repositioning. 2. The patient will rest quietly when undisturbed. 3. On a scale of 0 to 10, the patient will rate pain as a 3 while in bed or as a 4 during ambulation. 4. The patient will receive pain medication every 2 hours, as prescribed. 24. A patient had a bowel resection 5 days ago. Which patient behavior might alert the nurse that the patient has a history of substance abuse? 1. Requests oral pain medication once every 6 to 8 hours 2. Wants continued use of Patient-controlled analgesic 3. Requests oral pain medication instead of the IV form 4. Wants only nonpharmacological pain measures 25. A patient with Raynaud’s disease receives no symptomatic relief with medication. Which surgical intervention might be a treatment option for this patient to help provide pain relief? 1. Cordotomy 2. Rhizotomy 3. Neurectomy

4. Sympathectomy 26. A nurse using the Richmond Agitation-Sedation Scale documents a patient has a score of +1 before pain medication but after pain medication has a score of –2. Which patient behaviors did the nurse observe? 1. Was restless before the pain medication but after pain medication awakens with eye contact to verbal stimulation. 2. Was agitated before the pain medication but after pain medication was not responsive to voice or physical stimulation. 3. Was pulling on IV tubing before the pain medication but after pain medication was alert and calm. 4. Was combative before the pain medication but after pain medication was drowsy. 27. A patient with a history of mitral valve replacement on long-term anticoagulant therapy, hypertension, and type 2 diabetes mellitus undergoes emergency abdominal surgery. Which factor contraindicates the use of epidural analgesia in this patient? 1. Anticoagulant therapy 2. Diabetes mellitus 3. Hypertension 4. Emergency abdominal surgery 28. After undergoing dural puncture while receiving epidural pain medication, a patient reports a headache. Which action can help alleviate the patient’s pain? 1. Suggest the client ambulate to promote flow of spinal fluid. 2. Offer caffeinated beverages to constrict blood vessels in the head. 3. Encourage coughing and deep breathing to increase intracranial pressure. 4. Restrict oral fluid intake to prevent excess spinal pressure. 29. An older adult receiving hospice care has dementia as a result of metastasis to the brain. The bone cancer has progressed to an advanced stage. Why might the client fail to request pain medication as needed? 1. Experiences less pain than in earlier stages of cancer 2. Cannot communicate the character of the pain effectively 3. Does not feel pain because of the dementia 4. Relies on caregiver to provide pain relief without asking 30. What is typically the most reliable indicator of pain? 1. Patient’s self-report 2. Past medical history 3. Description by caregivers 4. Behavioral cues 31. To provide the most analgesic effect, a medication should bind with and block the pain impulse especially at which opioid receptor sites? 1. Mu

2. Delta 3. Kappa 4. Sigma 32. A 70-year-old male with diabetic peripheral neuropathy reports a burning sensation in his feet. He also states, “Those pain pills make me feel funny, and they don’t help my pain, so I don’t take them.” Which medication is likely to be most beneficial in treating this patient’s neuropathic pain? 1. Morphine 2. Fentanyl 3. Gabapentin 4. Hydromorphone 33. The patient has an epidural catheter for analgesia. Which signs and symptoms would alert the nurse to local anesthesia toxicity? 1. Loss of motor function 2. Leaking at the site 3. Urinary retention 4. Ringing in the ears 34. Which characteristic about pain would the nurse most consider when developing a pain management plan for a patient with chronic lower back pain? 1. An objective experience that disrupts daily living that can be measured with altered vital signs 2. An unpleasant sensory and emotional experience association with actual or potential tissue damage, or described in terms of such damage 3. A generalized response of the body as a result of trauma or damage to the tissues resulting in discomfort 4. An emotional response to tissue damage that differs significantly from one individual to another 35. The nurse conducting a pain assessment for a patient would recognize deep somatic pain as having which characteristic? 1. Achy 2. Superficial 3. “Pins and needles” 4. Crampy 36. The nurse is caring for several clients with patient controlled analgesia. It would be most important to assess for respiratory depression in the client with: 1. Diverticulitis 2. Gallbladder disease 3. Sleep apnea 4. Seasonal allergies

37. The pediatric nurse is caring for a 4-year-old child who is experiencing chronic pain secondary to tissue and joint injury from past sickle cell anemia crises. Which nonpharmacological pain reduction intervention might the nurse have the child try? 1. Perform vigorous activity. 2. Practice visualization. 3. Listen to rap music. 4. Watch a funny movie. 38. The nurse is caring for an immobile patient with chronic, unrelieved pain that is frequently severe. For which potential complication should the nurse monitor? 1. Urinary retention 2. Hypotension 3. Dehydration 4. Hypoglycemia 39. The postoperative patient who had arthroscopic right shoulder joint surgery is receiving pain medication through a pump directly into the shoulder joint. Which route for pain medication will the nurse report the patient is receiving? 1. Transdermal 2. Intrathecal 3. Intra-articular 4. Epidural 40. What is the primary reason the nurse incorporates pain assessment as a part of routine care? 1. Asking about pain may prompt patients to report pain more readily. 2. Frequent pain assessment is required by the state’s nurse practice act. 3. Pain is a vital sign much like blood pressure and heart rate. 4. Performing a pain assessment indicates the nurse cares about the patient. 41. The nurse is talking to a patient with chronic pain secondary to permanent joint damage from rheumatoid arthritis about developing a pain management program. Which goal identified by the patient would be realistic for the program? 1. “I would like all my pain to be gone and not recur in the future.” 2. “I want to be able to do all the things I used to do before this pain started.” 3. “I want to control the pain enough to allow me to perform my daily activities.” 4. “I would like to lead a normal life without experiencing so much pain every day.” 42. The patient reports pain after surgery, ranking it 6 on a scale of 1 to 10. The patient tells the nurse, “I don’t want to be all doped up. My family is coming to visit and I want to be alert enough to visit with them.” Which medication would most likely be effective for postoperative pain relief without excessive sedation? 1. Fentanyl IV 2. Morphine IV 3. Ibuprofen PO 4. Hydrocodone PO

43. Which action would the nurse prioritize first for the older adult patient who is experiencing neuropathic pain that interferes with activities of daily living (ADLs) and cannot find relief using a variety of methods? 1. Maintain a pain journal to document quality of the pain experience. 2. Meet with the healthcare team to discuss a pain management plan. 3. Attempt to take only analgesic medication when absolutely needed. 4. Suggest use of a deep-pressure back massage with effleurage technique. 44. A 73-year-old patient admitted after a stroke has expressive aphasia (inability to express words accurately). Which pain intensity scale would be most appropriate to use with this patient? 1. Simple descriptor scale 2. Numerical rating scale 3. Wong-Baker FACES rating scale 4. PAINAD scale Multiple Response Identify one or more choices that best complete the statement or answer the question. 45. A 64-year-old female patient just returned from surgery. She is breathing rapidly and moving constantly in bed. She states, “I am scared, and I hurt so much.” What would be appropriate interventions? Select all that apply. 1. Immediately notify the surgeon of these data (physical symptoms and patient’s statement). 2. State calmly, “I am going to do everything I can to make you more comfortable.” 3. Tell the patient, “Let’s take some deep breaths together; watch me, and we will breathe together.” 4. Have the unlicensed assistive personnel (UAP) stay with the patient, and prepare to administer an analgesic. 5. Ask the patient to describe where she is hurting and the intensity of the pain. 46. The nurse meets with a patient with chronic pain who has tried a new program to manage pain. On a scale of 1 to 10, the patient reports pain reduction from an 8 to a 5. Which questions would the nurse ask to further evaluate the effectiveness of this program? Select all that apply. 1. “Does this reduction in pain allow you to perform daily activities?” 2. “Are you satisfied with the degree of pain relief you have achieved?” 3. “May I review what you have recorded in your pain journal?” 4. “Is the pain less than before you started the program?” 5. “How is your quality of life, according to the family’s standards?” 47. The nurse is caring for a patient in the late stage of Alzheimer’s disease who is noncommunicative. The nurse suspects the patient is experiencing acute pain based on which assessment findings? Select all that apply. 1. Rapid blinking

2. 3. 4. 5.

Labored breathing Reduced respiratory rate Eating food regularly Restlessness

Chapter 31. Pain Answer Section MULTIPLE CHOICE 1. ANS: 1 Chapter: Chapter 31 Pain Objective: Classify pain according to origin, cause, duration, and quality. Page: 799 (V1) Heading: Duration of Pain Integrated Processes: Communication and Documentation Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Comprehension [Understanding] Concept: Comfort Difficulty: Easy Feedback 1 This is correct. Acute pain typically has a short duration and a rapid onset. 2 This is incorrect. Chronic pain lasts longer than 6 months and interferes with daily activities. 3 This is incorrect. Intractable pain is chronic and highly resistant to relief. 4 This is incorrect. Neuropathic pain is a type of chronic pain that occurs from injury to one or more nerves. PTS: 1 CON: Comfort 2. ANS: 3 Chapter: Chapter 31 Pain Objective: Classify pain according to origin, cause, duration, and quality. Page: 798 (V1) Heading: Origin of Pain Integrated Processes: Communication and Documentation Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Comprehension [Understanding] Concept: Comfort Difficulty: Moderate Feedback 1 This is incorrect. Cutaneous pain occurs in the superficial layers of the skin or subcutaneous tissue. 2 This is incorrect. Deep somatic pain originates in the ligaments, tendons, nerves, blood vessels, and bones. Deep somatic pain is localized and can be described as achy or tender. 3 This is correct. All organ cancers produce visceral pain. Visceral pain is caused

by the stimulation of deep internal pain receptors. This is incorrect. Neuropathic pain is a complex and often chronic pain that arises when injury to one or more nerves results in repeated transmission of pain signals even in the absence of painful stimuli.

PTS: 1 CON: Comfort 3. ANS: 2 Chapter: Chapter 31 Pain Objective: Classify pain according to origin, cause, duration, and quality. Page: 798 (V1) Heading: Origin of Pain Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Pain Cognitive Level: Comprehension [Understanding] Concept: Comfort Difficulty: Easy Feedback 1 This is incorrect. Psychogenic pain refers to pain that is believed to arise from the mind. The patient perceives the pain despite the fact that no physical cause can be identified. 2 This is correct. The nurse should document this finding as phantom pain. Phantom pain is pain that is perceived to originate in an area that has been amputated. Patients with amputated limbs may still perceive that the limb exists and experience burning, itching, and deep pain in that area. 3 This is incorrect. Referred pain occurs in an area distant from the original site. 4 This is incorrect. Radiating pain starts at the source but extends to other locations. PTS: 1 CON: Comfort 4. ANS: 3 Chapter: Chapter 31 Pain Objective: Discuss nonpharmacological pain relief measures. Page: 811 (V1) Heading: Oral Sucrose Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Comfort Difficulty: Moderate Feedback 1 This is incorrect. The nurse should treat the pain. Newborns have the same sensitivity to pain as older infants and children; preterm infants may have a

2 3 4

greater sensitivity (McCaffery & Pasero, 1999). This is incorrect. Placing the infant under the warmer will not help alleviate the pain. This is correct. Sucrose can help decrease newborns’ pain. It can be given orally, alone or in combination with other pain medication. This is incorrect. Administer analgesics using the least invasive route available. Avoid the intramuscular route when possible.

PTS: 1 CON: Comfort 5. ANS: 2 Chapter: Chapter 31 Pain Objective: Discuss the two physiological mechanisms involved in pain modulation. Page: 800 (V1) Heading: Transmission Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Knowledge [Remembering] Concept: Comfort Difficulty: Difficult Feedback 1 This is incorrect. In the process of transduction, nociceptors become activated by the perception of potentially damaging mechanical, thermal, and chemical stimuli. 2 This is correct. Peripheral nerves carry the pain message to the dorsal horn of the spinal cord during a process known as transmission. 3 This is incorrect. Perception involves the recognition of pain by the frontal cortex of the brain. 4 This is incorrect. During modulation, pain signals can be facilitated or inhibited, and the perception of pain can be changed. PTS: 1 CON: Comfort 6. ANS: 4 Chapter: Chapter 31 Pain Objective: Discuss the two physiological mechanisms involved in pain modulation. Page: 802 (V1) Heading: Pain Modulation > The Endogenous Analgesia System and Nonpharmacological Pain Relief Measures Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Comfort Difficulty: Moderate

1 2

3 4

Feedback This is incorrect. Music therapy does not release endogenous opioids during perception, which is recognizing the pain sensation. This is incorrect. Music therapy does not occur during transduction, which is converting potentially damaging stimuli into electrical activity leading to pain sensation. This is incorrect. Music therapy does not help control pain during transmission, which is relaying the pain message. This is correct. Music therapy can prompt the release of endogenous opioids during the modulation stage, which is the stage of the pain process where the perception of pain changes.

PTS: 1 CON: Comfort 7. ANS: 1 Chapter: Chapter 31 Pain Objective: Describe the physiological changes that occur with pain. Page: 803 (V1) Heading: Communication and Cognitive Impairments > Indicators of Pain Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Comfort Difficulty: Moderate Feedback 1 This is correct. This patient has an elevation in blood pressure, which is a physiological finding associated with pain. 2 This is incorrect. While the patient has a mild temperature elevation, this is not from pain. 3 This is incorrect. A physiological cue of a patient in pain is an elevated heart rate. This patient’s heart rate is within normal limits. 4 This is incorrect. Oxygen saturation is within normal limits and does not indicate pain. PTS: 1 CON: Comfort 8. ANS: 3 Chapter: Chapter 31 Pain Objective: Identify the effect of unrelieved pain on each of the body systems. Page: 805 (V1) Heading: Unrelieved Pain > Respiratory System Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying]

Concept: Comfort Difficulty: Difficult Feedback 1 This is incorrect. Respiratory acidosis, not metabolic alkalosis, may result from the shallow breaths caused by pain and restricted chest wall movement with splinting. 2 This is incorrect. Patients with rib fractures tend to breathe shallowly, leading to underventilation, not overventilation, when pain control is inadequate. 3 This is correct. Pain associated with rib fractures causes splinting. Splinting often causes the patient to breathe shallowly, leading to possible pneumonia, especially if pain control is inadequate. 4 This is incorrect. Hypercarbia, not hypocarbia, occurs from retained carbon dioxide if pain control is inadequate. PTS: 1 CON: Comfort 9. ANS: 1 Chapter: Chapter 31 Pain Objective: Explain why pain should be considered the fifth vital sign. Page: 805 (V1) Heading: Pain, the Fifth Vital Sign Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Comprehension [Understanding] Concept: Comfort Difficulty: Moderate Feedback 1 This is correct. The nurse would perform a pain assessment when there is a change in the patient’s condition. The change could be a result of pain. 2 This is incorrect. The patient’s needs are more important than the nurse’s task of charting. 3 This is incorrect. Pain should be assessed more frequently than every 4 hours in the immediate postoperative period. 4 This is incorrect. Some patients may not report pain unless they are specifically asked whether they are in pain. PTS: 1 CON: Comfort 10. ANS: 3 Chapter: Chapter 31 Pain Objective: Explain how to use a patient-controlled analgesia (PCA) system. Page: 648 (V1) Heading: Procedure 31-1 Setting Up and Managing Patient-Controlled Analgesia by Pump > Patient Teaching

Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Comfort Difficulty: Moderate Feedback 1 This is incorrect. The pump will deliver only the amount of medication prescribed. Pushing the button too many times will not result in overdosing. 2 This is incorrect. The patient cannot accidentally roll over on the button and unintentionally give additional medication. 3 This is correct. The patient is the only one who may push the pain-dosing button. Family members should not give “doses by proxy.” 4 This is incorrect. The PCA button is to relieve pain—not to help the patient sleep. PTS: 1 CON: Comfort 11. ANS: 1 Chapter: Chapter 31 Pain Objective: Describe pharmacological measures, including nonopioid analgesics, opioid analgesics, and adjuvant analgesics. Page: 812 (V1) Heading: Pharmacological Pain Relief Measures Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Comfort Difficulty: Moderate Feedback 1 This is correct. The nurse should administer the medication around the clock; prn (as needed) dosing is not as effective as around-the-clock (ATC) dosing. 2 This is incorrect. Analgesics work best if given before pain becomes too severe. “Keeping ahead of the pain” helps clients reduce suffering and helps them to cope better and perform activities of daily living more independently. 3 This is incorrect. The absence of signs and symptoms does not automatically mean that pain is absent. All clients react to pain differently. 4 This is incorrect. Some clients feel that they are being “bad” or “weak” if they express pain and will not report pain. If the nurse waits until the client reports pain, the pain may be too severe. PTS: 1 CON: Comfort 12. ANS: 2 Chapter: Chapter 31 Pain

Objective: Describe pharmacological measures, including nonopioid analgesics, opioid analgesics, and adjuvant analgesics. Page: 805 (V1) Heading: Pain, the Fifth Vital Sign Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Comfort Difficulty: Moderate Feedback 1 This is incorrect. The nurse should reassess the patient receiving intravenous medications 15 minutes after administration. 2 This is correct. The nurse should reassess pain in the patient who received an oral pain medication 30 minutes after administration. 3 This is incorrect. This length of time (90 minutes) is too long. The nurse should reassess earlier. 4 This is incorrect. The nurse should not wait until just before the patient can receive another dose. The patient may require additional pain medication before the next dose is due. PTS: 1 CON: Comfort 13. ANS: 4 Chapter: Chapter 31 Pain Objective: Describe a method for evaluating the effectiveness of a pain management program. Page: 808 (V1) Heading: Planning Interventions/Implementation Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Collaboration Difficulty: Moderate Feedback 1 This is incorrect. The nurse should not delay treatment for 3 hours until the next dose of medication is due. 2 This is incorrect. The nurse cannot administer an extra dose of ibuprofen without a prescriber’s order to do so. 3 This is incorrect. The nurse should not assume that the patient is not in pain simply because of facial expressions; pain is what the patient states it is. 4 This is correct. The nurse should notify the prescriber that the current pain management plan is ineffective. PTS:

CON: Collaboration

14. ANS: 3 Chapter: Chapter 31 Pain Objective: Discuss nonpharmacological pain relief measures. Page: 811 (V1) Heading: Cutaneous Stimulation > Application of Heat and Cold Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. The nurse should instruct the client to cover the cold pack with a washcloth, towel, or fitted sheet before applying it to the ankle to prevent tissue damage. 2 This is incorrect. An ice pack should not be left in place for longer than 15 minutes at a time. 3 This is correct. The client should check the skin frequently and discontinue the treatment immediately if redness or other signs of tissue irritation occur. 4 This is incorrect. A cold pack should be applied intermittently for the first 24 hours. PTS: 1 CON: Safety 15. ANS: 1 Chapter: Chapter 31 Pain Objective: Discuss nonpharmacological pain relief measures. Page: 811 (V1) Heading: Cognitive–Behavioral Interventions > Distraction Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Comprehension [Understanding] Concept: Comfort Difficulty: Easy Feedback 1 This is correct. Music is a form of distraction that has been shown to reduce pain and anxiety by allowing the patient to focus on something other than pain. 2 This is incorrect. Guided imagery uses auditory and imaginary processes to help the patient relax. Guided imagery uses directed words and music. 3 This is incorrect. In sequential muscle relaxation, the patient sits and tenses muscles for 15 seconds and then relaxes the muscles while breathing out. The patient starts at the facial muscles and works downward to the feet. This relaxation technique has also been effective for relieving pain. 4 This is incorrect. Hypnosis involves the induction of a deeply relaxed state.

PTS: 1 CON: Comfort 16. ANS: 3 Chapter: Chapter 31 Pain Objective: Individualize goals and interventions for clients with a nursing diagnosis of Acute Pain (Saba, 2017). Page: 811 (V1) Heading: Cognitive–Behavioral Interventions > Therapeutic Touch Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Comfort Difficulty: Moderate Feedback 1 This is incorrect. Tactile distraction involves activities, such as massage, hugging a favorite toy, holding a loved one, or stroking a pet. 2 This is incorrect. Guided imagery uses auditory and imaginary processes to help the patient relax. Guided imagery uses directed words and music. 3 This is correct. Therapeutic touch focuses on the use of hands to direct energy fields surrounding the body without directly touching the body. The nurse should document use of therapeutic touch and its effectiveness in the progress notes after performing the procedure. 4 This is incorrect. In sequential muscle relaxation, the patient sits and tenses muscles for 15 seconds and then relaxes the muscle while breathing out. The patient starts at the facial muscles and works downward to the feet. This relaxation technique is often effective for relieving pain. PTS: 1 CON: Comfort 17. ANS: 2 Chapter: Chapter 31 Pain Objective: Describe pharmacological measures, including nonopioid analgesics, opioid analgesics, and adjuvant analgesics. Page: 812 (V1) Heading: Nonopioid Analgesics > Nonsteroidal Anti-inflammatory Drugs Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. Taking the medication on an empty stomach will make the upset stomach worse.

3 4

This is correct. The nurse should instruct the patient to take the medication with food to lessen gastric irritation. However, prior to giving naproxen, be sure the patient has not had ulcers, stomach bleeding, or severe kidney or liver problems. If so, the patient is not a candidate for treatment with naproxen. This is incorrect. While taking the medication with 8 ounces of water is recommended, it will not decrease gastric irritation. This is incorrect. Taking the medication just before bedtime may cause gastric reflux, increasing gastric irritation.

PTS: 1 CON: Safety 18. ANS: 1 Chapter: Chapter 31 Pain Objective: Describe pharmacological measures, including nonopioid analgesics, opioid analgesics, and adjuvant analgesics. Page: 815 (V1) Heading: Planning Interventions/Implementation and Box 31-3 Preventing and Treating Side Effects From Opioids > Side Effect: Respiratory Depression Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 This is correct. The nurse should assess the patient’s respiratory status and level of alertness before administering the medication because respiratory depression can be a life-threatening effect. 2 This is incorrect. It is not necessary to auscultate heart sounds before administering morphine. 3 This is incorrect. The nurse does not need to check blood pressure while the patient lies down (supine position) and sits up before administering morphine. 4 This is incorrect. An elevated temperature does not need to be assessed before administration of morphine. Morphine can be given to a patient with an elevated temperature. PTS: 1 CON: Safety 19. ANS: 1 Chapter: Chapter 31 Pain Objective: Describe pharmacological measures, including nonopioid analgesics, opioid analgesics, and adjuvant analgesics. Page: 812 (V1) Heading: Nonsteroidal Anti-Inflammatory Drugs > Acetaminophen Integrated Processes: Teaching and Learning

Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 This is correct. Even in recommended doses (4,000 mg/daily) acetaminophen can cause hemotoxicity in those who consume alcohol. Therefore, the nurse should caution the client against combining acetaminophen with alcohol. 2 This is incorrect. Aspirin, not acetaminophen, increases the risk for bleeding because it inhibits platelet aggregation. 3 This is incorrect. NSAIDs, not acetaminophen, cause gastric irritation and should be taken with meals. Acetaminophen rarely causes gastrointestinal problems. 4 This is incorrect. Opioid analgesics, not acetaminophen, can cause physical dependence. PTS: 1 CON: Safety 20. ANS: 2 Chapter: Chapter 31 Pain Objective: Describe pharmacological measures, including nonopioid analgesics, opioid analgesics, and adjuvant analgesics. Page: 815 (V1) Heading: Box 31-3 Preventing and Treating Side Effects From Opioids > Side Effect: Drowsiness Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Comprehension [Understanding] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. A paradoxical reaction will not improve with time. Paradoxical reaction to opioids occurs when the opposite reaction occurs, such as a patient’s pain increases after receiving an opioid. 2 This is correct. Drowsiness and nausea are side effects of opioid therapy and commonly improve after a few doses are administered. 3 This is incorrect. Dry mouth does not typically lessen with use. 4 This is incorrect. Difficulty with urination can be a side effect of opioid use, but it will not lessen with time. PTS: 1 CON: Safety 21. ANS: 3 Chapter: Chapter 31 Pain

Objective: Describe pharmacological measures, including nonopioid analgesics, opioid analgesics, and adjuvant analgesics. Page: 815 (V1) Heading: Box 31-3 Preventing and Treating Side Effects From Opioids > Side Effect: Respiratory Depression Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. Piroxicam is an NSAID. It is not the antidote to treat respiratory depression from opioid use. 2 This is incorrect. Administering oxycodone would make the situation worse. Oxycodone is an opioid which would further depress respirations. 3 This is correct. The nurse should anticipate administering naloxone to reverse the respiratory depression associated with opioid use. 4 This is incorrect. Meperidine is an opioid which if given would make the respiratory depression worse. PTS: 1 CON: Safety 22. ANS: 3 Chapter: Chapter 31 Pain Objective: Identify the steps involved in creating a pain management program for a client. Page: 810 (V1) Heading: Box 31-2 Pain Management Tasks That May Be Delegated to Unlicensed Assistive Personnel (UAP) Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Collaboration Difficulty: Moderate Feedback 1 This is incorrect. The nurse should never delegate the responsibility of assessing the patient’s pain. This requires professional judgment. 2 This is incorrect. Evaluating the effectiveness of the pain medication is the responsibility of the professional nurse, not the UAP. 3 This is correct. The nurse can safely delegate providing a back massage for the patient in pain. 4 This is incorrect. The UAP cannot administer any oral medications; even acetaminophen cannot be administered by the UAP.

PTS: 1 CON: Collaboration 23. ANS: 3 Chapter: Chapter 31 Pain Objective: Individualize goals and interventions for clients with a nursing diagnosis of Acute Pain (Saba, 2017). Page: 804 (V1) Heading: Planning Outcomes and Nursing Care Plan 31-1 Pain Management: Nursing Care Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Comfort Difficulty: Difficult Feedback 1 This is incorrect. The patient verbalizing reduced pain is not specific enough. The nurse needs to know how much pain relief is achieved. A numerical score gives a clearer indication of the effectiveness of analgesia. The patient might have experienced a reduction in pain, but the pain level might still be intolerable. 2 This is incorrect. Saying the patient’s pain is relieved because he or she is resting quietly does not address the pain relief while awake. Some patients will sleep in an attempt to cope with pain, so this outcome could lead to inaccurate evaluation. 3 This is correct. A low pain rating is the best expected outcome for the patient with a nursing diagnosis of Acute Pain secondary to surgical resection of a ruptured spleen and possible inadequate analgesia because it is specific and measurable. 4 This is incorrect. Providing pain medication is a nursing intervention, not an expected outcome. PTS: 1 CON: Comfort 24. ANS: 2 Chapter: Chapter 31 Pain Objective: Individualize goals and interventions for clients with a nursing diagnosis of Acute Pain (Saba, 2017). Page: 820 (V1) Heading: Managing Pain in Patients With Substance Misuse and Abuse > Monitor for Substance Abuse Behaviors Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Addiction and Behaviors Difficulty: Easy

1 2

Feedback This is incorrect. Requesting oral pain medications every 6 to 8 hours is a typical behavior for a patient 5 days after surgery. This is correct. The patient underwent surgery 5 days ago; it is unlikely that the patient would require frequent dosing of the analgesic, as is possible with patient-controlled analgesia. The nurse should recognize this behavior as a possible indicator of current substance abuse or addiction. This is incorrect. Requesting an oral form of the drug does not indicate substance abuse. A refusal to try oral medication for pain relief is a possible sign of substance abuse. This is incorrect. Wanting nonpharmacological pain measures does not indicate substance abuse.

PTS: 1 CON: Addiction and Behaviors 25. ANS: 4 Chapter: Chapter 31 Pain Objective: Describe chemical and surgical pain relief measures. Page: 818 (V1) Heading: Surgical Interruption of Pain Conduction Pathways Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Knowledge [Remembering] Concept: Comfort Difficulty: Moderate Feedback 1 This is incorrect. Cordotomy interrupts pain and temperature sensation below the tract that is severed. This procedure is commonly performed to relieve trunk and leg pain. 2 This is incorrect. Rhizotomy interrupts the anterior or posterior nerve route located between the ganglion and the cord. It is commonly used to treat head and neck pain. 3 This is incorrect. Neurectomy is used to eliminate intractable localized pain. The pathways of peripheral or cranial nerves are interrupted to block pain transmission. 4 This is correct. Sympathectomy severs the pathways to the sympathetic nervous system. The procedure improves vascular blood supply and eliminates vasospasm. It is effective for the treatment of pain associated with vascular disorders, such as Raynaud’s disease. PTS: 1 CON: Comfort 26. ANS: 1 Chapter: Chapter 31 Pain

Objective: Describe a method for evaluating the effectiveness of a pain management program. Page: 805 (V1) Heading: sidebar >Focused Assessment > Richmond Agitation-Sedation Scale Integrated Processes: Communication and Documentation Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Safety Difficulty: Difficult Feedback 1 This is correct. On the Richmond Agitation-Sedation Scale restless is a +1 and awakens with eye contact to voice is a –2. 2 This is incorrect. On the Richmond Agitation-Sedation Scale agitated is a +2 and not responsive to voice or physical stimulation is a –5. 3 This is incorrect. On the Richmond Agitation-Sedation Scale pulling on IV tubing is a +3 and alert and calm is a 0. 4 This is incorrect. On the Richmond Agitation-Sedation Scale combative is a +4 and drowsy is a –1. PTS: 1 CON: Safety 27. ANS: 1 Chapter: Chapter 31 Pain Objective: Individualize goals and interventions for clients with a nursing diagnosis of Acute Pain (Saba, 2017). Page: 804 (V1) Heading: Clinical Insight 31-1 Caring for the Patient With an Epidural Catheter Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Collaboration Difficulty: Moderate Feedback 1 This is correct. Patients who undergo mitral valve replacement typically require long-term anticoagulant therapy. Anticoagulant therapy is a contraindication for epidural analgesia use because of the risk for spinal hematoma and uncontrolled bleeding. 2 This is incorrect. Diabetes mellitus is not a contraindication for epidural analgesia. 3 This is incorrect. Patients with hypertension can receive epidural analgesia. 4 This is incorrect. Epidural analgesia can be used after an emergency abdominal surgery. PTS:

CON: Collaboration

28. ANS: 2 Chapter: Chapter 31 Pain Objective: Individualize goals and interventions for clients with a nursing diagnosis of Acute Pain (Saba, 2017). Page: 805 (V1) Heading: Clinical Insight 31-1 Caring for the Patient With an Epidural Catheter > Monitoring Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Comfort Difficulty: Difficult Feedback 1 This is incorrect. Bedrest is the recommended treatment for a headache. Headaches will be more severe when the patient is sitting upright or ambulating. 2 This is correct. Caffeine is helpful for a headache and can even be administered IV if needed. 3 This is incorrect. Coughing and deep breathing is not recommended treatment for a headache from a dural puncture. 4 This is incorrect. Liberal hydration is recommended treatment for a headache. Fluid volume deficit will also aggravate a “spinal headache” after epidural anesthesia. PTS: 1 CON: Comfort 29. ANS: 2 Chapter: Chapter 31 Pain Objective: Discuss the factors that influence pain. Page: 803 (V1) Heading: Communication and Cognitive Impairments Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Comfort Difficulty: Moderate Feedback 1 This is incorrect. Since the cancer has metastasized, the pain may be greater than in previous stages. 2 This is correct. It is most likely that clients with dementia cannot effectively communicate the intensity or quality of pain and are, therefore, at risk for underassessment of pain and inadequate pain relief. Be aware of behavioral cues indicating pain rather than relying on verbal report. 3 This is incorrect. There is no evidence to suggest that clients with dementia and other forms of cognitive impairment do not experience pain.

This is incorrect. Failure to request pain medication is not likely a result of hesitation to habitually ask for it or reliance on others; rather, it is likely owing to inability to effectively express to the caregiver that analgesia is needed.

PTS: 1 CON: Comfort 30. ANS: 1 Chapter: Chapter 31 Pain Objective: Define pain. Page: 805 (V1) Heading: Assessment Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Comfort Difficulty: Easy Feedback 1 This is correct. The patient is the best reporter of pain. Even if patients have mild cognitive impairment, they are still the best source. Pain is a subjective experience. 2 This is incorrect. Perception of pain might be heightened if other medical conditions coexist, although this perception is also influenced by other factors, such as past experience with pain and the success or failure of the treatment to produce relief. 3 This is incorrect. Caregivers might not appreciate the extent of pain because pain is an individualized experience. Caregivers may even have misconceptions about the pain the patient is experiencing. 4 This is incorrect. A patient’s facial expression, vocalization, posture or position, or other behaviors do not always accurately indicate the intensity or quality of a patient’s experience of pain. The patient might be trying to hide signs of pain in order to be brave or strong. PTS: 1 CON: Comfort 31. ANS: 1 Chapter: Chapter 31 Pain Objective: Describe the physiological changes that occur with pain. Page: 814 (V1) Heading: Opioid Analgesics > Types of Opioids Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Comfort Difficulty: Moderate

1 2 3 4

Feedback This is correct. Mu receptors are the most effective in relieving pain. This is incorrect. Delta receptors are not the most effective at relieving pain. This is incorrect. Kappa receptors are not the most effective at relieving pain. This is incorrect. Sigma receptors are not the most effective at relieving pain.

PTS: 1 CON: Comfort 32. ANS: 3 Chapter: Chapter 31 Pain Objective: Describe pharmacological measures, including nonopioid analgesics, opioid analgesics, and adjuvant analgesics. Page: 819 (V1) Heading: Gero feature > Managing Pain in Older Patients > Administering Nonopioid Analgesic to Older Adults Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Comfort Difficulty: Difficult Feedback 1 This is incorrect. Opioids (e.g., morphine) are most effective for certain types of pain. For instance, visceral pain, which is more generalized, is most responsive to opioid treatment, whereas neuropathic pain is resistant to opioids. 2 This is incorrect. Fentanyl, an opioid, is not effective for treatment of neuropathic pain. 3 This is correct. Gabapentin has few side effects and can also be used in combination with nonopioid analgesics to relieve neuropathic pain. 4 This is incorrect. Hydromorphone is not recommended for treatment of neuropathic pain because it is an opioid. PTS: 1 CON: Comfort 33. ANS: 4 Chapter: Chapter 31 Pain Objective: Describe pharmacological measures, including nonopioid analgesics, opioid analgesics, and adjuvant analgesics. Page: 651 (V2) Heading: Clinical Insight 31-1 Caring for the Patient With an Epidural Catheter > Monitoring Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Application [Applying] Concept: Comfort Difficulty: Moderate

2 3 4

Feedback This is incorrect. Catheter migration, not toxicity, often produces nausea, a decrease in blood pressure, and loss of motor function without a recognizable cause. This is incorrect. Leaking at the site should not occur, but it is not a sign of local anesthesia toxicity. This is incorrect. Urinary retention is one side effect of epidural opioids, but it is not related to local anesthesia toxicity. This is correct. Signs of local anesthesia toxicity occur when anesthesia is injected directly into the bloodstream instead of the epidural space. The patient might report numbness or tingling around the mouth or ringing in the ears (tinnitus), or the nurse may assess irritability, tremors, seizures, or cardiac arrhythmias (Portenoy & McCaffery, 2011; Sawheney, 2012).

PTS: 1 CON: Comfort 34. ANS: 2 Chapter: Chapter 31 Pain Objective: Define pain. Page: 798 (V1) Heading: What Is Pain? Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Knowledge [Remembering] Concept: Comfort Difficulty: Moderate Feedback 1 This is incorrect. Pain is a subjective (not objective) experience; unlike a pulse or blood pressure. Pain is what the patient says it is. 2 This is correct. “Pain is an unpleasant sensory and emotional experience association with actual or potential tissue damage, or described in terms of such damage” (APS, 1994, p. 16; Merskey & Bogduk, 1994, p. 971). This definition emphasizes that pain is a complex experience. 3 This is incorrect. Pain is not a generalized response but, rather, a complex, neurological response. 4 This is incorrect. Although a patient with chronic back pain would experience an emotional response, the sensation of pain is primarily physiological, involving transmission of an impulse along a pain pathway. PTS: 1 CON: Comfort 35. ANS: 1 Chapter: Chapter 31 Pain Objective: Classify pain according to origin, cause, duration, and quality.

Page: 798 (V1) Heading: Origin of Pain Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Comfort Difficulty: Moderate Feedback 1 This is correct. Deep somatic pain is localized and can be described as achy or tender. 2 This is incorrect. Cutaneous or superficial pain arises in the skin or the subcutaneous tissue (e.g., a burn or an abrasion). Although the injury is superficial, it may cause short-term pain. 3 This is incorrect. Neuropathic pain is described as burning, numbness, itching, and “pins and needles” prickling pain. 4 This is incorrect. Visceral pain is not well localized and can be described as tight, pressure, or crampy pain. PTS: 1 CON: Comfort 36. ANS: 3 Chapter: Chapter 31 Pain Objective: Describe pharmacological measures, including nonopioid analgesics, opioid analgesics, and adjuvant analgesics. Page: 651 (V2) Heading: Procedure 31-1 Setting Up and Managing Patient-Controlled Analgesia by Pump > PreProcedure Assessment Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. Diverticulitis does not increase the risk for respiratory depression. 2 This is incorrect. There is not an increased risk for respiratory depression in a client with gallbladder disease. 3 This is correct. Respiratory depression is increased in clients who have sleep apnea, so the nurse would want to monitor this client closely. 4 This is incorrect. The risk for respiratory depression is not as high in a client with seasonal allergies. There is a client with a greater risk. PTS:

CON: Safety

37. ANS: 4 Chapter: Chapter 31 Pain Objective: Individualize goals and interventions for clients with a nursing diagnosis of Chronic Pain (Saba, 2017). Page: 812 (V1) Heading: Humor Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Analysis [Analyzing] Concept: Comfort Difficulty: Moderate Feedback 1 This is incorrect. Strenuous exercise would likely aggravate the pain experience and potentially cause injury. 2 This is incorrect. Visualization is associated with the endogenous analgesia system but might be too involved for a young child 4 years old to perform. 3 This is incorrect. Rap music is not a form of distraction for a 4-year-old and would not be recommended. Soft music is recommended. 4 This is correct. Laughter from watching a funny movie is likely to result in pain reduction without causing stress on the joints. For both children and adults, laughter is positive and may boost the immune system. PTS: 1 CON: Comfort 38. ANS: 1 Chapter: Chapter 31 Pain Objective: Identify the effect of unrelieved pain on each of the body systems. Page: 805 (V1) Heading: Unrelieved Pain > Genitourinary System Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Comfort Difficulty: Difficult Feedback 1 This is correct. This patient has an existing mobility problem. Unrelieved, chronic pain can lead to urinary retention. 2 This is incorrect. Hypertension is more likely to result than hypotension. 3 This is incorrect. Fluid overload, rather than dehydration, is more likely to occur secondary to excessive aldosterone, ADH, cortisol, angiotensin II, catecholamine, and prostaglandin secretion. 4 This is incorrect. Owing to decreased insulin production from unrelieved pain, hyperglycemia is more likely to result than is hypoglycemia.

PTS: 1 CON: Comfort 39. ANS: 3 Chapter: Chapter 31 Pain Objective: Describe pharmacological measures, including nonopioid analgesics, opioid analgesics, and adjuvant analgesics. Page: 816 (V1) Heading: Opioid Administration Routes > Intra-articular Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Comfort Difficulty: Moderate Feedback 1 This is incorrect. The transdermal route involves applying a patch to the skin; it does not involve the direct administration into a joint. 2 This is incorrect. Intrathecal analgesia is through the subarachnoid space and is inserted by an anesthesiologist or a certified registered nurse–anesthetist (CRNA). 3 This is correct. The nurse would report the intra-articular route. A pain pump is implanted into a joint during arthroscopic surgery as a measure to control postsurgical pain. The pump provides relief to patients by delivering continuous infusion of local anesthetic directly to the surgical site. 4 This is incorrect. An anesthesiologist or a CRNA places a catheter in the epidural (in the spine) space for epidural analgesia. PTS: 1 CON: Comfort 40. ANS: 1 Chapter: Chapter 31 Pain Objective: Explain why pain should be considered the fifth vital sign. Page: 805 (V1) Heading: Pain, the Fifth Vital Sign Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Comprehension [Understanding] Concept: Comfort Difficulty: Easy Feedback 1 This is correct. Patients often internalize their pain experience. Therefore, a regular pain assessment helps the nurse and the patient to communicate and better collaborate on the goals of pain therapy and ways to achieve better pain relief.

2 3

This is incorrect. The nurse practice act does not specify timing of interventions. This is incorrect. Pain is not a vital sign; instead, pain assessment might be performed regularly, just like a vital sign assessment, for more effective pain management. This is incorrect. Although asking how the patient feels and to rate the intensity and describe the quality of pain is an indication of caring, the goal of pain assessment is to optimize pain management.

PTS: 1 CON: Comfort 41. ANS: 3 Chapter: Chapter 31 Pain Objective: Individualize goals and interventions for clients with a nursing diagnosis of Chronic Pain (Saba, 2017). Page: 808 (V1) Heading: Planning Outcomes Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Comfort Difficulty: Moderate Feedback 1 This is incorrect. It is not realistic to think that the pain can be completely eliminated and not recur in the future, since the damage is permanent. 2 This is incorrect. Being able to do all the things before the pain started is not realistic because of the permanent joint damage. 3 This is correct. A reasonable goal is to obtain adequate pain control to allow for the patient to perform activities of daily living (“my daily activities”). 4 This is incorrect. The patient’s life will not be the same because the damaged joints will not return to normal; however, pain reduction enough to function and engage in activities of daily living is a reasonable expectation. PTS: 1 CON: Comfort 42. ANS: 3 Chapter: Chapter 31 Pain Objective: Describe pharmacological measures, including nonopioid analgesics, opioid analgesics, and adjuvant analgesics. Page: 812 (V1) Heading: Nonopioid Analgesics > Nonsteroidal Anti-inflammatory Drugs Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Comfort

Difficulty: Moderate Feedback 1 This is incorrect. Fentanyl is an opioid that will cause sedation, especially if given IV. 2 This is incorrect. If the patient desires to be alert, an opioid analgesic IV (morphine) would not be the best choice because it produces drowsiness. 3 This is correct. Ibuprofen is a nonsedating analgesic. This would be the best choice for this patient. 4 This is incorrect. Even though hydrocodone is PO, it is an opioid which can cause sedation. There is a better choice for this patient who wants to be alert. PTS: 1 CON: Comfort 43. ANS: 2 Chapter: Chapter 31 Pain Objective: Identify the steps involved in creating a pain management program for a client. Page: 808 (V1) Heading: Planning Interventions/Implementation Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Collaboration Difficulty: Moderate Feedback 1 This is incorrect. A pain journal is a useful assessment tool for collection of subjective and objective pain experiences, which would aid the healthcare team in developing a collaborative pain management plan with the patient, but the priority is to meet with the healthcare team. 2 This is correct. There are several issues that make this a complex situation that requires collaboration with the healthcare team: older adult, neuropathic pain, and has tried various pain methods with no relief. With complex pain management that has been unsuccessful in the past, it is important to collaborate with other members of the team to consider alternative approaches. 3 This is incorrect. Taking a prescribed analgesic is important for keeping the pain threshold at a tolerable level. Once the patient “gets behind” on managing pain, it is more difficult to achieve control. 4 This is incorrect. Although massage has been shown to be effective in reducing pain by providing cutaneous stimulation and relaxing the muscles, the priority is to develop an effective, comprehensive pain management plan for this patient. Since the patient has neuropathic pain, massage and effleurage may not be effective. PTS:

CON: Collaboration

44. ANS: 3 Chapter: Chapter 31 Pain Objective: Describe a method for evaluating the effectiveness of a pain management program. Page: 806 (V1) Heading: Assessment Guidelines and Tools > Using Pain Scales Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Analysis [Analyzing] Concept: Comfort Difficulty: Moderate Feedback 1 This is incorrect. Patients commonly find the simple descriptor scale difficult to understand. This scale uses a list of adjectives that describe pain intensity. The patient has expressive aphasia so this would be difficult to use. 2 This is incorrect. When using the numerical rating scale, the patient must choose a number from 0 to 10 to denote pain level. This scale is sometimes difficult for patients with cognitive impairments, such as expressive aphasia. 3 This is correct. The Wong-Baker FACES rating scale uses simple illustrations of faces to depict various levels of pain. The scale was developed for children but has proved effective for adults with communication and cognitive impairments. 4 This is incorrect. The Pain Assessment in Advanced Dementia (PAINAD) scale is a five-item, observational tool, specifically geared to older adults with dementia. The patient has expressive aphasia, not dementia. PTS:

CON: Comfort

MULTIPLE RESPONSE 45. ANS: 2, 3, 4, 5 Chapter: Chapter 31 Pain Objective: Individualize goals and interventions for clients with a nursing diagnosis of Acute Pain (Saba, 2017). Page: 809 (V1) Heading: Previous Pain Experience and Planning Interventions/Implementation and Diaphragmatic Breathing Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Comfort Difficulty: Difficult Feedback

2. 3. 4.

This is incorrect. The surgeon should not be notified immediately. The patient is not in a life-threatening situation. Patients may be scared and in pain after returning from surgery. The nurse should assess and intervene before notifying the surgeon. This is correct. The nurse would want to calm the patient by using therapeutic communication. Calming anxiety also helps to relieve pain. This is correct. Deep diaphragmatic breathing is a nonpharmacological intervention for pain and anxiety. Deep breathing would be appropriate in this situation. This is correct. Analgesics help reduce pain, which will also lessen the anxiety that can aggravate a pain experience. Since the patient is anxious, it would be good for the unlicensed assistive personnel to stay with the patient while the nurse prepares the pain medication. This is correct. The nurse should assess the pain to determine appropriate interventions.

PTS: 1 CON: Comfort 46. ANS: 1, 2, 3 Chapter: Chapter 31 Pain Objective: Describe a method for evaluating the effectiveness of a pain management program. Page: 809 (V1) Heading: Planning Outcomes and Evaluation Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Comfort Difficulty: Difficult

3. 4. 5.

Feedback This is correct. The nurse needs to determine what this reduction in pain means to the lifestyle of the patient because a pain level even as low as 5 may still diminish the patient’s ability to function. This is correct. The goal of pain management is for the patient to achieve satisfaction with the amount of pain relief obtained. Each patient’s pain experience is individual, and the amount of pain that a person can tolerate varies. This is correct. A pain journal can help the nurse evaluate the effectiveness of analgesic therapy as well as the patient’s feelings about the chronic pain. This is incorrect. The nurse already knows the pain has diminished from an 8 to a 5, so this question is not necessary. This is incorrect. While the nurse should ask about quality of life, it should focus on the patient’s standards, not the family’s.

PTS: 1 47. ANS: 1, 2, 5

CON: Comfort

Chapter: Chapter 31 Pain Objective: Discuss the factors that influence pain. Page: 803 (V1) Heading: Communication and Cognitive Impairments Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Comfort Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is correct. Rapid blinking can be seen as an indicator of pain in the noncommunicative older adult. This is correct. Pain should be a consideration when any patient suddenly develops labored breathing. This is incorrect. Respiratory rate is more likely to increase than decrease when the patient experiences acute pain. This is incorrect. When the noncommunicative older adult experiences pain, the patient is more likely to eat less or even refuse food. This is correct. Restlessness (fidgeting, increased pacing, or rocking) is a common finding in patients with pain, often secondary to attempting to find a position of comfort.

PTS:

CON: Comfort

Chapter 32. Physical Activity & Immobility Multiple Choice Identify the choice that best completes the statement or answers the question. 1. A 15-year-old patient complains of left ankle pain after being tackled while playing football. He asks the nurse what tests he needs to have to determine whether he has a strain or a fracture. How should the nurse reply? 1. “You don’t need tests; I can tell by the way your ankle looks and feels whether you have a strain or a fracture.” 2. “Sprains, strains, and fractures have similar symptoms at first; you will need an xray of the joint to be certain.” 3. “We will need to get a venous Doppler study to make sure that there is not a fracture.” 4. “First, we need to get an MRI to determine if you have a fracture, a strain, or a sprain.” 2. Which is the best treatment to protect the integument of the patient who is frail, malnourished, and immobile? 1. Offering the patient six small meals a day 2. Turning the patient at least every 2 hours 3. Assisting the patient to sit in a chair three times a day 4. Administering fluid boluses as directed by the healthcare provider 3. What action is most important in limiting the nurse’s risk of back injuries? 1. Use good body mechanics at all times. 2. Develop a lift team at the clinical site. 3. Avoid manual lifting by using assistive devices as often as possible. 4. Work with another nurse or an aide when lifting and turning patients. 4. The nurse is helping the patient to perform leg exercises after surgery to prevent thrombophlebitis. Which type of muscle is the patient using for these exercises? 1. Skeletal 2. Smooth 3. Cardiac 4. Slow-twitch fibers 5. A nurse is caring for a 25-year-old male quadriplegic patient. Which of the following treatments would the nurse perform to decrease the risk of joint contracture and promote joint mobility? 1. Active range of motion (ROM) 2. Passive ROM 3. Turning the patient every 2 hours 4. Administering glucosamine supplements

6. A nurse is assessing a healthy older adult patient for an exercise program to be offered at the local hospital. During the evaluation, the nurse notes the following vital signs: pulse (P) = 72 beats/min; respiratory rate (RR) = 16 breaths/min; blood pressure (BP) = 132/70 mm Hg. After 3 minutes of moderate-intensity running on the treadmill, the patient becomes short of breath and states, “I have to stop. I can’t do this anymore.” The nurse measures his vital signs again: P = 152 beats/min; RR = 40 breaths/min; BP = 172/98 mm Hg. She instructs him to rest. Vital signs return to baseline after 15 minutes. The nurse should recognize his symptoms as associated with which of the following? 1. Anxiety 2. Orthostatic hypotension 3. Limited activity tolerance 4. Respiratory distress 7. The patient with a spinal cord injury is experiencing autonomic dysfunctions. Which is an important aspect of care to assist in managing these dysfunctions? 1. Hold the patient upright if she begins to fall until assistance arrives. 2. Ask the patient to assist with turning by holding the siderails of the bed. 3. Place the patient in a high-back reclining wheelchair which can be lowered. 4. Ask the patient if a transfer belt would be helpful to support assisted walking. 8. An older patient with newly diagnosed osteoporosis asks the nurse to explain her health problem. Which is the correct description of osteoporosis? 1. Loss of bone density that increases the risk of fracture 2. Degenerative joint disease that produces pain and decreased function 3. Chronic inflammatory joint disease that must be treated with steroids 4. Acute infection in the bone that must be treated with antibiotics 9. When caring for a patient with osteoporosis, which of the following is the most important action to take to minimize progression of the disease? 1. Take a calcium supplement twice a day. 2. Start a weight-bearing exercise program. 3. Avoid strenuous activity that puts stress on bones. 4. Schedule regular healthcare checkups. 10. Which action, when demonstrated by the patient with osteoporosis, would indicate to the nurse that teaching was effective? 1. Taking a calcium supplement every day and increasing her phosphorus intake 2. Participating in an aerobic barbell strength class at the gym three times a week 3. Using a wheelchair to reduce the risk of spontaneous fractures to her legs and feet 4. Seeking healthcare by scheduling a follow-up examination with bone density testing 11. Which type of joint are the sutures between cranial bones? 1. Diarthroses 2. Synovial

3. Amphiarthroses 4. Synarthroses 12. A man has been admitted to the hospital unit with a medical diagnosis of chronic obstructive pulmonary disease (COPD). He is receiving supplemental oxygen at 2 L/min via a nasal cannula. Which positioning technique will best assist him with his breathing? 1. Fowler’s position 2. Sims’ position 3. Prone position 4. Lateral position 13. A nurse has been asked to design an exercise program with the goal of increasing a client’s muscular strength and endurance. Which exercise program would specifically focus on meeting that goal? 1. Flexibility training 2. Resistance training 3. Aerobic conditioning 4. Anaerobic conditioning 14. To achieve balance, body mass must be distributed around which point? 1. Line of gravity 2. Center of balance 3. Center of gravity 4. Base of support 15. A frail, elderly man is admitted to the hospital after a fall at home resulted in a left hip fracture. After surgery, he is to begin ambulating with a walker but must avoid weight bearing on his left lower leg. What is the best intervention to help him use his walker? 1. Aerobic exercise with deep breathing 2. Quadriceps and gluteal repetitions 3. Isometric toning of lower legs 4. Arm resistance training 16. Identify the most appropriate nursing diagnosis for promoting the safety of a frail, elderly patient after hip replacement surgery who also has a history of emphysema. 1. Activity Intolerance related to injury 2. Impaired Mobility related to weakness 3. Risk for Injury related to medical condition 4. Ineffective Breathing Pattern related to illness 17. Which would be the most appropriate goal for a frail, elderly patient with a history of emphysema and a nursing diagnosis of Risk for Injury after hip surgery? 1. Remain free from injury or falls throughout hospital stay. 2. Increase activity tolerance by discharge from hospital. 3. Demonstrate effective breathing when ambulating.

4. Increase mobility by the time of discharge from hospital. 18. A teenage boy was hospitalized 3 weeks ago. He has been confined to bed throughout his hospital stay because of a crushed pelvis. His parents tell the nurse, “Our son is just staring off into space; he won’t talk to us. He isn’t acting like himself.” Which response by the nurse is most appropriate? 1. “I will inform his doctor and see whether we can get your son started on an antidepressant medication.” 2. “He is at a critical time in his life; teens are often moody, and being in the hospital with an injury will only make that worse.” 3. “Your son had a major injury, and his immobility might be causing him to feel isolated and depressed.” 4. “He is bored because he has been in the hospital for 3 weeks; I’ll try to find something new for him to do.” 19. A healthy 32-year-old man wants to start a fitness program to increase his muscle tone and muscle strength. Based on the U.S. Department of Health and Human Services recommendations, which advice should the nurse offer him? 1. Exercising once weekly for 20 to 30 minutes is essential to increase strength. 2. Thirty minutes of moderate physical activity three times a week is appropriate. 3. Moderately intense exercise for 1 hour three times a week will be adequate. 4. Moderate physical activity 150 to 300 minutes or more per week is needed. 20. A patient fractured her right ulna 8 weeks ago and has just had her cast removed. The orthopedic surgeon prescribes isometric exercises for the right arm. Which of the following exercises complies with the surgeon’s orders? 1. Place a 5-pound dumbbell in the right hand and squeeze; hold the squeeze position for 6 to 8 seconds, and repeat 5 to 10 times. 2. Grasping the right wrist with the left hand, move the right arm up, down, and side to side; hold each position for 6 to 8 seconds, and repeat 5 to 10 times. 3. Grasping the right wrist with the left hand, pull the right arm across the body; hold this position for 6 to 8 seconds, and repeat 5 to 10 times. 4. Press the right hand against a wall; hold this position for 6 to 8 seconds, and repeat 5 to 10 times. 21. A woman with a high-risk pregnancy with triplets is in preterm labor; she is on strict bedrest for 5 days. During this time, she has not had a bowel movement, although she normally passes stool daily. She describes feeling bloated and uncomfortable. What information should the nurse give the patient when explaining constipation? 1. Immobility often causes constipation. 2. A low-fiber diet will resolve the problem. 3. A stool softener daily will relieve the problem. 4. Use of a bedpan results in bloating and constipation. 22. The patient who is on extended bedrest and experiencing constipation requests a fiber supplement. Which statement by the nurse is most appropriate?

1. “I will need to see if you have any allergies before I order a fiber supplement for you.” 2. “That is a good choice to manage constipation. I will contact the physician.” 3. “A fiber supplement won’t be very effective; we need to get you moving soon.” 4. “A stool softener could be used in place of a fiber supplement. Let’s try that medication now.” 23. A 32-year-old with a high spinal cord injury has been admitted to the hospital for antibiotic therapy to treat pneumonia. He lives independently and has developed strong upper-body strength to maximize his independence. Which transfer device should be used when transferring him from the bed to his wheelchair? 1. Mechanical lift 2. Transfer belt 3. Draw sheet 4. Transfer board 24. An 82-year-old patient is unsteady on her feet when walking about the room. She reports feeling a little sore but has no complaints of weakness. Which is the appropriate piece of equipment to use when helping her ambulate? 1. Crutches 2. Transfer belt 3. Cane 4. Walker 25. The nurse is helping an 82-year-old patient to ambulate in the hallway. Suddenly, she states, “I feel so light-headed and weak,” as her knees begin to buckle. Which is the best action by the nurse at this time? 1. Instruct the patient to grab the rail in the hallway while he calls for assistance 2. Immediately release the transfer device and place a wheelchair behind the patient 3. Assist the patient to slide down his leg as he guides her to a seated or lying position 4. Grasp her under the arms and across the chest to hold her up as he calls for assistance 26. According to the U.S. Department of Health and Human Services 2018 Physical Activity Guidelines for Americans, which of the following statements about the benefits of physical activity is correct? 1. Lesser amounts of activity provide little to no health benefits. 2. Physical activity in excess of recommendations for age is harmful. 3. The risks of participating in physical activity outweigh the health benefits. 4. Physical activity should be enjoyable, and a variety will improve adherence. 27. When encouraging a fitness program for healthy older adults, what must the nurse consider? 1. Older adults should engage in 75 to 150 minutes of moderate physical activity per week.

2. More than 150 minutes of moderate-intensity physical activity can be harmful to bones. 3. Structured fitness programs achieve greater health benefits for older adults. 4. Older adults at risk for falling should do activities that maintain or improve balance. 28. The nurse providing care to the patient with a fracture explains how bones heal. Which type of cells will the nurse indicate repairs damaged bone and builds new bone to keep the skeleton strong? 1. Amphiarthroses 2. Articular cartilage 3. Osteoblasts 4. Osteoclasts 29. Which type of exercise is performed by using specialized apparatuses that use resistance at a constant, preset speed? 1. Isokinetic 2. Isometric 3. Isotonic 4. Isomorphic 30. The nurse assessing the mobility of a patient with Parkinson’s disease might expect to observe which type of gait? 1. Antalgic 2. Propulsive 3. Scissors 4. Steppage 31. The nurse attempts to transfer a totally dependent patient from a stretcher to a bed. What is the best action to reduce the musculoskeletal risk factors for the nurse? 1. Use a mechanical lift to transfer the patient. 2. Use a wide base of support when transferring. 3. Ask a coworker to help transfer the patient. 4. Use transfer roller sheet when transferring. Multiple Response Identify one or more choices that best complete the statement or answer the question. 32. Which of the following body systems must interact to produce mobility and locomotion? Select all that apply. 1. Digestive system 2. Muscles 3. Skeleton 4. Nervous system

5. Endocrine system 33. Which of the following patients would you expect to be at risk for decreased activity? Select all that apply. 1. Older adult who walks at the mall for physical activity 2. Someone living in a skilled nursing facility 3. Healthy adult who works as a computer programmer 4. Obese child who enjoys video games 5. The patient with impaired arterial circulation 34. A patient has started a fitness program. Which program features illustrate that he has started a wellrounded program? Select all that apply. 1. Flexibility training 2. Balance exercises 3. Resistance training 4. Aerobic conditioning 5. Isotonic exercises 35. The nurse is instructing a patient about the need to replace fluid before, during, and after exercise to avoid dehydration. On what basis should she teach the patient to determine the amount of fluid to consume? Select all that apply. 1. Duration of exercise 2. Environmental temperature 3. Level of fitness 4. Degree of thirst 5. Intensity of exercise 36. Which of the following actions represent proper body mechanics for nurses providing care as well as teaching patients about safe body movements? Select all that apply. 1. Stand with the body in alignment and erect posture. 2. Bend at the waist to lift heavy objects from the floor. 3. Use a wide base of support with your feet at shoulder width. 4. Keep objects close to your body when carrying them. 5. Use a soft mattress to allow for the muscles to rest adequately. 37. The nurse planning care for a patient after severe head trauma and long-term unresponsiveness considers which effect of immobility affecting the lungs? Select all that apply. 1. Atelectasis 2. Hyperventilation 3. Pooled secretions 4. Reactive airway 5. Hypocarbia

Chapter 32. Physical Activity & Immobility Answer Section MULTIPLE CHOICE 1. ANS: 2 Chapter: Chapter 32 Physical Activity & Immobility Objective: Implement care related to a patient’s mobility problems. Page: 835 (V1) Heading: Factors Affecting Mobility and Activity > Developmental Stage > Trauma Integrated Processes: Teaching and Learning Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Mobility/Patient-Centered Care Difficulty: Easy Feedback 1 This is incorrect. Signs and symptoms associated with a sprain, strain, or fracture are the same. 2 This is correct. An x-ray allows the medical provider to visually observe for any breaks in a bone. 3 This is incorrect. A venous or arterial Doppler is used to detect blood flow. 4 This is incorrect. An x-ray is more practical than an MRI to diagnose a fracture. PTS: 1 CON: Mobility | Patient-Centered Care 2. ANS: 2 Chapter: Chapter 32 Physical Activity & Immobility Objective: Develop a plan of care for patients with decreased activity tolerance. Page: 844 (V1) Heading: Planning Interventions/Implementation > Positioning Patients Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Comprehension [Understanding] Concept: Mobility/Patient-Centered Care Difficulty: Easy Feedback 1 This is incorrect. The patient’s meals need to be protein rich to maintain muscle mass. 2 This is correct. External pressure from lying or sitting in one position compresses capillaries and obstructs blood flow to the skin. Immobile patients confined to a bed should be turned at least every 2 hours to protect their skin and relieve pressure. 3 This is incorrect. Sitting in a chair does not protect the integument for the patient

unless it is part of every 2 hour repositioning. This is incorrect. Fluid boluses do not support the integument. Fluid boluses could cause fluid volume overload in this patient.

PTS: 1 CON: Mobility | Patient-Centered Care 3. ANS: 3 Chapter: Chapter 32 Physical Activity & Immobility Objective: Use proper body mechanics when providing patient care. Page: 847 (V1) Heading: Planning Interventions/Implementation > Protecting the Nurse’s Back Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Difficult Feedback 1 This is incorrect. Using good body mechanics at all times is important; however, it is not the best answer. 2 This is incorrect. Developing a lift team does not protect the nurse from injury. 3 This is correct. Back injuries are the leading cause of injury among nurses. Good body mechanics and teamwork limit the risk of injury. However, the American Nurses Association (ANA) Handle With Care program advocates the regular use of assistive devices as well as avoiding manual lifting. 4 This is incorrect. Working with another nurse or aide does not fully protect the nurse’s back. PTS: 1 CON: Safety 4. ANS: 1 Chapter: Chapter 32 Physical Activity & Immobility Objective: Discuss the physiology of movement. Page: 831 (V1) Heading: Physical Activity and Exercise Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Mobility/Health Promotion Difficulty: Easy Feedback 1 This is correct. Skeletal muscle moves the bones with ligaments. 2 This is incorrect. Smooth muscle is found in the digestive tract and other hollow structures, such as the blood vessels and bladder. 3 This is incorrect. Cardiac muscle contracts spontaneously and as blood is ejected

out of the heart. This is incorrect. Slow-twitch fibers are a subtype of skeletal muscle cell. Slowtwitch fibers (type I), or “red” muscle, have a rich blood supply and are rich in mitochondria (the powerhouse of the cell) to give the muscle more oxygen and energy to sustain aerobic activity.

PTS: 1 CON: Mobility | Health Promotion 5. ANS: 2 Chapter: Chapter 32 Physical Activity & Immobility Objective: Use proper body mechanics when providing patient care. Page: 830 (V1) Heading: Body Mechanics > Joint Mobility Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Mobility/Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Active ROM would not be possible for a quadriplegic patient. 2 This is correct. Passive ROM involves moving the joints through their ROM when the patient is unable to do so for himself. Passive ROM promotes joint mobility. 3 This is incorrect. Turning the patient every 2 hours prevents skin breakdown but does not promote mobility or prevent contracture. 4 This is incorrect. Glucosamine is a building block for the formation and repair of cartilage. However, there is inconclusive scientific evidence regarding the benefit of this substance to improve joint function. PTS: 1 CON: Mobility | Patient-Centered Care 6. ANS: 3 Chapter: Chapter 32 Physical Activity & Immobility Objective: Identify patients who are at risk for immobility or activity intolerance. Page: 835 (V1) Heading: Factors Affecting Mobility and Activity > Activity Tolerance Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Analysis [Analyzing] Concept: Mobility/Health Promotion Difficulty: Moderate Feedback 1 This is incorrect. Anxiety might primarily manifest as difficulty getting enough air, elevated heart rate, and elevated systolic blood pressure.

2 3

This is incorrect. Orthostatic hypotension is a temporary lowering of blood pressure when suddenly standing up. It is not a finding related to exercise. This is correct. To assess for activity tolerance, assess and record vital signs before and after exercise. A rapid change from baseline vital signs or a slow return to baseline indicates limited activity tolerance. Vital signs would resolve when anxiety is reduced and not after exercise. This is incorrect. Aerobic exercise increases the heart and respiratory rates.

PTS: 1 CON: Mobility | Health Promotion 7. ANS: 3 Chapter: Chapter 32 Physical Activity & Immobility Objective: Identify patients who are at risk for immobility or activity intolerance. Page: 833 (V1) Heading: Factors Affecting Mobility and Activity > Planning Interventions/Implementation > Physical Conditioning Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Mobility/Patient-Centered Care Difficulty: Moderate

1 2

Feedback This is incorrect. If the patient begins to fall, the nurse should assist the patient to a sitting or lying position while calling for assistance. This is incorrect. The patient may be able to assist turning by holding the siderails of the bed; however, this is not a way to assist in managing autonomic dysfunctions. This is correct. If the patient experiences decreased blood pressure, the highback reclining wheelchair could be lowered as a means to help manage the patient until blood pressure stabilizes. This is incorrect. Asking the patient about use of a gait belt is not appropriate. The transfer belt is used at all times possible.

PTS: 1 CON: Mobility | Patient-Centered Care 8. ANS: 1 Chapter: Chapter 32 Physical Activity & Immobility Objective: Discuss the factors that affect body alignment and activity. Page: 837 (V1) Heading: Factors Affecting Mobility and Activity > Diseases and Abnormalities > Osteoporosis Integrated Processes: Teaching and Learning Client Need: Physiological Integrity Cognitive Level: Comprehension [Understanding]

Concept: Mobility/Patient-Centered Care Difficulty: Easy Feedback 1 This is correct. Osteoporosis is a decrease in total bone density. The internal structure of the bone diminishes, and the bone collapses in on itself. Women experience a rapid decline in bone mass after menopause. 2 This is incorrect. Osteoarthritis is a degenerative joint disease. 3 This is incorrect. Rheumatoid arthritis is a chronic inflammatory joint disease that must be treated with steroids. 4 This is incorrect. Osteomyelitis is a serious infection in the bone. PTS: 1 CON: Mobility | Patient-Centered Care 9. ANS: 2 Chapter: Chapter 32 Physical Activity & Immobility Objective: Discuss the factors that affect body alignment and activity. Page: 845 (V1) Heading: Planning Interventions/Implementation > Preventing and Treating Osteoporosis Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Mobility/Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. A calcium supplement can assist to prevent bone loss; however, it does not promote bone strength. 2 This is correct. Osteoporosis causes bones to become porous and weak. Starting a weight-bearing exercise program is the most important aid in promoting bone strength and decreasing the rate of bone loss. 3 This is incorrect. This is incorrect, strenuous activity that stresses bones can cause fractures. 4 This is incorrect. Regular healthcare checkups are important but do not actively minimize progression of the disease. PTS: 1 CON: Mobility | Patient-Centered Care 10. ANS: 2 Chapter: Chapter 32 Physical Activity & Immobility Objective: Discuss the factors that affect body alignment and activity. Page: 845 (V1) Heading: Planning Interventions/Implementation > Preventing and Treating Osteoporosis Integrated Processes: Teaching and Learning Client Need: Physiological Integrity Cognitive Level: Analysis [Analyzing]

Concept: Mobility/Patient-Centered Care Difficulty: Easy Feedback 1 This is incorrect. Calcium supplementation is also part of the treatment for osteoporosis. However, high phosphorus intake lowers calcium levels and would not be appropriate for a client with osteoporosis. 2 This is correct. Active participation in a weight-bearing and weight-lifting program demonstrates not only understanding of the treatment of osteoporosis but also commitment to an action plan to reduce bone loss that accompanies osteoporosis. 3 This is incorrect. Restricting weight-bearing activity to a wheelchair will actually lower bone density. 4 This is incorrect. Although follow-up care is appropriate for a client with osteoporosis, it does not indicate commitment to a daily treatment plan. PTS: 1 CON: Mobility | Patient-Centered Care 11. ANS: 4 Chapter: Chapter 32 Physical Activity & Immobility Objective: Discuss the physiology of movement. Page: 827 (V1) Heading: Physiology of Movement Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Knowledge [Remembering] Concept: Mobility Difficulty: Moderate Feedback 1 This is incorrect. Diarthroses joints, such as the shoulder and the knee, are freely movable. 2 This is incorrect. Synovial joints are also known as diarthroses joints. The shoulder and the knee are examples. 3 This is incorrect. Amphiarthroses joints, such as the vertebrae and pubic bones, allow limited movement. 4 This is correct. Synarthroses joints, such as those between the cranial bones, are immovable joints. Although these joints have some flexibility in youth to allow for growth, they gradually become rigid and immovable with age. PTS: 1 CON: Mobility 12. ANS: 1 Chapter: Chapter 32 Physical Activity & Immobility Objective: Discuss the factors that affect body alignment and activity. Page: 848 (V1)

Heading: Factors Affecting Mobility and Activity > Positioning Patients > Fowler’s Position. Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Mobility/Patient-Centered Care Difficulty: Easy

3 4

Feedback This is correct. Fowler’s position is a semi-sitting position, in which the head of the bed is elevated to 45 to 60 degrees. This position promotes respiratory function by lowering the diaphragm and allowing the greatest chest expansion. This is incorrect. Sims’ position is a side-lying position in which the patient is on his left side with left leg extended and right leg flexed. This position is commonly used for rectal examination. This is incorrect. The prone position is when the patient lies on his abdomen with his head turned to one side. This is incorrect. Lateral position simply means side lying.

PTS: 1 CON: Mobility | Patient-Centered Care 13. ANS: 2 Chapter: Chapter 32 Physical Activity & Immobility Objective: Discuss the concept of fitness. Page: 831 (V1) Heading: Physical Activity and Exercise > Planning and Evaluating a Fitness Program Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Mobility/Patient-centered care Difficulty: Moderate Feedback 1 This is incorrect. Flexibility training will not increase muscular strength. 2 This is correct. Resistance training involves movement against resistance, which increases muscular strength and endurance. Most commonly, resistance training refers to weight lifting and isotonic movement. When exercising for strength, the amount of resistance is increased with each exercise. When exercising for endurance, the number of repetitions is increased with each exercise. 3 This is incorrect. Aerobic conditioning may have some benefit on strength and endurance, but its primary focus is cardiovascular conditioning. Aerobic conditioning includes intensity, duration, frequency, and mode. 4 This is incorrect. Anaerobic exercise occurs when the amount of oxygen taken into the body does not meet oxygen requirements. Rapid, intense exercises, such as lifting heavy objects and sprinting, are examples.

PTS: 1 CON: Mobility | Patient-Centered Care 14. ANS: 3 Chapter: Chapter 32 Physical Activity & Immobility Objective: Use proper body mechanics when providing patient care. Page: 829 (V1) Heading: Body Mechanics > Balance Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Mobility/Patient-Centered Care Difficulty: Easy Feedback 1 This is incorrect. The line of gravity is an imaginary vertical line drawn from the top of the head through the center of gravity. 2 This is incorrect. The center of balance is located just below the ribcage, and balance is achieved from this portion of the body. 3 This is correct. Balance is achieved when the body is in alignment. To be balanced, a person’s line of gravity must pass through his center of gravity, and the center of gravity must be close to his base of support. The center of gravity is the point around which mass is distributed. 4 This is incorrect. The base of support is what holds the body up; the feet provide the base of support. PTS: 1 CON: Mobility | Patient-Centered Care 15. ANS: 4 Chapter: Chapter 32 Physical Activity & Immobility Objective: Describe the physical activity recommended for health promotion, cardiovascular fitness, and maintenance of healthy weight. Page: 831 (V1) Heading: Physical Activity and Exercise > Planning and Evaluating a Fitness Program Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Mobility/Patient-Centered Care Difficulty: Moderate Not a direct response to the item Feedback 1 This is incorrect. Aerobic exercise with deep breathing produces the greatest benefit to cardiovascular health and does little to improve the upper body strength needed for ambulating with an assistive device. 2 This is incorrect. Toning the lower body through exercise of the quadriceps and

3 4

gluteal muscles, although important for regaining strength in general after surgery, does not specifically aid in using a walker. This is incorrect. Isometric toning of the lower legs, while important to overall strength does not specifically aid in using a walker. This is correct. Arm strength is necessary for ambulating with a walker and other assistive devices. Upper body resistance training increases muscle strength and tone, which will aid him in using the walker more easily.

PTS: 1 CON: Mobility | Patient-Centered Care 16. ANS: 3 Chapter: Chapter 32 Physical Activity & Immobility Objective: Develop a plan of care for patients with decreased activity tolerance. Page: 844 (V1) Heading: Analysis/Nursing Diagnosis Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Synthesis [Creating] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. The patient is experiencing Activity Intolerance, but this is not his primary safety risk. A diagnosis of Activity Intolerance would focus the goals on increasing his endurance and conserving his energy. 2 This is incorrect. The patient does have Impaired Mobility; however, his Impaired Mobility puts him at Risk for Injury. A diagnosis of Impaired Mobility would focus the outcomes on improving his mobility rather than protecting him from further injury. 3 This is correct. The patient’s medical condition places him at an increased Risk for Injury: He is at risk for falls and for further injury to his hip. 4 This is incorrect. There is no data other than a diagnosis of Emphysema to indicate that he is experiencing Ineffective Breathing Pattern. PTS: 1 CON: Patient-Centered Care 17. ANS: 1 Chapter: Chapter 32 Physical Activity & Immobility Objective: Develop a plan of care related to a patient’s mobility problems. Page: 844 (V1) Heading: Planning Outcomes/Evaluation Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care

Difficulty: Easy Feedback 1 This is correct. Remaining free from injury or falls is a measurable goal, and it is directly related to the patient’s nursing diagnosis—Risk for Injury. 2 This is incorrect. Increasing activity tolerance by the time of discharge is not specific and measurable. Additionally, this outcome does not relate to Risk for Injury. 3 This is incorrect. A goal of effective breathing for a frail elderly patient after hip surgery does not relate to Risk for Injury. 4 This is incorrect. Increasing mobility by the time of discharge is not specific and measurable. Additionally, this outcome does not relate to Risk for Injury. PTS: 1 CON: Patient-Centered Care 18. ANS: 3 Chapter: Chapter 32 Physical Activity & Immobility Objective: Implement care related to a patient’s mobility problems. Page: 842 (V1) Heading: Example Problem: Prolonged Immobility Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Mobility/ Mood/ Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Decisions about treatment for mood problems occurring related to immobility are up to the physician. With short-term issues, nonpharmacological measures should be attempted and are within the nurse’s scope of practice. 2 This is incorrect. While teens may have mood swings, there is a clear, likely etiology of immobility occurring. This response minimizes and dismisses the parents’ concerns and does not address the real possibility of a mood disorder having developed. 3 This is correct. Being immobile, whether in the hospital or home, leads to isolation and mood changes. Patients who are in bed for long periods can suffer from psychological changes such as depression, anxiety, hostility, sleep disturbances, and changes in their ability to perform self-care activities. 4 This is incorrect. This response dismisses the parents’ concerns and the real possibility of a mood disorder related to immobility. While the nurse is appropriate to attempt to find a solution for the teen, it is not a complete response. PTS:

CON: Mobility | Mood | Patient-Centered Care

19. ANS: 4 Chapter: Chapter 32 Physical Activity & Immobility Objective: Describe the physical activity recommended for health promotion, cardiovascular fitness, and maintenance of healthy weight. Page: 845 (V1) Heading: Planning Interventions/Implementation Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Mobility/Patient-Centered Care/ Health Promotion Difficulty: Moderate Feedback 1 This is incorrect. Twenty to 30 minutes of exercise once weekly is significantly less than recommended by the U.S. Department of Health and Human Services. 2 This is incorrect. Thirty minutes of exercise three times weekly is less than recommended by the U.S. Department of Health and Human Services. 3 This is incorrect. One hour of exercise three times a week is within the U.S. Department of Health and Human Services recommendations but does not fully represent the recommendations. 4 This is correct. Exercise involves physical activity and increases muscle tone and strength. The U.S. Department of Health and Human Services recommends 150 to 300 minutes or more of moderate- or vigorous-intensity physical activity per week. PTS: 1 CON: Mobility | Patient-Centered Care | Health Promotion 20. ANS: 4 Chapter: Chapter 32 Physical Activity & Immobility Objective: Implement care related to a patient’s mobility problems. Page: 831 (V1) Heading: Physical Activity and Exercise > Types of Exercise > Isometric Exercises Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Mobility/Patient-Centered Care/Health Promotion Difficulty: Difficult Feedback 1 This is incorrect. Performing repetitions with a light weight increases strength but this would stress the healing fracture at this point in the rehabilitation. 2 This is incorrect. Passive range of motion does not build strength needed after a cast is removed. Passive range of motion is used when the patient is unable to do so herself. 3 This is incorrect. Pulling an arm across the body improves flexibility but does

not benefit the ulna while healing. This is correct. Isometric exercise involves muscle contraction without motion. Isometric exercises are useful for developing strength. This type of exercise is appropriate for the patient who has had an extremity confined to a cast because muscle atrophy occurs when the muscle is not used.

PTS: 1 CON: Mobility | Patient-Centered Care | Health Promotion 21. ANS: 1 Chapter: Chapter 32 Physical Activity & Immobility Objective: Implement care related to a patient’s mobility problems. Page: 842 (V1) Heading: Example Problem: Prolonged Immobility Integrated Processes: Nursing Process/Teaching and Learning Client Need: Physiological Integrity Cognitive Level: Comprehension [Understanding] Concept: Mobility/Elimination/Patient-Centered Care Difficulty: Easy Feedback 1 This is correct. Immobility slows peristalsis, which leads to constipation, gas, and difficulty evacuating stools from the rectum. 2 This is incorrect. Increasing fiber in the diet often prevents constipation. The use of a low-fiber diet would not resolve the problem. 3 This is incorrect. A stool softener may be ordered if other measures are unsuccessful. 4 This is incorrect. Some people do find the use of a bedpan difficult, which can exacerbate constipation. PTS: 1 CON: Mobility | Elimination | Patient-Centered Care 22. ANS: 2 Chapter: Chapter 32 Physical Activity & Immobility Objective: Implement care related to a patient’s mobility problems. Page: 842 (V1) Heading: Example Problem: Prolonged Immobility Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Analysis [Analyzing] Concept: Nursing Process/Communication/Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. The nurse will not order the fiber without a physician’s or a nurse practitioner’s order. It is important to check allergies before ordering any medication.

This is correct. Fiber supplement is an option to improve constipation. Dietary changes, including increasing fiber intake, should be used to prevent and resolve constipation. This is incorrect. A fiber supplement is likely to improve constipation. While increasing movement is important, it may not be reasonable, depending on the medical condition requiring bedrest. This is incorrect. A stool softener should not be used as first-line treatment for constipation; it is used after other measures fail.

PTS: 1 CON: Nursing Process | Communication | Patient-Centered Care 23. ANS: 4 Chapter: Chapter 32 Physical Activity & Immobility Objective: Implement care related to a patient’s mobility problems. Page: 845 (V1) Heading: Planning Interventions/Implementation >Transferring Patients Out of Bed Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Application [Applying] Concept: Mobility/Patient-Centered Care Difficulty: Easy Feedback 1 This is incorrect. A mechanical lift could be used, but it does not promote independence. 2 This is incorrect. A transfer belt is used for clients who are able to stand. 3 This is incorrect. A draw sheet is useful for moving a patient in bed rather than from bed to wheelchair. 4 This is correct. A transfer board is used by patients with longstanding mobility problems; it offers them the greatest amount of independence while ensuring safety. Patients moved by using a transfer board should have sufficient upperbody strength for the transfer to be performed safely. PTS: 1 CON: Mobility | Patient-Centered Care 24. ANS: 2 Chapter: Chapter 32 Physical Activity & Immobility Objective: Implement care related to a patient’s mobility problems. Page: 845 (V1) Heading: Planning Interventions/Implementation > A Transfer Belt Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Application [Applying] Concept: Mobility/Patient-Centered Care/Safety Difficulty: Easy

1 2

3 4

Feedback This is incorrect. Crutches are commonly used when the patient has an injured lower extremity. This is correct. The most appropriate equipment to use would be a transfer belt. A transfer belt allows the patient the greatest amount of independence while ensuring safety. This is incorrect. A cane is generally used for the patient with a lower-extremity injury or weakness. This is incorrect. A walker is generally used for the patient with a lowerextremity injury or weakness.

PTS: 1 CON: Mobility | Patient-Centered Care | Safety 25. ANS: 3 Chapter: Chapter 32 Physical Activity & Immobility Objective: Implement care related to a patient’s mobility problems. Page: 846 (V1) Heading: Planning Interventions/Implementation>Assisting the Patient to Walk Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Application [Applying] Concept: Mobility/Safety/Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. The patient who is light-headed may pass out and be unable to grab the rail. If the patient’s knees are buckling, they will not be able to support themselves. 2 This is incorrect. Releasing the transfer device will eliminate a means to support the patient and allow the patient to fall. 3 This is correct. If a patient becomes weak or begins to fall when walking, do not attempt to hold the patient up. Instead, protect the patient as you guide her to a seated or lying position. Create a wide base of support, and project forward the hip closest to the patient. Assist the patient to slide down your leg as you call for help. Protect the patient’s head as her body descends. 4 This is incorrect. Holding the patient up by grasping her under her arms and across the chest could cause injury to the nurse. The patient should be carefully lowered to a sitting or lying position. PTS: 1 CON: Mobility | Safety | Patient-Centered Care 26. ANS: 4 Chapter: Chapter 32 Physical Activity & Immobility Objective: Describe the physical activity recommended for health promotion, cardiovascular fitness, and maintenance of healthy weight.

Page: 844 (V1) Heading: Planning Interventions/Implementation Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Knowledge [Remembering] Concept: Mobility/Health Promotion Difficulty: Easy Feedback 1 This is incorrect. Additional health benefits are provided by increasing to 300 minutes a week of moderate-intensity aerobic physical activity, or 150 minutes a week of vigorous-intensity physical activity, or an equivalent combination of both. For all individuals, some activity is better than none. 2 This is incorrect. Some individuals prefer and tolerate more than the recommended physical activity. 3 This is incorrect. Physical activity is safe for almost everyone, and the health benefits of physical activity far outweigh the risks. 4 This is correct. Physical activity should be enjoyable and a variety improves adherence to an exercise regimen. PTS: 1 CON: Mobility | Health Promotion 27. ANS: 4 Chapter: Chapter 32 Physical Activity & Immobility Objective: Describe the physical activity recommended for health promotion, cardiovascular fitness, and maintenance of healthy weight. Page: 831 (V1) Heading: Physical Activity and Exercise Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Mobility/Health Promotion Difficulty: Easy Feedback 1 This is incorrect. Older adults should follow the adult guidelines, which are for 150 minutes per week of moderate-intensity or 75 minutes per week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity aerobic physical activity. Aerobic activity should be performed in periods of at least 10 minutes, preferably spread throughout the week. If this is not possible because of limiting chronic conditions, older adults should be as physically active as their abilities allow. They should avoid inactivity. 2 This is incorrect. More than 150 minutes of moderate-intensity exercise is not harmful to bones. Weight bearing exercise will improve bone density for most

older individuals. This is incorrect. Structured calisthenics programs are no more beneficial for achieving health benefits than other forms of moderate- and vigorous-intensity physical activity. Structured fitness programs can become boring for some individuals. A varied routine often improves compliance and consistency of exercise. This is correct. Older adults should do exercises that maintain or improve balance if they are at risk of falling.

PTS: 1 CON: Mobility | Health Promotion 28. ANS: 3 Chapter: Chapter 32 Physical Activity & Immobility Objective: Discuss the physiology of movement. Page: 827 (V1) Heading: Physiology of Movement Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Knowledge [Remembering] Concept: Mobility/Health Promotion Difficulty: Easy Feedback 1 This is incorrect. Amphiarthrosis is a type of joint that allows for limited movement. 2 This is incorrect. Articular cartilage is connective tissue found in the joints and skeleton. 3 This is incorrect. Osteoblasts repair damaged bone and build new bones, which would be needed for the patient with fractured bone. 4 This is correct. Osteoclasts are specialized cells that break down old or damaged bone, laying the groundwork for the osteoblasts to build a new, stronger foundation of bone. PTS: 1 CON: Mobility | Health Promotion 29. ANS: 1 Chapter: Chapter 32 Physical Activity & Immobility Objective: Discuss the physiology of movement. Page: 826 (V1) Heading: Physical Activity and Exercise Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Knowledge [Remembering] Concept: Mobility/Health Promotion Difficulty: Easy

3 4

Feedback This is correct. Isokinetic exercise provides variable resistance to controlled movement. Physical therapists often use specialized apparatuses that combine the best features of isometrics and weight training. This is incorrect. Isometric exercise involves muscle contraction without motion. The patient would apply pressure against an immovable surface, such as pushing against a wall. This is incorrect. Isotonic involves movement of the joint during the muscle contraction (e.g., weight lifting). This is incorrect. “Isomorphic” is not a type of exercise; it describes a body type.

PTS: 1 CON: Mobility | Health Promotion 30. ANS: 2 Chapter: Chapter 32 Physical Activity & Immobility Objective: Discuss the factors that affect body alignment and activity. Page: 840 (V1) Heading: Factors Affecting Mobility and Activity > Assessment Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Knowledge [Remembering] Concept: Mobility/Patient-Centered Care Difficulty: Easy Feedback 1 This is incorrect. An antalgic gait is a limp to avoid pain when bearing weight on an injured lower extremity. 2 This is correct. A propulsive gait is characterized by a stooped, rigid posture with the head and neck bent forward. The patient takes small, shuffling steps in involuntary acceleration, which is typical of a parkinsonian gait. 3 This is incorrect. In a scissors gait, the legs flex slightly at the hip and knees; the thighs cross in a scissor-like motion, common with cerebral palsy, stroke, head trauma, or brain tumor. 4 This is incorrect. A steppage gait is an exaggerated lifting of the leg that appears as though the foot is floppy and toes point downward. This occurs with GuillainBarré syndrome. PTS: 1 CON: Mobility | Patient-Centered Care 31. ANS: 4 Chapter: Chapter 32 Physical Activity & Immobility Objective: Use proper body mechanics when providing patient care. Page: 844 (V1) Heading: Planning Interventions/Implementation > Moving Patients in Bed

Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Application [Applying] Concept: Mobility/Safety Difficulty: Moderate Feedback 1 This is incorrect. A mechanical lift is a hydraulic device, such as a sling-style or ceiling-mount mechanical lift, used to safely transfer immobile patients who can sit or stand during the transfer. 2 This is incorrect. The American Nurses Association’s national campaign Handle with Care emphasizes the use of assistive devices to decrease the risk of injury and recommends virtually no manual lifting. Do not rely on body mechanics alone to prevent injury. Overexertion is the primary reason for work-related injury in the healthcare setting. 3 This is incorrect. Using a co-worker does not effectively reduce the manual lifting strain on the individual, thus placing both nurses/coworkers at risk for injury. The American Nurses Association’s national campaign Handle With Care emphasizes the use of assistive devices to decrease the risk of injury and recommends virtually no manual lifting. Do not rely on body mechanics alone to prevent injury. Overexertion is the primary reason for work-related injury in the healthcare setting. 4 This is correct. The nurse uses a friction-reducing device, such as a transfer roller sheet, when transferring an immobile patient who is unable to assist in the transfer. PTS:

CON: Mobility | Safety

MULTIPLE RESPONSE 32. ANS: 2, 3, 4 Chapter: Chapter 32 Physical Activity & Immobility Objective: Discuss the physiology of movement. Page: 827 (V1) Heading: Physiology of Movement Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Knowledge [Remembering] Concept: Mobility Difficulty: Easy

Feedback This is incorrect. The digestive system does not assist to produce mobility and

locomotion. This is correct. Activity and exercise require bodily movement (mobility) and locomotion (self-powered movement from one place to another). Mobility depends on the successful interaction among the skeleton, muscles, and the nervous system. This is correct. Activity and exercise require bodily movement (mobility) and locomotion (self-powered movement from one place to another). Mobility depends on the successful interaction among the skeleton, muscles, and the nervous system. This is correct. Activity and exercise require bodily movement (mobility) and locomotion (self-powered movement from one place to another). Mobility depends on the successful interaction among the skeleton, muscles, and the nervous system. This is incorrect. The endocrine system does not assist in mobility and locomotion.

PTS: 1 CON: Mobility 33. ANS: 2, 3, 4, 5 Chapter: Chapter 32 Physical Activity & Immobility Objective: Identify patients who are at risk for immobility or activity intolerance. Page: 835 (V1) Heading: Factors Affecting Mobility and Activity Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Mobility Difficulty: Moderate

Feedback This is incorrect. Physical activity doesn’t have to be a structured fitness class but can also be walking. Even walking in a mall or neighborhood, as long as the intensity is moderately vigorous, improves activity. This is correct. The person who lives in a skilled nursing facility might be sedentary because of advancing age and other age-associated medical problems that lead to inactivity. This is correct. A sedentary lifestyle, whether adult or child, contributes to obesity; activities, such as computer work and video games, are sedentary and require little physical activity. With obesity, movement becomes more difficult and strain on joints increases. This is correct. A sedentary lifestyle, whether adult or child, contributes to obesity; activities, such as computer work and video games, are sedentary and require little physical activity. With obesity, movement becomes more difficult and strain on joints increases. This is correct. The patient with impaired arterial circulation limits oxygen delivery to the tissue. As activity increases, muscle pain develops. Patients remain sedentary to reduce pain and discomfort.

PTS: 1 CON: Mobility 34. ANS: 1, 2, 3, 4, 5 Chapter: Chapter 32 Physical Activity & Immobility Objective: Describe the physical activity recommended for health promotion, cardiovascular fitness, and maintenance of healthy weight. Page: 831 (V1) Heading: Physical Activity and Exercise Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Mobility/Health Promotion Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is correct. Flexibility training helps warm up the muscles and prevents injury during exercise. This is correct. Exercises that maintain or improve balance and core strength are important for preventing falls, especially for older adults. This is correct. Resistance training increases muscular strength and endurance. This is correct. Aerobic conditioning affects fitness and body composition. This is correct. Isotonic exercises build muscle strength. Common examples are weight lifting.

PTS: 1 CON: Mobility | Health Promotion 35. ANS: 1, 2, 5 Chapter: Chapter 32 Physical Activity & Immobility Objective: Describe the physical activity recommended for health promotion, cardiovascular fitness, and maintenance of healthy weight. Page: 831 (V1) Heading: Physical Activity and Exercise Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Mobility/Health Promotion Difficulty: Easy

1. 2.

Feedback This is correct. The longer a person exercises, the more fluid the person will lose. The greater the duration of exercise, the more the person will need to drink. This is correct. Elevated environmental temperatures also increase the amount of fluid lost through sweating.

3. 4.

This is incorrect. Lost fluids must be replaced to decrease the risk of dehydration, regardless of level of fitness. This is incorrect. When athletes drink according to thirst, the risk of overdrinking and so developing exercise-associated hyponatremia is minimized (Noakes, 2007). Conversely, exercise can suppress thirst, making it an unreliable signal to replace fluids lost with exercise. This is correct. The more intense the exercise, the more fluid one can lose. During intense exercise, the body can lose 2 L of fluid for every hour of exercise.

PTS: 1 CON: Mobility | Health Promotion 36. ANS: 1, 3, 4 Chapter: Chapter 32 Physical Activity & Immobility Objective: Discuss the factors that affect body alignment and activity. Page: 831 (V1) Heading: Physical Activity and Exercise Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Cognitive Level: Comprehension [Understanding] Concept: Mobility/Health Promotion Difficulty: Moderate

1. 2.

3. 4. 5.

Feedback This is correct. Proper body mechanics involves good body alignment, erect posture, and a wide base of support. This is incorrect. Bending at the waist to lift objects uses the back muscles and increases the risk of injury. Instead, squat to lower your center of gravity, and use your leg muscles for lifting. This is correct. Proper body mechanics involves good body alignment, erect posture, and a wide base of support. This is correct. To prevent back injury resulting from reaching and straining muscles, carry objects close to the trunk. This is incorrect. A firm mattress provides the support needed to prevent injury.

PTS: 1 CON: Mobility | Health Promotion 37. ANS: 1, 3 Chapter: Chapter 32 Physical Activity & Immobility Objective: Compare the effects of exercise and immobility on the body. Page: 842 (V1) Heading: Example Problem: Prolonged Immobility Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding]

Concept: Mobility/Oxygenation/Patient-Centered Care Difficulty: Difficult

2. 3.

4. 5.

Feedback This is correct. Immobility decreases the strength of muscles involved in chest wall expansion, which also affects ventilation. The depth of respirations decreases (hypoventilation), and secretions pool in the airways. The ability to effectively cough and expectorate secretions diminishes as the muscle tone of the abdomen and chest decreases. As a result, pooled secretions block air passages and alveoli, decrease oxygen and carbon dioxide exchange (hypoxemia and hypercarbia), and often lead to atelectasis (collapse of air sacs) or pneumonia. This is incorrect. Immobility does not cause hyperventilation. Factors such as anxiety may cause hyperventilation. This is correct. Immobility decreases the strength of muscles involved in chest wall expansion, which also affects ventilation. The depth of respirations decreases (hypoventilation), and secretions pool in the airways. The ability to effectively cough and expectorate secretions diminishes as the muscle tone of the abdomen and chest decreases. As a result, pooled secretions block air passages and alveoli, decrease oxygen and carbon dioxide exchange (hypoxemia and hypercarbia), and often lead to atelectasis (collapse of air sacs), or pneumonia. This is incorrect. Immobility does not cause a reactive airway. Reactive airway is a response to some factor, such as an allergen. This is incorrect. Hypocarbia, also known as hypocapnia, is a decrease in alveolar and blood carbon dioxide levels. This does not happen as a result of increased secretion pooling or atelectasis.

PTS:

CON: Mobility | Oxygenation | Patient-Centered Care

Chapter 33. Sexual Health Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse is assessing a 16-year-old female client’s knowledge of sexuality. Which of her statements indicates that she requires further teaching? 1. “I don’t practice oral sex because it could lead to sexually transmitted infections (STIs).” 2. “I don’t have sexual intercourse because I want to remain a virgin until marriage.” 3. “My boyfriend and I are practicing abstinence by engaging in shared touching.” 4. “My parents are lesbians, but it has not affected my sexual orientation.” 2. A client confides to the nurse that he feels guilty because when he has intercourse with his girlfriend, he pretends that she is a certain female actress. What is the nurse’s most appropriate response? 1. “This behavior is known as a minimal voyeuristic disorder and is perfectly normal.” 2. “Perhaps we should discuss the problems in your relationship with your girlfriend?” 3. “Here is a referral to a sexual counselor to help work through your guilty feelings.” 4. “Fantasy before or during sexual intercourse can add excitement to a relationship.” 3. The nurse is assessing the older adult client when he states that although he can achieve an erection, he is unable to achieve an orgasm. The nurse recognizes that the client may be having difficulty completing which of the following phases of sexual arousal? 1. Desire 2. Excitement 3. Plateau 4. Resolution 4. A 19-year-old client asks if he is normal because he has always viewed himself as a female, although he has acted like a male to please his parents. The nurse should provide the client with education on which concept? 1. Bisexual 2. Intersex 3. Transgender 4. Transvestite 5. The nurse is discussing workplace issues with a 35-year-old client. The client tells the nurse that his boss requires him to massage her shoulders. His boss also rubs his legs, thighs, and genitals. He further states that he does not want to upset her because he needs the job. Which statement best applies to this situation? 1. The male is receiving sexual satisfaction from having his legs, thighs, and genitals

massaged. 2. This is an example of quid pro quo sexual harassment and should be reported to a supervisor. 3. This is an example of a hostile work environment and sexual harassment and should be immediately reported to a supervisor. 4. This is not a situation of harassment because no sexual intercourse has occurred, and the client can refuse. 6. The nurse is assessing a client in the pediatric office, when and the client’s parent voices concern about the new neighbor who is a convicted sex offender. She asks for advice on how to protect her child. What is the nurse’s best response? 1. “Keep the child indoors to prevent any contact with the sex offender.” 2. “Discuss your concerns with the sex offender and neighbors.” 3. “Teach your child to never let another person touch his or her private parts.” 4. “Teach your child to avoid the house of the known sex offender.” 7. The nurse is assessing a middle-aged client’s compliance with his medications. The client states that he has stopped all medications because he could not “perform sexually.” Which of the following medications do NOT negatively influence his sexual activity? 1. Beta blocker antihypertensive medication 2. Allergy and antihistamine medications 3. First-generation antimicrobials 4. Antipsychotics and antidepressants 8. The nurse feels uncomfortable when preparing to assess a client’s sexual health. Which of the following would be most important for a nurse to be able to do during the assessment? 1. Recognize and set aside personal biases or experiences related to sexuality. 2. Perform an accurate and comprehensive physical assessment. 3. Collect an accurate and comprehensive sexual history. 4. Acquire theoretical knowledge of sexual health concerns. 9. The nurse has completed teaching a group of adolescents about (STIs). Which of the following statements made by one of the adolescents would indicate that the teaching has been effective? 1. “A healthcare provider can tell whether you have an STI by asking if you have any symptoms.” 2. “The healthcare provider can diagnose most STIs with a surgical biopsy or blood draw.” 3. “A healthcare provider can tell whether you have an STI by getting a detailed sexual history.” 4. “The healthcare provider can swab the genitals to diagnose whether a person has an STI.” 10. The nurse is evaluating the treatment plan for the client with erectile dysfunction (ED). Which statement made by the client indicates treatment was successful? 1. “I feel very good about the treatment; I am now comfortable with my sexual

orientation.” 2. “I am happy with the treatment as I can now maintain an erection through orgasm.” 3. “Now I can communicate my sexual needs to my partner without embarrassment.” 4. “I now know how to communicate my sexual desires with my partner.” 11. During an initial assessment of the client’s sexual orientation, the nurse may utilize the PLISSIT model. What is the first step of this model? 1. Provide information about sexual orientation and common alterations. 2. Plan time to discuss concerns with the client in a private, comfortable setting. 3. Permit the client to speak openly by communicating an open, accepting attitude. 4. Provide referrals to the client so the client can identify resources to assist him in the future. 12. The nurse is preparing education for the prepubescent female client on the menstrual cycle. Which of the following statements best explains the portion of the cycle when the ovum is released? 1. Fertilization 2. Follicular phase 3. Luteal phase 4. Menstrual phase 13. The nurse is providing presurgical care to a patient scheduled for a total abdominal hysterectomy as treatment for cancer. The patient says, “I won’t be a woman after surgery.” The nurse recognizes that the patient connects having a uterus with which aspect of sexuality? 1. Eroticism 2. Intimacy 3. Reproduction 4. Role and identity 14. While admitting a young adult male into the family health clinic, the nurse asks about his occupation. The patient appears embarrassed and says, “You’re going to think I’m lazy, but I stay home with our young children while my wife works.” The nurse recognizes this patient is experiencing what type of conflict? 1. Sexual confusion 2. Gender role 3. Gender identity 4. Sexual orientation 15. The emergency room nurse cares for a male patient experiencing an acute myocardial infarction. The patient is dressed in a bra, panties, and nightgown. Which of the following is the most accurate inference the nurse can make regarding the client’s sexual expression? 1. The client is a transgender person. 2. The client is a cross-dresser. 3. The client is a homosexual person. 4. The client is a heterosexual person.

16. The nurse assesses a client’s medical history in a gynecology office prior to admission. As the nurse prepares the client for a female examination, the client confides about a form of cultural practice that she has been subjected to that is illegal in the United States. What is the name of that form of cultural practice? 1. Genitalia piercing 2. Hysterectomy 3. Female circumcision 4. Transgender surgery 17. The nurse is conducting a case meeting of an older client in the Alzheimer’s unit. The healthcare team is assembled to discuss the family’s concerns. The older client has developed a close relationship with another client in the facility. It appears that the two have become intimate recently and the family voices concerns that the client is unable to make decisions regarding this intimate relationship. Which of the following would be an appropriate nursing intervention for this client? 1. Assess whether the client is able to consent to sexual intimacy. 2. Assess and transfer one of the clients to another unit. 3. Provide privacy for the clients to engage in sexual activities. 4. Bring in the other client’s family members to discuss this fully. 18. The nurse is preparing to teach a group of adolescent male students about testicular self-exams. Which of the following would be an indication that the teaching was effective? 1. Monthly exams are necessary for early detection of lumps in the testicle. 2. Monthly exams for any changes in the testicle are a personal preference. 3. Monthly exams are not warranted if both testicles have not fully descended. 4. Monthly exams are not necessary once the male has become sexually active. 19. The mental health nurse has assessed a male client who has repeatedly made sexual comments and advances toward other clients. The nurse recognizes these behaviors as which possible mental health disorder? 1. Anxiety disorder 2. Bipolar disorder 3. Depressive disorder 4. Paranoid schizophrenia 20. The nurse is developing a plan of care for a female client who expresses loss of interest in sexual intimacy with her husband following a total hysterectomy several months ago. The client states “I just don’t have the energy to be intimate; besides I don’t feel like a woman anymore because I cannot have children.” What nursing diagnosis would be most appropriate for this patient? 1. Activity Intolerance and Fatigue 2. Disturbed Body Image 3. Ineffective Sexuality Patterns 4. Sexual Dysfunction

21. A physician frequently approaches a nurse and complements her on her appearance including making inappropriate comments about the nurse’s body shape. What is the most appropriate initial action of the nurse? 1. Inform the nursing supervisor of the physician’s behavior. 2. Call the medical board to report the physician’s behavior. 3. Document the physician’s behavior and report concern to the chief of staff. 4. Inform the physician the behavior is inappropriate and unwelcome. 22. The nurse is providing teaching to a group of prepubescent students regarding some common myths about sexuality and body functions. Which statement by the students is an indication that teaching was effective? 1. “I don’t to worry about birth control or STIs during my first time.” 2. “Condoms are the most effective birth control and the only way I can be sure I won’t get pregnant.” 3. “I only have to worry about being infected with an STI if I see a sore or have pain.” 4. “Enjoyable sexual relationships or reaching orgasm simultaneously do not indicate the quality of the relationship.” 23. The nurse is interviewing a client in the family practice clinic who has been diagnosed with pelvic inflammatory disease (PID). The client states that she uses several methods to stay clean “down there,” such as occasional condom use by the partner, twice-weekly douches, and taking daily bubble baths instead of showers. Which of the following practices may have increased her likelihood of this infection? 1. Wearing cotton underwear 2. Inconsistent condom use by the partner 3. Daily bubble baths 4. Twice-weekly douches 24. The patient tells the nurse, “My partner and I never have intercourse when I have my period because I read that it is dangerous.” What statement by the nurse is most appropriate? 1. “You can protect the bed linens by placing protective padding under the buttocks.” 2. “Reaching orgasm during your period can help to relieve menstrual cramps.” 3. “The blood is from the uterus, not the vagina, so intercourse will not harm the vagina.” 4. “The increased blood flow to the pelvis will make sex more pleasurable for you.” 25. The nurse is providing preoperative screening for the older adult male client who is scheduled for prostate surgery due to cancer. The client states that he knows that his girlfriend will leave him now because the surgery will ruin his sex life. What statement by the nurse would be most appropriate? 1. “I am so sorry to hear that. A close sexual relationship is so important.” 2. “It is possible to have a close, intimate relationship without intercourse.” 3. “Let’s talk a little more about the ways in which your sex life has been ruined.”

4. “You might want to try one of the medications available to treat erectile dysfunction.” Multiple Response Identify one or more choices that best complete the statement or answer the question. 26. The nurse is assessing an older female client in the clinic, when the client states that she is having issues with sexual intercourse due to lubrication. The nurse begins to use the PLISSIT model as the guideline for counseling for sexual problems. Which of the following are examples of the components of the PLISSIT model? Select all that apply. 1. “Some women experience decreased vaginal lubrication after menopause. Tell me how well you have been lubricating.” 2. “Should your sexual partner be in the room to further discuss this issue and find some methods to help you?” 3. “Some women experience decreased vaginal lubrication because of decreased hormone levels. “ 4. “Some women have found that using a water-soluble lubricant prior to sexual intercourse to be helpful.” 5. “I will send this information onto your gynecologist for you to further discuss possible treatments.” 27. A 2-year-old boy has come to the well-child clinic with his mother for a checkup. When the nurse asks his mother whether she has any concerns, the mother expresses concern that her son often touches his genitals. She says, “I have tried sitting him in a chair, smacking his hand, and telling him no, but he continues to do this. I just don’t know how to make him stop.” Which of the following would be the nurse’s most appropriate responses to address the mother’s concerns? Select all that apply. 1. “Give him a little time. The first two years of a child’s life are a time for them to explore their bodies. He’ll grow out of it.” 2. “How often do you punish him by giving him a time-out or by using physical discipline?” 3. “Physical punishment, such as smacking his hand, is not the best way to modify a child’s behavior.” 4. “It isn’t unusual for him to fondle his genitals, as this is part of his exploration of his body.” 5. “Perhaps he needs something to do. Have you tried distracting him with new toys and other activities?” 28. What are common reasons that a victim of domestic abuse might not report an incident of sexual assault? Select all that apply. 1. Fear that the significant other would be angry if the client reported it and repeat the assault 2. Belief that it was the client’s behavior that caused the significant other to “lose

their temper” 3. Idea that the legal system couldn’t prosecute the significant other for the assault 4. Desire to have the incident behind the client, as if it never happened in the first place 5. Financial independence of the client from the significant other 29. Which of the following are considered sexual response cycle disorders? Select all that apply. 1. Arousal disorder 2. Dysmenorrhea 3. Orgasmic disorder 4. Low libido 5. Retrograde ejaculation 30. The nurse is providing care to the client who was sexually assaulted. What is the nurse’s best approach for collecting information surrounding the event? Select all that apply. 1. Use a calm, reassuring voice when asking questions of the client. 2. Ask only close family members to describe events related to the incident. 3. Provide privacy by asking questions behind a closed curtain. 4. Document the details using the patient’s own words. 5. Refer the client to the sexual assault support group immediately. 31. The nurse is providing care to the menopausal client in the women’s health clinic. The client states she is tired all the time, and has frequent hot flashes, and then she asks about the advantages of hormone replacement therapy (HRT). Which of the following are advantages of hormone replacement therapy? Select all that apply. 1. HRT is the most effective treatment to relieve symptoms of menopause, such as hot flashes and sleep disturbances. 2. HRT decreases the risk of heart and vascular disease, such as arteriosclerosis and myocardial infarctions. 3. HRT often prevents loss of bone density (osteoporosis) and leads to fewer hip fractures. 4. HRT prevents blood clots and certain cancers, such as breast, ovarian, and colorectal cancers. 5. HRT decreases the likelihood of cerebral vascular accidents and dementia. 32. The nurse has finished teaching a class for adolescents and young adults on sexually transmitted infections (STIs) and safe sexual practices. The nurse determines that the teaching has been effective when class participants make which statements? Select all that apply. 1. “It is important for me to avoid STIs, so I will get a prescription for birth control pills.” 2. “I cannot contract an STI if we only perform oral sex on one another.” 3. “I should see my provider to be tested if I experience burning on urination.” 4. “If I contract an STI, it isn’t my fault because I had sex with only one person.” 5. “I need to have a discussion with my sexual partner about our past sexual

histories.” 33. The nurse is teaching a class on reproduction for adolescents. In the class, the nurse explains that which female reproductive organs become engorged and sensitive during stimulation? Select all that apply. 1. Bartholin’s glands 2. Clitoris 3. Labia minora 4. Labia majora 5. Vagina

Chapter 33. Sexual Health Answer Section MULTIPLE CHOICE 1. ANS: 3 Chapter: Chapter 33 Sexual Health Objective: Differentiate various forms of sexual expression Page: 868 (V1) Heading: What Factors Affect Sexuality? Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Sexuality Difficulty: Moderate Feedback 1 This is incorrect. STIs can be transmitted by oral sex. This is a correct statement and does not need further clarification. 2 This is incorrect. The client will lose her virginity status if she engages in sexual intercourse (penetration of the vagina.) This does not need further clarification. 3 This is correct. Abstinence occurs when persons refrain from any sexual activity. Shared touching or masturbation is an alternative to sexual intercourse but is a type of sexual activity. The nurse should clarify the two concepts. 4 This is incorrect. The sexual orientation of a person’s parents may not impact sexual orientation and does not need further clarification. PTS: 1 CON: Sexuality 2. ANS: 4 Chapter: Chapter 33 Sexual Health Objective: Explore physical and psychological issues that affect sexuality and sexual functioning. Page: 868 (V1) Heading: What Problems Affect Sexuality? Integrated Processes: Caring Client Need: Psychosocial Integrity Cognitive Level: Comprehension [Understanding] Concept: Sexuality Difficulty: Moderate Feedback 1 This is incorrect. Voyeurism disorder occurs when a person likes to observe an unsuspecting person who is disrobing, naked, or engaged in sexual activity. 2 This is incorrect. There is not enough information to determine whether there is a problem.

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This is incorrect. At this point, there is not enough information to determine whether this is a situation that would require a referral. This is correct. The client needs to understand that engaging in fantasy can be stimulating for the relationship—it increases self-esteem and arousal.

PTS: 1 CON: Sexuality 3. ANS: 3 Chapter: Chapter 33 Sexual Health Objective: Explore physical and psychological issues that affect sexuality and sexual functioning. Page: 868 (V1) Heading: What Problems Affect Sexuality? Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Knowledge [Remembering] Concept: Sexuality Difficulty: Easy Feedback 1 This is incorrect. The sexual response cycle is the sequence of physiological events that occur when a person becomes sexually aroused. A theorist named Basson identified five stages of physiological events that occur when a person becomes sexually aroused: desire, excitement, plateau, orgasm, and resolution. 2 This is incorrect. The sexual response cycle is the sequence of physiological events that occur when a person becomes sexually aroused. A theorist named Basson identified five stages of physiological events that occur when a person becomes sexually aroused: desire, excitement, plateau, orgasm, and resolution. 3 This is correct. The client may experience an erection but not be able to achieve an orgasm. The sexual response cycle is the sequence of physiological events that occur when a person becomes sexually aroused. A theorist named Basson identified five stages of physiological events that occur when a person becomes sexually aroused: desire, excitement, plateau, orgasm, and resolution. 4 This is incorrect. The sexual response cycle is the sequence of physiological events that occur when a person becomes sexually aroused. A theorist named Basson identified five stages of physiological events that occur when a person becomes sexually aroused: desire, excitement, plateau, orgasm, and resolution. PTS: 1 CON: Sexuality 4. ANS: 3 Chapter: Chapter 33 Sexual Health Objective: Differentiate various forms of sexual expression. Page: 864 (V1) Heading: Sexual Orientation Integrated Processes: Teaching and Learning

Client Need: Psychosocial Integrity Cognitive Level: Comprehension [Understanding] Concept: Sexuality Difficulty: Easy

1 2 3 4

Feedback This is incorrect. A bisexual person is attracted to both genders. This is incorrect. Intersex is a concept that describes a person born with ambiguous sex organs. This is correct. Transgender is the concept that describes a person whose gender identity is not the same as his or her assigned gender. This is incorrect. A transvestite is also known as a cross-dresser. The client has been functioning as a male, so there is no indication that he has worn women’s clothes.

PTS: 1 CON: Sexuality 5. ANS: 2 Chapter: Chapter 33 Sexual Health Objective: Describe approaches for dealing with inappropriate sexual behavior from patients or in the work environment Page: 876 (V1) Heading: Sexual Harassment and Sexual Assault Integrated Processes: Teaching and Learning Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Violence Difficulty: Moderate Feedback 1 This is incorrect. Touching is a sexual advance. The sexual advances in this situation are overt, and there is no discussion of the client’s feelings or the work environment. Sexual harassment is about the power difference, which can negate the element of consent; thus, it is irrelevant whether the client receives sexual satisfaction. Sexual harassment should be immediately reported because it is illegal. 2 This is correct. This is an example of quid pro quo sexual harassment—the employer makes the employee feel that he must engage in unwelcome sexual advances to maintain employment. 3 This is incorrect. Hostile environment situations consist of more subtle, persistent sexual advances that create an intimidating environment. 4 This is incorrect. Touching is a sexual advance. Sexual intercourse is not required in sexual harassment cases. Sexual harassment is about the power difference, which can negate the element of consent. Sexual harassment should

be immediately reported because it is illegal. PTS: 1 CON: Violence 6. ANS: 3 Chapter: Chapter 33 Sexual Health Objective: Explain how sexual health is challenged by high-risk sexual behaviors, sexually transmitted infections, menstrual problems, infertility, negative intimate relationships, sexual harassment, rape, and disorders of the sexual response cycle. Page: 884 (V1) Heading: Teaching Children About Predators Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. It is impractical to keep the child indoors at all times. 2 This is incorrect. Talking with the sex offender or the neighbors does not protect the child. 3 This is correct. The best way to protect children is to teach them how to protect themselves from strangers and sexual predators. The child should be taught not to let anyone touch his or her private parts or to be shown anyone’s private parts. The child should know never to get in the car with strangers and to tell an adult or parent if another person makes him or her feel uncomfortable. 4 This is incorrect. Avoiding the house is not the best answer, because the child can encounter the offender (and others) in numerous settings. PTS: 1 CON: Safety 7. ANS: 3 Chapter: Chapter 33 Sexual Health Objective: Explore physical and psychological issues that affect sexuality and sexual functioning. Page: 875 (V1) Heading: Sexual Response Disorders Integrated Processes: Teaching and Learning Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Health Promotion Difficulty: Moderate Feedback 1 This is incorrect. Beta blockers can negatively affect sexual activity and cause erectile dysfunction. 2 This is incorrect. Allergy medications, specifically antihistamines, can cause

3 4

erectile dysfunction. This is correct. There is no proof that antibiotics negatively affect sexual activity. This is incorrect. Antipsychotics and some antidepressants can cause erectile dysfunction.

PTS: 1 CON: Health Promotion 8. ANS: 1 Chapter: Chapter 33 Sexual Health Objective: Discuss strategies to increase your personal comfort and confidence in providing holistic nursing care. Page: 868 (V1) Heading: What Factors Affect Sexuality? Integrated Processes: Caring Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Easy Feedback 1 This is correct. In many cultures, people have been socialized to avoid talking openly about sexuality. The nurse must discuss a variety of issues that are vital for a client’s optimal wellness. Some of these discussions may include sexual concerns, dysfunctions, infections, or behaviors. As the nurse reflects on the issues of human sexuality, the nurse will be challenged to confront personal biases related to sexuality and to set those aside as while working with clients. 2 This is incorrect. This would occur during the assessment, not preparing for the assessment. 3 This is incorrect. This would be applying knowledge, not preparing for the assessment. 4 This is incorrect. Although theoretical knowledge is important, the nurse will be able to use it fully only after identifying and setting aside personal biases. PTS: 1 CON: Patient-Centered Care 9. ANS: 4 Chapter: Chapter 33 Sexual Health Objective: Explain how sexual health is challenged by high-risk sexual behaviors, sexually transmitted infections, menstrual problems, infertility, negative intimate relationships, sexual harassment, raps, and disorders of the sexual response cycle. Page: 868 (V1) Heading: What Problems Affect Sexuality? Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance

Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate

1 2 3 4

Feedback This is incorrect. Many STIs have few or no symptoms. This is incorrect. A surgical biopsy or blood draw may not diagnose many STIs. (A blood draw may diagnose HIV or hepatitis B.) This is incorrect. A detailed sexual history may provide risk factors but cannot diagnose an STI. This is correct. Many STIs have few or no symptoms. To find out whether a patient has an STI, you must obtain a swab culture of secretions. For a man, a culture is obtained from the urethra. For a woman, secretions are swabbed near the cervix.

PTS: 1 CON: Health Promotion 10. ANS: 2 Chapter: Chapter 33 Sexual Health Objective: Explore the physical and psychological issues that affect sexuality and sexual functioning. Page: 882 (V1) Heading: Sexual Response Disorders Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Sexuality Difficulty: Moderate Feedback 1 This is incorrect. ED is not related to sexual orientation or exposure to STIs. 2 This is correct. Men with ED have persistent or recurring inability to achieve or maintain an erection sufficient for satisfactory sexual performance. When the patient is maintaining penile erection through orgasm, this is an indication the interventions were successful. 3 This is incorrect. Comfort with communicating about sexual needs is helpful for sexual satisfaction, but discomfort with communication is not the cause of ED. 4 This is incorrect. Although discomfort with communication may be a reason for ED, it is not always the issue. PTS: 1 CON: Sexuality 11. ANS: 3 Chapter: Chapter 33 Sexual Health Objective: Complete a sexual history as part of a comprehensive nursing assessment.

Page: 887 (V1) Heading: Counseling for Sexual Problems Integrated Processes: Communication Client Need: Psychosocial Integrity Cognitive Level: Comprehension [Understanding] Concept: Communication and Documentation Difficulty: Moderate Feedback 1 This is incorrect. The PLISSIT model was developed as a guideline for sex therapy. The first step, P, does not stand for providing information about sexual orientation and common alterations. 2 This is incorrect. The first step, P, does not stand for planning time to discuss concerns with the client in a private, comfortable setting. The first step is to provide permission. 3 This is correct. The first step of the PLISSIT model, P, is to provide permission. Permission means that you communicate an open, accepting attitude so the client feels free to ask questions and express concerns and feelings. 4 This is incorrect. The PLISSIT model was developed as a guideline for sex therapy. The first three PLISSIT steps have been adapted to address sexual knowledge deficits that the nurse is qualified to treat. The first step, P, is to provide permission, not to provide referrals to the client so he can identify resources to assist him in the future. PTS: 1 CON: Communication and Documentation 12. ANS: 2 Chapter: Chapter 33 Sexual Health Objective: Identify the female and male reproductive organs. Page: 860 (V1) Heading: Sexual and Reproductive Anatomy and Physiology Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Knowledge [Remembering] Concept: Sexuality Difficulty: Moderate Feedback 1 This is incorrect. Fertilization occurs at the time of ovulation at which a sperm joins with the mature egg and the endometrium is ripe to support the embryo. 2 This is correct. The follicular phase occurs when the ovarian follicles mature until the ovum is released. 3 This is incorrect. The luteal phase occurs after the menstrual phase. At this time, the endometrial lining builds back up after being shed during menstruation. The luteal phase occurs after ovulation.

This is incorrect. During this phase, if fertilization does not occur, the progesterone level drops, and the menstrual cycle begins again.

PTS: 1 CON: Sexuality 13. ANS: 4 Chapter: Chapter 33 Sexual Health Objective: State the nursing diagnoses to describe sexuality problems, and explore the physical and psychological issues that affect sexuality and sexual functioning. Page: 869 (V1) Heading: Health and Illness Integrated Processes: Caring Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Self Difficulty: Easy Feedback 1 This is incorrect. The patient is not discussing concerns about eroticism or sexual function. 2 This is incorrect. The patient is not expressing concern about intimacy with a sexual partner. 3 This is incorrect. The patient is not talking about having children or the ability to reproduce currently. 4 This is correct. This patient is questioning her identity and role as a woman after removal of her uterus. PTS: 1 CON: Self 14. ANS: 2 Chapter: Chapter 33 Sexual Health Objective: Explain how gender, gender identity, and sexual orientation contribute to expression of sexuality throughout the life cycle. Page: 868 (V1) Heading: Gender Roles Integrated Processes: Culture and Spirituality Cognitive Level: Analysis [Analyzing] Concept: Sexuality Difficulty: Moderate Feedback 1 This is incorrect. The patient is not indicating confusion over whether he is male or female or has any sexual confusion. 2 This is correct. Gender roles are those behaviors society identifies as being male or female. This patient indicates conflict over being male and being the nurturer in the family instead of the breadwinner.

This is incorrect. Gender identity is an internal experience indicating whether the individual feels like a man or a woman; this is not what this patient is conflicted about, according to the statement made. This is incorrect. Sexual orientation involves to whom the person is sexually attracted, which is not an issue, according to the statement made by this patient.

PTS: 1 CON: Sexuality 15. ANS: 2 Chapter: Chapter 33 Sexual Health Objective: Explain how gender, gender identity, and sexual orientation contribute to expression of sexuality throughout the life cycle and differentiate various forms of sexual expression. Page: 864 (V1) Heading: Gender Identity Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Sexuality Difficulty: Moderate Feedback 1 This is incorrect. A transgender person has a gender identity that is not the same as his or her assigned gender. This is not clearly identified in for this patient and would require further information to determine. 2 This is correct. A cross-dresser is a person who occasionally or frequently wears clothing characteristics of the opposite sex, particularly the undergarments, as a form of sexual expression. Cross-dressing may be an occasional or frequent occurrence. This term best describes this patient. 3 This is incorrect. A homosexual person is attracted to those of the same sex, which is not indicated in this item. 4 This is incorrect. It is not correct to discern if the client is a heterosexual person based on clothing. PTS: 1 CON: Sexuality 16. ANS: 3 Chapter: Chapter 33 Sexual Health Objective: Differentiate various forms of sexual expression. Page: 868 (V1) Heading: What Factors Affect Sexuality? > Culture > Female Genital Mutilation Integrated Processes: culture and spirituality Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Sexuality Difficulty: Moderate

1 2 3 4

Feedback This is incorrect. Piercing of the genitalia is not illegal in the United States. This is incorrect. This is a surgical procedure that removes the uterus due to medical issues. This is not illegal in the United States. This is correct. Female circumcision, or female genital mutilation, is considered atypical and is illegal in many countries, including the United States. This is incorrect. Transgender surgery is not illegal in the United States. Transgender surgery is a natural procedure to assist a patient to transform his or her body into the sexual gender he or she most identifies with, if the patient requests the procedure.

PTS: 1 CON: Sexuality 17. ANS: 1 Chapter: Chapter 33 Sexual Health Objective: Provide nursing interventions that enhance sexual well-being and explain how sexual health is challenged by rape. Page: 880 (V1) Heading: Sexuality, Dementia, and Competency Integrated Processes: Caring Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Violence Difficulty: Easy Feedback 1 This is correct. Although this may be a difficult situation for the family, the relationship may be consensual. If both clients are safe and have a mutual relationship, they may be deemed to have a healthy relationship. 2 This is incorrect. This does not address the issue of consent in sexual relationships among clients with Alzheimer’s. 3 This is incorrect. It would best to be aware if the relationship is mutual and safe. 4 This is incorrect. This is not an issue that needs to be addressed, unless the relationship is not safe and mutual. PTS: 1 CON: Violence 18. ANS: 2 Chapter: Chapter 33 Sexual Health Objective: Explore physical and psychological issues that affect sexuality and sexual functioning. Page: 886 (V1) Heading: Screening Exams: Guidelines > Testicular Exam Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding]

Concept: Health Promotion Difficulty: Moderate Feedback 1 This is incorrect. A lump in the testicle could be a sign of testicular cancer, but some cancers may be at an advanced state before symptoms are present. 2 This is correct. Monthly exams are a personal preference; checking for lumps after puberty is a good idea to detect changes in the testicles. 3 This is incorrect. Undescended testicles can be a risk factor for testicular cancer, as well as previous germ cell tumor in one testicle, or a family history of testicular cancer. 4 This is incorrect. There is no scientific data to prove that this is true. PTS: 1 CON: Health Promotion 19. ANS: 2 Chapter: Chapter 33 Sexual Health Objective: Explore physical and psychological issues that affect sexuality and sexual functioning. Page: 887 (V1) Heading: Dealing With Inappropriate Sexual Behavior Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Violence Difficulty: Moderate Feedback 1 This is incorrect. Clients with anxiety disorder may exhibit irrational or inappropriate symptoms, but often attempt to avoid stimuli that may increase their anxiety. 2 This is correct. Clients with bipolar disorder, particularly during manic phases, are likely to be preoccupied with pleasurable activities and commonly display increased sexual activity in the form of verbalizing and acting out. 3 This is incorrect. Depressed clients often experience loss of interest in all activities, including pleasant ones, and are not likely to exhibit this type of behavior. 4 This is incorrect. Clients with schizophrenia experience delusions that interfere with sexuality, so they would not likely display this behavior. PTS: 1 CON: Violence 20. ANS: 3 Chapter: Chapter 33 Sexual Health Objective: State nursing diagnoses to describe sexuality problems Page: 869 (V1) Heading: Health and Illness > Surgeries

Integrated Processes: Caring Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Sexuality Difficulty: Difficult Feedback 1 This is incorrect. Although there are data cues for fatigue, it would not be the root cause of the problem. 2 This is incorrect. The client does not discuss the change in body image. Disturbed Body Image would not be the most appropriate nursing diagnosis for this patient. 3 This is correct. Ineffective Sexuality Patterns manifest as reported difficulties or alterations in sexual behavior or activities. It may result in a patient expressing broader concerns about sexuality and desirability as a sex partner. Therefore, the patient’s lack of sexual intimacy resulted following the hysterectomy and loss of childbearing most closely matches a diagnosis of Ineffective Sexuality Patterns. 4 This is incorrect. The patient’s situation is more general than an actual change in sexual function. The answer of Sexual Dysfunction is not the best choice for this patient because it does not address the primary cause (or etiology) of the patient’s change in desire for sexual intimacy. PTS: 1 CON: Sexuality 21. ANS: 4 Chapter: Chapter 33 Sexual Health Objective: Describe approaches for dealing with inappropriate sexual behavior from patients and others in the work environment. Page: 887 (V1) Heading: Dealing With Inappropriate Sexual Behavior Integrated Processes: Communication and documentation Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Violence Difficulty: Moderate Feedback 1 This is incorrect. The key word is “initial.” It may become necessary to inform the nursing supervisor of the physician’s behavior, but it is not the best first step for the nurse to take. 2 This is incorrect. Calling the medical board would be inappropriate and should not be the first step. 3 This is incorrect. Reporting the behavior to the chief of staff would ignore the chain of command and would be unprofessional. 4 This is correct. The first step the nurse should take is to inform the physician

that the behavior is both unwelcome and inappropriate, and the physician should be told to stop immediately. PTS: 1 CON: Violence 22. ANS: 4 Chapter: Chapter 33 Sexual Health Objective: Describe the physical, emotional, social, and spiritual aspects of human sexuality. Page: 870 (V1) Heading: Myths and Misconceptions Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Sexuality Difficulty: Moderate Feedback 1 This is incorrect. The statement that a person cannot get pregnant or be transmitted an STI the first time having sex is a myth and would indicate the need for further teaching. 2 This is incorrect. Although condoms may be highly effective when used correctly, they do not always prevent pregnancy; therefore, that statement indicates the need for further teaching. 3 This is incorrect. STIs may not produce noticeable symptoms, especially in women. Therefore, this statement indicates the need for further teaching. 4 This is correct. The goals of this teaching would be to dispel myths about sex and sexuality. The statement is accurate in that simultaneous orgasm and good sexual relations do not predict the quality of a relationship. This dispels a myth and reflects learning. PTS: 1 CON: Sexuality 23. ANS: 4 Chapter: Chapter 33 Sexual Health Objective: Explain how sexual health is challenged by high-risk behaviors, STIs, menstrual problems, infertility, negative intimate relationships, sexual harassment, rape, and disorders of the sexual response cycle. Page: 885 (V1) Heading: Body Function and Reproduction > Douching Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Health Promotion Difficulty: Difficult Feedback

1 2 3 4

This is incorrect. Wearing cotton underwear helps to wick moisture away from the perineal skin and reduces risk of PID. This is incorrect. Inconsistent condom use may increase the chances for STIs and pregnancy, but is not the most prevalent cause of PID. This is incorrect. Although this may increase the likelihood of urinary tract infections, it would not increase the likelihood of PID. This is correct. Douching washes away protective bacteria that protect the vagina from infection, so this behavior will increase the patient’s risk of PID.

PTS: 1 CON: Health Promotion 24. ANS: 3 Chapter: Chapter 33 Sexual Health Objective: Provide nursing interventions that enhance sexual well-being. Page: 870 (V1) Heading: Myths and Misconceptions Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Sexuality Difficulty: Difficult Feedback 1 This is incorrect. Although the statement about protecting bed linens is true, it does not address the patient’s concern that intercourse is dangerous during menstruation. 2 This is incorrect. Although the statement about orgasm reducing cramping is true, it does not address the patient’s concern that intercourse is dangerous during menstruation. 3 This is correct. The most important point for the nurse to make is that it is safe to have intercourse during menstruation so that the patient can make an informed choice about whether to do so; therefore, explaining that intercourse will not harm the vagina is the best response. This is a part of therapeutic communication and addressing the client’s concerns; the nurse may need to ask the client to clarify why she thinks this would be dangerous. 4 This is incorrect. Increased blood flow to the pelvis may or may not increase the patient’s pleasure; it does not address the patient’s concern about safety. PTS: 1 CON: Sexuality 25. ANS: 3 Chapter: Chapter 33 Sexual Health Objective: Describe the physical, emotional, social, and spiritual aspects of human sexuality Page: 870 (V1) Heading: Sexual Health

Integrated Processes: Communication and Documentation Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Sexuality Difficulty: Moderate Feedback 1 This is incorrect. “I’m sorry to hear that …” reflects kind intentions, but it does not help the patient or address his problem. 2 This is incorrect. It is true that one can have a close, intimate relationship without having intercourse; however, that statement does not help the patient or explore the meaning of “ruined,” nor obtain useful information. 3 This is correct. Seeking more specific information about the patient’s sex life and what he means by “ruined” will help the nurse understand the problem that the patient is experiencing. The nurse might ask further questions regarding the relationship with the girlfriend, knowing that human sexuality has more than just a physical aspect. 4 This is incorrect. It is outside the nurse’s scope of practice to discuss medications without an order from the physician. PTS:

CON: Sexuality

MULTIPLE RESPONSE 26. ANS: 1, 3, 4, 5 Chapter: Chapter 33 Sexual Health Objective: Complete a sexual history as part of a comprehensive nursing assessment Page: 887 (V1) Heading: Counseling for Sexual Problems Integrated Processes: Caring Client Need: HPM Cognitive Level: Analysis [Analyzing] Concept: Health Promotion Difficulty: Moderate

1. 2. 3.

Feedback This is correct. This is the permission component of PLISSIT, by using an open, accepting attitude, the client may feel free to ask open ended questions. This is incorrect. This implies that the client is comfortable discussing sexual issues with her partner. This is correct. This is the limited information component, supplying limited information may include teaching normal sexual functioning, expected changes in sexual functioning.

4. 5.

This is correct. Specific suggestions for self-care may facilitate sexual health. This is correct. Intensive therapy may be the next step if the client’s concerns are not relieved.

PTS: 1 CON: Health Promotion 27. ANS: 1, 2, 3, 4 Chapter: Chapter 33 Sexual Health Objective: Differentiate various forms of sexual expression. Page: 865 (V1) Heading: How Does Sexuality Develop? Integrated Processes: Caring Client Need: HPM Cognitive Level: Application [Applying] Concept: Sexuality Difficulty: Moderate

4. 5.

Feedback This is correct. The first 2 years of life are highly sensual as infants are nursed, stroked, bathed, and massaged, and they develop their first attachment experience through bonding with the mother. It is not unusual for infants and preschoolers to fondle their genitals and enjoy being nude. This is part of their exploration of their bodies, and parents should not overreact. This is correct. Although health teaching about normal sexual development of toddlers is important, this mother’s comments are a red flag with regard to appropriate discipline. Her exaggerated response using physical reprimands to a 2year-old child bears further exploration about other potential for physical harm or abuse within the home. The nurse has a responsibility to assess risk to the child for an abusive situation and counsel the mother about alternative methods of dealing with the behavior. This is correct. The mother’s exaggerated response using physical reprimands to a 2year-old child bears further exploration about other potential for physical harm or abuse within the home. The nurse has a responsibility to assess risk to the child for an abusive situation and counsel the mother about alternate methods of dealing with the behavior. This is correct. This statement explains normal childhood behaviors and may alleviate the mothers’ concerns. This is incorrect. This may reinforce the mother’s concerns that this is not a normal behavior.

PTS: 1 28. ANS: 1, 2, 3, 4

CON: Sexuality

Chapter: Chapter 33 Sexual Health Objective: Explain how sexual health is challenged by high-risk sexual behaviors, STI, negative intimate relationships, sexual harassment, rape, and disorders of the sexual response cycle. Page: 879 (V1) Heading: Why Many Rapes Go Unreported Integrated Processes: Caring Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Violence Difficulty: Moderate

2. 3.

Feedback This is correct. Reasons for not reporting sexual assault include fear of the assailant, fear of consequences to the assailant, and knowledge of the low conviction rate for perpetrators of assault. This is correct. Reasons for not reporting sexual assault include fear of consequences to the assailant, the desire to avoid a trial, shame and embarrassment, and self-blame. This is correct. Reasons for not reporting sexual assault include knowledge of the low conviction rate for perpetrators of assault, the desire to avoid a trial, and past sexual history. This is correct. Reasons for not reporting sexual assault may include the desire to “move on” and not face possible consequences involving pregnancy and sexually transmitted infection. This is incorrect. Many abused individuals are either emotionally or financially dependent on their partners and believe that staying in the relationship is their only option. If a client is financially independent from their significant other, this status would not be a common reason for the client to not report an incident of sexual assault.

PTS: 1 CON: Violence 29. ANS: 1, 3, 4 Chapter: Chapter 33 Sexual Health Objective: Explain how sexual health is challenged by high-risk sexual behaviors, STI, menstrual problems, infertility, negative intimate relationships, sexual harassment, rape, and disorders of the sexual response cycle. Page: 880 (V1) Heading: Sexual Response Cycle Disorders Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Cognitive Level: Comprehension [Understanding] Concept: Sexuality Difficulty: Easy

3. 4. 5.

Feedback This is correct. Low libido, arousal disorder, and orgasmic disorder all affect the sexual response cycle. These disorders affect desire, arousal, excitement, and orgasm. This is incorrect. Dysmenorrhea is painful menstruation caused by strong uterine contractions that cause ischemia of the uterus. This may prevent sexual intercourse but is not a sexual response cycle disorder. This is correct. Orgasmic disorders affect the sexual response cycle. This is correct. Low libido affects the sexual response cycle. This is correct. Retrograde ejaculation may be considered an arousal or orgasmic disorder.

PTS: 1 CON: Sexuality 30. ANS: 1, 4 Chapter: Chapter 33 Sexual Health Objective: Provide nursing interventions that enhance sexual well-being. Page: 879 (V1) Heading: Rape Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Violence Difficulty: Moderate

Feedback This is correct. Therapeutic communication skills such as the use of a calm, professional approach, will help with the collection of sexual data from the clients. These skills will not only help clients to feel more comfortable and confident but will yield more honest and complete information. This is incorrect. The client might have difficulty discussing the events relating to the assault; however, this is a private matter and not a topic to discuss with family members, regardless of the apparent closeness of the relationship. This is incorrect. When asking personal questions, provide privacy and be sensitive to your client’s cues. A curtain is not secure enough because conversation easily could be overheard. This is correct. Clear, unambiguous documentation is extremely important because of the criminal nature of sexual crime. Using the patient’s own words is a way for the nurse to avoid misinterpreting the facts as well as to keep from introducing bias or drawing conclusions about the event. This is incorrect. The referral should occur quickly, but the client should not be made to wait for the referral to discuss the rape.

PTS: 1 CON: Violence 31. ANS: 1, 3 Chapter: Chapter 33 Sexual Health Objective: Complete a sexual history as part of a comprehensive nursing assessment. Page: 885 (V1) Heading: Menopause: Hormone Replacement Therapy (HRT) Integrated Processes: Teaching and Learning Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate

3. 4.

Feedback This is correct. HRT remains the most effective treatment to relieve symptoms of menopause, such as itching, dryness, discomfort with intercourse, hot flashes, and sleep disturbances. This is incorrect. In a small number of women, the risks associated with long-term use of HRT include heart disease, blood clots, breast and ovarian cancers, and dementia. This is correct. Prevention of loss of bone density in menopausal women leads to fewer hip fractures. This is incorrect. In a small number of women, the risks associated with long-term use of HRT include heart disease, blood clots, breast and ovarian cancers, and dementia. This is incorrect. In a small number of women, the risks associated with long-term use of HRT include heart disease, blood clots, breast and ovarian cancers, and dementia.

PTS: 1 CON: Health Promotion 32. ANS: 3, 5 Chapter: Chapter 33 Sexual Health Objective: Explain how sexual health is challenged by high-risk behaviors, STI, menstrual problems, infertility, negative intimate relationships, sexual harassment, rape, and disorders of the sexual response cycle. Page: 896 (V1) Heading: Preventing Sexually Transmitted Infections Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Health Promotion Difficulty: Difficult

1. 2. 3.

Feedback This is incorrect. Oral birth control pills will not protect the individual from STIs. This statement indicates the need for further teaching. This is incorrect. STIs can be transmitted through oral sex, which involves an exchange of body fluids; therefore, further teaching is needed. This is correct. A person should see a provider with symptoms of burning on urination; the statement is correct and would not indicate the need for further teaching. This is incorrect. Blaming the partner suggests that the person is not taking personal responsibility; therefore, teaching is needed to encourage actions of self-protection from STIs. This is correct. Partners should discuss sexual histories with each other; that statement is correct and does not indicate need for further teaching.

PTS: 1 CON: Health Promotion 33. ANS: 2, 4 Chapter: Chapter 33 Sexual Health Objective: Identify female and male reproductive organs. Page: 870 (V1) Heading: What Is the Sexual Response Cycle? Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Sexuality Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is incorrect. Although Bartholin’s glands secrete mucus during sexual arousal, they do not become engorged or sensitive. This is correct. The clitoris becomes engorged and increases in sensitivity during sexual stimulation. This is correct. The labia minora become engorged and increase in sensitivity during sexual stimulation. This is incorrect. The labia majora do not increase in sensitivity or engorge with stimulation. This is incorrect. The vagina does not increase in sensitivity or engorge with stimulation.

PTS:

CON: Sexuality

Chapter 34. Sleep & Rest Multiple Choice Identify the choice that best completes the statement or answers the question. 1. A person who is deprived of rapid eye movement (REM) sleep for several nights in succession will usually experience: 1. Extended non–rapid eye movement (NREM) sleep 2. Insomnia 3. Parasomnia 4. REM rebound 2. A client states that many of his friends told him to ask for Valium or Ativan to help him sleep while hospitalized. The nurse knows that nonbenzodiazepines (e.g., Ambien) are often preferred over benzodiazepines (Ativan or Valium). Why is this? 1. The benzodiazepine Ativan has a shorter half-life and provides a full night of sleep. 2. The nonbenzodiazepine Ambien alters the sleep cycle and causes daytime sleepiness. 3. The benzodiazepine Ativan can alter the sleep cycle and produce daytime sleepiness. 4. The nonbenzodiazepine Ambien has a longer half-life and produces daytime sleepiness. 3. The nurse in a rehabilitation center is providing care to a client who complains of insomnia. The client states that the room is noisy, and that they often take naps during the day because they are a “night owl” from working the nightshift for several years. The nurse develops a care plan that allows the client to start their rehab therapy later in the day, provides the client with a sleep aide and a white noise fan in the room, and allows the client to nap during the day when tired. Which of the following would be a priority for this plan? 1. Allowing the client to sleep later in the day 2. Providing a white noise fan in the room 3. Providing a sleep aide, as prescribed 4. Promoting frequent naps during the day 4. When developing a care plan for the sleep-deprived client, the nurse should consider major factors that regulate sleep. Which is a major factor regulating sleep? 1. Electrical impulses transmitted to the cerebellum 2. Level of sympathetic nervous system stimulation 3. Individual patterns for amounts of sleep 4. Amount of light received through the eyes

5. The nurse is assessing the client in the family clinic, who asks about the difference between rest and sleep. Which of the following statements would explain the main difference between sleep and rest? 1. In sleep, the body may respond to external stimuli. 2. Short periods of sleep do not restore the body as much as short periods of rest. 3. Sleep is characterized by an altered level of consciousness. 4. The metabolism slows less during sleep than during rest. 6. A client complains of trouble falling asleep at night despite extreme fatigue. A review of symptoms reveals no physical problems or a history of medications. The client has recently quit smoking, is trying to eat healthier foods, and has started a moderate-intensity exercise program. The client’s sleep history reveals no changes in bedtime routine, stress level, or environment. Based on this information, the most appropriate nursing diagnosis would be Disturbed Sleep Pattern related to: 1. Increased exercise 2. Nicotine withdrawal 3. Caffeine intake 4. Environmental changes 7. The nurse is providing education to the client who has difficulty sleeping. Which of the following teachings would be most therapeutic for this client with sleep disturbance? 1. “Give yourself at least 60 minutes to fall asleep.” 2. “Avoid eating carbohydrates before going to sleep.” 3. “Catch up on sleep by napping or sleeping in, when possible.” 4. “Do not go to bed feeling upset about a conflict.” 8. The nurse is developing a care plan for the client experiencing poor sleep patterns. Which of the following would be an expected outcome (goal) for a client with Disturbed Sleep Pattern? The client will: 1. Limit exercise to 1 hour per day early in the day 2. Consume only one caffeinated beverage per day 3. Demonstrate effective guided imagery to aid relaxation 4. Verbalize that she is sleeping better and feels less fatigued 9. When making rounds on the night shift, the nurse observes her client to be in a deep sleep. His muscles are very relaxed. When he arouses as the nurse changes the intravenous (IV) tubing, he is confused. What stage of sleep was the client most likely experiencing? 1. NREM I 2. NREM II 3. NREM III 4. REM 10. The nurse is providing teaching to the client who comes to the sleep clinic. The nurse instructs the client to start a sleep diary. What is the rationale of using a sleep diary? 1. Identify sleep–rest patterns over a 1-year period. 2. Note the trend in sleep–wakefulness patterns over a 2-week period.

3. Note typical sleep habits and most common daily routines. 4. Examine the preparation, preferences, and routines surrounding sleep. 11. The nurse is providing care to client in the long-term care facility. The nurse notes that the night shift staff have reported that the client has appeared to have been sleepwalking this past week. What is the medical term for this behavior? 1. Parasomnias 2. Dyssomnias 3. Insomnia 4. Hypersomnia 12. A 6-year-old boy is admitted to the hospital for a surgical procedure associated with a hospital stay. When the nurse asks his mother about the boy’s sleep patterns, she says, “Sometimes he will get out of bed, walk into the kitchen, and get the cereal out of the cabinet. Then he just turns around and goes back to bed.” The nurse explains that he is sleepwalking. The best nursing diagnosis for the boy would be: 1. Risk for Insomnia related to sleepwalking 2. Risk for Fatigue related to sleepwalking 3. Disturbed Sleep Pattern related to dyssomnia 4. Risk for Injury related to sleepwalking 13. The primary focus of the nursing interventions for a 6-year-old client who experiences somnambulation (sleep walking) would be to: 1. Maintain client safety during episodes of somnambulation 2. Administer and teach about medications to suppress stage III sleep 3. Encourage the client to verbalize feelings regarding sleep pattern 4. Provide a quiet environment for nighttime sleep 14. The nurse recognizes that the client with anxiety has the potential for sleep disorders. Which of the following would be an explanation for the physiological factors in this sleep disorder? 1. Anxiety increases norepinephrine levels. 2. Anxiety can decrease insulin production. 3. Anxiety alters the central nervous system. 4. Anxiety can cause malfunction of melatonin. 15. The nurse is assessing the 19-month-old client in the family clinic. The mother states that she is concerned that the child doesn’t sleep enough, as the child has stopped taking their usual morning nap. What is the nurse’s best response to this concern? 1. Oftentimes, most toddlers take only one nap per day and require about 12 to 14 hours of sleep in a 24-hour period. 2. Oftentimes, most toddlers take at least two naps and need approximately 12 to 16 hours of sleep in a 24-hour period. 3. Oftentimes, most toddlers should be sleeping approximately 8 to 10 hours in a 24hour period. 4. Oftentimes, most toddlers need approximately 7 to 9 hours of sleep in a 24-hour

period, without any naps. 16. The client asks the nurse for suggestions to promote rest. Which of the following would be the most appropriate intervention suggestions to promote rest? 1. Take routine benzodiazepine as prescribed. 2. Avoid caffeine for several hours after meals. 3. Meditate for 30 to 60 minutes in the evening. 4. Avoid watching television in the bedroom. 17. The nurse is teaching the client about foods that promote sleep versus those that may disrupt sleep. Which diet chosen by the client demonstrates understanding of foods that promote sleep? 1. Hamburger, potato fries, and a milkshake 2. Turkey fettuccini, whole wheat bread, and a glass of milk 3. Chicken salad sandwich, pineapple salad, and a diet cola 4. Fish, broccoli, applesauce, and a cup of tea 18. The client tells the nurse, “After a couple of glasses of wine, I sleep very soundly.” After assessing further about the client’s alcohol history, what response by the nurse is most accurate? 1. “Although alcohol helps you fall asleep, you will be more likely to awaken during the night and have trouble falling back to sleep.” 2. “If you quit drinking, you will find falling asleep more difficult, but you’ll feel more rested when you awaken.” 3. “I know alcohol helps you to sleep, but you could take a sleeping pill instead to help you fall asleep.” 4. “Is there anything else that you do on a regular basis that helps you to fall asleep and stay asleep?” 19. The pediatric nurse is assessing the 3-year-old client when the mother states the child is having sleep disturbances lately. The pediatric nurse recognizes the most likely cause of sleep disturbances would be which of the following? 1. Concerns about friends 2. Staying up to watch television 3. Side effect of medication 4. Fear of imaginary monsters 20. The postpartum nurse is preparing a teaching plan for the first-time mother for discharge to home. What information should be included in the teaching plan? 1. Try to reduce work-related stress to promote sleep. 2. Nap frequently during the day when you can. 3. Avoid fluids in the evening to reduce nocturia. 4. Avoid vigorous-intensity exercise to reduce fatigue. 21. The client tells the nurse, “I have terrible insomnia. It seems as though I am exhausted all the time.” What question is most appropriate for the nurse to ask this client? 1. “What time do you go to bed at night?”

2. “Are you experiencing much stress right now?” 3. “Have you tried meditation to help you relax?” 4. “Do you have trouble falling asleep or staying asleep?” 22. The nurse is caring for a client newly diagnosed with narcolepsy. What is the priority teaching point the nurse would share with the client? 1. Do not drive or operate heavy equipment. 2. Men are more likely to be diagnosed than women. 3. There is no treatment; symptoms must be managed. 4. Getting more sleep will correct narcolepsy. 23. The nurse is performing a sleep assessment and suspects a client is experiencing sleep apnea. What will be implemented next to confirm the diagnosis? 1. Instruct the client to start a sleep diary. 2. Assess the client’s sleep history. 3. Arrange for a polysomnography. 4. Arrange for continuous positive airway pressure (CPAP) therapy. 24. The nurse is performing a sleep assessment for a newly admitted client. He says his sleep habits are satisfactory and that he normally feels well rested. What question would the nurse ask next? 1. “Would you be willing to complete a sleep diary?” 2. “What time do you usually go to bed and awaken?” 3. “How many times do you usually awaken?” 4. “Do you have trouble falling asleep at night?” 25. The nurse is developing a plan of care for a client admitted following a motor vehicle accident (MVA) who reports regularly sleeping only 2 to 3 hours per night. The client says this is the third MVA he’s been involved in this year. The client thinks he might have been asleep when he got into the accident. What is the most appropriate nursing diagnosis for this client? 1. Insomnia 2. Sleep Deprivation 3. Disturbed Sleep Pattern 4. Risk for Injury 26. Which of the following clients with inadequate or poor quality of sleep would be the best choice for a nursing diagnosis of Disturbed Sleep Patterns? 1. An adolescent diagnosed with somnambulism 2. A client with obstructive sleep apnea 3. An attorney who says she has no time for sleep 4. A new mother of twins 27. The spouse of a client recently diagnosed with cancer reports feeling anxious and is having trouble sleeping at night despite feeling tired. The spouse says sleep was never previously a problem. What type of interventions would be first priority for the spouse? 1. Promote physical comfort.

2. Support bedtime routines. 3. Create a restful environment. 4. Promote relaxation. 28. The nurse teaches a class for new parents promoting safe sleep for infants. The nurse determines a participant understood the important safety points when a parent makes which statement? 1. “I will gently lay my son down on his back with a soft pillow to support his head.” 2. “I will put my son on a firm crib mattress on his back and remove all padding.” 3. “I will position my son to sleep on his back and place soft pads around the crib to prevent injury.” 4. “I will have my son sleep in my bed so I can be sure he is safe at night.” Multiple Response Identify one or more choices that best complete the statement or answer the question. 29. The nurse is providing care to the older adult client who complains of sleep issues. Which of the following statements are factors that may help resolve the client’s sleep issues? Select all that apply. 1. “I use a fan on low to help me sleep.” 2. “I take my thyroid medicine every morning.” 3. “I have had Parkinson’s disease for over 10 years.” 4. “I have 4 beers a night to help me sleep.” 5. “I take a small dose of melatonin to help me sleep.” 30. A mother expresses concern that her 7-year-old has episodes of nocturnal enuresis approximately three to four times per week. The nurse’s best response would be which of the following? Select all that apply. 1. “Your child’s bladder is still developing at this point in life.” 2. “Be patient; most children outgrow enuresis.” 3. “Wake your child every 4 hours to use the bathroom.” 4. “You might consider purchasing protective pads for the bed.” 5. “Try a bed alarm when the child starts wetting the bed at night.” 31. The nurse is providing care to the client that has recently been diagnosed with obstructive sleep apnea (OSA). Which of the following are symptoms associated with OSA? Select all that apply. 1. Bruxism 2. Enuresis 3. Daytime fatigue 4. Snoring 5. Drooling 32. The nurse is caring for a client admitted to the hospital’s hospice unit with terminal cancer and acute cancer pain. What factors does this client have that will interrupt circadian rhythms? Select all that apply.

1. 2. 3. 4. 5.

Poorly controlled pain Fear of the unknown Nursing rounds at night Extraneous lights in room Cool, dark room

33. The client tells the nurse, “I’ve always been able to maintain a steady weight by exercising and watching what I eat, but lately I seem to be steadily gaining weight.” The nurse then collects a thorough sleep history. Why will the nurse ask the client about her sleep habits? Select all that apply. 1. Lack of sleep causes increased insulin production. 2. Lack of sleep reduces activity levels. 3. Lack of sleep increases appetite. 4. Lack of sleep leads to poor glucose tolerance. 5. Lack of sleep reduces total energy expenditure.

Chapter 34. Sleep & Rest Answer Section MULTIPLE CHOICE 1. ANS: 4 Chapter: Chapter 34 Sleep & Rest Objective: Describe the functions and physiology of sleep. Page: 898 (V1) Heading: How Is Sleep Regulated? Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological adaptation. Cognitive Level: Knowledge [Remembering] Concept: Sleep and Rest Difficulty: Easy

1 2

3 4

Feedback This is incorrect. NREM sleep, or deep or slow-wave sleep, does not increase after REM sleep deprivation. This is incorrect. Insomnia as defined by the Diagnostic and Statistical Manual, 5th edition (DSM-5), is the predominant complaint of dissatisfaction with sleep quantity, associated with the inability to fall asleep, remain asleep, or go back to sleep. This is incorrect. Parasomnia is defined as patterns of waking behavior that appear during sleep (e.g., sleepwalking). This is correct. A person who is deprived of REM sleep for several nights will usually experience REM rebound. The person will spend a greater amount of time in REM sleep on successive nights, generally keeping the total amount of REM sleep constant over time.

PTS: 1 CON: Sleep and Rest 2. ANS: 3 Chapter: Chapter 34 Sleep & Rest Objective: Identify factors that influence rest and sleep. Page: 913 (V1) Heading: Administer and Teach About Sleep Medications Integrated Processes: Teaching and Learning Client Need: Physiological integrity: Pharmacological and Parenteral Therapies Cognitive Level: Analysis [Analyzing] Concept: Sleep and Rest Difficulty: Difficult Feedback

1 2 3

This is incorrect. Ativan is a long-acting benzodiazepine and often causes daytime sleepiness. This is incorrect. Ambien does not alter the sleep pattern to the point of causing daytime sleepiness. This is correct. Nonbenzodiazepines (e.g., Ambien) are preferred because they have a short half-life, which means that they are eliminated from the body quickly, and often do not cause daytime sleepiness. Ativan, as a long-acting benzodiazepine, remains in the body longer than Ambien and often causing daytime sleepiness. This is incorrect. Nonbenzodiazepines, like Ambien, have a short half-life and often do not cause daytime sleepiness.

PTS: 1 CON: Sleep and Rest 3. ANS: 1 Chapter: Chapter 34 Sleep & Rest Objective: Plan, implement, and evaluate nursing care related to specific nursing diagnoses addressing sleep problems. Page: 897 (V1) Heading: How Do Circadian Rhythms Influence Sleep? Integrated Processes: Nursing Process Client Need: Health Promotion Maintenance Cognitive Level: Analysis [Analyzing] Concept: Sleep and Rest Difficulty: Difficult Feedback 1 This is correct. An individual’s circadian rhythm is a biorhythm based on the day–night pattern in a 24-hour cycle. Sleep quality is best when the time at which the person goes to sleep and awakens is in synchrony with his or her circadian rhythm. 2 This is incorrect. Although promoting adequate sleep hygiene is important, the individual’s circadian rhythm is of higher importance. 3 This is incorrect. Although this may help the client rest, the circadian rhythm has been interrupted and is a priority. 4 This is incorrect. Napping on and off throughout the day might disrupt the natural circadian rhythm. PTS: 1 CON: Sleep and Rest 4. ANS: 4 Chapter: Chapter 34 Sleep & Rest Objective: Describe the functions and physiology of sleep. Page: 898 (V1) Heading: How Is Sleep Regulated?

Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Sleep and Rest Difficulty: Moderate Feedback 1 This is incorrect. The electrical impulses within the cerebellum regulate the voluntary processes of the body. 2 This is incorrect. The autonomic nervous system (rather than central nervous system) controls the involuntary processes of the body, such as sleep, digestion, immune function, and so on. 3 This is incorrect. Although it is important to know the individual client’s sleep patterns, the major factor in regulating sleep is light received in the eyes. 4 This is correct. A major factor in regulating sleep is the amount of light received through the eyes. PTS: 1 CON: Sleep and Rest 5. ANS: 3 Chapter: Chapter 34 Sleep & Rest Objective: Explain why rest and sleep are important. Page: 895 (V1) Heading: About the Key Concepts Integrated Processes: Teaching and Learning Client Need: Health Promotion Maintenance Cognitive Level: Comprehension [Understanding] Concept: Sleep and Rest Difficulty: Easy Feedback 1 This is incorrect. A sleeping person may respond selectively to certain external stimuli. However, at rest, the body is disturbed by all external stimuli. 2 This is incorrect. Sleep restores the body more than does rest. 3 This is correct. During rest, the mind remains active and conscious; sleep is characterized by altered consciousness. 4 This is incorrect. The metabolism decreases more during sleep than during rest. PTS: 1 CON: Sleep and Rest 6. ANS: 2 Chapter: Chapter 34 Sleep & Rest Objective: Identify factors that influence rest and sleep. Page: 901 (V1) Heading: What Factors Affect Sleep? > Nicotine and Caffeine Integrated Processes: Nursing Process

Client Need: Physiological integrity Cognitive Level: Analysis [Analyzing] Concept: Sleep and Rest Difficulty: Moderate Feedback 1 This is incorrect. The timing of exercise can affect alertness levels; however, participating in an exercise program can promote restful sleep. 2 This is correct. People who use nicotine tend to have more difficulty falling asleep and are more easily aroused than those who are nicotine free. People who stop smoking often experience temporary sleep disturbances during the withdrawal period. 3 This is incorrect. There is no indication of caffeine withdrawal. 4 This is incorrect. Based on the information given, the client is not experiencing significant stress, or change in sleep routine or environment, which commonly lead to insomnia. PTS: 1 CON: Sleep and Rest 7. ANS: 4 Chapter: Chapter 34 Sleep & Rest Objective: Identify factors that influence rest and sleep. Page: 901 (V1) Heading: What Factors Affect Sleep? Lifestyle Factors Integrated Processes: Teaching and Learning Client Need: Physiological integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Sleep and Rest Difficulty: Moderate Feedback 1 This is incorrect. Lying awake longer than 30 minutes is counterproductive. 2 This is incorrect. Eating a small amount of a complex carbohydrate can aid in falling asleep. Avoid simple sugars because sucrose can lead to a short-term energy boost instead of relaxation. 3 This is incorrect. Taking naps during the day and sleeping late on some mornings can exacerbate a sleep disturbance. It’s better to establish a consistent routine for wake and sleep. The extra sleep during the day can interfere with the body’s readiness for sleep at night. 4 This is correct. Intense emotion before bedtime can interfere with rest and sleep. PTS: 1 CON: Sleep and Rest 8. ANS: 4 Chapter: Chapter 34 Sleep & Rest

Objective: Plan, implement, and evaluate nursing care related to specific nursing diagnoses addressing sleep problems. Page: 901 (V1) Heading: What Factors Affect Sleep? Integrated Processes: Nursing Process Client Need: Physiological integrity: Basic Care and Comfort Cognitive Level: Analysis [Analyzing] Concept: Sleep and Rest Difficulty: Moderate Feedback 1 This is incorrect. This option demonstrates that the client took a certain action. The completion of this action does not demonstrate that the problem of Disturbed Sleep Pattern had been resolved. 2 This is incorrect. This option demonstrates that the client took a certain action. The completion of this action does not demonstrate that the problem of Disturbed Sleep Pattern had been resolved. 3 This is incorrect. This option demonstrates that the client took a certain action. The completion of this action does not demonstrate that the problem of Disturbed Sleep Pattern had been resolved. 4 This is correct. The client would verbalize that she is sleeping better and feels less fatigued. The expected outcome (goal) is based on the nursing diagnosis, and its achievement should reflect resolution of the problem. PTS: 1 CON: Sleep and Rest 9. ANS: 3 Chapter: Chapter 34 Sleep & Rest Objective: Describe the function and physiology of sleep Page: 900 (V1) Heading: Table 34-2: Characteristics of Stages of Sleep Integrated Processes: Nursing Process Client Need: Health Promotion Maintenance Cognitive Level: Application [Applying] Concept: Sleep and Rest Difficulty: Easy Feedback 1 This is incorrect. Stage I NREM is characterized as the transition between wakefulness and sleep (falling asleep), with slow eye movements. A person in this stage can be awakened easily and is relaxed but aware of surroundings. 2 This is incorrect. Stage II NREM is characterized as light sleep, where the temperature, heart rate, and blood pressure decrease slightly. A person in this stage is easily roused. 3 This is correct. Stage III NREM is the deepest sleep. In this stage, the delta

waves are highest in amplitude, slowest in frequency, and highly synchronized. The body, mind, and muscles are very relaxed. It is difficult to awaken someone in stage III sleep; if awakened, the person may appear confused and react slowly. During this stage, the body releases human growth hormone, which is essential for repair and renewal of brain and other cells. This is incorrect. REM is characterized as highly active sleep with spontaneous awakenings with rapid eye movement and twitching small muscles. It is less restful than NREM sleep.

PTS: 1 CON: Sleep and Rest 10. ANS: 2 Chapter: Chapter 34 Sleep & Rest Objective: Perform a comprehensive sleep assessment using appropriate interview questions, a sleep diary, and a sleep history. Page: 910 (V1) Heading: Assessment Integrated Processes: Nursing Process Client Need: Health Promotion Maintenance Cognitive Level: Knowledge [Remembering] Concept: Sleep and Rest Difficulty: Moderate Feedback 1 This is incorrect. A sleep diary provides specific information about the client’s sleep–wakefulness patterns over a certain period. The diary is typically kept for 14 days. 2 This is correct. A sleep diary provides specific information about the client’s sleep–wakefulness patterns over a certain period. It allows identification of trends in sleep–wakefulness patterns and associates specific behaviors interfering with sleep. The diary is typically kept for 14 days. 3 This is incorrect. A sleep diary provides specific information about the client’s sleep–wakefulness patterns over a certain period. It allows identification of trends in sleep–wakefulness patterns and associates specific behaviors interfering with sleep. 4 This is incorrect. A sleep history includes in-depth questions about the person’s preparation, preferences, and routines for sleep. PTS: 1 CON: Sleep and Rest 11. ANS: 1 Chapter: Chapter 34 Sleep & Rest Objective: Identify at least five common sleep disorders. Page: 904 (V1) Heading: What Are Some Common Sleep Disorders?

Integrated Processes: Nursing Process Client Need: Physiological integrity: Basic Care and Comfort Cognitive Level: Comprehension [Understanding] Concept: Sleep and Rest Difficulty: Easy Feedback 1 This is correct. Parasomnias are patterns of waking behavior that appears during sleep. Sleepwalking, sleep talking, and bruxism are parasomnias. 2 This is incorrect. Dyssomnias are sleep disorders characterized by insomnia or excessive sleepiness. They include insomnia, sleep–wake schedule (circadian) disorders, sleep apnea, restless leg syndrome, hypersomnia, and narcolepsy. 3 This is incorrect. Insomnia as defined by the Diagnostic and Statistical Manual, 5th edition (DSM-5) is the predominant complaint of dissatisfaction with sleep quantity, associated with the inability to fall asleep, remain asleep, or go back to sleep. 4 This is incorrect. Hypersomnia is excessive sleeping, especially in the daytime. PTS: 1 CON: Sleep and Rest 12. ANS: 4 Chapter: Chapter 34 Sleep & Rest Objective: Identify at least five sleep disorders & Formulate nursing diagnoses that identify sleep problems that may be treated through specific nursing interventions. Page: 904 (V1) Heading: What Are Some Common Sleep Disorders? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Analysis [Analyzing] Concept: Sleep and Rest Difficulty: Moderate Feedback 1 This is incorrect. Insomnia is a medical diagnosis rather than a nursing diagnosis. 2 This is incorrect. The boy does not awaken while sleepwalking and is not likely to experience fatigue from the event. 3 This is incorrect. Certainly, his sleep pattern is disturbed; however, there is little in the way of independent actions that the nurse could take for either the problem or etiology of this diagnosis, so it would not be useful. 4 This is correct. Sleepwalking occurs during stage III NREM sleep. The sleeper leaves the bed and walks about with little awareness of surroundings. He may perform what appear to be conscious motor activities but does not wake up and has no memory of the event on awakening. The boy is at high risk for injury when sleepwalking because of his lack of awareness of his surroundings.

PTS: 1 CON: Sleep and Rest 13. ANS: 1 Chapter: Chapter 34 Sleep & Rest Objective: Plan, implement, and evaluate nursing care related to specific nursing diagnoses addressing sleep problems. Page: 904 (V1) Heading: What Are Some Common Sleep Disorders? Integrated Processes: Physiological Integrity: Reduction of Risk Potential Client Need: Safe and Effective Care Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 This is correct. Sleepwalking places the client at Risk for Injury because of his lack of awareness of the surroundings. The nurse’s primary intervention would be to protect the client from injury (e.g., falls) while sleepwalking, also called somnambulation. 2 This is incorrect. Because the child is only 6 years old, administering and teaching about medications would not be useful. 3 This is incorrect. Because the child is only 6 years old, having him verbalize feelings would not be useful. 4 This is incorrect. Providing a quiet environment would likely be ineffective and certainly not the focus of interventions. PTS: 1 CON: Safety 14. ANS: 1 Chapter: Chapter 34 Sleep & Rest Objective: Identify factors that influence rest and sleep. Page: 901 (V1) Heading: What Factors Affect Sleep? Illness Integrated Processes: Nursing Process Client Need: Physiological integrity: Physiological adaptation Cognitive Level: Comprehension [Understanding] Concept: Sleep and Rest Difficulty: Moderate Feedback 1 This is correct. Anxiety can interfere with the sympathetic nervous system and increase the norepinephrine levels. 2 This is incorrect. There is no indication that this occurs with anxiety. 3 This is incorrect. Anxiety often interferes with the sympathetic nervous system, not the central nervous system.

This is incorrect. There is no indication that anxiety interferes with melatonin production or function.

PTS: 1 CON: Sleep and Rest 15. ANS: 1 Chapter: Chapter 34 Sleep & Rest Objective: Describe nursing interventions for age-related differences in the sleep cycle. Page: 897 (V1) Heading: Table 34-1: Average Sleep Requirements and Characteristics Integrated Processes: Caring Client Need: Health Promotion and Maintenance Cognitive Level: Knowledge [Remembering] Concept: Growth and Development Difficulty: Easy Feedback 1 This is correct. The nurse should provide reassurance to the mother that a toddler needs less sleep than an infant. By 18 to 21 months, most toddlers take only one nap per day and need a total of 11 to 14 hours in a 24-hour period. 2 This is incorrect. Most infants sleep several hours during the overnight period, with a morning and afternoon nap each day, often totaling 12 to 16 hours in a 24-hour period. And as they grow, they need less sleep. 3 This is incorrect. This is typically the amount of sleep an adolescent would need. 4 This is incorrect. This would typically be the amount of sleep for an older adult. PTS: 1 CON: Growth and Development 16. ANS: 3 Chapter: Chapter 34 Sleep & Rest Objective: Identify factors that influence rest and sleep. Page: 895 (V1) Heading: About the Key Concepts Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Sleep and Rest Difficulty: Easy Feedback 1 This is incorrect. Medications are used to promote sleep, not rest. 2 This is incorrect. Caffeine before bedtime can disturb sleep, so this would not be the best advice to promote rest. 3 This is correct. Meditation helps to calm and relax the client, reducing anxiety and stress, promoting rest. 4 This is incorrect. Although watching television in the bedroom can interfere

with falling asleep (generally it is best that the bedroom be an area used only for sleeping), television viewing is a passive activity and can be restful for some (depending on the program). PTS: 1 CON: Sleep and Rest 17. ANS: 2 Chapter: Chapter 34 Sleep & Rest Objective: Identify factors that influence rest and sleep. Page: 902 (V1) Heading: Lifestyle Factors > Diet Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Sleep and Rest Difficulty: Difficult Feedback 1 This is incorrect. This meal is high in saturated fat, which is slow to digest, and can interfere with sleep. 2 This is correct. Turkey, pasta, whole wheat bread, and milk (presuming the client is not lactose intolerant or gluten sensitive) contain L-tryptophan and carbohydrates that may help to promote sleep. Carbohydrates found in fruit also promote relaxation. 3 This is incorrect. Diet cola contains caffeine, which can interfere with sleep patterns. 4 This is incorrect. While some tea is caffeine free, many teas are high in caffeine, which interferes with sleep. However, keep in mind that this meal is not as effective at promoting sleep as other options. PTS: 1 CON: Sleep and Rest 18. ANS: 4 Chapter: Chapter 34 Sleep & Rest Objective: Identify factors that influence rest and sleep. Page: 902 (V1) Heading: What Factors Affect Sleep? > Alcohol?4 Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Sleep and Rest Difficulty: Moderate Feedback 1 This is incorrect. Although this statement is accurate—alcohol (even wine), especially consumed in excess, hastens the onset of sleep, but it disrupts rapid

2 3 4

eye movement (REM) sleep and slow-wave sleep to possibly cause spontaneous awakenings and difficulty returning to sleep—the nurse does not address the underlying issue of sleep difficulty. This is incorrect. Though the nurse should advise the client to avoid alcohol, this is not the first step that should be taken to address the issue of sleep difficulty. This is incorrect. Taking a sleeping pill instead of drinking alcohol is not an ideal trade-off because the goal is to promote natural sleep. This is correct. Collecting a complete sleep history is the first step in caring for a client with sleep difficulty.

PTS: 1 CON: Sleep and Rest 19. ANS: 4 Chapter: Chapter 34 Sleep & Rest Objective: Describe nursing implications for age-related differences in the sleep cycle. Page: 902 (V1) Heading: What Factors Affect Sleep? > Toddlers and Preschoolers Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Sleep and Rest Difficulty: Easy Feedback 1 This is incorrect. Social concerns (worries about friends) are more likely to be seen in an older child. 2 This is incorrect. Although the child may have trouble falling asleep from a lack of opportunity to “wind down” prior to bedtime, staying up to watch television is more of a concern for older children. 3 This is incorrect. Use of medication that interferes with sleep is more common in adolescents and young adults. 4 This is correct. Toddlers and preschoolers are likely to fear monsters or imaginary figures. PTS: 1 CON: Sleep and Rest 20. ANS: 2 Chapter: Chapter 34 Sleep & Rest Objective: Describe nursing implications for age-related differences in the sleep cycle. Page: 902 (V1) Heading: What Factors Affect Sleep? > Parents of Young Children Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Sleep and Rest

Difficulty: Moderate Feedback 1 This is incorrect. The postpartum client who is employed would be most likely on leave from work for the first weeks after discharge, so this would not be a component of client teaching. 2 This is correct. The mother should be taught to nap when the baby naps and as frequently as possible to meet her sleep needs. Sleep deprivation is more likely due to interruptions related to infant feedings and other nighttime awakenings. 3 This is incorrect. The older adult is more likely to experience frequent nocturia, and reducing hydration status is not an effective or safe sleeping strategy. 4 This is incorrect. Physical activity improves strength, circulation, and feelings of well-being. PTS: 1 CON: Sleep and Rest 21. ANS: 4 Chapter: Chapter 34 Sleep & Rest Objective: Identify factors that influence rest and sleep. Page: 903 (V1) Heading: What Are Some Common Sleep Disorders? > Insomnia Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Sleep and Rest Difficulty: Difficult Feedback 1 This is incorrect. The time the client goes to sleep is not as important as how long she sleeps or whether there has been a significant change in sleep patterns. 2 This is incorrect. While assessing stress is an important factor in various alterations in sleep, the nurse would first gather information about the sleep quantity and quality before assessing specific factors contributing to insomnia. 3 This is incorrect. This would be an assessment of interventions. Before recommending interventions to promote sleep, it is important for the nurse to gather data related to what the patient means by insomnia. 4 This is correct. The first question the nurse should ask the client with an alteration in sleep is whether there is trouble with falling asleep, staying asleep, or returning to sleep after awakening. PTS: 1 CON: Sleep and Rest 22. ANS: 1 Chapter: Chapter 34 Sleep & Rest Objective: Identify at least five common sleep disorders. & Plan, implement, and evaluate nursing care related to specific nursing diagnoses addressing sleep problems.

Page: 903 (V1) Heading: What Are Some Common Sleep Disorders? > Narcolepsy Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Safety Difficulty: Easy Feedback 1 This is correct. For safety reasons, it is important to advise clients with a sleep disorder to avoid driving or operating heavy equipment until their condition is stabilized. 2 This is incorrect. Men and women are equally likely to be diagnosed with narcolepsy. 3 This is incorrect. Narcolepsy is treated with central nervous system stimulants that control the symptoms. 4 This is incorrect. Although pseudo-narcolepsy may result from inadequate sleep, more sleep will not correct narcolepsy. PTS: 1 CON: Safety 23. ANS: 3 Chapter: Chapter 34 Sleep & Rest Objective: Identify at least five common sleep disorders & Plan, implement, and evaluate nursing care related to specific nursing diagnoses addressing sleep problems. Page: 903 (V1) Heading: What Are Some Common Sleep Disorders? > Sleep Apnea Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Sleep and Rest Difficulty: Easy Feedback 1 This is incorrect. If the nurse performed a sleep assessment, then a sleep history would have been part of the process. A sleep history is more comprehensive than a sleep diary, although both would contribute to assessing the nature and extent of the client’s sleep issue. 2 This is incorrect. If the nurse performed a sleep assessment, then a sleep history would have been part of the process. 3 This is correct. Polysomnography is the sleep study often implemented to confirm sleep apnea and to determine the significance and cause of the problem. 4 This is incorrect. CPAP is an intervention (not an assessment tool). This is a device that delivers oxygen using forced air pressure to keep the airways open when apnea occurs.

PTS: 1 CON: Sleep and Rest 24. ANS: 2 Chapter: Chapter 34 Sleep & Rest Objective: Perform a comprehensive sleep assessment using appropriate interview questions, a sleep diary, and a sleep history. Page: 911 (V1) Heading: Assessment Guidelines and Tools, Focused Assessments: Questions for a Sleep History and Sleep Log, in Volume 2. Integrated Processes: Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Sleep and Rest Difficulty: Moderate Feedback 1 This is incorrect. If the client is satisfied with his sleep habits and feels rested, then there is no need for a sleep diary. 2 This is correct. If the client is happy with his sleep habits and feels rested, the nurse need only support normal sleep habits and bedtime rituals; therefore, asking when the client goes to bed would be important to meet his needs. 3 This is incorrect. If the client is satisfied with his sleep habits, then there is no need to inquire about sleep problems, such as awakening at night. 4 This is incorrect. If the client is satisfied with his sleep habits, then there is no need to inquire about sleep problems, such as having trouble falling asleep. PTS: 1 CON: Sleep and Rest 25. ANS: 1 Chapter: Chapter 34 Sleep & Rest Objective: Discuss how sleep impacts physical, mental, and spiritual well-being & Formulate nursing diagnoses that identify sleep problems that may be treated through specific nursing interventions. Page: 903 (V1) Heading: What Are Some Common Sleep Disorders? > Insomnia Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Difficult Feedback 1 This is correct. The most appropriate nursing diagnosis for this client is Insomnia. The duration of quality sleep is inadequate and it is impairing the client’s daily functioning (e.g., multiple MVAs caused by sleeping while

2 3 4

driving). This is incorrect. Sleep Deprivation would not be appropriate because the client is not describing symptoms associated with lack of sleep. This is incorrect. Disturbed Sleep Patterns would not be indicated because this client’s lack of sleep is a regular occurrence and not time limited. This is incorrect. Although this client may be at Risk for Injury due to lack of sleep, this diagnosis does not address the cause of the problem; therefore, it would not be the best choice.

PTS: 1 CON: Safety 26. ANS: 4 Chapter: Chapter 34 Sleep & Rest Objective: Plan, implement, and evaluate nursing care related to specific nursing diagnoses addressing sleep problems. Page: 901 (V1) Heading: What Factors Affect Sleep? > Lifestyle Factors Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Sleep and Rest Difficulty: Moderate Feedback 1 This is incorrect. The client who is reported to walk during sleep (somnambulism) would not fit the diagnosis of Disturbed Sleep Patterns because sleepwalking would not be time limited. In this case, the client may not know about the sleepwalking and may report no sleep problems. 2 This is incorrect. The client diagnosed with obstructive sleep apnea would not fit the diagnosis because the irregular breathing pattern during sleep is not time limited. 3 This is incorrect. This client does not have a time-limited change in sleep patterns and would not fit the diagnosis. 4 This is incorrect. The new mother of twins would experience disturbed sleep until the babies are mature enough to sleep through the night; therefore, this is a time-limited sleep problem and fits the diagnosis of Disturbed Sleep Patterns. PTS: 1 CON: Sleep and Rest 27. ANS: 4 Chapter: Chapter 34 Sleep & Rest Objective: Plan, implement, and evaluate nursing care related to specific nursing diagnoses addressing sleep problems. Page: 901 (V1) Heading: What Factors Affect Sleep? > Lifestyle Factors

Integrated Processes: Caring Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Sleep and Rest Difficulty: Moderate Feedback 1 This is incorrect. The spouse is not experiencing pain, so interventions aimed at promoting comfort would not help this person to sleep. 2 This is incorrect. The spouse is physically tired; therefore, supporting bedtime rituals and routines would not resolve the underlying issue that is keeping the spouse from achieving restful sleep. 3 This is incorrect. The spouse reports feeling tired, so restful environment interventions would not resolve the anxiety causing the spouse to experience insomnia. 4 This is correct. The stress of having a loved one diagnosed with cancer appears to be causing anxiety; therefore, interventions aimed at helping the spouse to relax would be most helpful in resolving the problem. PTS: 1 CON: Sleep and Rest 28. ANS: 2 Chapter: Chapter 34 Sleep & Rest Objective: Plan, implement, and evaluate nursing care related to specific nursing diagnoses addressing sleep problems. Page: 911 (V1) Heading: Nursing Process Head: Planning Interventions/Implementation Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. Pillows should never be used for infants because they can lead to poor airway alignment, which increases the risk for apnea and even sudden infant death syndrome. 2 This is correct. According to the American Academy of Pediatrics, it is safest for infants to sleep positioned on their back on a firm surface with no soft padding (e.g., stuffed animals, blankets, or pillows). 3 This is incorrect. Supine position is especially discouraged before 3 months or at the point that the infant develops strength of his head, neck, and upper body. 4 This is incorrect. The safest place for an infant to sleep is in the same room as the caregiver, but not in the same bed. Sleeping with the newborn is associated with smothering or rolling on top of the baby and should be discouraged.

PTS:

CON: Safety

MULTIPLE RESPONSE 29. ANS: 1, 2, 5 Chapter: Chapter 34 Sleep & Rest Objective: Identify factors that influence rest and sleep. Page: 901 (V1) Heading: What Factors Affect Sleep? Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Comprehension [Understanding] Concept: Sleep and Rest Difficulty: Moderate

1. 2.

3. 4. 5.

Feedback This is correct. White noise machines may facilitate sleep. This is correct. Although this needs more information, because many disease processes, such as hyperthyroidism, can negatively affect sleep patterns, proper adherence to the medication regime may facilitate sleep. This is incorrect. Disease processes, such as Parkinson’s disease, may negatively affect sleep patterns. This is incorrect. Alcohol use is an example of a lifestyle factor that negatively affects sleep. This is correct. Often, older adults have decreased production of melatonin. Taking a supplemental dose at the correct time of day may facilitate sleep.

PTS: 1 CON: Sleep and Rest 30. ANS: 2, 4 Chapter: Chapter 34 Sleep & Rest Objective: Describe nursing implications for age-related differences in the sleep cycle. Page: 911 (V1) Heading: Nursing Process Head: Planning Interventions/Implementation Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Growth and Development Difficulty: Moderate

Feedback This is incorrect. Enuresis is nighttime incontinence past the stage at which toilet

2. 3. 4.

training has been well established and does not involve the development of the bladder. This is correct. As the great majority of children outgrow enuresis, the best strategy is patience. This is incorrect. Most incidents occur during NREM sleep when the child is difficult to arouse. This is correct. As the great majority of children outgrow enuresis, the best strategy is patience. In the meantime, protecting the mattress from moisture and odor will help reduce frustration and embarrassment. This is incorrect. A bed alarm can be used for older children (typically older than age 10 to 12 years) who are resistant to other behavioral strategies.

PTS: 1 CON: Growth and Development 31. ANS: 3, 4 Chapter: Chapter 34 Sleep & Rest Objective: Identify at least five common sleep disorders. Page: 904 (V1) Heading: What Are Some Common Sleep Disorders? > Sleep Apnea Integrated Processes: Nursing Process Client Need: Physiological integrity Cognitive Level: Comprehension [Understanding] Concept: Sleep and Rest Difficulty: Moderate

1. 2. 3.

4. 5.

Feedback This is incorrect. Bruxism is defined as grinding or clenching of the teeth. This is not a symptom of OSA. This is incorrect. Enuresis is defined as nighttime urination or bedwetting. This is correct. OSA is caused by partial airway occlusion (usually by the tongue or palate) during sleep. The client experiences interrupted sleep due to frequent arousal to clear the airway. As a result, the client has episodes of daytime fatigue. This is correct. OSA is caused by partial airway occlusion (usually by the tongue or palate) during sleep. As a result, the client has episodes of snoring. This is incorrect. Drooling is not often a symptom of OSA, which is caused by partial airway occlusion during sleep.

PTS: 1 CON: Sleep and Rest 32. ANS: 1, 2, 4 Chapter: Chapter 34 Sleep & Rest Objective: Explain circadian rhythms and how they relate to sleep. Page: 897 (V1) Heading: Physiology of Sleep: Circadian Rhythm Hospitalization

Integrated Processes: Caring Client Need: Safe and Effective Care Environment Cognitive Level: Analysis [Analyzing] Concept: Sleep and Rest Difficulty: Easy

1. 2. 3.

Feedback This is correct. Uncontrolled pain can disrupt circadian rhythms and make sleep difficult. This is correct. Fear of the unknown, such as fear of death, can disrupt circadian rhythms and make sleep difficult. This is incorrect. Nursing rounds can be performed without waking the client. Vital signs would not be taken at night for a client who is terminal, as changes in vital signs will not require interventions or alter outcome. This is correct. Lights in the client’s room in a hospice unit should be turned out to avoid alterations in circadian rhythm, and the door to the room can be closed to block out light from the hallway. This is incorrect. The room should have good sleep hygiene such as cool temperatures, turned off lights in the client’s room, and a closed door to the room to block out light from the hallway.

PTS: 1 CON: Sleep and Rest 33. ANS: 2, 3, 4, 5 Chapter: Chapter 34 Sleep & Rest Objective: Explain why rest and sleep are important. Page: 896 (V1) Heading: Why Do We Need to Sleep? Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Sleep and Rest Difficulty: Difficult

1. 2. 3. 4. 5.

Feedback This is incorrect. Lack of sleep increases insulin resistance, not insulin production. This is correct. Lack of sleep may increase the body’s energy output to maintain the body’s function, but exhaustion leads to less activity. This is correct. Leptin and ghrelin hormone levels (hormones that regulate appetite) are altered with lack of sleep; this leads to an increase in appetite. This is correct. Lack of sleep makes the body less able to tolerate glucose and causes greater insulin resistance, leading to weight gain. This is correct. Sleep deprivation leads to reduced energy expenditure.

PTS:

CON: Sleep and Rest

Chapter 35. Skin Integrity & Wound Healing Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse is reviewing the history and physical records of the newly admitted client in the wound care clinic. There is a notation that states there is an absence of the stratum corneum. Which of the following explains why this is a concern? 1. The stratum corneum provides insulation for temperature regulation. 2. The stratum corneum promotes strength and elasticity to the skin. 3. The stratum corneum protects the body against the entry of pathogens. 4. The stratum corneum produces new skin cells on a continuing basis. 2. The nurse understands that the client who takes antihypertensive medications is at risk for compromised skin integrity and poor wound healing. What is the rationale for that understanding? 1. Antihypertensives can cause cellular toxicity. 2. Antihypertensives increase the risk of ischemia. 3. Antihypertensives can delay wound healing. 4. Antihypertensives predispose to hematoma formation. 3. The nurse is assessing the client with a wound that is considered chronic. The client asks the nurse to explain the difference between chronic and acute wounds. Which of the following would best describe the primary difference between chronic and acute? 1. Chronic wounds are often full-thickness wounds, but acute wounds are superficial. 2. Chronic wounds are the result of pressure, but acute wounds result from surgery. 3. Chronic wounds are usually infected, whereas acute wounds are contaminated. 4. Chronic wounds exceed the typical healing time, but acute wounds heal readily. 4. The nurse is assessing the client who presents to the outpatient clinic with an ischial wound that extends through the epidermis into the dermis. When documenting the depth of the wound, how would the nurse classify it? 1. Stage 1 2. Stage 2 3. Stage 3 4. Stage 4 5. A client underwent abdominal surgery for a ruptured appendix. The surgeon did not surgically close the wound. The wound healing process described in this situation is: 1. Approximation intention healing 2. Primary intention healing 3. Secondary intention healing 4. Tertiary intention healing

6. The nurse is developing a teaching plan for a client that has a surgical incision that has been left open. Which of the following points would the nurse make? 1. The client will need to have twice daily wet to dry dressing changes until the wound is completely healed. 2. The client will need to start a course of antibiotics for the infection until the wound is completely healed. 3. The client will have more scar tissue formation than there would be for a wound closed at surgery. 4. The client should expect to remain hospitalized in an isolation room until the wound is completely healed. 7. What type of wound can be described as a superficial wound, usually self-inflicted due to excessive scratching or mechanical force? 1. Laceration 2. Contusion 3. Excoriation 4. Incision 8. The nurse documents that the new wound has serosanguineous drainage. How is serosanguineous described? 1. Bloody 2. Red, watery, clear 3. Purulent drainage 4. Straw colored 9. The nurse is reviewing the client’s surgical report and notes that the client has a history of evisceration. The nurse researches the differences between dehiscence and evisceration. Which of the following describes the difference between dehiscence and evisceration? 1. Dehiscence involves a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site. 2. Dehiscence is an urgent complication that requires surgery as soon as possible; evisceration is not as urgent. 3. Dehiscence involves the protrusion of internal viscera from the incision site; with evisceration, there is a separation of one or more layers of wound tissue. 4. Dehiscence involves rupture of subcutaneous tissue; evisceration involves damage to dermal tissue. 10. The nurse will know that the plan of care for the diabetic client with severe peripheral neuropathy is effective if the client: 1. Begins an aggressive exercise program 2. Follows a diet plan of 1,200 calories per day 3. Is fitted for deep-depth diabetic footwear 4. Remains free of foot wounds

11. The nurse recognizes that pressure ulcers are directly caused by which of the following conditions at the site? 1. Ischemia 2. Edema 3. Shearing forces 4. Vascular issues 12. A client hospitalized in a long-term rehabilitation facility is immobile and requires mechanical ventilation with a tracheostomy. There is a pressure area on the client’s coccyx measuring 5  3 cm. The area is covered with 100% eschar. What would the nurse identify this as? 1. Stage 2 pressure ulcer 2. Stage 3 pressure ulcer 3. Stage 4 pressure ulcer 4. Unstageable pressure ulcer 13. A client developed a stage 4 pressure ulcer in his sacrum 6 weeks ago, and now the ulcer appears to be a shallow crater involving only partial skin loss. What would the nurse now classify the pressure ulcer as? 1. Stage 1 pressure ulcer, healing 2. Stage 2 pressure ulcer, healing 3. Stage 3 pressure ulcer, healing 4. Stage 4 pressure ulcer, healing 14. The nurse is assessing a client that has an underlying cardiac disease and a draining wound, all of which requires careful monitoring of his fluid balance. Which of the following methods for evaluating his wound drainage would be most appropriate for assessing fluid loss? 1. Draw a circle around the area of drainage on a dressing. 2. Classify drainage as less or more than the previous drainage. 3. Weigh the client at the same time each day on the same scale. 4. Weigh dressings before they are applied and after they are removed. 15. The nurse is providing care to the client who is 2 days status post cerebrovascular accident with residual decreased left-sided mobility. During the assessment, the nurse discovers a stage 1 pressure area on the client’s left heel. What is the initial treatment for this pressure ulcer? 1. Antibiotic treatment for 2 weeks 2. Normal saline irrigation of the ulcer daily 3. Debridement to the left heel 4. Elevation of the left heel off the bed 16. The nurse obtains a swab culture from a chronic wound and understands that this may have limited findings. Why is the information obtained from a swab culture of a wound limited? 1. A positive culture does not necessarily indicate infection because chronic wounds are often colonized by bacteria. 2. A negative culture may not indicate infection because chronic wounds are often colonized by bacteria.

3. Most wound infections are viral, so the swab culture would not be indicative of an infection. 4. A swab culture result does not include bacterial sensitivity information necessary to provide treatment. 17. The nurse is developing plan of care for the client with a stage 4 pressure ulcer, what would an applicable client goal/outcome be? 1. Client will maintain intact skin throughout hospitalization. 2. Client will limit pressure to wound site throughout treatment course. 3. Wound will close with no evidence of infection within 6 weeks. 4. Wound will improve prior to discharge as evidenced by a decrease in drainage. 18. The nurse is developing a plan of care for a client who was injured in a motor vehicle accident yesterday. The client is to be sedated for more than 2 weeks while breathing with the assistance of a mechanical ventilator. Which of the following would be an appropriate nursing diagnosis for him at this time? 1. Risk for Infection related to subcutaneous injuries 2. Risk for Impaired Skin Integrity related to immobility 3. Impaired Tissue Integrity related to ventilator dependency 4. Impaired Skin Integrity related to ventilator dependency 19. The nurse is assessing the client’s wound and notes that the wound bed shows granulation. What phase of wound healing is described by the nurse’s note? 1. Hemostasis 2. Inflammation 3. Proliferative 4. Maturation 20. The nurse is preparing to perform wound care for the client that has a stage 2 pressure ulcer on their right buttock. The ulcer is covered with dry, yellow slough that tightly adheres to the wound. What is the best treatment the nurse could recommend for treating this wound? 1. Dry gauze dressing changed twice daily 2. Nonadherent dressing with daily wound care 3. Hydrocolloid dressing changed as needed 4. Wet-to-dry dressings changed three times a day 21. Which of the following would be the most appropriate outcome for the client with a stage 2 pressure ulcer? 1. The ulcer is completely healed with minimal scarring. 2. The client reports no pain at the site. 3. A minimal amount of drainage is noted. 4. The wound bed contains 100% granulated tissue.

22. The nurse is preparing to perform a dressing change on the client who has a wound. The nurse notes this is a deep wound on the right hip, with tunneling at the 8 o’clock position extending 5 cm. The wound is draining large amounts of serosanguinous fluid and contains 100% red beefy tissue in the wound bed. Of the following, which would be an appropriate dressing choice? 1. Alginate dressing 2. Dry gauze dressing 3. Hydrogel 4. Hydrocolloid dressing 23. The nurse is preparing to perform a wound irrigation. Which of the following is the best choice for performing wound irrigation? 1. Sterile water jet irrigation 2. 35-mL syringe with a 19-gauge angiocatheter 3. 5-mL syringe with a 23-gauge needle 4. Clean bulb syringe and canister 24. The nurse is preparing to provide wound care to a client with many open wounds. Which of the following actions would be the most appropriate method for dressing changes of multiple open wounds that require treatment? 1. Remove all of the soiled dressings before beginning wound treatment. 2. Cleanse wounds from the most contaminated area to the least contaminated area. 3. Treat wounds on the client’s side first and then the front and back of the client. 4. Irrigate wounds from the least contaminated area to the most contaminated area. 25. The client is status post abdominal surgery. The incision has been closed by primary intention, and the staples are intact. To provide more support to the incision site and decrease the risk of dehiscence, it would be appropriate to apply which of the following? 1. Steri-Strips 2. Abdominal binder 3. T-binder 4. Paper tape 26. A client has an area of nonblanchable erythema on his coccyx. The nurse has determined this to be a stage 1 pressure ulcer. What would be the most important treatment for this client? 1. Transparent film dressing 2. Sheet hydrogel 3. Frequent turn schedule 4. Enzymatic debridement 27. The nurse is preparing to apply heat therapy alternated with cold therapy to a wound. What is the proper method for this therapy? 1. Leave the therapy on each area no longer than 15 minutes. 2. Leave the therapy on each area no longer than 30 minutes. 3. When using heat, ensure the temperature is at least 135°F (57.2°C) before applying it.

4. When using cold, ensure the temperature is less than 32°F (0°C) before applying it. 28. The nurse is preparing to provide care to the client who has a contaminated right hip wound that requires dressing changes twice daily. The surgeon informs the nurse that when the wound “heals a little more” he will suture it closed. The nurse recognizes that the surgeon is using which form of wound healing? 1. Primary intention 2. Regenerative healing 3. Secondary intention 4. Tertiary intention 29. The nurse is reviewing a wound care nurse’s narrative note that states there is a fistula in the lower abdominal wall as a result of a poorly healing surgical wound. What is a common cause of a fistula? 1. Ischemic pressure to a bony prominence 2. Diminished venous return to the site 3. Abscess formation from infection or debris 4. Abnormal straining over the incisional site 30. Which of the following clients does the nurse recognize as being at greatest risk for pressure ulcers? 1. An infant with skin excoriations in the diaper region 2. A young adult with diabetes in skeletal traction 3. A middle-aged adult with quadriplegia 4. An older adult requiring use of assistive device for ambulation 31. The nurse working in the emergency department is preparing heat therapy for one of the clients in the unit. Which one is it most likely to be? 1. The client who is actively bleeding 2. The client who has swollen, tender insect bite 3. The client who has just sprained her ankle 4. The client who has lower back pain 32. The nurse assesses assigned clients and determines which client is at highest risk for altered skin integrity? 1. A young adult in traction who has a low-protein diet and dehydration 2. An older client diagnosed with well-controlled type 2 diabetes 3. A middle-aged adult with metabolic syndrome taking antihypertensives 4. An adolescent in bed with influenza, having periods of high fever and diaphoresis 33. The nurse assesses the surrounding skin of the client’s colostomy. The client has been incorrectly applying his ostomy appliance and which caused a wound due to the continuous contact with liquid stool. The nurse notes bleeding and purulent drainage that has extended into the dermis. How will the nurse classify and document this contaminated wound? 1. Acute, full-thickness, open

2. Chronic, partial-thickness, closed 3. Acute, partial-thickness, closed 4. Chronic, unstageable, open 34. The nurse is providing care to the client that has experienced extensive third-degree burns. The nurse is aware that this client will have what type of healing? 1. Primary intention 2. Second intention 3. Tertiary intention 4. Primary intention if no infection occurs 35. The nurse in the emergency department admits a client with a gunshot wound to the lower abdomen accompanied by heavy bleeding. What type of drainage does the nurse expect to see on the dressing? 1. Serous 2. Sanguineous 3. Purosanguineous 4. Purulent 36. An adult client is fully able to detect and respond to pain and discomfort. He has no incontinence or mobility limitations. He is of normal weight and consumes a nutritious diet. The client has no problem with rubbing, friction, or shear. What is the Braden score for this client? 1. 10 2. 15 3. 20 4. 23 37. The nurse admits an older adult client to the long-term care facility. When assessing for pressure ulcer risk, what should the nurse do after conducting the first Braden scale assessment? 1. Apply transparent film dressings to buttocks. 2. Reassess by using the Braden Q scale. 3. Conduct another assessment in 3 days. 4. Massage areas over the bony prominences. 38. The client has shiny ulcerations on a red base over the medial calf of the right leg. There is quite a bit of fluid drainage. He takes anticoagulants because of recurrent deep vein thrombosis. He also reports a sedentary lifestyle. How would the nurse classify this chronic wound? 1. Pressure ulcer 2. Venous stasis ulcer 3. Diabetic foot ulcer 4. Arterial ulcer 39. While applying a wet-to-dry dressing, how would the nurse explain to the client how this procedure works for promoting healing? A wet-to-dry dressing is a: 1. Method of submerging the wound in water, allowing it to soak before drying the

wound bed 2. Procedure that uses proteolytic agents to break down necrotic tissue in the wound bed 3. Means of debriding the wound but also removing granulation tissue from the wound 4. Form of debridement that uses an occlusive, moisture-retaining dressing to break down necrotic tissue 40. The nurse is caring for a client with an infected full-thickness wound with moderate drainage and no odor. What type of dressing will be most appropriate for the nurse to apply? 1. Alginate 2. Antimicrobial petroleum gauze 3. Foam dressing 4. Antimicrobial collagen dressings 41. The nurse is preparing to apply cold therapy. Which of the following diagnoses are contraindicated for cold therapy? 1. The client with a bleeding wound 2. The client with a sprained wrist 3. The client with an infected wound 4. The client with a pressure ulcer Multiple Response Identify one or more choices that best complete the statement or answer the question. 42. Select the process(es) that occur(s) during the inflammatory phase of wound healing. Select all that apply. 1. Granulation 2. Hemostasis 3. Epithelialization 4. Inflammation 5. Maturation 43. Which of the following are the two risk assessment tools most commonly used in the United States to evaluate a client’s risk for pressure ulcers? Select all that apply. 1. Pressure Ulcer Healing Chart 2. PUSH tool 3. Braden scale 4. Norton scale 5. Braden Q Scale 44. Which of the following are examples of nonselective mechanical debridement methods? Select all that apply. 1. Wet-to-dry dressings

2. 3. 4. 5.

Sharp debridement Whirlpool Pulsed lavage Foam alginate

45. Why is an accurate description of the location of a wound important? Select all that apply. 1. Influences the rate of healing 2. Determines the appropriate treatment choice 3. Will affect the frequency of dressing changes 4. Affects client movement and mobility 5. Provides cues of wound etiology 46. The nurse learns in report that the assigned client has a stage 3 pressure ulcer. What type of tissue does the nurse expect to visualize in the wound? Select all that apply. 1. Muscle 2. Eschar 3. Subcutaneous tissue 4. Dermis 5. Fascia 47. Which actions would the nurse take when emptying the client’s closed-wound drainage system? Select all that apply. 1. Don sterile gloves and personal protective equipment. 2. Inspect the drainage tube site and suture sites. 3. Check that tubing to drainage system is intact. 4. Test the suction apparatus at the prescribed pressure. 5. Document the color, type, and amount of drainage. 48. The home health nurse learns that an elderly client isn’t able to get to the grocery store. She doesn’t have much food in her home, and eats and drinks little. Most of her time is spent sitting in her chair watching television, often not realizing that she has bladder leakage. Which nursing actions would she implement to reduce the risk of developing a pressure ulcer? Select all that apply. 1. Help her to get out of the chair every 2 hours. 2. Change her clothing frequently. 3. Bath the client using soap and water. 4. Promote intake of green tea throughout the day. 5. Encourage her to wear incontinence products.

Chapter 35. Skin Integrity & Wound Healing Answer Section MULTIPLE CHOICE 1. ANS: 3 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Discuss factors that affect skin integrity. Page: 918 (V1) Heading: What Factors Affect Skin Integrity? Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Comprehension [Understanding] Concept: Tissue Integrity Difficulty: Moderate Feedback 1 This is incorrect. The subcutaneous layer is composed of adipose and connective tissue that provide insulation, protection, and an energy reserve (adipose). 2 This is incorrect. The dermis is composed of irregular fibrous connective tissue that provides strength and elasticity to the skin. 3 This is correct. The stratum corneum is the outermost layer of the epidermis and is composed of numerous thicknesses of dead cells. Functioning as a barrier to the environment, it restricts water loss, prevents entry of fluids into the body, and protects the body against the entry of pathogens and chemicals. 4 This is incorrect. The stratum germinativum is the innermost layer of the skin that produces new cells, pushing older cells toward the skin surface. PTS: 1 CON: Tissue Integrity 2. ANS: 2 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Discuss factors that affect skin integrity. Page: 918 (V1) Heading: What Factors Affect Skin Integrity? > Medications Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Comprehension [Understanding] Concept: Tissue Integrity Difficulty: Moderate Feedback 1 This is incorrect. Chemotherapeutic agents delay wound healing because of their cellular toxicity. 2 This is correct. Antihypertensive medications decrease the amount of pressure

required to occlude blood flow to an area, creating a risk for ischemia. This is incorrect. Anticoagulants can lead to extravasation of blood into subcutaneous tissue, predisposing to hematoma formation with minimal pressure or injury. This is incorrect. Antihypertensives do not increase the clotting factor.

PTS: 1 CON: Tissue Integrity 3. ANS: 4 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Differentiate the kinds of chronic wounds. Page: 922 (V1) Heading: Types of Wounds > Wounds > Length of Time for Healing Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Understanding [Comprehension] Concept: Tissue Integrity Difficulty: Easy Feedback 1 This is incorrect. Both chronic and acute wounds can vary in thickness. 2 This is incorrect. Both chronic and acute wounds can result from pressure (pressure ulcers) or from surgery. Factors that delay healing wounds may cause chronic wounds. 3 This is incorrect. Acute wounds may become infected as often as chronic wounds. 4 This is correct. The length of time for healing is the determining factor when classifying a wound as acute or chronic. Acute wounds are expected to be of short duration. Wounds that exceed the anticipated length of recovery are classified as chronic wounds. PTS: 1 CON: Tissue Integrity 4. ANS: 2 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Assess and categorize pressure injury based on the pressure injury staging system. Page: 934 (V1) Heading: Table 35-3 Staging Pressure Injury Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Tissue Integrity Difficulty: Moderate Feedback 1 This is incorrect. A stage 1 pressure injury is an area of persistent redness and

2 3

does not blanch. This is correct. A stage 2 pressure injury involves partial-thickness skin loss of the epidermis, dermis, or both. This is incorrect. A stage 3 pressure injury is characterized by full-thickness skin loss involving damage or necrosis of subcutaneous tissue, which may extend down to, but not through, the underlying fascia. The ulcer appears as a deep crater. This is incorrect. A stage 4 pressure injury involves full-thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bone, or support structures. Undermining and sinus tracts (blind tracts underneath the epidermis) are common.

PTS: 1 CON: Tissue Integrity 5. ANS: 3 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Distinguish primary intention healing, secondary intention healing, and tertiary intention healing. Page: 925 (V1) Heading: Types of Healing Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Comprehension [Understanding] Concept: Tissue integrity Difficulty: Moderate Feedback 1 This is incorrect. Approximation is another word for the joining of wound edges. 2 This is incorrect. Primary intention healing occurs when a wound is surgically closed. 3 This is correct. Secondary intention healing occurs when a wound is left open, and it heals from the inner layer to the surface by filling in with beefy red granulation tissue. 4 This is incorrect. Tertiary intention healing occurs when a wound that was previously left open to heal by secondary intention is closed by joining the margins of granulation tissue. PTS: 1 CON: Tissue Integrity 6. ANS: 3 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Review the major complications of wound healing. Page: 925 (V1) Heading: Types of Healing Integrated Processes: Teaching and Learning

Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Tissue Integrity Difficulty: Moderate Feedback 1 This is incorrect. There is not enough data to use this teaching point. Wound treatment is individualized, and there is no indication of twice daily wet to dry dressing changes in the narrative. 2 This is incorrect. There is no indication that the wound is infected. Although open wounds are more prone to contamination and infection, this is not an expected outcome, and antibiotics would not necessarily be needed. 3 This is correct. Because the wound edges are not approximated, more scar tissue will form. 4 This is incorrect. A client with an open wound should not expect an extended hospital stay if wound care can be provided in the home or an outpatient setting. PTS: 1 CON: Tissue Integrity 7. ANS: 3 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Describe the three phases of wound healing. Page: 922 (V1) Heading: Table 35-1 Types of Wounds Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Knowledge [Remembering] Concept: Tissue Integrity Difficulty: Easy Feedback 1 This is incorrect. A laceration can be described as skin or mucous membranes that are torn open, resulting in a wound with jagged margins. 2 This is incorrect. A contusion can be described as a “bruise” or ecchymotic area caused by blunt trauma. 3 This is correct. Excoriation can be described as a superficial wound, usually self-inflicted due to excessive scratching or mechanical force. 4 This is incorrect. Incision can be described as an open, intentional wound. PTS: 1 CON: Tissue Integrity 8. ANS: 2 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Describe three types of wound drainage. Page: 926 (V1) Heading: Types of Wound Drainage

Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Comprehension [Understanding] Concept: Tissue Integrity Difficulty: Easy Feedback 1 This is incorrect. “Bloody drainage” is the description for the term sanguineous. 2 This is correct. Serosanguineous drainage is described as red and watery. 3 This is incorrect. Purosanguineous (purulent) drainage is bloody, pus-filled fluid. 4 This is incorrect. Serous drainage is described as straw-colored fluid. PTS: 1 CON: Tissue Integrity 9. ANS: 1 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Review the major complications of wound healing. Page: 927 (V1) Heading: Complications of Wound Healing Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Tissue Integrity Difficulty: Moderate Feedback 1 This is correct. With dehiscence, there is separation of one or more layers of wound tissue, whereas evisceration involves the protrusion of internal viscera from the incision site. 2 This is incorrect. Evisceration is an urgent complication usually requiring immediate surgical intervention. 3 This is incorrect. Evisceration is the protrusion of internal viscera from an incisional site, dehiscence is the separation of the surgical wound. 4 This is incorrect. Evisceration can damage internal organs, while dehiscence can damage dermal tissue. PTS: 1 CON: Tissue Integrity 10. ANS: 4 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Provide nursing care that limits the risk of pressure injury development. Page: 940 (V1) Heading: Planning Interventions/Implementation > What Wound Care Competencies Do I Need? Integrated Processes: Nursing Process Client Need: Physiological Integrity

Cognitive Level: Synthesis [Creating] Concept: Tissue Integrity Difficulty: Difficult Feedback 1 This is incorrect. An aggressive exercise program would not be appropriate for a client with severely diminished sensation in the feet. 2 This is incorrect. Although diabetic clients experiencing difficulty with blood sugar control are prone to the development of peripheral neuropathy, which results in decreased sensation in the feet and lower extremities, a 1,200-calorie diet would be inadequate for most clients. 3 This is incorrect. Being fitted for diabetic footwear is an intervention rather than a goal. 4 This is correct. Decreased sensation in the feet places the client at increased risk for development of wounds or pressure ulcers in the feet. The nurse will know this plan of care is effective when the client’s feet remain free of wounds. PTS: 1 CON: Tissue Integrity 11. ANS: 1 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Explain the factors involved in the development of pressure injury. Page: 935 (V1) Heading: Assessment Guidelines and Tools > Braden Scale for Predicting Pressure Sore Risk, Norton Pressure Sore Risk-Assessment Scale, and The PUSH Tool for Evaluation of Pressure Ulcers Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Comprehension [Understanding] Concept: Tissue Integrity Difficulty: Easy Feedback 1 This is correct. Pressure ulcers are caused by unrelieved pressure that compromises blood flow to an area, resulting in ischemia (inadequate blood supply) in the underlying tissue. 2 This is incorrect. Edema leads to compromised skin and tissue integrity, which is more prone to pressure injury. 3 This is incorrect. Although friction and shear are extrinsic factors affecting skin integrity and increase the risk of pressure ulcers, they are not the direct cause. 4 This is incorrect. Inadequate arterial blood flow to an area as a result of pressure causes the development of a pressure ulcer. PTS: 1 12. ANS: 4

CON: Tissue Integrity

Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Assess and categorize pressure injury based on the pressure injury staging system. Page: 936 (V1) Heading: Table 35-3 Staging Pressure Injury Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Tissue Integrity Difficulty: Moderate

Feedback This is incorrect. Stage 2 is defined as “involves partial-thickness loss of dermis.” Stage 2 pressure injuries are open but shallow and with a red pink wound bed. There is no slough (tan, yellow, gray, green, or brown necrotic tissue). It may also be an intact or open/ruptured serum-filled blister or a shiny or dry shallow ulcer without slough or bruising. This is incorrect. Stage 3 is defined as “a deep crater characterized by fullthickness skin loss with damage or necrosis of subcutaneous tissue.” Adipose tissue is visible and it may extend down to, but not through, underlying fascia. Undermining (deeper-level damage under boggy superficial layers) of adjacent tissue may be present and bone/tendon is not visible or directly palpable. This is incorrect. Stage 4 is defined as “involves full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or support structures.” Exposed bone/tendon/cartilage is visible or directly palpable. Slough or eschar (tan, black, or brown leathery necrotic tissue) may be present. Epibole (rolled edges), undermining, and sinus tracts (blind tracts underneath the epidermis) are common. This is correct. An eschar is a black, leathery covering made up of necrotic tissue. An ulcer covered in eschar cannot be classified using a staging method because it is impossible to determine the depth.

PTS: 1 CON: Tissue Integrity 13. ANS: 4 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Assess and categorize pressure injury based on the pressure injury staging system. Page: 936 (V1) Heading: Table 35-3 Staging Pressure Injury Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Analysis [Analyzing] Concept: Tissue Integrity Difficulty: Moderate

Feedback This is incorrect. This would remain a stage 4 pressure ulcer that has healed. Reverse staging is not done because as the ulcer heals with granulation tissue and becomes shallower, the lost muscle, subcutaneous fat, and dermis are not replaced. Pressure ulcers maintain their original staging classification throughout the healing process but are accompanied by the modifier healing. This is incorrect. Reverse staging is not done because as the ulcer heals with granulation tissue and becomes shallower, the lost muscle, subcutaneous fat, and dermis are not replaced. Pressure ulcers maintain their original staging classification throughout the healing process but are accompanied by the modifier healing. This is incorrect. Reverse staging is not done because as the ulcer heals with granulation tissue and becomes shallower, the lost muscle, subcutaneous fat, and dermis are not replaced. Pressure ulcers maintain their original staging classification throughout the healing process but are accompanied by the modifier healing. This is correct. This remains a stage 4 pressure ulcer that is healing. Reverse staging is not done because as the ulcer heals with granulation tissue and becomes shallower, the lost muscle, subcutaneous fat, and dermis are not replaced. Pressure ulcers maintain their original staging classification throughout the healing process but are accompanied by the modifier healing.

PTS: 1 CON: Tissue Integrity 14. ANS: 4 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Review the major complications of wound healing. Page: 933 (V1) Heading: Assessment Guidelines and Tools, Physical Examination > Wound Assessment Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Synthesis [Creating] Concept: Tissue Integrity Difficulty: Moderate Feedback 1 This is incorrect. Marking a circle around the wound is useful for determining the extent of drainage seeping out of a wound but it does not provide information on how much fluid is draining. 2 This is incorrect. Classifying the drainage would illustrate the type of drainage, not the amount of fluid lost. 3 This is incorrect. Weighing the client daily would evaluate his overall fluid balance but is not sensitive to fluid loss through the wound. 4 This is correct. By weighing the dressing before it is applied and after it is

removed, the nurse can accurately determine the amount of drainage. PTS: 1 CON: Tissue Integrity 15. ANS: 4 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Assess and categorize pressure injury based on the pressure injury staging system. Page: 936 (V1) Heading: Table 35-3 Staging Pressure Injury Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Tissue Integrity Difficulty: Moderate Feedback 1 This is incorrect. Antibiotics treat infection; a stage 1 pressure injury is not infected. 2 This is incorrect. Skin of a stage I pressure wound is intact but has nonblanchable redness; therefore, irrigation is not indicated for stage 1 pressure wounds. 3 This is incorrect. The area may be painful, firm, soft, or warmer or cooler as compared with adjacent tissue, but is not deep enough for debridement. 4 This is correct. Pressure ulcers are caused by pressure to an area that restricts blood flow, causing ischemia to underlying tissue. The primary treatment is to relieve the pressure, thus improving blood flow. Elevating the client’s left heel off the bed would relieve pressure to this area. PTS: 1 CON: Tissue Integrity 16. ANS: 1 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Review the major complications of wound healing. Page: 918 (V1) Heading: What Factors Affect Skin Integrity? Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 This is correct. The information obtained from a swab culture is limited because a positive culture may not indicate infection. A needle aspiration of the wound would provide more definitive information about whether the wound is infected or not and can be performed by a registered nurse. However, the most accurate

2 3 4

wound information is obtained by tissue biopsy performed by a specially trained provider. This is incorrect. Chronic wounds are often colonized by bacteria, but this does not require antibiotic treatment. This is incorrect. Most wound infections are bacterial, not viral. This is incorrect. Swab specimens have been shown to be accurate in representing bacteria counts biopsied from a wound.

PTS: 1 CON: Infection 17. ANS: 3 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Provide nursing care that limit as the risk of pressure injury development. Page: 922 (V1) Heading: Skin Integrity and Wound Healing Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Synthesis [Creating] Concept: Tissue Integrity Difficulty: Difficult Feedback 1 This is incorrect. Intact skin throughout hospitalization is not realistic with a stage 4 pressure ulcer. 2 This is incorrect. Limiting pressure to a wound site is incorrect because total pressure relief must be provided to the area. 3 This is correct. The goal for any wound is for healing to take place with no complications (e.g., infection). 4 This is incorrect. Improved wound drainage before discharge is not a realistic expectation for a stage 4 pressure ulcer. PTS: 1 CON: Tissue Integrity 18. ANS: 2 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Provide nursing care that limits the risk of pressure injury development. Page: 939 (V1) Heading: Analysis/Nursing Diagnosis Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Analysis [Analyzing] Concept: Tissue Integrity Difficulty: Moderate Feedback 1 This is incorrect. There is no mention of subcutaneous injuries, ruling out Risk

3 4

for Infection related to subcutaneous injuries. This is correct. This client is at Risk for Impaired Skin Integrity because he is being kept in a sedated state. Thus, he is unable to turn himself to relieve pressure. This is incorrect. Impaired Tissue Integrity has no supporting evidence for this nursing diagnosis. This is incorrect. There is no supporting evidence for Impaired Skin Integrity.

PTS: 1 CON: Tissue Integrity 19. ANS: 3 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Describe the three phases of wound healing. Page: 925 (V1) Heading: Wounds: Phases of Healing Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Tissue Integrity Difficulty: Moderate Feedback 1 This is incorrect. Hemostasis is a component of the inflammation phase. At the time of injury, tissue and capillaries are destroyed, causing blood and plasma to leak into the wound. Area vessels constrict to limit blood loss. Platelets aggregate (clump together) to slow bleeding. At the same time, the clotting mechanism is activated to form a blood clot. 2 This is incorrect. The inflammatory reaction is characterized by edema, erythema, pain, temperature elevation, and migration of white blood cells into the wound tissues. Within 24 hours, macrophages begin engulfing bacteria (phagocytosis) and clearing debris. Along with plasma proteins and fibrin, they form a scab on the wound surface, which seals the wound and helps prevent microbial invasion. 3 This is correct. In the proliferation phase, granulation, also called regeneration or healing, occurs from days 5 to 21. Cells develop to fill the wound defect and resurface the skin. Fibroblasts (connective tissue cells) migrate to the wound where they form collagen, a protein substance that adds strength to the healing wound. New blood and lymph vessels sprout from the existing capillaries at the edge of the wound. The result is the formation of granulation tissue, a beefy red tissue that bleeds readily and is easily damaged. As the clot or scab is dissolved, epithelial cells begin to grow into the wound from surrounding healthy tissue and seal over the wound (epithelialization). 4 This is incorrect. In the maturation phase, epithelialization is the final stage of the healing process. Also known as remodeling, this phase begins in the second

or third week and continues even after the wound has closed. During the next 3 to 6 months, the initial collagen fibers that were laid in the wound bed during the proliferation phase are broken down and remodeled into an organized structure (e.g., scar tissue), increasing the tensile strength of the wound. PTS: 1 CON: Tissue Integrity 20. ANS: 3 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Discuss when and how to use absorbent, alginate, collagen, gauze dressings, transparent films, hydrocolloids, hydrogels, and foam and antimicrobial dressings. Page: 941 (V1) Heading: Choosing the Dressing Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Tissue Integrity Difficulty: Difficult Feedback 1 This is incorrect. Dry gauze dressing would cover the wound but would not aid in removing the slough. 2 This is incorrect. Nonadherent dressing (e.g., Telfa) would cover the wound but would not aid in removing the slough. 3 This is correct. A hydrocolloid dressing would conform to this area and form a protective layer against friction and bacterial invasion. It would also promote autolytic debridement of the slough and absorb the exudate from the autolysis. 4 This is incorrect. A wet-to-dry dressing is a form of mechanical debridement. It would aid in removing the slough but is nonselective; therefore, it could cause damage to healthy tissue as well. PTS: 1 CON: Tissue Integrity 21. ANS: 4 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Provide nursing care that limits the risk of pressure injury development. Page: 940 (V1) Heading: Planning Outcomes/Evaluation Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Tissue Integrity Difficulty: Difficult Feedback 1 This is incorrect. A wound can heal and leave a scar.

2 3

This is incorrect. Although pain is an indicator of inflammation, no pain at the wound site does not indicate proper healing is occurring. This is incorrect. Although drainage is an indicator of inflammation, infection, bleeding, and drainage at the wound site does not indicate proper healing is occurring. This is correct. A healing wound contains granulating tissue.

PTS: 1 CON: Tissue Integrity 22. ANS: 1 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Discuss when and how to use absorbent, alginate, collagen, gauze dressings, transparent films, hydrocolloids, hydrogels, and foam and antimicrobial dressings. Page: 945 (V1) Heading: Table 35-5: Types of Wound Dressings Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Tissue Integrity Difficulty: Moderate Feedback 1 This is correct. Alginates are highly absorbent and are appropriate for wounds with moderate to large amounts of drainage. They are ideal for wounds with tunneling, as they will conform to fill the tunnel. 2 This is incorrect. Gauze and hydrocolloids have limited absorptive ability. Gauze could adhere to the wound bed and cause trauma when removed. 3 This is incorrect. A hydrogel would increase the drainage, with the potential of macerating surrounding skin. 4 This is incorrect. Hydrocolloids have limited absorptive ability. A hydrogel would increase the drainage, with the potential of macerating surrounding skin. PTS: 1 CON: Tissue Integrity 23. ANS: 2 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Demonstrate appropriate techniques for irrigating a wound. Page: 923 (V1) Heading: Procedure 35-2: Performing a Sterile Wound Irrigation Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Tissue Integrity Difficulty: Moderate Feedback

3 4

This is incorrect. The water jet irrigation unit and 5-mL syringe with a 23-gauge needle would deliver the solution above the recommended pressure range of 4 to 15 pounds per square inch (psi). This is correct. A 35-mL syringe with a 19-gauge angiocatheter is the best choice for irrigation because it will deliver the irrigation solution at approximately 8 psi. This is incorrect. The 5-mL syringe with a 23-gauge needle would deliver the solution above the recommended pressure range of 4 to 15 psi. This is incorrect. A bulb syringe is not an appropriate choice because there is an increased risk of aspirating drainage from the wound.

PTS: 1 CON: Tissue Integrity 24. ANS: 4 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Review the major complications of wound healing. Page: 938 (V1) Heading: Procedure 35-4: Removing and Applying Dry Dressings Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Synthesis [Creating] Concept: Safe and Effective care Environment: Safety and Infection Control Difficulty: Moderate Feedback 1 This is incorrect. This would leave all of the wounds open to contamination during a dressing change. 2 This is incorrect. The proper method would be to proceed from “clean” to “dirty” areas, to avoid cross contamination. 3 This is incorrect. There is not enough information to describe the placement of the wounds. 4 This is correct. To avoid the possibility of cross-contamination, the wound with the least amount of contamination should be treated first, progressing to the wound with the most contamination. PTS: 1 CON: Tissue Integrity 25. ANS: 2 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Demonstrate bandage and binder application. Page: 924 (V1) Heading: Types of Healing Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying]

Concept: Tissue Integrity Difficulty: Easy Feedback 1 This is incorrect. Steri-Strips would not be needed for an approximated incision that has intact staples or sutures. 2 This is correct. An abdominal binder provides added support to an incision site and decreases the risk of wound dehiscence 3 This is incorrect. A T-binder is used in the perineal area. 4 This is incorrect. Paper tape would not be needed for an approximated incision that has intact staples or sutures. PTS: 1 CON: Tissue Integrity 26. ANS: 3 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Discuss when and how to use absorbent, alginate, collagen, gauze dressings, transparent films, hydrocolloids, hydrogels, and foam and antimicrobial dressings. Page: 929 (V1) Heading: Example Problem: Pressure Injury Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Analysis [Analyzing] Concept: Tissue Integrity Difficulty: Moderate Feedback 1 This is incorrect. Although a transparent film dressing would protect the area, a stage 1 wound is not open so a dressing is not warranted. 2 This is incorrect. A sheet hydrogel treatment is not warranted, as the wound is not open. 3 This is correct. The client should be placed on a turn schedule to relieve the pressure. If pressure is not relieved, the wound will worsen. 4 This is incorrect. Enzymatic debridement is used to remove slough or eschar in an open wound. PTS: 1 CON: Tissue Integrity 27. ANS: 1 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Describe guidelines to follow when applying heat or cold therapy. Page: 922 (V1) Heading: Clinical Insight 35-1 Applying Local Heat Therapy Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Comprehension [Understanding]

Concept: Tissue Integrity Difficulty: Easy Feedback 1 This is correct. Apply heat or cold therapies intermittently, leaving them on for no more than 15 minutes at a time in an area. This helps prevent tissue injury and also makes the therapy more effective by preventing rebound phenomenon. 2 This is incorrect. Leaving the heat or cold therapies on longer than 15 minutes could cause tissue damage. 3 This is incorrect. Temperatures should be kept between 59°F and 113°F (15°C and 45°C), depending on the type of therapy chosen and what is comfortable to the client. Temperatures colder or hotter than those recommended can damage tissue. 4 This is incorrect. Temperatures should be kept between 59°F and 113°F (15°C and 45°C), depending on the type of therapy chosen and what is comfortable to the client. Temperatures colder or hotter than those recommended can damage tissue. PTS: 1 CON: Tissue Integrity 28. ANS: 4 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Demonstrate bandage and binder application. Page: 924 (V1) Heading: Wound Healing Process > Types of Healing Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Comprehension [Understanding] Concept: Tissue Integrity Difficulty: Moderate Feedback 1 This is incorrect. Primary intention healing occurs when a wound involves minimal or no tissue loss and has edges that are well approximated (closed). Little scarring is expected. A clean surgical incision heals by this method. Even so, a scar is only 80% as strong as the original tissue. 2 This is incorrect. Regenerative/epithelial healing occurs when a wound affects only the epidermis and dermis. No scar forms and the new (regenerated) epithelial and dermal cells form new skin that cannot be distinguished from the intact skin. Partial-thickness wounds heal by regeneration. 3 This is incorrect. Secondary intention healing occurs when a wound (1) involves extensive tissue loss, which prevents wound edges from approximating (coming together), or (2) should not be closed (e.g., because it is infected). Because the wound is left open, it heals from the inner layer to the surface by filling in with beefy red granulation tissue (a form of connective tissue with an abundant blood

supply). Epithelial tissue may appear in the wound as small pink or pearl-like areas. This is correct. Tertiary intention is used when a wound is clean-contaminated or “dirty” (potentially infected). Initially, the wound can heal by secondary intention, and when there is no evidence of edema, infection, or foreign matter, granulating tissue is brought together, and the wound edges are sutured closed.

PTS: 1 CON: Tissue Integrity 29. ANS: 3 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Review the major complications of wound healing. Page: 927 (V1) Heading: Complications of Wound Healing > Integrated Processes: Client Need: Physiological Integrity Cognitive Level: Comprehension [Understanding] Concept: Tissue Integrity Difficulty: Moderate Feedback 1 This is incorrect. This describes the etiology of a pressure ulcer. 2 This is incorrect. This describes the etiology of a venous stasis ulcer, not a fistula. 3 This is correct. A fistula is an abnormal passage connecting two body cavities or a cavity and the skin. Fistulas often result from infection or debris left in the wound. An abscess forms, which breaks down surrounding tissue and creates the abnormal passageway. Chronic drainage from the fistula may lead to skin breakdown and delayed wound healing. The most common sites of fistula formation are the gastrointestinal and genitourinary tracts. 4 This is incorrect. This describes a wound dehiscence. The client may cough or strain and feel a “pop” followed by an opening forming in the incision. PTS: 1 CON: Tissue Integrity 30. ANS: 3 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Use the Braden scale to assess risk for pressure injury. Page: 752 (V2) Heading: The Braden Scale for Predicting Pressure Sore Risk Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Analysis [Analyzing] Concept: Tissue Integrity Difficulty: Moderate Feedback

1 2

3 4

This is incorrect. The infant with disruption to the skin from diaper rash is at risk for skin infection but not for a pressure sore. This is incorrect. The young adult with diabetes is at increased risk for delayed wound healing but not likely for a pressure sore. This client is likely to shift weight in bed and respond to discomfort of pressure on a bony site. This is correct. The client at greatest risk for pressure sores is the one with a lack of sensory perception at the site (e.g., quadriplegia). This is incorrect. The older adult is normally at risk for pressure injury, but when mobile, even with an assistive device, the risk is minimal.

PTS: 1 CON: Tissue Integrity 31. ANS: 4 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Demonstrate bandage and binder application. Page: 952 (V1) Heading: Using Heat and Cold Therapy Integrated Processes: Nursing Process Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Tissue Integrity Difficulty: Moderate Feedback 1 This is incorrect. Applying heat promotes vasodilation and reduces blood thickness (viscosity) and leaky capillaries, all of which would be harmful to the client who is actively bleeding. It can lead to a drop in blood pressure. 2 This is incorrect. Heat should not be applied to a site with inflammation (insect bite) because it can increase edema to the site. 3 This is incorrect. Heat should not be applied to a site with inflammation (acute joint injury with swelling) because it can increase edema to the site. 4 This is correct. Heat therapy is used to relieve stiffness and discomfort commonly associated with musculoskeletal soreness. Heat causes dilation of the blood vessels and improves delivery of oxygen and nutrients to the tissues. It promotes relaxation and is used to aid in the healing process. PTS: 1 CON: Tissue Integrity 32. ANS: 1 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Discuss the factors that affect skin integrity. Page: 939 (V1) Heading: Analysis/Nursing Diagnosis Integrated Processes: Tissue Integrity Client Need: Physiological Integrity

Cognitive Level: Synthesis [Creating] Concept: Tissue Integrity Difficulty: Difficult Feedback 1 This is correct. The young adult client in traction has multiple risk factors, including immobility, dehydration, and inadequate protein intake. Healthy skin depends on adequate protein levels to maintain the skin, repair minor defects, and preserve intravascular volume. Therefore, this client is at greatest risk for altered skin integrity. 2 This is incorrect. An elderly client with well-controlled diabetes has only one risk factor, and therefore is not at highest risk among the group of clients in the scenario. 3 This is incorrect. The middle-aged adult with metabolic syndrome, which involves obesity, hyperlipidemia, and hypertension, has compromised health, although not necessarily compromised skin integrity—unless the client were immobile, which he is not. 4 This is incorrect. Although fever and skin moisture can compromise skin integrity, the adolescent’s condition is likely transient. PTS: 1 CON: Tissue Integrity 33. ANS: 1 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Differentiate the kinds of chronic wounds. Page: 932 (V1) Heading: Assessment > Assessment Guidelines and Tools, Physical Examination > Wound Assessment Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Analysis [Analyzing] Concept: Tissue Integrity Difficulty: Moderate Feedback 1 This is correct. The wound is acute because it developed recently. The wound is full-thickness because it involves the dermis. 2 This is incorrect. The wound is open because it was bleeding, so the skin must be broken. The wound is contaminated because it is exposed to stool and appears to be infected. 3 This is incorrect. The wound is open and full thickness due to involvement of the dermis. 4 This is incorrect. This is a new wound, not chronic, and stageable as it involves the dermis.

PTS: 1 CON: Tissue Integrity 34. ANS: 3 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Distinguish primary intention healing, secondary intention healing, and tertiary intention healing. Page: 924 (V1) Heading: Types of Healing Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Comprehension [Understanding] Concept: Tissue Integrity Difficulty: Easy Feedback 1 This is incorrect. Wound healing by primary intention occurs when there is minimal or no tissue loss, and edges are well approximated. With a third-degree burn the edges cannot approximate for primary intention healing. 2 This is incorrect. Secondary intention healing occurs when a wound (1) involves extensive tissue loss, which prevents wound edges from approximating (coming together), or (2) should not be closed (e.g., because it is infected). Because the wound is left open, it heals from the inner layer to the surface by filling in with beefy red granulation tissue (a form of connective tissue with an abundant blood supply) 3 This is correct. A third-degree burn heals by tertiary intention. Skin grafts would be required to bring edges of granulation tissue together. 4 This is incorrect. Wound healing by primary intention occurs when there is minimal or no tissue loss, and edges are well approximated. With a third-degree burn the edges cannot approximate for primary intention healing. Even if no infection occurs, this wound will not heal by primary intention because of deep tissue loss. PTS: 1 CON: Tissue Integrity 35. ANS: 2 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Identify wounds based on accepted classification schemes. Page: 926 (V1) Heading: Types of Wound Drainage Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Comprehension [Understanding] Concept: Tissue Integrity Difficulty: Easy Feedback

1 2 3

This is incorrect. Serous drainage is clear, faintly yellow drainage. Serous drainage occurs when there is inflammation, such as with a burn injury. This is correct. Sanguineous drainage contains blood, which would be expected from a wound with active bleeding. This is incorrect. Purosanguineous fluid contains pus, which occurs with infection. This client has a wound from an acute injury. Although infection risk is high with gunshot wounds, infection generally takes 2 or more days to occur. This is incorrect. Purulent drainage indicates infection. This wound is too recent to demonstrate infection.

PTS: 1 CON: Tissue Integrity 36. ANS: 4 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Use the Braden scale to assess risk for pressure injury. Page: 752 (V2) Heading: The Braden Scale for Predicting Pressure Sore Risk Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Analysis [Analyzing] Concept: Tissue Integrity Difficulty: Moderate Feedback 1 This is incorrect. The Braden scale evaluates six major risk factors: sensory perception, moisture, activity, mobility, nutrition, and friction and sheer. Each category is rated on a scale of 1 to 4, excluding the friction and shear, which is rated on a scale of 1 to 3. The final score reflects the client’s risk: the lower the score, the more likely it is the client will develop a pressure ulcer. 2 This incorrect. The Braden scale evaluates six major risk factors: sensory perception, moisture, activity, mobility, nutrition, and friction and sheer. Each category is rated on a scale of 1 to 4, excluding the friction and shear, which is rated on a scale of 1 to 3. The final score reflects the client’s risk: the lower the score, the more likely it is the client will develop a pressure ulcer. 3 This is incorrect. The Braden scale evaluates six major risk factors: sensory perception, moisture, activity, mobility, nutrition, and friction and sheer. Each category is rated on a scale of 1 to 4, excluding the friction and shear, which is rated on a scale of 1 to 3. The final score reflects the client’s risk: the lower the score, the more likely it is the client will develop a pressure ulcer. 4 This is correct. The Braden scale evaluates six major risk factors: sensory perception, moisture, activity, mobility, nutrition, and friction and sheer. Each category is rated on a scale of 1 to 4, excluding the friction and shear, which is rated on a scale of 1 to 3. The final score reflects the client’s risk: the lower the score, the more likely it is the client will develop a pressure ulcer. The client

receives 4 points for sensory perception, moisture, activity, mobility, and nutrition and 3 points for friction and shear, making a total of 23 points, which is a perfect score. PTS: 1 CON: Tissue Integrity 37. ANS: 3 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Provide nursing care that limits the risk of pressure injury development. Page: 752 (V2) Heading: The Braden Scale for Predicting Pressure Sore Risk Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Tissue Integrity Difficulty: Difficult Feedback 1 This is incorrect. Application of barrier products, such as transparent film dressing, prior to a thorough and accurate assessment of need is premature and possibly not needed. 2 This is incorrect. The Braden Q scale is used to assess pressure ulcer risk in children. Massaging the area over bony prominences could irritate the skin and lead to injury. 3 This is correct. The initial Braden scale assessment should be repeated in 48 to 72 hours to establish an accurate baseline. 4 This is incorrect. Massaging the area over bony prominences could irritate the skin and lead to injury. PTS: 1 CON: Tissue Integrity 38. ANS: 2 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Differentiate the kinds of chronic wounds. Page: 922 (V1) Heading: Table 35-1: Types of Wounds Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Comprehension [Understanding] Concept: Tissue Integrity Difficulty: Easy Feedback 1 This is incorrect. A pressure ulcer is unlikely to develop on the medial side of the calf because it is neither a bony area nor one that is likely to be an area where there is pressure.

This is correct. The location of the ulcers and the history of past deep vein thrombosis would make venous stasis ulcers the most likely classification for these wounds. They occur usually between the inside ankle and the knee, not necessarily over a bony prominence, and are typically red in color, shiny, and taut, and may even feel warm or hot. Fluid drainage can be significant. This is incorrect. There is no indication that this client is diabetic, and the wound is not on the foot. An arterial (ischemic) ulcer tends to be dry and pale, with little drainage. Arterial ulcers are usually very painful, especially at night. This is incorrect. An arterial (ischemic) ulcer tends to be dry and pale, with little drainage. Arterial ulcers are usually very painful, especially at night.

PTS: 1 CON: Tissue Integrity 39. ANS: 3 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Differentiate the five forms of wound debridement. Page: 945 (V1) Heading: Table 35-5 Types of Wound Dressings Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Comprehension [Understanding] Concept: Tissue Integrity Difficulty: Moderate Feedback 1 This is incorrect. Hydrotherapy or whirlpool treatments are nonselective debridement wherein the wound is submerged in a whirlpool containing tepid water for a prescribed amount of time (usually 5 to 15 minutes). This form of debridement is reserved for wounds with a large amount of nonviable tissue, such as burns. 2 This is incorrect. Enzymatic debridement uses proteolytic agents to break down necrotic tissue without affecting viable tissue in the wound. To use an enzymatic product, clean the wound with normal saline, apply a thin layer of the cream, and cover with a moisture-retaining dressing. 3 This is correct. A wet-to-dry dressing uses coarse gauze moistened with normal saline that is packed into the wound, allowed to dry, and then removed, perhaps several times a day. This form of nonselective debridement removes not only debris but also granulation tissue from the wound. It is also quite painful. 4 This is incorrect. Autolysis breaks down necrotic tissue by using an occlusive, moisture-retaining dressing (e.g., transparent dressing) and the body’s own enzymes and defense mechanisms. This process takes more time than the other techniques, but it is better tolerated. PTS:

CON: Tissue Integrity

40. ANS: 4 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Discuss when and how to use absorbent, alginate, collagen, gauze dressings, transparent films, hydrocolloids, hydrogels, and foam and antimicrobial dressings. Page: 945 (V1) Heading: Table 35-5 Types of Wound Dressings Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Analysis [Analyzing] Concept: Tissue Integrity Difficulty: Moderate Feedback 1 This is incorrect. Although alginate dressings will absorb the drainage, they do not treat the infection. 2 This is incorrect. Petroleum gauze is not absorbent and would not be the best choice for a draining wound. 3 This is incorrect. Foam dressings are highly absorbent, but they will not treat the infected wound. 4 This is correct. An antimicrobial collagen dressing promotes wound healing, is absorbent and is treated with an antimicrobial to promote infection resolution. PTS: 1 CON: Tissue Integrity 41. ANS: 4 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Demonstrate bandage and binder application. Page: 952 (V1) Heading: Using Heat and Cold Therapy Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Analysis [Analyzing] Concept: Tissue Integrity Difficulty: Moderate Feedback 1 This is incorrect. A cold pack may be used for the client with active bleeding because it causes vasoconstriction and would reduce bleeding. 2 This is incorrect. Cold therapy is appropriate for the client with a sprain to reduce edema, inflammation, and pain. 3 This is incorrect. Application of cold slows bacterial growth, so this may be used for an infected wound that is warm to the touch and inflamed. 4 This is correct. The client with a pressure ulcer would not benefit from a cold application because it would slow blood supply and wound healing and increase risk of further tissue damage.

PTS:

CON: Tissue Integrity

MULTIPLE RESPONSE 42. ANS: 2, 4 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Describe the three phases of wound healing. Page: 924 (V1) Heading: Wound Healing Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Knowledge [Remembering] Concept: Tissue integrity Difficulty: Moderate

3. 4. 5.

Feedback This is incorrect. In the proliferation phase, granulation, also called regeneration or healing, occurs from days 5 to 21. Cells develop to fill the wound defect and resurface the skin. This is correct. After an injury, blood vessels constrict to limit blood loss, and platelets migrate to the site and aggregate to stop bleeding. Together, this results in hemostasis. This is incorrect. This is beginning of the proliferation phase, also called the regeneration or healing phase. This is correct. Inflammation follows as a defense against infection at the wound site. This is incorrect. In the maturation phase, epithelialization is the final stage of the healing process, known as remodeling. It begins in the second or third week and continues even after the wound has closed. During the next 3 to 6 months, the initial collagen fibers that were laid in the wound bed during the proliferation phase are broken down and remodeled into an organized structure (e.g., scar tissue), increasing the tensile strength of the wound.

PTS: 1 CON: Tissue Integrity 43. ANS: 3, 4, 5 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Explain the factors involved in the development of pressure injury & Use the Braden Scale to assess risk for pressure injury. Page: 752 (vol2 ) Heading: The Braden Scale for Predicting Pressure Sore Risk Integrated Processes: Nursing Process

Client Need: Physiological Integrity Cognitive Level: Knowledge [Remembering] Concept: Tissue Integrity Difficulty: Moderate

Feedback This is incorrect. The PUSH (Pressure Ulcer Scale for Healing) tool provides a comprehensive means of reporting the progression of a pressure ulcer. Surface area, exudate, and type of wound tissue are scored and totaled. The Pressure Ulcer Healing Chart is part of the PUSH tool, which is used to monitor the progression of a pressure ulcer. This is incorrect. The PUSH tool provides a comprehensive means of reporting the progression of a pressure ulcer. Surface area, exudate, and type of wound tissue are scored and totaled. The Pressure Ulcer Healing Chart is part of the PUSH tool, which is used to monitor the progression of a pressure ulcer. This is correct. The Braden scale is a tool used to predict the risk of developing a pressure sore. Evaluation is based on six areas (indicators): sensory perception, moisture, activity, mobility, nutrition, and friction or shear. This is correct. The Norton scale is another tool used to assess the risk for pressure ulcers based on the client’s physical condition, mental state, activity, mobility, and incontinence. This is correct. The Braden Q scale is used to evaluate the risk potential for pediatric clients.

PTS: 1 CON: Tissue Integrity 44. ANS: 1, 3, 4 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Discuss when and how to use absorbent, alginate, collagen, gauze dressings, transparent films, hydrocolloids, hydrogels, and foam and antimicrobial dressings. Page: 946 (V1) Heading: Table 35-5 Types of Wound Dressings Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Comprehension [Understanding] Concept: Tissue Integrity Difficulty: Moderate

Feedback This is correct. Wet-to-dry dressings and hydrotherapy (e.g., whirlpool and pulsed lavage) are nonselective forms of debridement, which means that healthy tissue as well as devitalized tissue can be removed with their use. This is incorrect. Sharp debridement is a selective form of debridement. With sharp

3. 4. 5.

debridement, only devitalized tissue is removed. This is correct. Hydrotherapy is a nonselective form of debridement, which means that healthy tissue as well as devitalized tissue can be removed with its use. This is correct. Pulsed Lavage is a form of hydrotherapy that debrides healthy as well as nonviable tissue. This is incorrect. Foam alginate is an absorbent dressing, not a debriding agent.

PTS: 1 CON: Tissue Integrity 45. ANS: 1, 2, 4, 5 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Accurately document assessment of a wound. Page: 938 (V1) Heading: Assessing Treated Wounds Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Analysis [Analyzing] Concept: Tissue Integrity Difficulty: Moderate

1. 2.

3. 4.

Feedback This is correct. Wounds in highly vascular areas heal more rapidly than do wounds in less vascular regions. This is correct. Wounds that can be stabilized also heal more readily than those in areas in which there is movement or pressure. Some wounds can be partially identified by their location. For instance, a venous stasis ulcer occurs in the lower extremities. Therefore, a wound located on an upper extremity would not be related to venous congestion. This is incorrect. The frequency of dressing changes will be dependent on the type of wound and amount of drainage, but not necessarily the location. This is correct. Wounds located on a plantar surface would impede the client’s mobility. Those in a location causing pain would also likely lead to restricted range of motion and movement (mobility). This is correct. Location can give you clues to the wound etiology. A wound over a bony prominence could be related to pressure, whereas one on the bottom of the foot could be a diabetic foot ulcer.

PTS: 1 CON: Tissue Integrity 46. ANS: 3, 4, 5 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Discuss the different kinds of tissue found in wounds. Page: 918 (V1) Heading: What Are the Main Points in This Chapter?

Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Knowledge [Remembering] Concept: Tissue Integrity Difficulty: Moderate

1. 2. 3.

Feedback This is incorrect. This would be a stage 4 pressure ulcer. This is incorrect. This would be unstageable pressure ulcer. This is correct. A stage 3 pressure injury is characterized by full-thickness skin loss involving damage or necrosis of subcutaneous tissue, which may extend down to, but not through, the underlying fascia. The ulcer appears as a deep crater. This is correct. A stage 3 pressure injury is characterized by full-thickness skin loss involving damage or necrosis of subcutaneous tissue, which may extend down to, but not through, the underlying fascia. The ulcer appears as a deep crater. This is correct. A stage 3 pressure injury is characterized by full-thickness skin loss involving damage or necrosis of subcutaneous tissue, which may extend down to, but not through, the underlying fascia. The ulcer appears as a deep crater.

PTS: 1 CON: Tissue Integrity 47. ANS: 2, 3, 4, 5 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Describe care of a wound with a drain. Page: 942 (V1) Heading: Types of Drains Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Tissue Integrity Difficulty: Difficult

2. 3. 4.

Feedback This is incorrect. Emptying a closed-wound drainage system is not a sterile procedure; therefore, sterile gloves and personal protective equipment (e.g., mask, gown, goggles) would not be necessary. Clean gloves would protect the nurse from contamination and prevent the transmission of microbes with exposure to drainage. This is correct. The nurse would inspect the appearance of the insertion site of the drain for signs of infection or skin irritation. This is correct. The nurse would check the tubing to be sure it is tightly connected and there is no leakage. This is correct. The nurse assesses the suction apparatus to ensure the system is working properly.

This is correct. Documentation of the amount and characteristics of the drainage (e.g., color, type, thickness, odor) would aid care providers in assessing the potential for development of wound infection.

PTS: 1 CON: Tissue Integrity 48. ANS: 1, 2, 5 Chapter: Chapter 35 Skin Integrity & Wound Healing Objective: Provide nursing care that limits the risk of pressure injury development. Page: 929 (V1) Heading: Example Problem: Pressure Injury Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Tissue Integrity Difficulty: Moderate

Feedback This is correct. Immobility is a major cause of skin breakdown, especially when skin integrity is already compromised with poor nutritional status and poor hydration. Therefore, it is very important for the client to get up out of the chair and move around periodically. This is correct. The moisture from wet clothing is a source of skin breakdown. The nurse would not only need to help the woman put on dry undergarments but also implement a plan for incontinence care, including using protective pads and absorption garments. This is incorrect. Clean skin is important for optimizing skin integrity. However, soap can be drying to the skin, which could increase risk of alterations in skin integrity. This is incorrect. Although this client is at risk for dehydration and undernourishment, which compromises skin integrity, the nurse should educate the client to drink noncaffeinated fluids, especially water. Caffeine can aggravate incontinence. This is correct. The nurse would not only need to help the woman put on dry undergarments but also implement a plan for incontinence care, including using protective pads and absorption garments.

PTS:

CON: Tissue Integrity

Chapter 36. Oxygenation Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse is providing care to a pregnant woman in preterm labor. The client is 32 weeks pregnant. Initially, the client states, “I’ve gained 30 pounds. That should be enough for the baby. Everything will be okay if I deliver now.” After teaching the client about fetal development, the nurse will know her teaching is effective if the client makes which of the following statements? 1. “The baby’s lungs are well developed now, but he will be at increased risk for sudden infant death syndrome (SIDS) if I deliver early.” 2. “We should try to stop this labor now because the baby will be born with sleep apnea if I deliver this early.” 3. “If I deliver this early, my baby is at risk for respiratory distress syndrome (RDS), a condition that can be life threatening.” 4. “Thanks for reassuring me; I was pretty sure there isn’t much risk to the baby this far along in my pregnancy.” 2. While a client is receiving hygiene care, the chest tube becomes disconnected from the water-seal chest drainage unit (CDU). Which action should the nurse take immediately? 1. Clamp the chest tube close to the insertion site with rubber-shod hemostats. 2. Set up a new drainage system, and quickly connect it to the chest tube. 3. Have the client take a deep breath while the nurse reconnects the tube to the CDU. 4. Place the disconnected end nearest the client into a bottle of sterile water. 3. The nurse administers an antitussive/expectorant cough preparation to a client with bronchitis. Which of the following responses indicates to the nurse that the medication is effective? 1. The amount of sputum the client expectorates decreases with each dose administered. 2. Cough is completely suppressed, and the client is able to sleep through the night. 3. Dry, unproductive cough is reduced, but her voluntary coughing is more productive. 4. Involuntary coughing produces large amounts of thick yellow sputum. 4. The nurse is admitting to the medical-surgical unit an older adult with a diagnosis of pulmonary hypertension and right-sided heart failure. The client is complaining of shortness of breath, and the nurse observes conversational dyspnea. What is the first action the nurse should take? 1. Review and implement the primary care provider’s prescriptions for treatments. 2. Perform a quick physical examination of breathing, circulation, and oxygenation. 3. Gather a thorough medical history, including current symptoms, from the family. 4. Administer supplemental oxygen to the client through a nasal cannula.

5. The nurse is providing care for a young adult client with an intracranial hemorrhage secondary to a closed head injury. During the assessment, the nurse notices that the client’s respirations follow a cycle progressively increasing in depth, then progressively decreasing in depth, followed by a period of apnea. Which of the following appropriately describes this respiratory pattern? 1. Biot’s breathing 2. Kussmaul’s respirations 3. Sleep apnea 4. Cheyne-Stokes respirations 6. The nurse is providing care to the adult client with mechanically ventilated client who has a tracheostomy. The client has a pulse oximetry reading at 85%, heart rate at 113 beats/min, and respiratory rate at 30 breaths/min. The client has become restless and has labored gurgling respirations. The nurse auscultates bilateral crackles and rhonchi. What is the most appropriate nursing action at this time? 1. Call the respiratory therapist for ventilator assessment. 2. Provide sterile endotracheal suctioning. 3. Provide sterile tracheostomy and stoma care. 4. Notify the physician of the client’s signs of fluid overload. 7. Which of the following best describes the function of type 1 alveolar cells? 1. They add moisture to the inhaled air in the lungs. 2. They open the airway during breathing to allow air to move. 3. They facilitate gas exchange in the lungs. 4. They produce surfactant to lubricate the lungs. 8. The nurse is providing teachings on smoking cessation to an older client with emphysema. The client states, “My doctor wants me to quit smoking. It’s too late now, though; I already have lung problems.” Which of the following would be the best response to his statement? 1. “You should quit so your family does not get sick from exposure to secondhand smoke.” 2. “You will need to use an oxygen tank, but remember it is a fire hazard to smoke with the oxygen tank in your home.” 3. “Once you stop smoking, your body will begin to repair some of the damage to your lungs.” 4. “You should ask your primary care provider for a prescription for a nicotine patch to help you quit.” 9. The nurse is preparing to administer medication to the client with an exacerbation of asthma. Which of the following medications would improve the respiratory function of the client? 1. Opioid 2. Vasodilator 3. Antianxiety medication 4. Bronchodilator

10. When using sterile technique to perform care of a new tracheostomy, which of the following is correct? 1. Cleanse the area with hot soapy water, and rinse well. 2. Place the client in semi-Fowler’s position, if possible. 3. Clean the stoma under the faceplate with hydrogen peroxide. 4. Cut a slit in sterile 4  4 inch gauze halfway through to make a dressing. 11. A client is unable to breathe independently and is now on mechanical ventilation. Which of the following is a correct nursing intervention for maintenance? 1. Keep the head of the bed flat for 6 hours. 2. Avoid using mouth rinses or mouthwashes. 3. Provide the client with a paper and pencil or letter board. 4. Drain condensation into the humidifier when it collects in the tubing. 12. The nurse is administering a purified protein derivative (PPD) test to a nursing student. Which of the following statements concerning PPD testing is true? 1. A positive reaction indicates that the client has active tuberculosis (TB). 2. A positive reaction indicates that the client has been exposed to the disease. 3. A negative reaction always excludes the diagnosis of TB. 4. The PPD can be read within 12 to 24 hours after the injection. 13. A nurse is preparing to obtain a sputum specimen from an adult client. Which of the following nursing actions will facilitate obtaining the specimen? 1. Limiting fluid intake prior to collection 2. Having the client take deep breaths 3. Asking the client to spit into the collection container 4. Asking the client to obtain the specimen after eating 14. A nurse is suctioning a client via an open system tracheostomy tube. When suctioning, the nurse must limit the suctioning time to a maximum of: 1. 5 seconds 2. 15 seconds 3. 30 seconds 4. 45 seconds 15. The nurse is caring for a 6-month-old infant diagnosed with respiratory syncytial virus (RSV) infection. What consideration will most influence the nurse’s plan of care? 1. Infants breathe more rapidly than adults. 2. Infants’ airways are narrower and easily obstructed. 3. Infants’ lower hemoglobin (HgB) levels reduce oxygenation. 4. Infants have larger tonsils and adenoids. 16. The nurse is providing care for a client admitted with a diagnosis of muscular dystrophy resulting in inadequate muscle strength to draw enough air into the lungs. What nursing diagnosis would be most appropriate for this client?

1. 2. 3. 4.

Ineffective Breathing Pattern Ineffective Airway Clearance Impaired Gas Exchange Impaired Spontaneous Ventilation

17. The nurse is planning care for an older adult client newly admitted with a medical diagnosis of pneumonia and a nursing diagnosis of Ineffective Airway Clearance. Which of the following is the nurse’s priority intervention? 1. Teach the importance of pneumonia immunization. 2. Teach coughing and deep breathing exercises. 3. Position the client to optimize maximum ventilation. 4. Encourage the use of incentive spirometer every hour. 18. The nurse is preparing to obtain sputum specimens from several clients. Which of the following clients could the nurse collect a sputum specimen without using a suction catheter? 1. The client with a newly placed tracheostomy 2. The client with an endotracheal tube 3. The client with late-stage amyotrophic lateral sclerosis 4. The client admitted with chronic bronchitis 19. The client was admitted to the intensive care unit (ICU) for respiratory acidosis secondary to smoke inhalation and exposure to caustic gases. After placement of an endotracheal tube and connection to a mechanical ventilator, the arterial blood gas results are pH = 7.28; partial pressure of oxygen (PaO2) = 85; partial pressure of carbon dioxide (PaCO2) = 60. What changes to care does the nurse anticipate? 1. Wean the client from the ventilator. 2. Increase the concentration of oxygen delivered. 3. Decrease the concentration of oxygen delivered. 4. Increase the number of breaths per minute on the ventilator. 20. The nurse is caring for a client diagnosed with pneumonia, teaching him or her how to cough and deep-breathe. The client asks, “Why is drinking fluids so important?” What is the nurse’s best response? 1. “The doctor ordered increased fluid intake.” 2. “Fluids prevent pathogens from growing in your lungs.” 3. “Fluids help to flush infection away so it doesn’t grow in your lungs.” 4. “Fluids make secretions thin, making them easier to cough up.” 21. The nurse admits a client to the surgical unit from the postanesthesia care unit. The client has an oral airway in place and awakens only to painful stimuli. What is the priority nursing action? 1. Remove the oral airway, and elevate the head of the bed. 2. Position the client with the head turned to the side. 3. Measure vital signs, and check surgical dressing. 4. Call the surgeon, and obtain postoperative prescriptions.

22. Which procedure can the nurse safely delegate to the certified nursing assistant who is knowledgeable and experienced in the procedure? 1. Suctioning the newly placed tracheostomy tube 2. Suctioning the endotracheal tube 3. Suctioning the laryngopharynx 4. Suctioning the oropharynx 23. The nurse, working in the postanesthesia care unit inserts an oral airway into the semiconscious client to prevent airway obstruction. When should the airway be removed? 1. When the client can be aroused 2. When the client is 24 hours postoperative 3. When the client removes it 4. When the provider prescribes that it be removed 24. The nurse is caring for a client requiring a mechanical ventilator. When checking the inline thermometer, the nurse finds what temperature acceptable? 1. 78°F 2. 84°F 3. 96°F 4. 105°F 25. The student nurse observes the staff nurse providing care to a client with a chest tube. Which of the nurse’s actions should the student recognize as incorrect and report to the nursing instructor? 1. Recording drainage from chest tube as output 2. Securing the chest tube to the chest tube dressing 3. Checking the water seal chamber for bubbling 4. Milking the chest tube to promote drainage 26. The nurse is caring for a client with a chest tube. What outcome would indicate the chest tube can be discontinued? 1. No further bubbling is seen in the water seal chamber. 2. No further drainage is measured from the chest tube. 3. Chest x-ray shows the lungs are fully inflated. 4. The client’s respirations are regular and unlabored. Multiple Response Identify one or more choices that best complete the statement or answer the question. 27. The nurse is counseling a 17-year-old girl on smoking cessation. The nurse should include which of the following helpful tips in her education? Select all that apply. 1. “Keep healthy snacks or gum available to chew instead of smoking a cigarette.” 2. “Don’t tell anyone that you are trying to quit until you are confident of your success.” 3. “Plan a time to quit when you will not have many other demands or stressors in

your life.” 4. “Reward yourself with an activity you enjoy when you quit smoking.” 5. “Ask your physician for a prescription for smoking cessation medications.” 28. The nurse is assessing the client has a history of chronic obstructive pulmonary disease (COPD). At this time, the client’s pulse oximetry reading is 97%. What other findings would indicate adequate tissue and organ oxygenation? Select all that apply. 1. Normal urine output 2. Strong peripheral pulses 3. Clear breath sounds bilaterally 4. Normal muscle strength 5. Abnormal muscle twitching 29. The nurse is teaching a client about her chest drainage system. Which of the following should the nurse include in the teaching? Select all that apply. 1. Perform frequent coughing and deep-breathing exercises. 2. Sit up in a chair, but do not walk while the drainage system is in place. 3. Get out of bed independently as often as possible. 4. Immediately notify the nurse of any increased shortness of breath. 5. If the tube becomes disconnected, pinch it off, and use your call light to get help. 30. When providing safety education to the mother of a toddler, the nurse would inform the mother that based on the child’s developmental stage, he is at high risk for which of the following factors that influence oxygenation? Select all that apply. 1. Frequent, serious respiratory infections 2. Airway obstruction from aspiration of small objects 3. Drowning in small amounts of water 4. Development of asthma 5. Frequent bouts of tonsillitis 31. Obesity is associated with higher risk for which of the following conditions that affect the pulmonary and cardiovascular systems? Select all that apply. 1. Reduced alveolar–capillary gas exchange 2. Lower respiratory tract infections 3. Sleep apnea 4. Hypertension 5. Arthrosclerosis 32. Which of the following is/are accurate about nasotracheal suctioning? Select all that apply. 1. Apply suction for no longer than 15 sec during a single pass. 2. Apply suction while inserting and removing the catheter. 3. Reapply oxygen between suctioning passes for clients on a ventilator. 4. Gently rotate the suction catheter as you remove it. 5. This may be delegated to an LPN on the unit.

33. Which of the following factors influence normal lung volumes and capacities? Select all that apply. 1. Age 2. Race 3. Body size 4. Activity level 5. Environment 34. Of the following interventions, which of the following may reduce the risk of postoperative atelectasis? Select all that apply. 1. Administer bronchodilators. 2. Apply low-flow oxygen. 3. Encourage coughing and deep breathing. 4. Administer pain medication. 5. Suction the airway prn (as needed). 35. The nurse assesses a client diagnosed with pneumonia. Which data findings indicate that the client is not oxygenating adequately? Select all that apply. 1. Oxygen saturation 87% 2. Arterial blood gas pH 7.33 3. Respiratory rate 52 breaths/min 4. Fine rales in the left lower lobe 5. Cyanosis of the nailbeds and lips 36. The nurse is caring for a client who had experienced an acute asthma event. What classification of medications would the nurse anticipate administering to this client? Select all that apply. 1. Expectorant 2. Corticosteroid 3. Bronchodilator 4. Cough suppressant 5. Antibiotic

Chapter 36. Oxygenation Answer Section MULTIPLE CHOICE 1. ANS: 3 Chapter: Chapter 36 Oxygenation Objective: Identify individual, environmental, and pathological factors that influence oxygenation. Page: 960 (V1) Heading: Developmental Stage > Infants Integrated Processes: Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 This is incorrect. There is no evidence of a correlation between SIDS and welldeveloped lungs. 2 This is incorrect. Premature birth is not a guarantee that the baby will have sleep apnea. 3 This is correct. Premature infants (younger than 33 weeks’ gestation) are born before the alveolar surfactant system is fully developed. Therefore, they are at high risk for RDS. RDS is characterized by widespread atelectasis (collapse of alveoli), usually related to a deficiency of surfactant that keeps air sacs open. 4 This is incorrect. There is a high risk for RDS for premature infants. PTS: 1 CON: Oxygenation 2. ANS: 4 Chapter: Chapter 36 Oxygenation Objective: Safely and correctly perform common nursing procedures related to oxygenation, breathing, and gas exchange. Page: 798 (V2) Heading: Volume 2, Procedure 36-11 Setting Up Disposable Chest Drainage Systems Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Oxygenation Difficulty: Moderate Feedback 1 This is incorrect. Do not clamp the chest tube because this can rapidly lead to a tension pneumothorax. 2 This is incorrect. A new drainage system should be set up to decrease the risk of

3 4

infection, but the immediate action is to place the disconnected end into a bottle of sterile water. This is incorrect. Reconnecting the tube is not the immediate nursing action. This is correct. Recollapse of the lung can occur because of loss of negative pressure within the system. This is commonly caused by air leaks, disconnections, or cracks in the bottles or chambers. If any of these occur, the nurse should immediately place the disconnected end nearest the client into a bottle of sterile water or saline to a depth of 2 cm to serve as an emergency water seal until a new system can be connected.

PTS: 1 CON: Oxygenation 3. ANS: 3 Chapter: Chapter 36 Oxygenation Objective: Recognize medications used to enhance pulmonary function. Page: 964 (V1) Heading: Table 36-1 Respiratory Medications that Promote Ventilation and Oxygenation Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Oxygenation Difficulty: Difficult Feedback 1 This is incorrect. Antitussives are cough suppressants that reduce the frequency of an involuntary, dry, nonproductive cough. The goal is to reduce the coughing but make voluntary coughing more productive. 2 This is incorrect. Although antitussives are useful for adults when coughing is unproductive and frequent and leads to throat irritation or interrupted sleep. This is not the purpose of the combined medication. 3 This is correct. The goal of an antitussive/expectorant combination is to reduce the frequency of dry, unproductive coughing while making voluntary coughing more productive. 4 This is incorrect. Although expectorants help make coughing more productive, the client may need an antitussive to reduce the frequency of the dry nonproductive cough. PTS: 1 CON: Oxygenation 4. ANS: 2 Chapter: Chapter 36 Oxygenation Objective: Assess oxygenation, breathing, and gas exchange. Page: 973 (V1) Heading: Assessment: For Someone in Obvious Respiratory Distress Integrated Processes: Nursing Process

Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 This is incorrect. Following a quick assessment, the nurse should then review and implement physician’s orders. Administering oxygen is not appropriate without knowing what treatments the primary care provider has prescribed. 2 This is correct. The first action the nurse should take is to make a quick assessment of the adequacy of breathing, circulation, and oxygenation to determine the type of immediate intervention required. The nurse’s assessment should include simple questions about current symptoms. 3 This is incorrect. A more thorough medical history can be gathered once the client’s oxygenation needs are addressed. 4 This is incorrect. Following a quick assessment, the nurse should then review and implement physician’s orders. Administering oxygen is not appropriate without knowing what treatments the primary care provider has prescribed. PTS: 1 CON: Oxygenation 5. ANS: 4 Chapter: Chapter 36 Oxygenation Objective: Assess oxygenation, breathing, and gas exchange. Page: 973 (V1) Heading: Assessing Breathing Patterns Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Easy Feedback 1 This is incorrect. Biot’s breathing is irregular respirations of variable depth (usually shallow), alternating with periods of apnea. This pattern is often associated with damage to the medullary respiratory center or high intracranial pressure as a result of brain injury. 2 This is incorrect. Kussmaul’s respirations are regular but increased in rate and abnormally deep respirations. These may be a compensatory mechanism for metabolic disorders that lower blood pH, as well as a form of hyperventilation caused by fear, anxiety, or panic. 3 This is incorrect. Sleep apnea is intermittent absence of breathing, characterized with snoring respirations. 4 This is correct. This respiratory pattern is known as Cheyne-Stokes respirations. It is often associated with damage to the medullary respiratory center or high

intracranial pressure due to brain injury. PTS: 1 CON: Oxygenation 6. ANS: 2 Chapter: Chapter 36 Oxygenation Objective: Safely and correctly perform common nursing procedures related to oxygenation, breathing, and gas exchange. Page: 984 (V1) Heading: Transtracheal Oxygen Delivery > Transtracheal Oxygen Delivery Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 This is incorrect. There is no indication that the ventilator is not set properly. 2 This is correct. Increased pulse and respiratory rates, decreased oxygen saturation, gurgling sounds during respiration, auscultation of adventitious breath sounds, and restlessness are signs that indicate the need for suctioning. Airways are suctioned to remove secretions and maintain patency. The client’s symptoms should subside once the airway is cleared. 3 This is incorrect. There is no indication for tracheostomy and stoma care at this time. The symptoms indicate and issue with airway clearance, not a stoma issue. 4 This is incorrect. The symptoms do not indicate fluid overload at this time. Although it is appropriate to notify the physician of the client’s status, it is imperative that the airway be cleared first. PTS: 1 CON: Oxygenation 7. ANS: 3 Chapter: Chapter 36 Oxygenation Objective: Describe the structure and function of the respirator system. Page: 957 (V1) Heading: The Pulmonary System: The Lungs Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Knowledge [Remembering] Concept: Oxygenation Difficulty: Moderate Feedback 1 This is incorrect. The airway adds moisture to the inhaled air. 2 This is incorrect. The epiglottis is a flap that prevents aspiration of foreign objects into the lungs and opens to allow air into the lungs.

3 4

This is correct. Type 1 alveolar cells within the lungs are the gas exchange cells. This is incorrect. Type 2 alveolar cells produce surfactant, a lipoprotein that lowers the surface tension within alveoli to allow them to inflate during breathing.

PTS: 1 CON: Oxygenation 8. ANS: 3 Chapter: Chapter 36 Oxygenation Objective: Identify individual, environmental, and pathological factors that influence oxygenation. Page: 964 (V1) Heading: BOX 36-1 Benefits of Smoking Cessation Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 This is incorrect. The suggestion that the client’s family will become ill appears to be a scare tactic, which can be seen as coercive and would not be effective in motivating the client to stop smoking. 2 This is incorrect. The suggestion and that use of the oxygen tank is a fire hazard appear to be scare tactic, which can be seen as coercive, and would not be effective in motivating the client to stop smoking. 3 This is correct. The nurse’s response should focus on correcting the client’s misinformation rather than on convincing him to stop smoking. Once a person stops smoking, the body begins to repair the damage. During the first few days, the person will cough more as the cilia begin to clear the airways. Then, the coughing subsides and breathing becomes easier. Even long-time smokers can benefit from smoking cessation. 4 This is incorrect. Although asking the primary care provider for a prescription may help the client to stop smoking, it does not address his incorrect belief that it is “too late” for him to do so. PTS: 1 CON: Oxygenation 9. ANS: 4 Chapter: Chapter 36 Oxygenation Objective: Recognize the medications used to enhance pulmonary function. Page: 960 (V1) Heading: What External Factors Influence Pulmonary Function? > Medications Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies. Cognitive Level: Analysis [Analyzing]

Concept: Safety Difficulty: Moderate

1 2

3 4

Feedback This is incorrect. Opioids are potent respiratory depressants. Clients receiving opioids should be monitored for decreased rate and depth of respirations. This is incorrect. Drugs that block beta-2 adrenergic receptors (e.g., used to lower the blood pressure) have little effect on healthy lungs but can lead to serious bronchiole constriction in people with asthma. This is incorrect. Antianxiety medications, such as valium, can depress the respiratory function. This is correct. Bronchodilators, such as theophylline, can enhance the breathing of an asthmatic client.

PTS: 1 CON: Safety 10. ANS: 2 Chapter: Chapter 36 Oxygenation Objective: Safely and correctly perform common nursing procedures related to oxygenation, breathing, and gas exchange. Page: 987 (V1) Heading: Managing Endotracheal and Tracheostomy Tubes & Procedure 36-5 Performing Tracheostomy Care Using Modified Sterile Technique Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Application [Applying] Concept: Oxygenation Difficulty: Easy

1 2 3 4

Feedback This is incorrect. Hot soapy tap water may contain contaminates and contaminate the tracheostomy. This is correct. Semi-Fowler’s position promotes lung expansion and prevents back strain in the nurse. This is incorrect. The stoma should be cleansed with sterile saline to prevent contamination. This is incorrect. Never cut a 4  4 inch gauze for the dressing because lint and fibers from the cut edge could enter the trachea and cause respiratory distress.

PTS: 1 CON: Oxygenation 11. ANS: 3 Chapter: Chapter 36 Oxygenation

Objective: Safely and correctly perform common nursing procedures related to oxygenation, breathing, and gas exchange. Page: 987 (V1) Heading: Caring for a Patient Requiring Mechanical Ventilation Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Application [Applying] Concept: Oxygenation Difficulty: Difficult

Feedback This is incorrect. Maintain client in semi-recumbent position (head of bed elevated 30 to 45 degrees). This is extremely important to promote lung expansion, reduce gastric reflux, and prevent ventilator-associated pneumonia (VAP). Clients being mechanically ventilated are at high risk for developing VAP, which is associated with high mortality rates. This is incorrect. Mouth rinses and mouthwashes are part of the recommended routine for preventing VAP. They also provide comfort and preserve the integrity of the mucous membranes. This is correct. The client being mechanically ventilated is unable to speak. This can produce extreme anxiety. An alternative method of communication must be used so the client can express her needs and concerns. This is incorrect. This nurse should check the ventilator tubing frequently for condensation. Drain the fluid into a collection device or waste receptacle because condensation in the ventilator tubing can cause resistance to airflow. Moreover, the client can aspirate it if it backflows down into the endotracheal tube. The fluid should not be drained into the humidifier because the client’s secretions may have contaminated it.

PTS: 1 CON: Oxygenation 12. ANS: 2 Chapter: Chapter 36 Oxygenation Objective: Interpret diagnostic testing related to oxygenation, breathing, and gas exchange. Page: 976 (V1) Heading: Diagnostic Testing > Skin Testing Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Moderate Feedback 1 This is incorrect. A positive reaction means the client has been exposed to TB; it

2 3 4

isn’t conclusive of the presence of active disease. A positive reaction consists of palpable swelling and induration of 5 to 15 mm. This is correct. A positive reaction means the client has been exposed to TB. This is incorrect. In immunosuppressed clients, a negative reaction doesn’t exclude the presence of active disease. This is incorrect. The test can be read 48 to 72 hours after the injection.

PTS: 1 CON: Oxygenation 13. ANS: 2 Chapter: Chapter 36 Oxygenation Objective: Interpret diagnostic testing related to oxygenation, breathing, and gas exchange. Page: 975 (V1) Heading: Obtaining Sputum Samples Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 This is incorrect. Sputum can be thinned by fluids or by a respiratory treatment such as inhalation of nebulized saline or water. 2 This is correct. To obtain a sputum specimen, the client should rinse his mouth to reduce contamination, breathe deeply for three or four breaths, hold his breath, and then cough into a sputum specimen container. 3 This is incorrect. The client should be encouraged to cough and not spit in order to obtain sputum. 4 This is incorrect. A specimen should be obtained 1 to 2 hours after eating to prevent vomiting and aspiration risk. PTS: 1 CON: Oxygenation 14. ANS: 2 Chapter: Chapter 36 Oxygenation Objective: Safely and correctly perform common nursing procedures related to oxygenation, breathing, and gas exchange. Page: 786 (V1) Heading: Procedure 36-6: Performing Tracheostomy Suctioning (Open System) Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback

1 2

3 4

This is incorrect. This would not facilitate adequate suctioning of the tracheostomy. This is correct. Hypoxemia and tissue trauma can be caused by prolonged suctioning. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to no longer than 15 seconds. This is incorrect. This may cause hypoxemia and tissue trauma with prolonged suctioning. This is incorrect. Hypoxemia and tissue trauma can be caused by prolonged suctioning. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to no longer than 15 seconds.

PTS: 1 CON: Oxygenation 15. ANS: 2 Chapter: Chapter 36 Oxygenation Objective: Evaluate adequacy of oxygenation, breathing, and gas exchange, and modify nursing activities appropriately based on outcomes. Page: 960 (V1) Heading: What External Factors Influence Pulmonary Function? > What Pathophysiological Conditions Alter Gas Exchange? > Infections of the Lower Airways Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Oxygenation Difficulty: Difficult Feedback 1 This is incorrect. Although infants do breathe more rapidly than adults, this consideration will not influence the plan of care for this client. 2 This is correct. The narrower airways mean that the copious secretions caused by the infection could result in airway obstruction, so the plan of care must include mobilizing secretions to maintain a clear airway to allow for adequate oxygenation. 3 This is incorrect. Infants’ HgB levels are not lower than those of adults, so this is not a true statement. 4 This is incorrect. Toddlers, not infants, have enlarged tonsils and adenoids. PTS: 1 CON: Oxygenation 16. ANS: 4 Chapter: Chapter 36 Oxygenation Objective: Develop nursing diagnoses related to oxygenation, breathing, and gas exchange. Page: 978 (V1) Heading: Analysis/Nursing Diagnosis > Problems of Ventilation and Gas Exchange Integrated Processes: Nursing Process

Client Need: Physiological Integrity Cognitive Level: Analysis [Analyzing] Concept: Oxygenation Difficulty: Moderate Feedback 1 This is incorrect. This client’s breathing is altered but does not fit this diagnosis because respiratory rate is unknown, so it is impossible to know what pattern of breathing is occurring based on the information given. 2 This is incorrect. There is no indication of an obstructed airway or increased secretions that would measure ability to clear airway. 3 This is incorrect. There is no indication in the question regarding the client’s gas exchange, so this is not the best choice, even though it would be easy to read into the question and suspect hypoxia. 4 This is correct. The best diagnosis for this client is Impaired Spontaneous Ventilation because without external support, this client’s muscle strength is inadequate to maintain breathing adequate to support life. PTS: 1 CON: Oxygenation 17. ANS: 3 Chapter: Chapter 36 Oxygenation Objective: Develop nursing diagnoses related to oxygenation, breathing, and gas exchange. Page: 978 (V1) Heading: Planning Interventions/Implementation > Position for Maximum Ventilation Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 This is incorrect. Although teaching the client the importance of receiving immunizations is important, it is not the priority with a newly admitted client. 2 This is incorrect. Teaching coughing and deep breathing exercises is high on the priority list, but it is not the top priority. 3 This is correct. The highest priority is to optimize ventilation as soon as the client is admitted. Only when the client is adequately oxygenating can other interventions be addressed. 4 This is incorrect. Use of an incentive spirometer will promote deep breathing, which will help to mobilize secretions, but it is not the top priority intervention at this time. PTS: 1 18. ANS: 4

CON: Oxygenation

Chapter: Chapter 36 Oxygenation Objective: Safely and correctly perform common nursing procedures related to oxygenation, breathing, and gas exchange. Page: 765 (V2) Heading: Highlights of Procedures 36-1 Through 36-13 Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Analysis [Analyzing] Concept: Oxygenation Difficulty: Easy Feedback 1 This is incorrect. The client with a newly placed tracheostomy will need help clearing the airway and can provide a sputum specimen only by having the airway suctioned. 2 This is incorrect. A client with an endotracheal tube in place can contribute a sputum specimen only with the assistance of suctioning. 3 This is incorrect. A client in the later stages of a muscle-wasting disease would not have the strength to expectorate a sputum specimen and would require suctioning. 4 This is correct. The client with a chronic cough, if there are no other considerations, would be able to expectorate a sputum specimen and would not require suctioning. PTS: 1 CON: Oxygenation 19. ANS: 4 Chapter: Chapter 36 Oxygenation Objective: Interpret diagnostic testing related to oxygenation, breathing, and gas exchange. Page: 977 (V1) Heading: Diagnostic Testing > Arterial Blood Gases Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Analysis [Analyzing] Concept: Oxygenation Difficulty: Difficult Feedback 1 This is incorrect. The client is still in a state of respiratory acidosis and is not ready for extubation and weaning from the ventilator. 2 This is incorrect. The PaO2 is adequate, so there is no need to increase the delivered oxygen concentration. 3 This is incorrect. The PaO2 is adequate, so there is no need to decrease the delivered oxygen concentration. 4 This is correct. Increasing the number of breaths per minute provided by the

mechanical ventilator will help the client to blow off more carbon dioxide, which will result in an improved pH. PTS: 1 CON: Oxygenation 20. ANS: 4 Chapter: Chapter 36 Oxygenation Objective: Plan outcomes and interventions for maintaining and improving oxygenation. Page: 982 (V1) Heading: Planning Interventions/Implementation > Maintain Hydration Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Easy Feedback 1 This is incorrect. Although the doctor may have prescribed increased fluid intake, this does not explain why it is important. 2 This is incorrect. Fluids do not prevent the growth of pathogens. 3 This is incorrect. Fluids do not flush out the lungs because they do not, normally, enter the lungs. 4 This is correct. Fluids help to thin secretions and keep them from becoming thick and glue-like, which would be much harder to mobilize. Thin secretions will reduce the effort required by the client to cough mucus into the larger airways and expectorate it. PTS: 1 CON: Health Promotion 21. ANS: 2 Chapter: Chapter 36 Oxygenation Objective: Evaluate adequacy of oxygenation, breathing, and gas exchange, and modify nursing activities appropriately based on outcomes. Page: 981 (V1) Heading: Promoting Optimal Respiratory Function > Position for Maximum Ventilation Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 This is incorrect. The oral airway should not be removed until the client is more awake, and elevating the head of the bed is not appropriate until the client is more responsive. 2 This is correct. The most important priority is to position the client with the head

3 4

turned to the side to prevent aspiration of secretions or emesis if the client should vomit. This is incorrect. Vital signs and dressing checks are important but not the highest priority. This is incorrect. Postsurgical prescriptions are written when the client is in postanesthesia care and come to the floor with the client.

PTS: 1 CON: Oxygenation 22. ANS: 4 Chapter: Chapter 36 Oxygenation Objective: Safely and correctly perform common nursing procedures related to oxygenation, breathing, and gas exchange. Page: 985 (V1) Heading: Suctioning Airways > Collaborating and Delegating Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Analysis [Analyzing] Concept: Professionalism Difficulty: Easy Feedback 1 This is incorrect. Suctioning a new tracheostomy requires sterile technique, which cannot be delegated to a certified nursing assistant (CNA). 2 This is incorrect. Suctioning an endotracheal tube requires sterile technique, which cannot be delegated to a CNA. 3 This is incorrect. Deep (laryngopharyngeal) suctioning requires a nurse, owing to the risk of the procedure and complexity of care. 4 This is correct. The CNA would be capable of performing oral suctioning or assisting a client to suction his own mouth. PTS: 1 CON: Professionalism 23. ANS: 3 Chapter: Chapter 36 Oxygenation Objective: Evaluate adequacy of oxygenation, breathing, and gas exchange, and modify nursing activities appropriately based on outcomes. Page: 987 (V1) Heading: Orotracheal or Nasotracheal (NT) Approach Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback

1 2 3 4

This is incorrect. A semiconscious client can be aroused but is not awake enough to have the airway removed. This is incorrect. Maintaining an airway in place for 24 hours would cause trauma to the airway and is longer than the client will need this to be in place. This is correct. When the client is awake enough to find the airway annoying, the client will remove it, and that will be the safest time. This is incorrect. If the provider were to write a prescription specifying when to remove the airway, it would be based on the client’s level of alertness.

PTS: 1 CON: Oxygenation 24. ANS: 3 Chapter: Chapter 36 Oxygenation Objective: Safely and correctly perform common nursing procedures related to oxygenation, breathing, and gas exchange. Page: 795 (V2) Heading: Procedure 36-10 Caring for Patients Requiring Mechanical Ventilation Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment Cognitive Level: Application [Applying] Concept: Thermoregulation Difficulty: Easy Feedback 1 This is incorrect. A temperature of 78°F would be too cold and could result in hypothermia. 2 This is incorrect. A temperature of 84°F is too cold and could result in hypothermia. 3 This is correct. The temperature should be near body temperature, so 96°F would be acceptable. 4 This is incorrect. A temperature of 105°F is too high and could cause damage to the respiratory tract. PTS: 1 CON: Thermo-regulation 25. ANS: 4 Chapter: Chapter 36 Oxygenation Objective: Safely and correctly perform common nursing procedures related to oxygenation, breathing, and gas exchange. Page: 988 (V1) Heading: Caring for a Patient Requiring Chest Tubes Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment Cognitive Level: Understanding Concept: Oxygenation

Difficulty: Difficult Feedback 1 This is incorrect. Recording drainage from the chest tube as output would be an appropriate nursing action. 2 This is incorrect. Securing the chest tube to the chest tube dressing helps to prevent dislocation or removal of the chest tube and is an appropriate nursing action. 3 This is incorrect. A lack of bubbling in the water seal chamber indicates air is no longer being evacuated, so it is an appropriate nursing assessment. 4 This is correct. Milking the chest tube, or squeezing it from the client to the drainage collection device, is not an evidence-based practice and should not be done. Seeing a nurse doing this would indicate the need for corrective action, which should not be provided by a student. PTS: 1 CON: Oxygenation 26. ANS: 1 Chapter: Chapter 36 Oxygenation Objective: Evaluate adequacy of oxygenation, breathing, and gas exchange, and modify nursing activities appropriately based on outcomes. Page: 988 (V1) Heading: Caring for a Patient Requiring Chest Tubes Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Analysis [Analyzing] Concept: Oxygenation Difficulty: Difficult Feedback 1 This is correct. When the pleural space is free of air, and there is no longer air leaking into the pleural space, bubbling in the water seal chamber will stop, indicating the chest tube can be discontinued. 2 This is incorrect. It is expected that the largest quantity of drainage will occur when the chest tube is first placed. Although reduced drainage is a positive sign, this is not an adequate sign to discontinue the chest tube. 3 This is incorrect. Chest x-rays will often reflect a fully inflated lung shortly after the chest tube is placed, indicating the chest tube is doing its job. Premature discontinuation will cause the affected lung to collapse again. 4 This is incorrect. Respirations should ease as soon as the chest tube is placed, and this is not an indication the chest tube can be removed. PTS:

MULTIPLE RESPONSE

CON: Oxygenation

27. ANS: 1 Chapter: Chapter 36 Oxygenation Objective: Plan outcomes and interventions for maintaining and improving oxygenation. Page: 980 (V1) Heading: Support Smoking Cessation Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Health Promotion Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is correct. Having something to chew (e.g., carrot sticks, gum, nuts, or seeds) can distract from the desire to smoke a cigarette. This is incorrect. People who are trying to quit smoking often are more successful when they are accountable to other people who are encouraging and supportive. This is correct. Setting a date to stop smoking and choosing a time of low stress are two strategies that help people be more successful with smoking cessation. This is correct. Self-reward for meeting goals is a form of positive reinforcement. This is incorrect. If the above-mentioned interventions do not work, then the client might consider a medication.

PTS: 1 CON: Health Promotion 28. ANS: 1 Chapter: Chapter 36 Oxygenation Objective: Assess oxygenation, breathing, and gas exchange. Page: 964 (V1) Heading: Hypoxia—Inadequate Oxygenation of Organs and Tissues Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Difficult

1. 2.

Feedback This is correct. Impaired tissue oxygenation to the kidneys would result in abnormal kidney function (e.g., poor urine output). This is correct. To determine adequacy of tissue oxygenation, the nurse should assess respiration, circulation, and tissue/organ function. Good peripheral circulation is characterized by strong peripheral pulses. This is incorrect. Adequacy of tissue oxygenation cannot be determined by assessing

4. 5.

pulmonary ventilation alone; circulation must also be assessed. This is correct. Hypoxic limb tissue would result in abnormal muscle functioning (e.g., muscle weakness and pain with exercise). This is incorrect. This is an indication of hypocarbia (hypocapnia)—a low level of dissolved carbon dioxide in blood—not oxygenation.

PTS: 1 CON: Oxygenation 29. ANS: 1 Chapter: Chapter 36 Oxygenation Objective: Plan outcomes and interventions for maintaining and improving oxygenation. Page: 988 (V1) Heading: Clinical Insight 37-5: Managing Chest Tubes Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Health Promotion Difficulty: Moderate

1. 2.

Feedback This is correct. Clients should regularly perform coughing and deep-breathing exercises to promote lung re-expansion. This is incorrect. The nurse should also encourage the client to be as active as her condition permits, rather than telling her not to walk. Chest drainage systems are bulky, but clients with disposable systems can still get out of bed and ambulate. This is incorrect. However, the client will need assistance from one or two staff members to protect and monitor the system and to monitor her responses to activity; she should not get out of bed on her own. This is correct. If a client with a chest drainage system becomes acutely short of breath, the client should immediately notify the nurse so that the nurse can check for occlusion of the system, which can result in a tension pneumothorax. This is incorrect. Although the client must get immediate help, the client should not “pinch it off” as it may cause a pneumothorax.

PTS: 1 CON: Health Promotion 30. ANS: 2 Chapter: Chapter 36 Oxygenation Objective: Identify individual, environmental, and pathological factors that influence oxygenation. Page: 960 (V1) Heading: What External Factors Influence Pulmonary Function? > Development > Toddlers Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding]

Concept: Growth and Development Difficulty: Moderate

3. 4. 5.

Feedback This is incorrect. As a toddler’s respiratory and immune systems mature, the risk for frequent and serious infections is less than it is in infancy. Most children recover from upper respiratory infections without difficulty. This is correct. Toddlers’ airways are relatively short and small and may be easily obstructed, and they often put objects in their mouth as part of exploring their environment, thus increasing their risk for aspiration and airway obstruction. This is correct. In addition, toddlers are at high risk for drowning in very small amounts of water around the home (e.g., in a bucket of water or toilet bowl). This is incorrect. The risk for developing asthma is not significantly influenced by the child’s developmental stage. This is correct. The tonsils and adenoids are relatively large, predisposing to tonsillitis.

PTS: 1 CON: Growth and Development 31. ANS: 2 Chapter: Chapter 36 Oxygenation Objective: Identify individual, environmental, and pathological factors that influence oxygenation. Page: 960 (V1) Heading: What External Factors Influence Pulmonary Function? > Obesity Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Health Promotion Difficulty: Easy

1. 2.

4. 5.

Feedback This is incorrect. Obesity does not cause reduced alveolar–capillary gas exchange. This is correct. Obesity causes multiple health problems, many of which affect the lungs, heart, and circulation. Large abdominal fat stores press upward on the diaphragm, preventing full chest expansion and leading to hypoventilation and dyspnea on exertion. The risk for respiratory infection increases because lower lung segments are poorly ventilated, and secretions are not removed effectively. This is correct. When an obese person lies down, chest expansion is limited even more. Excess neck girth and fat stores in the upper airway often lead to obstructive sleep apnea. This is correct. Obesity also increases the risk of developing hypertension. This is correct. Obesity increases the risk of developing atherosclerosis.

PTS: 1 CON: Health Promotion 32. ANS: 1 Chapter: Chapter 36 Oxygenation Objective: Recognize the medications used to enhance pulmonary function. Page: 788 (V2) Heading: Procedure 36-7 Performing Tracheostomy or Endotracheal Suctioning (In-line Closed System) Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Oxygenation Difficulty: Moderate

1. 2. 3.

4. 5.

Feedback This is correct. Limiting suctioning to 15 seconds or less and reapplying oxygen between suctioning passes prevent hypoxia. This is incorrect. Suction should be applied only while withdrawing the catheter. This is incorrect. Endotracheal suctioning is used when the client is being mechanically ventilated, and most ventilator clients have in-line suctioning, so there is no need to reapply oxygen. This is correct. Suction should be applied only while withdrawing the catheter by using a continuous rotating motion to prevent trauma to the airway. This is incorrect. As a rule, an RN should not delegate tracheostomy or endotracheal suctioning to an LPN or UAP, because both procedures require professional-level theoretical knowledge, assessment skills, and problem-solving ability. Refer to the individual state board of nursing for rules on delegating this procedure.

PTS: 1 CON: Oxygenation 33. ANS: 1 Chapter: Chapter 36 Oxygenation Objective: Describe the structure and function of the respirator system. Page: 960 (V1) Heading: What External Factors Influence Pulmonary Function? Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Health Promotion Difficulty: Easy

1. 2.

Feedback This is correct. Normal lung volumes and capacities vary with age. This is incorrect. Race does not influence normal lung volumes and capacities.

3. 4. 5.

This is correct. Volumes and capacities are higher in men, in large people, and in athletes. This is correct. Normal lung volumes and capacities vary with exercise level. Volumes and capacities are higher in athletes. This is incorrect. Although environmental factors such as altitude, air quality, and stress can affect oxygenation, it does not correlate with lung volumes and capacities.

PTS: 1 CON: Health Promotion 34. ANS: 3 Chapter: Chapter 36 Oxygenation Objective: Identify individual, environmental, and pathological factors that influence oxygenation. Page: 973 (V1) Heading: Assessment > Assessing for Risk Factors Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Synthesis [Creating] Concept: Oxygenation Difficulty: Moderate

1. 2. 3. 4.

Feedback This is incorrect. There is no indication for a need of a bronchodilator for the postoperative client, and it will not reduce the risk for atelectasis. This is incorrect. This will increase oxygenation but will not reduce the risk for postoperative atelectasis. This is correct. By encouraging the client to cough and breathe deeply, this will help to open air sacs and mobilize secretions in the airways. This is correct. Pain alters the rate and depth of respirations. Often, clients in pain breathe shallowly, which puts them at risk for atelectasis. Regularly assess all clients for pain. This is incorrect. There is no indication for a need to suction, and it will not prevent atelectasis.

PTS: 1 CON: Oxygenation 35. ANS: 1 Chapter: Chapter 36 Oxygenation Objective: Interpret diagnostic testing related to oxygenation, breathing, and gas exchange. Page: 973 (V1) Heading: Assessment > Physical Examination Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Analysis [Analyzing] Concept: Oxygenation

Difficulty: Difficult

1. 2.

3. 4. 5.

Feedback This is correct. An oxygen saturation of 87% is below the accepted range and indicates inadequate oxygenation. This is incorrect. A pH of 7.33 indicates acidosis, but further information is needed to determine whether the cause is respiratory or metabolic. A respiratory acidosis indicates poor gas exchange, but oxygenation may be adequate with inadequate carbon dioxide exchange. This is correct. A respiratory rate of 52 breaths/min does not allow adequate time for gas exchange and would contribute to a finding of inadequate oxygenation. This is incorrect. Fine rales indicate an altered airway, but this finding alone is not adequate for indicating lack of oxygenation. This is correct. Cyanosis is caused by lack of oxygen to the tissues and is a good indicator of inadequate oxygenation.

PTS: 1 CON: Oxygenation 36. ANS: 2 Chapter: Chapter 36 Oxygenation Objective: Recognize medications used to enhance pulmonary function. Page: 960 (V1) Heading: What External Factors Influence Pulmonary Function? > Asthma Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Oxygenation Difficulty: Difficult

1. 2. 3.

Feedback This is incorrect. Expectorants help to mobilize secretions and would not be an anticipated classification of medication to be administered to this client. This is correct. Corticosteroids reduce inflammation of tissues in the airway and are often administered during acute asthma events. This is correct. Bronchodilators help to expand airways and are usually a primary classification of medication administered to clients experiencing an acute asthma event. This is incorrect. Cough suppressants help to reduce the cough reflex and would not be appropriate to administer to a client experiencing an acute asthma event because it does not treat the cause of the problem. This is incorrect. Use of antibiotics would not be anticipated unless the event was triggered by a bacterial event. Because most asthma attacks are not the result of bacterial infections, this would be an unlikely medication classification to be

administered. PTS:

CON: Oxygenation

Chapter 37. Circulation & Perfusion Multiple Choice Identify the choice that best completes the statement or answers the question. 1. A client diagnosed with hypertension is taking an angiotensin-converting enzyme (ACE) inhibitor. When planning care, which of the following outcomes would be appropriate for the client? 1. Blood pressure (BP) will be lower than 135/85 mm Hg on all occasions. 2. BP will be normal after 2 to 3 weeks on medication. 3. Client will not experience dizziness on rising. 4. Urine output will increase to at least 50 mL/hr. 2. The nurse is preparing the nursing care plan for a middle-aged client admitted to the intensive care unit for acute myocardial infarction. The client’s symptoms include tachycardia, palpitations, anxiety, jugular vein distention, and fatigue. Which of the following nursing diagnoses is most appropriate? 1. Decreased Cardiac Output 2. Impaired Tissue Perfusion 3. Impaired Cardiac Contractility 4. Impaired Activity Tolerance 3. The nurse is assessing a client and asks if they have any chronic stress. The client wants to know how chronic stress affects the body. The nurse responds that when the body is under stress, it releases a chemical that increases the heart rate and the tendency of the blood to clot. Which of the following chemicals is the nurse discussing? 1. Histamine 2. Catecholamines 3. Cortisol 4. Protease 4. The nurse is teaching a pregnant woman about the increased oxygen demand that develops during pregnancy. The nurse knows the client comprehends the teaching when she makes the following statement: 1. “I may need to drink more fluids to make more oxygen.” 2. “I may need to take an iron supplement so that I am not anemic.” 3. “I will need a multivitamin supplement for several months.” 4. “I will need to eat more fruits and vegetables.” 5. The nurse is providing care to the client who is 3 days status post cardiac bypass grafting. The client has incisions to his right leg from the graft harvest of the veins. The client complains of warmth and tenderness to their right calf. The nurse notes a 3-cm periwound, with erythema and swelling at the distal end of the incision. Staples are intact along the incision, and there is no drainage. Vital signs are stable. The nurse would suspect that the client has what kind of complication?

1. 2. 3. 4.

Deep vein thrombosis (DVT) Dehiscence of the wound Internal bleeding Infection at the incisional site

6. A nurse is performing CPR on an infant. When performing chest compressions, the nurse understands that the compression rate should be at least: 1. 60 times a minute 2. 80 times a minute 3. 100 times a minute 4. 120 times a minute 7. A client with heart failure has BP 120/60 mm Hg, heart rate (HR) 64 beats/min, respiratory rate (RR) 18 breaths/min, temperature (T) 97.6°F, coarse crackles bilaterally, and 3+ edema to the lower extremities. An appropriate nursing diagnosis for this client is: 1. Impaired Gas Exchange 2. Excess Fluid Volume 3. Ineffective Tissue Perfusion 4. Deficient Knowledge 8. The client diagnosed with inadequate closure of the mitral valve is scheduled for surgery and asks the nurse, “Why does it matter if my valve leaks?” What is the nurse’s best response to explain why this mitral valve needs to be repaired? 1. “Blood backflows from the left ventricle to the left atrium, reducing available blood flowing to the body.” 2. “Blood backflows from the right ventricle to the right atrium, reducing available blood flow to the lungs.” 3. “Blood backflows from the aorta into the left ventricle, reducing blood pressure and causing dizziness.” 4. “Blood backflows from the pulmonary artery into the right ventricle, reducing blood flow to the lungs.” 9. The nurse is providing teaching for a weight loss group on the cardiac dangers of obesity. Which statement, if made by the nurse, would be incorrect? 1. “Obesity increases the risk of atherosclerosis.” 2. “Obesity increases the risk of hypertension.” 3. “Obesity can reduce pumping action of the heart.” 4. “Obesity can diminish tissue perfusion.” 10. The nurse is assessing a client who is complaining of chest pain, clutching his chest, and short of breath. Which assessment question would be appropriate for the nurse to ask? 1. “Please describe your pain, its location, and what you’ve done to treat it.” 2. “Does the pain radiate to your arm, jaw, or shoulder?” 3. “What are your current medications, including supplements or vitamins?” 4. “What is your medical history, beginning with most recent?”

11. The nurse is assessing an adult client diagnosed with chronic heart failure 10 years ago. Which finding would indicate poor perfusion to the tissues? 1. Blood pressure reading of 102/64 mm Hg 2. Absence of hair on the lower legs and feet 3. Pulse rate of 104 beats/min 4. Shortness of breath when supine 12. The nurse is reviewing the results of the client’s laboratory findings and notes an elevated Creactive protein (CRP) level. What does this indicate? 1. The client had a myocardial infarction. 2. The client has inflammation in the body. 3. The client has reduced cardiac output. 4. The client’s diet is high in cholesterol. 13. The nurse analyzes the client’s electrocardiogram (ECG) and compares it with a baseline ECG recorded before the client began having chest pain. What finding indicates a problem with the ventricle? 1. Prolonged QRS segment 2. Elevated P wave 3. Absence of T wave 4. Prolonged P-R interval 14. The nurse administers a beta-adrenergic agent to a client with congestive heart failure. What assessment findings would indicate that the drug is working? 1. Heart rate changes from 92 beats/min to 76 beats/min. 2. Cardiac monitor shows narrowing of the QRS segment. 3. Statements of tingling in the fingers and toes. 4. Urine output has increased to equal input. 15. The nurse is providing care to the client who complains of chest pains after a large meal and after strenuous exercise. What is the most appropriate nursing intervention with this client’s pain? 1. Immediately administer a vasodilator at the onset of the chest pain. 2. Have the client recognize triggers and keep a log of any symptoms. 3. Obtain CRP and a venogram to rule out myocardial infarction. 4. Prepare the client for emergency cardiac catheterization. 16. For which client might the nurse use the nursing diagnosis Risk for Ineffective Renal Tissue Perfusion? 1. The client with hypertension who is noncompliant with medication administration 2. The client with angina who takes nitroglycerine when experiencing chest pain 3. The client diagnosed with pneumonia, becoming short of breath with activity 4. The client with a hemorrhagic stroke secondary to head trauma

17. The nurse is planning care for an elderly client diagnosed with end-stage heart failure and a nursing diagnosis of Decreased Cardiac Output secondary to ineffective left ventricular function. What outcome would the nurse plan for this client to measure improvement in cardiac output? 1. Brisk capillary refill in feet bilaterally 2. Heart rate within expected range 3. Breath sounds clear with no shortness of breath 4. Regular pulse rhythm 18. The nurse administers sublingual nitroglycerine to a client diagnosed with angina. When the client’s chest pain is not relieved, the nurse prepares to give another nitroglycerine tablet. What is the nurse’s priority action prior to administering the next dose of medication? 1. Notify the physician. 2. Elevate the head of the bed. 3. Measure the client’s blood pressure. 4. Place the client on a cardiorespiratory monitor. 19. The nurse is caring for a client with reduced perfusion to the extremities. The nurse evaluates the client and finds the response to therapy is not optimal. What lifestyle change does the nurse suspect is contributing to the lack of response? 1. Following a vegetarian diet 2. Taking daily brisk walks 3. Ingesting 1,500 mL of fluid per day 4. Smoking cessation when the diagnosis was received 20. The nurse plans to maintain hydration for the client at risk for thrombus formation. What evaluation finding is an indicator that the intervention is successful? 1. The client denies pain in the lower legs. 2. The client denies chest pain or difficulty breathing. 3. Urine output exceeds 1,500 mL per 24-hour period. 4. There is a weight gain of 5 pounds within 24 hours. 21. The nurse is preparing client teaching for a client diagnosed with peripheral edema secondary to right-sided heart failure. What intervention will promote circulation and reduce edema in the lower extremities? 1. Encourage frequent ambulation. 2. Administer antihypertensive medications. 3. Encourage vigorous exercise for 30 minutes a day. 4. Administer oxygen when the client is short of breath. Multiple Response Identify one or more choices that best complete the statement or answer the question. 22. Which of the following medications would the nurse expect to be included in the treatment of a client with congestive heart failure (CHF)? Select all that apply.

1. 2. 3. 4. 5.

Nitrates Beta-adrenergic agents Anticoagulants Diuretics Statins

23. As the nurse caring for a client who has suffered myocardial infarction that has damaged the sinoatrial (SA) node, you should plan to monitor for which of the following potential complications? Select all that apply. 1. Decreased heart rate 2. Increased heart rate 3. Decreased cardiac output 4. Decreased strength of ventricular contractions 5. Increased peripheral edema 24. The nurse is assessing the client’s home medication and note that although the client denies hypertension, there are several antihypertensive medications. Which of the following medications lower blood pressure? Select all that apply. 1. Atenolol 2. Digoxin 3. Lisinopril 4. Nifedipine 5. Warfarin 25. The nurse is assessing a healthy older client who has comes to the health clinic because she reports not feeling like herself. The client complains of increased fatigue when walking up stairs and performing normal household activities. What are normal physiological changes in the cardiovascular system that occur with aging? Select all that apply. 1. Cardiac contractile strength is reduced. 2. Heart valves become more rigid. 3. Peripheral vessels lose elasticity. 4. Heart responds to increased oxygen demands. 5. Sympathetic nervous system decreases. 26. The nurse is assessing a young adult client in the allergy clinic. The nurse recognizes that an allergic reaction will cause which of the following cardiac events? Select all that apply. 1. Erythema of the affected areas 2. Rhinitis and runny eyes 3. Swelling of the area 4. Pruritus and hives 5. Bradycardia

Chapter 37. Circulation & Perfusion Answer Section MULTIPLE CHOICE 1. ANS: 1 Chapter: Chapter 37 Circulation & Perfusion Objective: Evaluate adequacy of circulation and perfusion and modify nursing activities appropriately based on outcomes. Page: 1012 (V1) Heading: Planning Interventions/Implementation > Administer Cardiovascular Medications Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback 1 This is correct. Goals must be clearly stated so that it is easy to evaluate whether they have been met. “BP … lower than 135/85 …” is clearly stated and easily evaluated. 2 This is incorrect. Although the goal is to have normal BP, this does not clearly state the desired endpoint. 3 This is incorrect. Freedom from dizziness on rising is probably not achievable because ACE inhibitors are vasodilating agents, which may cause vessel dilation and hypotension, especially when the client arises from a seated or lying position. Clients should be warned of this effect. 4 This is incorrect. The expected/desired effect of the ACE inhibitor is to lower blood pressure; urine output is minimally relevant in determining that outcome, if at all. PTS: 1 CON: Perfusion 2. ANS: 1 Chapter: Chapter 37 Circulation & Perfusion Objective: Develop nursing diagnoses related to circulation and perfusion. Page: 1007 (V1) Heading: Analysis/Nursing Diagnosis Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Analysis [Analyzing] Concept: Perfusion Difficulty: Difficult Feedback

This is correct. The client’s symptoms reflect altered cardiac preload, a component of cardiac output. Acute myocardial infarction is often associated with decreased cardiac output as a result of altered cardiac pumping ability. This is incorrect. Although the other nursing diagnoses might be associated with Decreased Cardiac Output, this diagnosis cannot be determined from the symptoms presented. This is incorrect. Although the other nursing diagnoses might be associated with Decreased Cardiac Output, this diagnosis cannot be determined from the symptoms presented. This is incorrect. Impaired Cardiac Contractility is not a NANDA-I nursing diagnosis.

PTS: 1 CON: Perfusion 3. ANS: 2 Chapter: Chapter 37 Circulation & Perfusion Objective: Identify individual, environmental, and pathological factors that influence circulation and perfusion. Page: 999 (V1) Heading: What Factors Influence Cardiovascular Function? Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Perfusion Difficulty: Moderate Feedback 1 This is incorrect. Histamines are released as a response to allergens, not stress. 2 This is correct. The stress response stimulates release of catecholamines from the sympathetic nervous system. This results in increased heart rate and contractility, vasoconstriction, and increased tendency of blood to clot. 3 This is incorrect. Cortisol is also released in the stress response, but it is more indirectly related to development of cardiovascular disease through altered glucose, fat, and protein metabolism. 4 This is incorrect. Protease is a reaction to an allergen. PTS: 1 CON: Perfusion 4. ANS: 2 Chapter: Chapter 37 Circulation & Perfusion Objective: Identify individual, environmental, and pathological factors that influence circulation and perfusion. Page: 1000 (V1) Heading: What Factors Influence Cardiovascular Function? > Pregnancy Integrated Processes: Teaching and Learning

Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Growth and Development Difficulty: Moderate Feedback 1 This is incorrect. Although the mother’s blood volume increases by 30%, this increase may fail to compensate for fetal demand for oxygen. 2 This is correct. During pregnancy, oxygen demand increases dramatically. To compensate, the mother’s blood volume increases by 30%. The woman requires additional iron to produce this blood as well as to meet fetal requirements. Failure to meet these iron demands can result in maternal anemia, reducing tissue oxygenation of the mother. 3 This is incorrect. Although a multivitamin may be recommended, it does not compensate for the increased oxygen demand. 4 This is incorrect. Although more fruits and vegetables are needed for a wellbalanced diet, it does not compensate for the increased oxygen demand. PTS: 1 CON: Growth and Development 5. ANS: 1 Chapter: Chapter 37 Circulation & Perfusion Objective: Assess circulation and perfusion. Page: 1005 (V1) Heading: Assessment > Assess Peripheral Circulation Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback 1 This is correct. DVT is formation of a clot in the veins that are deep under the muscles of the leg. DVT can occur after surgery, after lengthy bedrest, or after trauma. Symptoms include pain, warmth, redness, and swelling of the leg. Dorsiflexion of the foot (pulling toes forward) and Pratt’s sign (squeezing calf to trigger pain) have not been found to be reliable in diagnosing DVT. 2 This is incorrect. Dehiscence is the rupture of a suture line, whereas evisceration is the protrusion of internal organs through the rupture. 3 This is incorrect. Internal bleeding is a wound-healing complication associated with hematoma formation, pain, hypotension, and tachycardia. 4 This is incorrect. Infection is a complication of wound healing that causes warmth, pain, inflammation of the affected area, and changes in vital signs (i.e., elevated pulse and temperature).

PTS: 1 CON: Perfusion 6. ANS: 3 Chapter: Chapter 37 Circulation & Perfusion Objective: Safely and correctly perform common nursing procedures related to circulation and perfusion. Page: 1013 (V1) Heading: Self-Care: Teaching Your Client Hands-Only CPR Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback 1 This is incorrect. This would not be rapid enough to promote adequate perfusion for the infant. 2 This is incorrect. This would not be rapid enough to promote adequate perfusion for the infant. 3 This is correct. Rescuers should focus on delivering high-quality CPR providing chest compressions of adequate rate (at least 100 compressions per minute). The prompt initiation of effective chest compressions is a fundamental aspect of resuscitation after cardiac arrest. CPR improves the victim’s chance of survival by providing heart and brain circulation. Rescuers should perform chest compressions for all victims in cardiac arrest, regardless of rescuer skill level, victim characteristics, or available resources. 4 This is incorrect. This is too rapid for the infant and would not promote adequate perfusion for the infant. PTS: 1 CON: Perfusion 7. ANS: 2 Chapter: Chapter 37 Circulation & Perfusion Objective: Develop nursing diagnoses related to circulation and perfusion. Page: 1000 (V1) Heading: Analysis/Nursing Diagnosis Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Perfusion Difficulty: Moderate

Feedback This is incorrect. There is no indication that this client is experiencing Impaired Gas Exchange based on the information provided.

3 4

This is correct. Excess Fluid Volume is an appropriate nursing diagnosis for someone demonstrating increased isotonic fluid retention, as demonstrated by adventitious breath sounds (crackles bilaterally) and edema. This is incorrect. There is no indication that this client is experiencing Ineffective Tissue Perfusion based on the information provided. This is incorrect. Although the client may have Deficient Knowledge, this is not a priority at this time.

PTS: 1 CON: Perfusion 8. ANS: 1 Chapter: Chapter 37 Circulation & Perfusion Objective: Describe the structure and function of the cardiovascular system. Page: 997 (V1) Heading: What Are the Structures of the Cardiovascular System? Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Perfusion Difficulty: Difficult Feedback 1 This is correct. The mitral valve is located between the left atrium and left ventricle, so backflow of blood results in reduced cardiac output to the body. 2 This is incorrect. The damaged mitral valve does not impact blood flow to the lungs but may impact blood flow from the lungs to the left atrium. 3 This is incorrect. The aortic valve is located between the aorta and the left ventricle. 4 This is incorrect. The pulmonic valve is located between the pulmonary artery and right ventricle. PTS: 1 CON: Perfusion 9. ANS: 4 Chapter: Chapter 37 Circulation & Perfusion Objective: Identify individual, environmental, and pathological factors that influence circulation and perfusion. Page: 999 (V1) Heading: What Factors Influence Cardiovascular Function? > Obesity Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Comprehension [Understanding] Concept: Perfusion Difficulty: Difficult Feedback

1 2 3 4

This is incorrect. Obesity increases the risk of atherosclerosis, particularly if obesity results from excess sugar or saturated fat intake. This is incorrect. Obesity does increase the risk of hypertension; even young children should be monitored for hypertension if they are obese. This is incorrect. Fat builds up around the heart of obese individuals, resulting in reduced pumping action of the heart. This is correct. In obesity, the workload of the heart is increased in an attempt to perfuse excess body tissue; however, tissue perfusion is not diminished until the heart is damaged and can no longer adequately perfuse the tissues.

PTS: 1 CON: Perfusion 10. ANS: 2 Chapter: Chapter 37 Circulation & Perfusion Objective: Assess circulation and perfusion. Page: 1005 (V1) Heading: Assessment: Cardiac Pain Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Perfusion Difficulty: Difficult Feedback 1 This is incorrect. Asking the client to describe the pain, location, and selftreatment would require an extended verbal response from a client who is having trouble breathing. It would stress the client to try to respond. 2 This is correct. In a situation in which breathing and/or circulation are inadequate, questions should be phrased to allow short (e.g., yes or no) answers that do not tax the client’s ability to breathe and talk. 3 This is incorrect. Although a list of medications is important to determine, the client with compromised breathing and circulation is unlikely to be able to provide this information. 4 This is incorrect. The client who is having difficulty breathing is unlikely to be able to supply information about past medical history despite its importance. Asking a spouse or close relative is likely to yield a more complete reply. PTS: 1 CON: Perfusion 11. ANS: 2 Chapter: Chapter 37 Circulation & Perfusion Objective: Assess circulation and perfusion. Page: 1005 (V1) Heading: Assessment > Assess Peripheral Circulation Integrated Processes: Nursing Process

Client Need: Physiological Integrity Cognitive Level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate Feedback 1 This is incorrect. A blood pressure of 102/64 mm Hg is lower than the average range but may be normal for this client. It would not indicate poor perfusion to the tissues. 2 This is correct. Absence of hair on the lower extremities is an indicator of poor perfusion because hair growth requires adequate gas exchange. 3 This is incorrect. The client with heart failure is likely to have a slightly elevated heart rate if not taking medications that slow heart rate because the increased rate compensates for reduced cardiac output. 4 This is incorrect. Although shortness of breath may occur with heart failure, this is the result of poor pumping action of the heart, allowing fluid to accumulate in the lungs; it is not an indicator of peripheral circulation. PTS: 1 CON: Perfusion 12. ANS: 2 Chapter: Chapter 37 Circulation & Perfusion Objective: Interpret diagnostic testing related to circulation and perfusion. Page: 1006 (V1) Heading: Diagnostic Testing: Laboratory Testing Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate Feedback 1 This is incorrect. Many conditions can cause an elevated CRP level, so the CRP level is not specific to myocardial infarction, as is the troponin or creatine phosphokinase, myocardial-bound (CPK-MB) level. 2 This is correct. An elevated CRP level indicates the presence of inflammation in the body. This may, but does not necessarily, include arterial inflammation or a myocardial infarction. 3 This is incorrect. CRP level is not related to measuring cardiac output. 4 This is incorrect. Elevation of the CRP level is not an indication of an elevated cholesterol level or a diet high in cholesterol. PTS: 1 CON: Perfusion 13. ANS: 1 Chapter: Chapter 37 Circulation & Perfusion

Objective: Interpret diagnostic testing related to circulation and perfusion. Page: 1007 (V1) Heading: Diagnostic Testing: Electrocardiogram Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Analysis [Analyzing] Concept: Perfusion Difficulty: Difficult Feedback 1 This is correct. The QRS segment is an indicator of contraction of the ventricle. If there is ischemia to the ventricle, the impulse will travel more slowly, especially if there are damaged or dead cells along the impulse pathway; therefore, the QRS segment would prolonged. 2 This is incorrect. The P wave is an indicator of atrial activity, not ventricular activity. 3 This is incorrect. The T wave is an indication of repolarization of the cardiac tissue, so it would not indicate ventricular ischemia. 4 This is incorrect. The P-R interval measures the time it takes for the impulse to move from the atria to the ventricles and is not a measure of ventricular ischemia. PTS: 1 CON: Perfusion 14. ANS: 1 Chapter: Chapter 37 Circulation & Perfusion Objective: Recognize medications used to enhance cardiovascular function. Page: 1012 (V1) Heading: Administer Cardiovascular Medications > Beta-Adrenergic Agents Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Perfusion Difficulty: Easy Feedback 1 This is correct. Beta-adrenergic blockers reduce heart rate and myocardial oxygen demand and improve contractility of the heart. Therefore, the client’s reduced rate would be an expected finding that indicates the drug is working. 2 This is incorrect. Beta blockers would not alter the movement of the electrical impulse through the ventricle, so there should be no change in QRS appearance. 3 This is incorrect. There would be no expectation of tingling in the hands and feet after taking a beta blocker. 4 This is incorrect. Increased urine output would be anticipated with use of diuretics, but the only improvement in urine output with beta blockers would be

indirect if the client had reduced kidney perfusion. This would not be a primary anticipated effect. PTS: 1 CON: Perfusion 15. ANS: 2 Chapter: Chapter 37 Circulation & Perfusion Objective: Interpret diagnostic testing related to circulation and perfusion. Page: 1003 (V1) Heading: Cardiovascular Abnormalities > Stable Angina & Volume 2 Diagnostic Testing Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback 1 This is incorrect. This is not indicative of unstable angina which would necessitate a vasodilator, such as nitroglycerin, at the onset of chest pain to prevent necrosis of cardiac tissue. 2 This is correct. This appears to be stable angina, which often subsides with rest and avoidance of the known triggers, such as vigorous activity, stress, large meals. 3 This is incorrect. The CRP level would rule out inflammation, and the venogram would be used to identify any blood clots or unusual narrowing or blockage of venous blood flow. 4 This is incorrect. Unless there is an apparent myocardial infarction, there would be no need for emergent cardiac catheterization. PTS: 1 CON: Perfusion 16. ANS: 1 Chapter: Chapter 37 Circulation & Perfusion Objective: Develop nursing diagnoses related to circulation and perfusion. Page: 1009 (V1) Heading: Example Problem: Decreased Cardiac Output Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate Nursing Processes: Diagnosis Feedback 1 This is correct. The client with hypertension who is not taking medications as prescribed can risk damage to the tiny arterioles in the kidneys, resulting in poor

2 3 4

renal tissue perfusion. This would be an appropriate diagnosis. This is incorrect. Nitroglycerine is a vasodilator that improves perfusion, rather than risking poor perfusion. This is incorrect. The client with pneumonia requires an oxygenation diagnosis and does not risk ineffective renal perfusion unless the heart is damaged. This is incorrect. When the body suffers blood loss, perfusion to the internal organs is not affected because the body compensates by reducing blood flow to the periphery, and the quantity of blood loss in the brain is limited by the enclosed compartment.

PTS: 1 CON: Perfusion 17. ANS: 3 Chapter: Chapter 37 Circulation & Perfusion Objective: Develop nursing diagnoses related to circulation and perfusion. Page: 1004 (V1) Heading: Volume 2 Assessment Guidelines & Tools: Part II. Focused Physical Examination Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Analysis [Analyzing] Concept: Perfusion Difficulty: Difficult Feedback 1 This is incorrect. When the right ventricle is compromised by heart failure, venous return is slowed and peripheral edema results; however, this client has left-sided failure. 2 This is incorrect. Medications to treat heart failure are meant to alter heart rate, so this would not be the best indicator of improvement in the client’s condition. 3 This is correct. Left-sided failure causes blood to back up into the lungs and can result in pulmonary edema; therefore, clear breath sounds with no shortness of breath would be an effective outcome. 4 This is incorrect. A client with heart failure may have a regular rhythm even before treatment, so this is not the best choice for an indication of improved cardiac output. PTS: 1 CON: Perfusion 18. ANS: 3 Chapter: Chapter 37 Circulation & Perfusion Objective: Recognize medications used to enhance cardiovascular function. Page: 1008 (V1) Heading: Planning Interventions/Implementation > Administer Cardiovascular Medications Integrated Processes: Nursing Process Client Need: Physiological Integrity

Cognitive Level: Application [Applying] Concept: Perfusion Difficulty: Difficult Feedback 1 This is incorrect. There would be no reason to notify the physician unless the client does not respond by the third dose of nitroglycerine. 2 This is incorrect. Elevating the head of the bed would be contraindicated, especially if the client develops hypotension from vasodilation. 3 This is correct. It is most important at this time for the nurse to measure the client’s blood pressure because vasodilating medications can result in a significant drop in blood pressure. 4 This is incorrect. Although placing the client on a monitor is indicated, this is not related to administering the client’s medication. PTS: 1 CON: Perfusion 19. ANS: 3 Chapter: Chapter 37 Circulation & Perfusion Objective: Evaluate adequacy of circulation and perfusion and modify nursing activities appropriately based on outcomes. Page: 999 (V1) Heading: What Factors Influence Cardiovascular Function? > Lifestyle Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Perfusion Difficulty: Easy Nursing Processes: Evaluating Feedback 1 This is incorrect. A vegetarian diet is usually low in cholesterol and fat, so this is an appropriate lifestyle change that would not reduce response to therapy. Further assessment of diet may be needed. 2 This is incorrect. Daily exercise promotes perfusion, so this would not be the anticipated cause of reduced response to therapy. 3 This is correct. Intake of 1,500 mL of fluid is lower than optimal, and the client should be encouraged to increase fluid intake to 2,000 mL per day. This could have a negative impact on perfusion if the client is dehydrated, even mildly so. 4 This is incorrect. Quitting smoking should improve response to therapy and would not be the likely cause of the client’s failure to respond to treatment. PTS: 1 CON: Perfusion 20. ANS: 3 Chapter: Chapter 37 Circulation & Perfusion

Objective: Evaluate adequacy of circulation and perfusion and modify nursing activities appropriately based on outcomes. Page: 1008 (V1) Heading: Planning Interventions/Implementation > Prevent Clot Formation Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Analysis [Analyzing] Concept: Perfusion Difficulty: Easy Feedback 1 This is incorrect. Pain in the lower legs is a good indicator that the client does not have a thrombus in the lower legs but does not indicate hydration. 2 This is incorrect. Absence of chest pain or shortness of breath is a good indicator that the client doesn’t have a significant pulmonary embolism but does not indicate the client is hydrated. 3 This is correct. Urine output is the best indicator of hydration, and urine output greater than 1,500 mL would be expected within the normal range. 4 This is incorrect. Weight gain of 5 pounds in 24 hours would indicate overhydration. PTS: 1 CON: Perfusion 21. ANS: 1 Chapter: Chapter 37 Circulation & Perfusion Objective: Provide measures to promote peripheral circulation. Page: 1007 (V1) Heading: Assessment > Physical Examination > Peripheral Circulation Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback 1 This is correct. Frequent walking will not overtax the client’s heart but will provide muscle activity to promote venous return. 2 This is incorrect. Antihypertensives would be indicated only if the client has high blood pressure; the scenario does not indicate this. 3 This is incorrect. Vigorous exercise would not be tolerated by a client with heart failure and could be very dangerous. 4 This is incorrect. Shortness of breath would indicate the need to notify the provider, and oxygen would not promote circulation. PTS:

CON: Perfusion

MULTIPLE RESPONSE 22. ANS: 2, 4 Chapter: Chapter 37 Circulation & Perfusion Objective: Recognize the medications used to enhance cardiovascular function. Page: 1011 (V1) Heading: Planning Interventions/Implementation > Table 37-1 Medications That Promote Circulation Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies. Cognitive Level: Comprehension [Understanding] Concept: Perfusion Difficulty: Moderate

1. 2.

3. 4.

Feedback This is incorrect. Nitrates are used to control blood pressure but are not indicated for the treatment of CHF. This is correct. Beta-adrenergic agents block stimulation of beta receptors in the heart, lungs, and blood vessels and decrease heart rate, slow conduction through the atrioventricular (AV) node, and decrease myocardial oxygen demand by reducing myocardial contractility. This is incorrect. Anticoagulants may be indicated for treatment of cardiac dysrhythmias, not CHF. This is correct. Diuretics increase removal of sodium and water from the body through increased urine output. Diuretics reduce the volume of circulating blood and prevent accumulation of fluid in the pulmonary circulation. This is incorrect. Anticholesterol (statin) medications would not be used for CHF.

PTS: 1 CON: Perfusion 23. ANS: 1, 3 Chapter: Chapter 37 Circulation & Perfusion Objective: Describe the structure and function of the cardiovascular system & Provide measures to promote peripheral circulation. Page: 996 (V1) Heading: What Are the Structures of The Cardiovascular System? > Electrical Conduction Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Perfusion Difficulty: Difficult

2. 3. 4. 5.

Feedback This is correct. Normally, the SA node is the primary pacemaker for the heart and initiates a rate of 60 to 100 beats per minute. If the SA node fails, the atrioventricular node can take over as the pacemaker, but it generally triggers a slower heart rate. This is incorrect. If the SA node fails, the atrioventricular node can take over as the pacemaker, but it generally triggers a slower heart rate. This is correct. Cardiac output will decrease as a result of the decrease in heart rate. This is incorrect. Damage to the SA node interferes with the electrical activity of the heart but does not directly affect the pumping action of the heart. This is incorrect. Although cardiac output will decrease as a result of the decreased heart rate, there is no indication that this will cause peripheral edema.

PTS: 1 CON: Perfusion 24. ANS: 1, 3, 4 Chapter: Chapter 37 Circulation & Perfusion Objective: Recognize the medications used to enhance cardiovascular function. Page: 1002 (V1) Heading: Table 37-1 Medications That Promote Circulation Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Perfusion Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is correct, beta blockers, such as atenolol, control blood pressure. This is incorrect. Cardiac glycosides, such as digoxin, are used to control cardiac rhythm, not blood pressure. This is correct, angiotensin-converting enzyme (ACE) inhibitors, such as lisinopril, are used to control blood pressure. This is correct. Calcium channel blockers, such as nifedipine, may control blood pressure. This is incorrect. Anticoagulants, such as warfarin, do not control blood pressure.

PTS: 1 CON: Perfusion 25. ANS: 1, 2, 3 Chapter: Chapter 37 Circulation & Perfusion Objective: Identify individual, environmental, and pathological factors that influence circulation and perfusion. Page: 1000 (V1) Heading: What Factors Influence Cardiovascular Function? > Older adults Integrated Processes: Nursing Process

Client Need: Physiological Integrity Cognitive Level: Comprehension [Understanding] Concept: Perfusion Difficulty: Moderate

1. 2. 3. 4.

Feedback This is correct. Cardiac efficiency gradually declines as the heart muscle loses contractile strength. This is correct. Heart valves become thicker and more rigid during the aging process. This is correct. The peripheral vessels become less elastic, which creates more resistance to ejection of blood from the heart. This is incorrect. As a result of physiological changes from aging, the heart becomes less able to respond to increased oxygen demands, and it needs longer recovery times after responding. This is incorrect. There is no correlation with the sympathetic nervous system and aging in relation to the cardiac system.

PTS: 1 CON: Perfusion 26. ANS: 1, 2, 3, 4 Chapter: Chapter 37 Circulation & Perfusion Objective: Identify individual, environmental, and pathological factors that influence circulation and perfusion. Page: 998 (V1) Heading: How Is Cardiovascular Function Regulated? & Allergic Reactions and Air Quality Integrated Processes > Allergic Reactions and Air Quality Client Need: Physiological Integrity Cognitive Level: Analysis [Analyzing] Concept: Perfusion Difficulty: Difficult Nursing Processes: Diagnosis

1. 2. 3. 4. 5.

Feedback This is correct. Blood vessels dilate in areas affected by the allergen and may be seen as erythema (redness of the site.) This is correct. When eosinophils are attracted to the reaction site, rhinitis (runny nose) may occur. This is correct. Swelling or edema from an allergic reaction would be caused by an increase in the capillary permeability and fluid leakage. This is incorrect. Although this is an allergic reaction, it is not a cardiac event. This is incorrect. The parasympathetic nervous system is not affected by an allergic reaction. Parasympathetic fibers innervate the heart through the vagus nerve, which can result in a slowed heart rate. The sympathetic nervous system may stimulate an

increased heart rate in response to the allergen. PTS:

CON: Perfusion

Chapter 38. Fluids, Electrolytes, & Acid–Base Balance Multiple Choice Identify the choice that best completes the statement or answers the question. 1. After morning care, the nurse lowered the height of the IV container infusing via gravity flow, at the client’s request. What is the nurse’s next best action? 1. Calculate the new infusion rate. 2. Readjust the infusion rate, as needed. 3. Change the IV site and move it to the other arm. 4. Instruct the client to call when the IV bag is empty. 2. The nurse has started to infuse the first of two units of packed red blood cells (PRBCs) on her client. What is the nurse’s next best action? 1. Delegate to the UAP to take vital signs every 15 minutes for 1 hour. 2. Infuse the blood at a rate of 100 mL/hr. so it will infuse in 4 hours. 3. Infuse an IV solution of lactated Ringer’s with the blood. 4. Remain with the client for the first 15 minutes of the infusion. 3. The nurse is assessing a client in the acute care unit. The client’s blood pressure is 80/40 mm Hg, pulse 120 beats/min and thready, has poor skin turgor, and has dry mucus membranes. Which of the following IV fluids would the nurse expect the healthcare provider to prescribe for this client’s condition? 1. 0.9% normal saline 2. Serum albumin 3. 0.45% normal saline 4. D5W with normal saline 4. The nurse is providing care to the client with hypokalemia. Which of the following disease conditions may have contributed to the hypokalemia? 1. Congestive heart failure 2. Renal failure 3. Gastroenteritis 4. Major trauma 5. A client is admitted to the emergency department (ED) in respiratory distress. The results of the arterial blood gases are the following: pH = 7.30; partial pressure of carbon dioxide (PCO2) = 40; bicarbonate (HCO3) = 19 mEq/L; partial pressure of oxygen (PO2) = 80. The nurse interprets the findings as which of the following? 1. Respiratory acidosis with normal oxygen levels 2. Respiratory alkalosis with hypoxia 3. Metabolic acidosis with normal oxygen levels 4. Metabolic alkalosis with hypoxia

6. A client is admitted to the emergency department in respiratory distress. The initial arterial blood gases (ABGs) results are pH = 7.30; partial pressure of carbon dioxide (PCO2) = 40; bicarbonate (HCO3) = 19 mEq/L; partial pressure of oxygen (PO2) = 80. The nurse evaluates the client’s treatment plan by examining repeat ABGs. The results are pH = 7.38; PCO2 = 32; HCO3 = 19 mEq/L. The nurse concludes which of the following? 1. Respiratory acidosis; the treatment plan is ineffective. 2. Metabolic alkalosis; the treatment plan is effective. 3. Partial compensation; the treatment plan is ineffective. 4. Full compensation; the treatment plan is effective. 7. When a client has metabolic acidosis; which body system influences the acid–base imbalance to produce the compensatory changes in the arterial blood gases? 1. Respiratory system 2. Renal system 3. Vascular system 4. Neurological system 8. A client’s arterial blood gas results are as follows: pH = 7.30; partial pressure of carbon dioxide (PCO2) = 40; bicarbonate (HCO3) = 19 mEq/L; partial pressure of oxygen (PO2) = 80. An appropriate nursing diagnosis for the client is which of the following? 1. Impaired Gas Exchange 2. Metabolic Acidosis 3. Risk for Impaired Gas Exchange 4. Risk for Acid–Base Imbalance 9. The nurse is caring for a client who has the following lab results: sodium (Na) 147; potassium (K) 3.6; calcium (Ca) 8.8; magnesium (Mg) 1.9. The following prescriptions are written in the client’s electronic health record. Which one should the nurse question? 1. Administer intravenous (IV) D5W at 125 mL/hr. 2. Perform strict intake and output (I&O) monitoring. 3. Restrict oral intake to 900 mL per 24 hours. 4. Monitor serum electrolytes every 4 hours. 10. Which of the following best describes the sodium–potassium pump that maintains the unique composition of extracellular and intracellular compartments? 1. Diffusion 2. Osmosis 3. Filtration 4. Active transport 11. The nurse records a client’s hourly urine output from an indwelling catheter as follows: 0700: 36 mL 0800: 45 mL 0900: 85 mL 1000: 62 mL

1100: 50 mL 1200: 48 mL 1300: 94 mL 1400: 78 mL 1500: 60 mL The nurse can conclude that the client’s urine output should be described as which of the following? 1. Low 2. Within normal limits 3. High 4. Inconclusive 12. The nurse recognizes that a balance of fluid and electrolytes is essential to maintain homeostasis. Excesses or deficits can lead to severe disorders. Which of the following is the principal site for regulation of fluid and electrolyte balance? 1. Cardiac system 2. Vascular system 3. Pulmonary system 4. Renal system 13. Which electrolyte is the primary regulator of fluid volume? 1. Potassium 2. Calcium 3. Sodium 4. Magnesium 14. An 82-year-old woman was brought to the emergency department by her granddaughter. She is a widow and lives alone, although her granddaughter checks on her daily. She has been vomiting for 2 days and has not been able to eat or drink anything during this time. She has not urinated for 12 hours. Physical examination reveals the following: temperature (T) = 99.6°F (37.6°C) orally; pulse (P) = 110 beats/min, weak and thready; blood pressure (BP) = 80/52 mm Hg. Her skin and mucous membranes are dry, and there is decreased skin turgor. The client states that she feels very weak. The following are her laboratory results: Sodium 138 mEq/L Potassium 3.7 mEq/L Calcium 9.2 mg/dL Magnesium 1.8 mg/dL Chloride 99 mEq/L Blood urea 29 mg/dL nitrogen (BUN) The nurse recognizes that the client is displaying symptoms associated with which of the following? 1. Hypovolemia

2. Hypervolemia 3. Hypernatremia 4. Hyponatremia 15. The nurse is assessing a client who has been vomiting for 2 days and has not been able to eat or drink anything during this time. The client’s mucous membranes are dry, there is decreased skin turgor, and the client complains of weakness. The client’s vital signs are blood pressure (BP) 80/52; temperature (T) = 99.6°F (37.6°C) orally; pulse (P) = 110 beats/min, weak and thready. Her skin and mucous membranes are dry, and there is decreased skin turgor. The following are the laboratory results: Sodium 138 mEq/L Potassium 3.7 mEq/L Calcium 9.2 mg/dL Magnesium 1.8 mg/dL Chloride 99 mEq/L 29 mg/dL Blood urea nitrogen (BUN) Which of the following is an appropriate nursing diagnosis for this client? 1. Impaired Gas Exchange related to ineffective breathing 2. Excess Fluid Volume related to limited fluid output 3. Deficient Fluid Volume related to abnormal fluid loss 4. Electrolyte Imbalance related to decreased oral intake 16. Which of the following is the most appropriate goal for a client with the nursing diagnosis of Deficient Fluid Volume? 1. Electrolyte balance restored, as evidenced by improved levels of alertness and cognitive orientation 2. Electrolyte balance restored, as evidenced by sodium and potassium returning to normal range 3. Fluid balance restored, as evidenced by lowered blood pressure and absence of jugular venous distention 4. Fluid balance restored, as evidenced by moist mucous membranes and urinating every 4 hours 17. Which laboratory result on a client’s health record should alert the nurse to a potential problem? 1. Sodium (Na+) = 137 mEq/L 2. Potassium (K+) = 5.2 mEq/L 3. Calcium (Ca2+) = 9.2 mg/dL 4. Magnesium (Mg2+) = 1.8 mg/dL

18. A client’s vital signs prior to a blood transfusion were: temperature (T) = 97.6°F (36.4°C); pulse (P) = 72 beats/min; respirations (R) = 22 breaths/min; blood pressure (BP) = 132/76 mm Hg. Twenty minutes after the transfusion was begun, the client began complaining of feeling “itchy and hot.” The nurse discovered a rash on the client’s trunk. Vital signs were T = 100.8°F (38.2°C); P = 82 beats/min; R = 24 breaths/min; BP = 146/88 mm Hg. Based on these findings, what is the most appropriate initial intervention? 1. Administer an antihistamine medication. 2. Flush the blood tubing with D5W immediately. 3. Prepare for emergency resuscitation. 4. Stop the blood transfusion immediately. 19. A client is receiving an IV infusion of lactated Ringer’s solution and 40 mEq of potassium chloride (KCl) at 100 mL/hr. When assessing the IV site, the nurse notes swelling, erythema, and warmth. There is a palpable cord along the vein, and the infusion is sluggish. The client is complaining of pain at the site. The nurse would recognize these findings to be consistent with which of the following? 1. Infiltration 2. Extravasation 3. Hematoma 4. Phlebitis 20. The nurse assesses that her client’s intravenous solution has infiltrated into the tissues. What action should she take first? 1. Aspirate, and then inject 0.5 mL normal saline. 2. Restart the IV line in a different vein. 3. Stop the infusion immediately. 4. Notify the primary care provider. 21. The client presents to the emergency department with a bicarbonate (HCO3-) level of 14 mEq/L. What may be the explanation for this laboratory result? 1. The client’s kidneys are not able to conserve HCO3-. 2. The client has not included enough HCO3-in the diet. 3. The client’s kidneys are retaining too much HCO3-. 4. The client’s diet includes too much carbonic acid. 22. A healthcare provider prescribes 250 mL of 0.9% sodium chloride to be infused over 2 hours. A micro-drip infusion set is being used. What is the drip rate (drops/min) that the nurse should monitor? 1. 60 2. 75 3. 125 4. 250 23. The nurse examines the electrocardiography (ECG) tracing of a client and notes tall T waves. What electrolyte imbalance should the nurse suspect?

1. 2. 3. 4.

Hypokalemia Hypophosphatemia Hyperkalemia Hyperphosphatemia

24. The nurse gathers the following data: blood pressure (BP) = 150/94 mm Hg; neck veins distended; pulse (P) = 104 beats/min; pulse bounding; respiratory rate (RR) = 20 breaths/min; temperature (T) = 37C (98.6F). What disorder should the nurse suspect? 1. Hypovolemia 2. Hypokalemia 3. Hyperkalemia 4. Hypervolemia 25. A client has a continuous IV infusion at 60 mL/hr. The right-hand IV has infiltrated, and the nurse has started a new IV line on the left forearm. Which of the following interventions should the nurse also perform? 1. Elevate the client’s left forearm. 2. Schedule daily IV dressing changes. 3. Change the administration set. 4. Place the client in Fowler’s position. 26. When performing a central venous catheter dressing change, which of the following steps is correct? 1. Wear sterile gloves while removing and discarding the soiled dressing. 2. Apply pressure on the catheter-hub junction when removing the soiled dressing. 3. Place a sterile transparent dressing over the site and the catheter–hub junction. 4. Have the client wear a mask or turn his head away from the site. 27. The nurse is assessing the client in the long-term care facility and notes that client has bilateral pedal pitting edema. The nurse knows that this signifies excess volume in which fluid compartment? 1. Intracellular 2. Interstitial 3. Intravascular 4. Transcellular 28. The nurse is providing care for the adult male client with a hematocrit of 30. Which condition would accurately explain this finding? 1. Elevated blood cell count 2. Excess transcellular fluid 3. Extracellular fluid deficit 4. Intravascular fluid excess

29. The nurse is providing care to the adult client in the acute care center. When the nurse began to assess the client’s blood pressure, the client’s hand began to “cramp” and involuntarily flex. What is the possible answer to this phenomenon? 1. The client is displaying signs of hyponatremia. 2. The client is displaying signs of hypocalcemia. 3. The client is displaying signs of hypokalemia. 4. The client is displaying signs of hypophosphatemia. 30. The nurse is assessing the client with renal failure and notes that the client’s respirations are depressed, the client is lethargic with depressed respirations. His blood pressure (BP) is 80/40 mm Hg; pulse (P) is 58 beats/min; respiration rate (RR) is 12 breaths/min; and hypoactive reflexes are present. Which of the following may be the cause of these symptoms? 1. The client took frequent doses of magnesium-based laxative. 2. The client continued use of potassium-sparing diuretics after the renal failure diagnosis. 3. The client took calcium supplements and increased diary intake due to osteoporosis. 4. The client did not adhere to the prescribed fluid restriction and now has fluid overload. 31. The nurse is to administer an intravenous (IV) solution to a client with diffuse edema. Which of the following prescriptions for this client would the nurse question? 1. 5% Dextrose in water (D5W) 2. 10% Dextrose in water (D10W) 3. 5% Dextrose in normal saline (D5 0.9% sodium chloride [NaCl]) 4. 5% Dextrose lactated Ringer’s solution (D5LR) 32. Which of the following older clients’ needs to increase the daily fluid intake? One who typically drinks (assume three meals per day): 1. 200 mL at each meal, plus 1,000 mL throughout the day 2. 250 mL at each meal, plus 600 mL throughout the day 3. 300 mL at each meal, plus 1,000 mL throughout the day 4. 400 mL at each meal, plus 500 mL throughout the day 33. At a first aid station on a marathon route, a client complains of headache, muscle cramps, weakness, nausea, and confusion after the race. Which statement made by the client might explain these symptoms? 1. “I was really thirsty after the race. I drank several large bottles of water.” 2. “I perspired quite a bit during the race, so I drank sports drinks when I finished.” 3. “I take steroids regularly and did not stop taking them for the race.” 4. “I am diabetic and checked my blood sugar after the race. It was normal.” 34. A 60-year-old woman complains of muscle weakness, constipation, nausea, and frequent urination and is displaying bizarre behavior. The woman takes prescribed thiazide diuretics and steroids for asthma. What statement made by the client might indicate an additional cause of her symptoms?

1. 2. 3. 4.

“I have been working hard to drink plenty of water to prevent dehydration.” “I should probably tell you I take steroids regularly because of my asthma.” “I take calcium supplements to prevent osteoporosis and eat lots of dairy foods.” “I recently quit drinking alcohol. I quit cold turkey and did it all by myself.”

35. A client had gastric surgery 10 days ago and continues to require gastric suction because of a paralytic ileus. The client reports tingling in the fingers, has hypertonic reflexes, and has a respiratory rate of 8 breaths per minute that are deep in nature. The nurse recognizes that these symptoms are consistent with which diagnosis? 1. Respiratory alkalosis 2. Metabolic acidosis 3. Respiratory acidosis 4. Metabolic alkalosis 36. The nurse is caring for a client with gastroenteritis who has been vomiting for 48 hours. A family member of the client asks the nurse, “Why is he breathing that way?” What is the nurse’s most accurate response after explaining the meaning of pH? 1. “He is breathing fast and deep to help reduce carbon dioxide to increase his pH.” 2. “He is breathing slow and shallow to try to retain carbon dioxide to decrease his pH.” 3. “He is breathing fast and deep to help reduce carbon dioxide to decrease his pH.” 4. “He is breathing slow and shallow to try to retain carbon dioxide to increase his pH.” 37. The nurse is caring for a client with no spontaneous respiratory effort who requires mechanical ventilation. The first blood gas after initiating the ventilator shows a pH of 7.52 and partial pressure of carbon dioxide (PCO2) of 20. What intervention is required to correct this pH imbalance? 1. Increase fluid infusion. 2. Increase oxygen percentage. 3. Reduce number of breaths/min. 4. Increase number of breaths/min. 38. A new father begins to hyperventilate as his baby is about to be born; he becomes light headed. The nurse instructs him to breathe into the paper bag until his breathing slows down. When he feels better he asks the nurse why using the paper bag helped him. What is the nurse’s best response? “Breathing into the paper bag allowed you to 1. Rebreathe carbon dioxide to correct respiratory alkalosis” 2. Reduce carbon dioxide to correct respiratory acidosis” 3. Rebreathe carbon dioxide to correct metabolic alkalosis” 4. Reduce carbon dioxide to correct metabolic acidosis” 39. The nurse is caring for a client with heart failure. The client has chronic fluid volume excess secondary to ineffective pumping action of the heart. When teaching this client about fluid and electrolyte balance, which diet is most important for the nurse to explain?

1. 2. 3. 4.

High-calcium Low-sodium Low-potassium High-magnesium

Multiple Response Identify one or more choices that best complete the statement or answer the question. 40. The nurse is aware that a balance between fluid intake and output is essential to maintain homeostasis. Excesses or deficits of intake can lead to severe disorders. In a healthy adult, which of the following regulate body fluids? Select all that apply. 1. Hormone levels 2. Kidney function 3. Oxygen saturation 4. Thirst mechanism 5. Integumentary function 41. A client has been admitted to the nursing unit with a diagnosis of chronic renal failure. The client is scheduled for the first dialysis session in the morning. Which of the following are appropriate nursing interventions for the client? Select all that apply. 1. Encourage oral fluid intake, as desired. 2. Place the client on strict intake and output (I&O) monitoring. 3. Weigh the client before and after dialysis. 4. Maintain a total fluid restriction of 1,000 mL, as prescribed. 5. Provide a dinner rich in magnesium and potassium. 42. Identify the mechanisms involved in acid–base balance. Select all that apply. 1. Respiratory mechanisms 2. Active transport mechanisms 3. Renal mechanisms 4. Buffer systems 5. Osmotic pressure systems 43. Identify the appropriate interventions for a client with hypovolemia. Select all that apply. 1. Teach deep-breathing techniques. 2. Monitor intake and output (I&O) daily. 3. Encourage fluid intake. 4. Monitor electrolyte balance. 5. Monitor daily weights. 44. A client’s blood group is B. The nurse knows the client can receive blood only from donors with what group of blood? Select all that apply. 1. A 2. B

3. O 4. AB 5. AO 45. A nurse is caring for a client with a peripheral IV line located in the right forearm. The client informs the nurse that the IV site is burning. Upon assessment the nurse determines that the IV solution has infiltrated. What site(s) is/are appropriate to consider when restarting the IV line? Select all that apply. 1. Left hand 2. Right wrist 3. Right antecubital area 4. Right saphenous vein 5. Left antecubital area 46. A client has been diagnosed with hypovolemia. Which prescriptions for hydration should the nurse question? Select all that apply. 1. 0.9% (normal) saline at 100 mL/hr 2. Lactated Ringer’s solution at 100 mL/hr 3. D50W at 100 mL/hr 4. D5W solution at 100 mL/hr 5. D5W with 20 mEq potassium chloride (KCl) 47. When assisting with bedside central venous catheter (CVC) placement, which nursing intervention is appropriate? Select all that apply. 1. Don sterile gloves and mask (and possibly gown). 2. Verify that informed consent has been obtained. 3. Scrub the insertion site with antibacterial soap for 1 min. 4. Place the client in low-Fowler’s position. 5. Have the client wear a mask or turn their head. 48. The nurse is caring for a client with metabolic acidosis secondary to renal failure caused by poor glucose regulation. The client reports a headache, weakness, and nausea. The nurse assesses an elevated blood sugar, Kussmaul’s breathing, and peripheral vasodilation. What collaborative interventions will the nurse anticipate to restore pH balance? Select all that apply. 1. Insulin to lower blood sugar 2. Tylenol for headache 3. Mechanical ventilation to correct breathing 4. Dialysis to remove toxins 5. Bicarbonate administration 49. The nurse is caring for a client who is normally healthy but is experiencing dehydration secondary to acute diarrhea and vomiting. What assessment findings would indicate a return to fluid homeostasis? Select all that apply. 1. Urine output of 35 mL/hour 2. Elevated antidiuretic hormone levels

3. Reduced renin production 4. Reduced aldosterone release 5. Formed stools

Chapter 38. Fluids, Electrolytes, & Acid–Base Balance Answer Section MULTIPLE CHOICE 1. ANS: 2 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Apply the nursing process to clients with fluid, electrolyte, and acid–base imbalances. Page: 1035 (V1) Heading: Parenteral Replacement of Fluids and Electrolytes > Calculating Flow Rates Integrated Processes: Nursing Process Client Need: Health Promotion Maintenance Cognitive Level: Application [Applying] Concept: Fluid and Electrolyte Balance Difficulty: Easy Feedback 1 This is incorrect. The drip rate is based on the administration set and prescribed rate and is not affected by the height of the IV solution. 2 This is correct. The rate of an IV infusing via gravity draining will be altered by raising or lowering the IV solution. Thus, if the IV pole is lowered, the rate will need to be verified and adjusted, as needed. 3 This is incorrect. The IV site will need to be changed only when clinically indicated. 4 This is incorrect. The nurse should not rely on the client but should monitor the infusion amount. PTS: 1 CON: Fluid and Electrolyte Balance 2. ANS: 4 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Apply the nursing process to clients with fluid, electrolyte, and acid–base imbalances. Page: 849 (V2) Heading: Procedure 38-8A Administering Blood and Blood Products & Procedure 38-8B Managing a Transfusion Reaction, in Volume 2 Integrated Processes: Nursing Process Client Need: Physiological integrity: Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. The nurse should not delegate the initial vital sign to the UAP. 2 This is incorrect. Although the blood transfusion should be infused within 4 hours, this is not the best action after starting the blood.

3 4

This is incorrect. The only compatible IV solution that can infuse with blood is normal saline (0.9% NS). This is correct. The nurse’s next best action is to stay with the client and assess for a transfusion reaction, which is more likely with the first 50 mL of the blood.

PTS: 1 CON: Safety 3. ANS: 1 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Apply the nursing process to clients with fluid, electrolyte, and acid–base imbalances. Page: 1018 (V1) Heading: How Do Fluids and Electrolytes Move in the Body? > Types of Intravenous Solutions Integrated Processes: Nursing Process Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies. Cognitive Level: Analysis [Analyzing] Concept: Fluid and Electrolyte Balance Difficulty: Difficult Feedback 1 This is correct. The client is displaying signs of hypovolemia, so an isotonic solution may be ordered. An isotonic solution is of the same osmolality as blood; thus, no osmosis (movement of water) will occur. Isotonic fluids are often given by IV infusion if blood volume is low, because the fluid will remain in the vascular space. 2 This is incorrect. The client is displaying signs of hypovolemia and dehydration, and needs fluid replacement that would hydrate the cells via osmosis. This is a hypertonic solution which would draw fluid from the cells into the interstitial space. 3 This is incorrect. The client is displaying hypovolemia. This is a hypotonic solution. When a hypotonic solution is infused, water moves by osmosis from the vascular system into the cells. 4 This is incorrect. The client is displaying signs of hypovolemia and dehydration. This may exacerbate the dehydration by drawing fluid out of the cells. Compared with blood, a hypertonic solution contains a higher concentration of solutes. When a hypertonic solution is given to a client, water moves by osmosis from the cells into the extracellular fluid (ECF). PTS: 1 CON: Fluid and Electrolyte Balance 4. ANS: 3 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Summarize the major fluid and electrolyte balance disorders. Page: 844 (V2) Heading: Table 38-5 Electrolyte Imbalances Integrated Processes: Nursing Process

Client Need: Physiological integrity: Pharmacological and Parenteral Therapies Cognitive Level: Analysis [Analyzing] Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 This is incorrect. Congestive heart failure would not cause a low potassium level. 2 This is incorrect. Renal failure would cause hyperkalemia, or high potassium. 3 This is correct. Gastroenteritis often manifests as diarrhea and vomiting, which would prohibit absorption or intake of adequate amounts of potassium. 4 This is incorrect. Major trauma would cause cell disruption and high levels of serum potassium. PTS: 1 CON: Safety 5. ANS: 3 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Compare and contrast respiratory and metabolic acidosis and alkalosis. Page: 845 (V2) Heading: Table 38-6 Using ABGs to Assess Acid–Base Balance Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Acid–Base Balance Difficulty: Difficult Feedback 1 This is incorrect. The client’s pH is acidotic, but per the labs, there is no indication that this is respiratory in nature. 2 This is incorrect. The client’s pH indicates acidosis, and although the client is in respiratory distress, the labs do not indicate that this is respiratory in nature. 3 This is correct. The pH is acidotic. The HCO3 of 19 mEq/L is low and has moved in the same direction as the pH, indicating a metabolic disorder. The PCO2 level is within normal range with no signs of compensation. The PO2 level is normal. 4 This is incorrect. The client’s pH is acidotic, not alkaline. PTS: 1 CON: Acid–Base Balance 6. ANS: 4 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Compare and contrast respiratory and metabolic acidosis and alkalosis. Page: 845 (V2) Heading: Table 38-6 Using ABGs to Assess Acid–Base Balance Integrated Processes: Nursing Process

Client Need: Physiological integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Acid–Base Balance Difficulty: Difficult Feedback 1 This is incorrect. The lab results indicate a normal pH level at this time. 2 This is incorrect. The lab results do not indicate any abnormal pH levels at this time. 3 This is incorrect.t the lab results do not indicate a partial compensation as the pH is within the normal range at this time. 4 This is correct. Full compensation has occurred as the PCO2 has returned the pH to the normal range, and both PCO2 and HCO3 are still abnormal. This change indicates that the treatment plan is effective. Partial compensation would be indicated by changes in the PCO2, but the pH would still be outside the normal range. PTS: 1 CON: Acid–Base Balance 7. ANS: 1 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Describe compensatory mechanisms for acid–base imbalances. Page: 1024 (V1) Heading: How Is Acid–Base Balance Regulated? Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [understanding] Concept: Acid–Base Balance Difficulty: Easy

1 2

3 4

Feedback This is correct. In a metabolic problem, the respiratory system compensates. This is incorrect. In a respiratory problem, the renal system must compensate. The respiratory system compensates early in the disorder, but it may take up to 3 days for the renal system to compensate fully. This is incorrect. The vascular system does not directly compensate for acid– base imbalances. This is incorrect. The neurological system does not directly compensate for acid–base imbalances.

PTS: 1 CON: Acid–Base Balance 8. ANS: 1 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Apply the nursing process to clients with fluid, electrolyte, and acid–base imbalances.

Page: 1028 (V1) Heading: Imbalances: Fluid, Electrolyte, and Acid–Base > Example Problem: Acid–Base Imbalances Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Acid–Base Balance Difficulty: Moderate Feedback 1 This is correct. An appropriate diagnosis is Impaired Gas Exchange. The arterial blood gas (ABG) results provide the defining characteristics for Impaired Gas Exchange. 2 This is incorrect. The ABG results demonstrate metabolic acidosis; however, this is not a nursing diagnosis. 3 This is incorrect. The client has an actual problem; therefore, the “risk for” nursing diagnoses are incorrect. Additionally, there is no such nursing diagnosis as Acid–Base Imbalance or Risk for Acid–Base Imbalance. 4 This is incorrect. The client has an actual problem; therefore, the “risk for” nursing diagnoses are incorrect. Additionally, there is no such nursing diagnosis as Acid–Base Imbalance or Risk for Acid–Base Imbalance. PTS: 1 CON: Acid–Base Balance 9. ANS: 3 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Apply the nursing process to clients with fluid, electrolyte, and acid–base imbalances. Page: 844 (V1) Heading: Table 38-5 Electrolyte Imbalances Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Analysis [Analyzing] Concept: Fluid and Electrolyte Balance Difficulty: Difficult Feedback 1 This is incorrect. IV infusion of D5W fluid is appropriate because this solution does not contain sodium. Hydrating the client with D5W would reduce the serum sodium level. 2 This is incorrect. Strict I&O monitoring would ensure that the client is safely rehydrated. 3 This is correct. Restricting the oral intake of a client with hypernatremia (Na+ greater than 145 mEq/L) would lead to further elevation in the serum sodium level. 4 This is incorrect. Monitoring laboratory evaluation of electrolytes every 4 hours

would ensure that the client is safely rehydrated. PTS: 1 CON: Fluid and Electrolyte Balance 10. ANS: 4 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Differentiate among active and passive transport, osmosis, diffusion, and filtration. Page: 1017 (V1) Heading: How Do Fluids and Electrolytes Move in the Body? > Passive Transport Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Remembering [Remembering] Concept: Fluid and Electrolyte Balance Difficulty: Easy Feedback 1 This is incorrect. Diffusion is a passive process by which molecules of a solute move through a cell membrane from an area of higher concentration to an area of lower concentration. Movement occurs until the concentrations are equivalent on both sides of the membrane. 2 This is incorrect. Osmosis is a form of passive transport that involves movement of water (or other pure solute) across a membrane from an area of a less concentrated solution to an area of more concentrated solution. Water moves across the membrane to dilute the higher concentration of solutes. Recall that a solute is a substance dissolved in body fluid. Solutes may be crystalloids or colloids. 3 This is incorrect. Filtration is the passive movement of both water and smaller particles from an area of high pressure to one of low pressure. 4 This is correct. Active transport occurs when molecules move across cell membranes from an area of low concentration to an area of high concentration. Active transport requires energy expenditure for the movement to occur against a concentration gradient. In the presence of adenosine triphosphate (ATP), the sodium–potassium pump actively moves sodium from the cell into the extracellular fluid. Active transport is vital for maintaining the unique composition of both the extracellular and intracellular compartments. PTS: 1 CON: Fluid and Electrolyte Balance 11. ANS: 2 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Describe the body mechanisms for maintaining fluid and electrolyte balance. Page: 1017 (V1) Heading: How Do Fluids and Electrolytes Move in the Body? > Fluid Output > Urine Integrated Processes: Nursing Process Client Need: Physiological Integrity

Cognitive Level: Analysis [Analyzing] Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 This is incorrect. The client has had 558 mL urine output in an 8-hour shift, and normal urine output for an average-sized adult is approximately 1,500 mL in 24 hours. 2 This is correct. Urine output varies according to intake and activity but should remain at least 30 to 50 mL per hour. The client’s urine output is within the normal range. 3 This is incorrect. Urine output varies according to intake and activity but should remain at least 30 to 50 mL per hour or 1500 mL in 24 hours. 4 This is incorrect. The client’s average urine output is within the normal range, that is, 30 to 50 mL per hour. PTS: 1 CON: Fluid and Electrolyte Balance 12. ANS: 4 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Describe the body mechanisms for maintaining fluid and electrolyte balance. Page: 1020 (V1) Heading: How Does the Body Regulate Electrolytes? Integrated Processes: Nursing Process Client Need: Physiological integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Fluid and Electrolyte Balance Difficulty: Easy Feedback 1 This is incorrect. The cardiac system is involved in fluid balance but not in electrolyte balance and not as dramatically in fluid balance as are the kidneys— that is, they do not actually regulate electrolytes. 2 This is incorrect. The vascular system is involved in fluid balance but not in electrolyte balance and not as dramatically in fluid balance as are the kidneys— that is, they do not actually regulate electrolytes. 3 This is incorrect. The pulmonary system plays a major role in regulation of acid–base balance. 4 This is correct. The kidneys are the principal regulator of fluid and electrolyte balance and are the primary source of fluid output. Specific hormones (e.g., antidiuretic hormone [ADH], aldosterone) cause the kidneys to regulate the body’s fluid and electrolyte balance. PTS: 1 13. ANS: 3

CON: Fluid and Electrolyte Balance

Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Describe the location and function of the major electrolytes of the body. Page: 1016 (V1) Heading: Body Fluids and Solutes > In Extracellular Fluid (ECF) Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Knowledge [Remembering] Concept: Fluid and Electrolyte Balance Difficulty: Easy Feedback 1 This is incorrect. Potassium is a key electrolyte in cellular metabolism. 2 This is incorrect. Calcium is responsible for bone health and neuromuscular and cardiac functions. It is also an essential factor in blood clotting. 3 This is correct. Sodium is the major action in extracellular fluid (ECF). Its primary function is to regulate fluid volume. When sodium is reabsorbed in the kidney, water and potassium are also reabsorbed, thereby maintaining ECF volume. 4 This is incorrect. Magnesium is a mineral used in more than 300 biochemical reactions in the body. PTS: 1 CON: Fluid and Electrolyte Balance 14. ANS: 1 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Summarize the major fluid and electrolyte balance disorders. Page: 1033 (V1) Heading: Imbalances: Fluid, Electrolyte, and Acid–Base Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Analysis [Analyzing] Concept: Fluid and Electrolyte Balance Difficulty: Difficult Feedback 1 This is correct. Hypovolemia may occur as a result of insufficient intake of fluid; bleeding; excessive loss through urine, the skin, or the gastrointestinal tract; insensible losses; or loss of fluid into a third space. The first symptom of hypovolemia is thirst. Other symptoms are a rapid, weak pulse, a low blood pressure (although initially the blood pressure may rise), dry skin and mucous membranes, decreased skin turgor, and decreased urine output. Temperature increases because the body is less able to cool itself through perspiration. The person with fluid volume deficit usually has elevated BUN (blood urea nitrogen) and hematocrit levels. 2 This is incorrect. Hypervolemia involves excessive retention of sodium and

water in the extracellular fluid, and the vital sign changes are opposite those of a client with hypovolemia. This is incorrect. The lab results do not indicate an issue with sodium levels, so hypernatremia is not applicable because the client’s sodium level is within normal range. This is incorrect. The sodium level is within normal range.

PTS: 1 CON: Fluid and Electrolyte Balance 15. ANS: 3 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Summarize the major fluid and electrolyte balance disorders. Page: 1033 (V1) Heading: Imbalances: Fluid, Electrolyte, and Acid–Base Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Analysis [Analyzing] Concept: Fluid and Electrolyte Balance Difficulty: Difficult Feedback 1 This is incorrect. There is no information to indicate that the client has respiratory problems or Impaired Gas Exchange. 2 This is incorrect. The client’s symptoms are not consistent with Excess Fluid Volume. 3 This is correct. Vomiting has made this client hypovolemic; therefore, the client has a Deficient Fluid Volume. There is no information to indicate that she has respiratory problems or Impaired Gas Exchange. Her symptoms are not consistent with Excess Fluid Volume. Electrolyte Imbalance is not a nursing diagnosis. 4 This is incorrect. Electrolyte Imbalance is not a nursing diagnosis. PTS: 1 CON: Fluid and Electrolyte Balance 16. ANS: 4 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Describe the body mechanisms for maintaining fluid and electrolyte balance. Page: 1033 (V1) Heading: Imbalances: Fluid, Electrolyte, and Acid–Base Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback

3 4

This is incorrect. Electrolyte imbalance does not necessarily occur with Deficient Fluid Volume; if electrolyte imbalance were present, the nursing diagnosis would be different. This is incorrect. Electrolyte imbalance does not necessarily occur with Deficient Fluid Volume; if electrolyte imbalance were present, the nursing diagnosis would be different. This is incorrect. This would be an appropriate goal for fluid volume excess, not deficit. This is correct. Moist mucous membranes and urinating every 4 hours would demonstrate restoration of fluid balance.

PTS: 1 CON: Fluid and Electrolyte Balance 17. ANS: 2 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Describe the body mechanisms for maintaining fluid and electrolyte balance. Page: 1033 (V1) Heading: Imbalances: Fluid, Electrolyte, and Acid–Base Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Comprehension [Understanding] Concept: Fluid and Electrolyte Balance Difficulty: Easy Feedback 1 This is incorrect. This indicates a normal range for sodium. 2 This is correct. A potassium level of 5.2 mEq/L indicates hyperkalemia. 3 This is incorrect. This indicates a normal range for calcium. 4 This is incorrect. This indicates a normal range for magnesium. PTS: 1 CON: Fluid and Electrolyte Balance 18. ANS: 4 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Apply the nursing process to clients with fluid, electrolyte, and acid–base imbalances. Page: 851 (V2) Heading: Table 38-8B Transfusion Reactions Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. Diphenhydramine (an antihistamine) may be ordered once the physician has been notified of the client’s condition.

2 3 4

This is incorrect. A new IV line of normal saline, not D5W should be hung. This is incorrect. There is no information indicating that the client is in danger of cardiovascular collapse or requires resuscitation. This is correct. The nurse should suspect a transfusion reaction. When a transfusion reaction is suspected, the infusion should be stopped immediately.

PTS: 1 CON: Safety 19. ANS: 4 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Apply the nursing process to clients with fluid, electrolyte, and acid–base imbalances. Page: 1036 (V1) Heading: Peripheral Vascular Access Devices > Complications of Intravenous Therapy Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Difficult Feedback 1 This is incorrect. Infiltration presents as erythema, pain, and swelling. However, there is no palpable cord with inflammation. 2 This is incorrect. Extravasation is infiltration of a vesicant substance into the tissues. Differentiating symptoms include blanching and coolness of the surrounding skin; the formation of blisters and subsequent tissue sloughing, and necrosis are later signs. 3 This is incorrect. A hematoma is a localized mass of blood outside the blood vessel. This is generally seen when a vein is nicked during an unsuccessful insertion of an IV line or when an IV line is discontinued without pressure applied over the site. 4 This is correct. Phlebitis is an inflammation of the vein. It may be caused by the infusion of solutions that are irritating to the vein. Clients receiving IV solutions with KCl are at a higher risk for phlebitis, as it is irritating to the vein. A palpable cord along the vein distinguishes this as phlebitis. PTS: 1 CON: Safety 20. ANS: 3 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Apply the nursing process to clients with fluid, electrolyte, and acid–base imbalances. Page: 1036 (V1) Heading: Peripheral Vascular Access Devices > Complications of Intravenous Therapy Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Application [Applying]

Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. Because the IV fluid has infiltrated, you must assume that the nurse has already checked the patency of the line by aspirating. There is no point in injecting saline because doing so puts even more fluid in the tissues. Injecting fluid to try to clear a clot from the catheter is not recommended because of the possibility of causing an embolism. 2 This is incorrect. Once the infusion is stopped, the nurse must assess whether the client needs additional IV therapy. If so, a new IV line must be restarted above the site of infiltration or in the opposite arm. 3 This is correct. The nurse should first stop the infusion to avoid further tissue trauma. 4 This is incorrect. The nurse may need to inform the primary care provider if she is unable to find a new IV site or if she believes the client no longer needs IV infusion. PTS: 1 CON: Safety 21. ANS: 1 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Describe the body mechanisms for maintaining fluid and electrolyte balance. Page: 1020 (V1) Heading: How Does the Body Regulate Electrolytes? > Bicarbonate & Table 38-3 Major Electrolytes Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 This is correct. The HCO3- is low (range 22–26 mEq/L). The kidneys regulate extracellular HCO3-to maintain acid–base balance. When serum levels rise, the kidneys excrete excess HCO3-. If serum levels are low, the kidneys conserve HCO3-. 2 This is incorrect. Although the HCO3- is low, it is that kidneys regulate extracellular bicarbonate to maintain acid–base balance. HCO3-is not consumed in the diet but is produced by the body to meet current needs. 3 This is incorrect. The HCO3- is low, not high (range 22–26mEq/L). The kidneys regulate extracellular HCO3-to maintain acid–base balance. When serum levels rise, the kidneys excrete excess HCO3-. If serum levels are low, the kidneys conserve HCO3-. 4 This is incorrect. HCO3- is low, and HCO3- is not consumed in the diet but is

produced by the body to meet current needs. PTS: 1 CON: Fluid and Electrolyte Balance 22. ANS: 3 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Apply the nursing process to clients with fluid, electrolyte, and acid–base imbalances. Page: 1019 (V1) Heading: Procedure 38-2 Regulating the IV Flow Rate, in Volume 2 Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate

1 2 3

Feedback This is incorrect. Refer to the formula to calculate micro-drip rates. This is incorrect. Refer to the formula to calculate micro-drip rates. This is correct. The nurse should calculate the drip rate by multiplying the number of milliliters to be infused per hour (hourly rate) by the drop factor in drops/mL, divided by 60 (minutes). An infusion of 250 mL in 2 hours results in an hourly rate of 125 mL/hr. 125 (mL/hr)  60 (drops/mL) = 125 drops/min 60 min This is incorrect. Refer to the formula to calculate micro-drip rates.

PTS: 1 CON: Safety 23. ANS: 3 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Summarize the major fluid and electrolyte balance disorders. Page: 1027 (V1) Heading: Table 38-5 Electrolyte Imbalances Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Analyzing [Analysis] Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 This is incorrect. Potassium levels affect the heart. A flat T wave is associated with hypokalemia. 2 This is incorrect. Phosphorous levels do not trigger ECG changes. 3 This is correct. Potassium levels affect the heart. A tall, peaked T wave on an ECG is associated with hyperkalemia. A flat T wave is associated with

hypokalemia. This is incorrect. Phosphorous levels do not trigger ECG changes.

PTS: 1 CON: Fluid and Electrolyte Balance 24. ANS: 4 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Summarize the major fluid and electrolyte balance disorders. Page: 1025 (V1) Heading: Imbalances: Fluid, Electrolyte, and Acid–Base Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 This is incorrect. Hypovolemia would not display these symptoms; BP would be low, pulse would be tachycardic and weak, and neck veins would be flat. 2 This is incorrect. These are not signs of hypokalemia, low blood potassium levels. 3 This is incorrect. These are not signs of hyperkalemia, high blood potassium levels. 4 This is correct. Hypervolemia results from retention of sodium and water. Blood pressure rises, the pulse is bounding, and neck veins become distended owing to increased intravascular volume. PTS: 1 CON: Fluid and Electrolyte Balance 25. ANS: 3 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Apply the nursing process to clients with fluid, electrolyte, and acid–base imbalances. Page: 1043 (V1) Heading: Clinical Insight 38-5 Managing Infiltration and Extravasation, in Volume 2 Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Application [Applying] Concept: Safety Difficulty: Easy Feedback 1 This is incorrect. There is no rationale to elevate the client’s left forearm. 2 This is incorrect. IV dressings are usually changed every 72 to 96 hours when the IV site is rotated. 3 This is correct. Reusing an IV set from a previous site increases the risk of contamination.

This is incorrect. There is no rationale to place the client in Fowler’s position.

PTS: 1 CON: Safety 26. ANS: 4 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Apply the nursing process to clients with fluid, electrolyte, and acid–base imbalances. Page: 844 (V2) Heading: Procedure 38-5 Changing IV Dressings, in Volume 2 Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Application [Applying] Concept: Safety Difficulty: Difficult Feedback 1 This is incorrect. Sterile gloves should be worn when placing the new sterile dressing; however, procedure gloves are used to remove the soiled dressing. 2 This is incorrect. The nurse should stabilize the catheter while removing the soiled dressing, but not apply pressure to the catheter–hub junction. 3 This is incorrect. The transparent dressing should cover the hub of the catheter, but not the catheter–hub junction; this makes it too difficult to remove without disturbing the integrity of the IV line or the site. 4 This is correct. Aseptic technique should be used when approaching the insertion site. Therefore, both nurse and client should wear a mask. If the client cannot wear a mask, have him turn his head away from the insertion site during the procedure. PTS: 1 CON: Safety 27. ANS: 2 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Identify the fluid compartments within the body. Page: 1025 (V1) Heading: Imbalances: Fluid, Electrolyte, and Acid–Base > What Are the Body Fluids Compartments? Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 This is incorrect. Intracellular fluid is located within the bloodstream and would not be assessed as edema. 2 This is correct. Interstitial fluid is contained in the spaces within the body cells

3 4

and will be manifested as edema. This is incorrect. Intravascular fluid is the plasma within the blood, allowing blood cells to be transported through the vessels. This is incorrect. Transcellular fluid is fluid located in body spaces (e.g., cerebrospinal fluid).

PTS: 1 CON: Fluid and Electrolyte Balance 28. ANS: 4 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Identify the fluid compartments within the body. Page: 1026 (V1) Heading: Assessment > Example Problem: Fluids, Electrolytes, and Acid–Base Imbalances & Volume 2 Diagnostic Testing Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 This is incorrect. The hematocrit level is lower than the range for men is 43% to 49%. Hematocrit is a blood test that measures the percentage of the volume of whole blood that is made up of red blood cells (RBCs). An elevated blood cell count would cause a less than normal fluid amount in relation to blood cells. 2 This is incorrect. The hematocrit level is lower than the range for men (i.e., 43% to 49%). Because hematocrit is a measure of fluid-to-cell ratio within the vascular system, transcellular fluid status would explain a low hematocrit value. 3 This is incorrect. Because hematocrit is a measure of fluid-to-cell ratio within the vascular system, extracellular fluid status would explain a low hematocrit value. The hematocrit level is lower than the range for men (i.e., 43% to 49%). 4 This is correct. The hematocrit is lower than the level range for men is 43% to 49%. Hematocrit is a blood test that measures the percentage of the volume of whole blood that is made up of RBCs. This measurement depends on the number of and size of RBCs in the vascular system, as well as the amount of fluid in blood. An “excess” of fluid in the intravascular space (e.g., overhydration) would explain a low hematocrit value because the number of cells would appear low in relation to the fluid volume. Low hematocrit, of course, has other causes (e.g., blood loss, decreased production of RBCs). PTS: 1 CON: Fluid and Electrolyte Balance 29. ANS: 2 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Apply the nursing process to clients with fluid, electrolyte, and acid–base imbalances.

Page: 860 (V2) Heading: Assessment Guidelines and Tools > Assessing for Trousseau’s and Chvostek’s Signs, in Volume 2 Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Analysis [Analyzing] Concept: Fluid and Electrolyte Balance. Difficulty: Moderate Feedback 1 This is incorrect. These are not signs of hyponatremia, or low serum sodium. 2 This is correct. This is Trousseau, a sign of low serum calcium, hypocalcemia. 3 This is incorrect. This is not a sign of low serum potassium, hypokalemia. 4 This is incorrect. This is not a sign of low serum phosphorous, hypophosphatemia. PTS: 1 CON: Fluid and Electrolyte Balance 30. ANS: 1 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Summarize the major fluid and electrolyte balance disorders. Page: 1026 (V1) Heading: Table 38-5 Electrolyte Imbalances Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 This is correct. The client is in renal failure and unable to excrete magnesium. The signs and symptoms are indicative of hypermagnesemia. 2 This is incorrect. The scenario and symptoms are not indicative of hyperkalemia. 3 This is incorrect. The scenario and symptoms are not indicative of hypercalcemia. 4 This is incorrect. The scenario and symptoms are not indicative of fluid overload. PTS: 1 CON: Fluid and Electrolyte Balance 31. ANS: 1 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Differentiate among active and passive transport, osmosis, diffusion, and filtration. Page: 1035 (V1) Heading: Types of Intravenous Solutions

Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 This is correct. Edema is the presence of excess fluid within the interstitial spaces. D5W is a hypotonic fluid in the body, and it has a tendency to pull fluids out of the intravascular compartment into the interstitial compartment and thus increase the client’s edema. 2 This is incorrect. Edema is the presence of excess fluid within the interstitial spaces. Hypertonic fluids, when administered, pull fluids and electrolytes from the intracellular and interstitial compartments into the intravascular compartment. Hypertonic fluids can help stabilize blood pressure, increase urine output, and reduce edema. D10W is a hypertonic fluid, so the nurse would likely not question a prescription for it. 3 This is incorrect. Edema is the presence of excess fluid within the interstitial spaces. Hypertonic fluids, when administered, pull fluids and electrolytes from the intracellular and interstitial compartments into the intravascular compartment. Hypertonic fluids can help stabilize blood pressure, increase urine output, and reduce edema. D5 0.9% NaCl is a hypertonic fluid, so the nurse would likely not question a prescription for it. 4 This is incorrect. Edema is the presence of excess fluid within the interstitial spaces. Hypertonic fluids, when administered, pull fluids and electrolytes from the intracellular and interstitial compartments into the intravascular compartment. Hypertonic fluids can help stabilize blood pressure, increase urine output, and reduce edema. D5LR is a hypertonic fluid, so the nurse would likely not question a prescription for it. PTS: 1 CON: Fluid and Electrolyte Balance 32. ANS: 2 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Apply the nursing process to clients with fluid, electrolyte, and acid–base imbalances. Page: 1019 (V1) Heading: How Does the Body Regulate Fluids? > Fluid Intake Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback

This is incorrect. The fluid requirement is 1,500 to 2,000 mL per day. Drinking 200 mL per meal provides 600 mL and with an additional 1,000 mL totals to 1,600, which is adequate. This is correct. The fluid requirement is 1,500 to 2,000 mL per day. Drinking 250 mL  3 meals provides a 750 mL intake. Adding 600 mL totals to only 1,350 mL per day. This is incorrect. The fluid requirement is 1,500 to 2,000 mL per day. Drinking 300 mL  3 meals = 900 mL; 900 + 1,000 yields a total of 1,900 mL, which is within the acceptable range. This is incorrect. The fluid requirement is 1,500 to 2,000 mL per day. Drinking 400 mL  3 meal – 1,200 mL+ 500 mL totals to 1,700 mL, which is within the acceptable range.

PTS: 1 CON: Fluid and Electrolyte Balance 33. ANS: 1 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Summarize the major fluid and electrolyte balance disorders. Page: 1026 (V1) Heading: Table 38-5 Electrolyte Imbalances Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Analysis [Analyzing] Concept: Fluid and Electrolyte Balance Difficulty: Difficult Feedback 1 This is correct. Excess intake of hypotonic solutions (e.g., several large bottles of water) will result in hyponatremia, explaining the symptoms described by this client. 2 This is incorrect. Sports drinks contain electrolytes lost through perspiration, so this would not explain the client’s symptoms, indicating hyponatremia. 3 This is incorrect. Steroid administration can result in hypokalemia, but the client’s symptoms do not match the symptoms of hypokalemia, so this is not a good explanation. 4 This is incorrect. The statement about diabetes does not provide information relevant to the client’s symptoms or to the situation. PTS: 1 CON: Fluid and Electrolyte Balance 34. ANS: 3 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Summarize the major fluid and electrolyte balance disorders. Page: 1026 (V1) Heading: Table 38-5 Electrolyte Imbalances

Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Analysis [Analyzing] Concept: Fluid and Electrolyte Balance Difficulty: Difficult Feedback 1 This is incorrect. Drinking too much water would explain hyponatremia, not hypercalcemia; also, the client did not say how much water she drank. 2 This is incorrect. Steroids would explain hypokalemia, but not hypercalcemia. 3 This is correct. The client is exhibiting symptoms of hypercalcemia. Thiazide diuretics can cause elevated calcium levels in the blood by decreasing the amount of calcium excreted in urine. Excessive intake of calcium would add to this effect and would explain why the symptoms occurred. 4 This is incorrect. Alcohol withdrawal would explain hypophosphatemia, but not hypercalcemia. PTS: 1 CON: Fluid and Electrolyte Balance 35. ANS: 4 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Compare and contrast respiratory and metabolic acidosis and alkalosis. Page: 1029 (V1) Heading: Table 38-7 Acid–Base Imbalances Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Analysis [Analyzing] Concept: Acid–Base Balance Difficulty: Moderate Feedback 1 This is incorrect. A client with respiratory alkalosis would present with confusion, difficulty focusing, headache, tingling, palpitations, and tremors; this would not be the anticipated problem based on the scenario in the question. 2 This is incorrect. A client with metabolic acidosis presents with headache, confusion, weakness, peripheral vasodilation, nausea and vomiting, and Kussmaul’s breathing; this would not be the expected diagnosis based on information presented in the scenario. 3 This is incorrect. A client with respiratory acidosis presents with increased pulse and respiratory rate, headache, dizziness, confusion, and muscle twitching. The scenario described would not result in respiratory acidosis. 4 This is correct. Metabolic alkalosis can result from excessive gastric secretion, and the symptoms would match the described symptoms. PTS:

CON: Acid–Base Balance

36. ANS: 2 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Describe compensatory mechanisms for acid–base imbalances. Page: 1029 (V1) Heading: Table 38-7 Acid–Base Imbalances Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Acid–Base Balance Difficulty: Moderate Feedback 1 This is incorrect. Because the client has metabolic alkalosis, his breathing is more likely to be slow and shallow, so both statements beginning with “He is breathing fast and deep” to affect his pH are incorrect. 2 This is correct. The client’s history suggests metabolic alkalosis (due to loss of acid in the stomach resulting from vomiting) so the client is likely to have decreased respiratory rate and depth as a means of retaining carbon dioxide and decreasing his pH. 3 This is incorrect. Because the client has metabolic alkalosis, his breathing is more likely to be slow and shallow, so both statements beginning with “He is breathing fast and deep” to affect his pH are incorrect 4 This is incorrect. In metabolic alkalosis, the pH is too high; trying to increase the pH by breathing slow and shallow would not be desirable, even if it were possible. PTS: 1 CON: Acid–Base Balance 37. ANS: 3 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Apply the nursing process to clients with fluid, electrolyte, and acid–base imbalances. Page: 1029 (V1) Heading: Table 38-7 Acid–Base Imbalances Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Acid–Base Balance Difficulty: Difficult Feedback 1 This is incorrect. Fluid administration will not reduce pH or increase carbon dioxide retention. 2 This is incorrect. Administering oxygen will not reduce pH or increase carbon dioxide retention and would be indicated only if partial pressure of oxygen (PO2) were low.

3 4

This is correct. The client’s PCO2 is too low and his pH is too high; reducing the breaths per minute will help the client to retain CO2, which will increase the pH. This is incorrect. Increasing the number of breaths per minute would further lower PCO2 and increase pH.

PTS: 1 CON: Acid–Base Balance 38. ANS: 1 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Apply the nursing process to clients with fluid, electrolyte, and acid–base imbalances. Page: 1029 (V1) Heading: Table 38-7 Acid–Base Imbalances Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Acid–Base Balance Difficulty: Moderate Feedback 1 This is correct. When the father used the paper bag, he rebreathed the carbon dioxide he was expelling to maintain adequate carbon dioxide levels and prevent or correct respiratory alkalosis. 2 This is incorrect. Rebreathing carbon dioxide would increase carbon dioxide levels and increase pH; it would not correct respiratory acidosis. 3 This is incorrect. The man’s problem is not a metabolic one; neither of the statements ending in “to correct metabolic alkalosis” is accurate. 4 This is incorrect. The man’s problem is not a metabolic one; neither of the statements ending in “to correct metabolic alkalosis” is accurate. PTS: 1 CON: Acid–Base Balance 39. ANS: 2 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Summarize the major fluid and electrolyte balance disorders. Page: 1033 (V1) Heading: Preventing Fluid and Electrolyte Imbalances > Table 38-5 Electrolyte Imbalances Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Fluid and Electrolyte Balance Difficulty: Easy Feedback 1 This is incorrect. Before teaching a client about consuming a high-calcium diet, more information would be needed to determine the client’s calcium intake. 2 This is correct. Reducing sodium intake helps promote fluid balance and prevent

fluid overload because sodium intake increases fluid retention. This is incorrect. Although a high potassium intake may be needed if the client is taking diuretics that cause potassium loss, more information would be needed to determine this; it is unlikely a low-potassium diet would be of benefit. This is incorrect. Magnesium deficiency is rare; low levels may be found in individuals who have a high alcohol intake. It is unlikely this client needs added magnesium.

PTS:

CON: Fluid and Electrolyte Balance

MULTIPLE RESPONSE 40. ANS: 1, 2, 5 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Describe the body mechanisms for maintaining fluid and electrolyte balance. Page: 1019 (V1) Heading: How Does the Body Regulate Fluids? Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Comprehension [Understanding] Concept: Fluid and Electrolyte Balance Difficulty: Moderate

1. 2. 3. 4.

Feedback This is correct. Specific hormones (e.g., antidiuretic hormone [ADH], aldosterone) cause the kidneys to regulate the body’s fluid and electrolyte balance). This is correct. The kidneys are the principal regulator of fluid and electrolyte balance and are the primary source of fluid output. This is incorrect. Although the thirst mechanism may stimulate the need for fluid intake, it does not regulate the fluid balance. This is incorrect. Oxygen saturation does not regulate fluids. It measures the saturation of oxygen on hemoglobin and is influenced by the partial pressure of oxygen, alveolar–arterial gradient lung disease, and the amount and type of hemoglobin (e.g., sickle cell anemia). This is correct. The integumentary system can cause sensible loss via perspiration.

PTS: 1 CON: Fluid and Electrolyte Balance 41. ANS: 2, 3, 4 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Apply the nursing process to clients with fluid, electrolyte, and acid–base imbalances. Page: 1026 (V1) Heading: Table 38-5 Electrolyte Imbalances

Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Fluid and Electrolyte Balance Difficulty: Moderate

Feedback This is incorrect. Fluids are restricted in clients with chronic renal failure because of decreased renal function. Therefore, encouraging oral fluids would not be appropriate. This is correct. Appropriate nursing interventions for this client include monitoring I&O, weighing the client before and after dialysis, following a strict renal diet, and monitoring laboratory values. This is correct. Appropriate nursing interventions for this client include monitoring I&O, weighing the client before and after dialysis, following a strict renal diet, and monitoring laboratory values. This is correct. Appropriate nursing interventions for this client include monitoring I&O, weighing the client before and after dialysis, following a strict renal diet, and monitoring laboratory values. This is incorrect. The client is at risk for electrolyte imbalances, such as hypermagnesemia and hyperkalemia; therefore, the client should be on a strict renal diet that is low in electrolytes, such as potassium and magnesium.

PTS: 1 CON: Fluid and Electrolyte Balance 42. ANS: 1, 3, 4 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Describe compensatory mechanisms for acid–base imbalances. Page: 1024 (V1) Heading: How Is Acid–Base Balance Regulated? Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Acid–Base Balance Difficulty: Moderate

Feedback This is correct. The lungs (respiratory mechanisms) control the carbonic acid supply via carbon dioxide. Conditions that cause retention of carbon dioxide, such as chronic obstruction pulmonary disease, lower the pH, whereas tachypneic conditions, such as hyperventilation syndrome, “blow off” carbon dioxide and increase the pH. This is incorrect. Active transport involves the movement of fluids and electrolytes

4. 5.

in the body. This is correct. The kidneys (renal mechanisms) regulate the concentration of plasma bicarbonate. By reabsorbing or excreting bicarbonate, the kidneys affect acid–base balance. This is correct. Buffer systems prevent wide swings in pH by absorbing or releasing free hydrogen ions. This is incorrect. Osmotic pressure involves the movement of fluids and electrolytes in the body.

PTS: 1 CON: Acid–Base Balance 43. ANS: 2, 3, 4 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Apply the nursing process to clients with fluid, electrolyte, and acid–base imbalances. Page: 1033 (V1) Heading: Preventing Fluid and Electrolyte Imbalances Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Fluid and Electrolyte Balance Difficulty: Easy

1. 2. 3. 4. 5.

Feedback This is incorrect. Deep-breathing techniques do not address fluid balance; there is no evidence that the client has a respiratory disorder. This is correct. Hypovolemia occurs when more fluid is lost than is taken into the body. Monitoring I&O provides information to evaluate the status of the problem. This is correct. Hypovolemia occurs when more fluid is lost than is taken into the body. Encouraging fluid intake helps to correct the problem. This is correct. It is good to monitor electrolytes because electrolyte imbalance can occur with hypovolemia (although it may not occur at first). This is incorrect. Monitoring daily weights would be appropriate to monitor for fluid overload, not dehydration.

PTS: 1 CON: Fluid and Electrolyte Balance 44. ANS: 2, 3 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Apply the nursing process to clients with fluid, electrolyte, and acid–base imbalances. Page: 1047 (V1) Heading: Blood Typing and Crossmatching Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Analysis [Analyzing]

Concept: Safety Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is incorrect. Those with blood group AB may receive AB, A, B, and O blood. Blood group A persons may receive blood from A and O donors. This is correct Persons with blood group B can receive blood only from the blood groups B and O. This is correct. Persons with blood group B can receive blood only from the blood groups B and O. This is incorrect. Blood group AB persons are considered universal recipients, and blood group O persons are considered universal donors. This is incorrect. There is no AO blood type.

PTS: 1 CON: Safety 45. ANS: 1, 3, 5 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Apply the nursing process to clients with fluid, electrolyte, and acid–base imbalances. Page: 1022 (V1) Heading: Clinical Insight 38-3: Guidelines for Selecting a Peripheral Venipuncture Site, in Volume 2 Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate

1. 2. 3. 4.

Feedback This is correct. The opposite extremity (e.g., left hand) may be used. This is incorrect. The IV line after an infiltration should be inserted above the old site. This is correct. When restarting an IV line after an infiltration, you must restart above the site of infiltration. As a result, the right antecubital area is correct. This is incorrect. The right saphenous vein is incorrect because that vein is located in the leg. The leg should be used as a last resort for an IV site. The primary care provider should be notified if a leg is being considered as an IV site. This is correct. The opposite extremity may be used to restart an IV after an infiltrate.

PTS: 1 CON: Safety 46. ANS: 3, 4, 5 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance

Objective: Describe the body mechanisms for maintaining fluid and electrolyte balance. Page: 1036 (V1) Heading: Types of Intravenous Solutions Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Difficult

3. 4. 5.

Feedback This is incorrect. Hypovolemia occurs when there is a proportional loss of water and electrolytes from the ECF. Lactated Ringer’s and 0.9% (normal) saline are isotonic fluids that remain inside the intravascular space, thus increasing volume. The D5W is a hypotonic solution that would pull body water from the intravascular compartment into the interstitial fluid compartment. D50W is used to treat diabetic clients who have severe hypoglycemia (low blood sugar). This is incorrect. Hypovolemia occurs when there is a proportional loss of water and electrolytes from the ECF. Lactated Ringer’s and 0.9% (normal) saline are isotonic fluids that remain inside the intravascular space, thus increasing volume. This is correct. The D5W is a hypotonic solution that would pull body water from the intravascular compartment into the interstitial fluid compartment. This is correct. D50W is used to treat diabetic clients who have severe hypoglycemia (low blood sugar). This is correct. There is no indication that the client is hypokalemic, so the added potassium is not indicated.

PTS: 1 CON: Safety 47. ANS: 1, 2, 5 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Apply the nursing process to clients with fluid, electrolyte, and acid–base imbalances. Page: 852 (V2) Heading: Procedure 38-9 Assisting with Percutaneous Central Venous Catheter Placement, in Volume 2 Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate

Feedback This is correct. Maximum barrier sterile technique is used for CVC insertion (sterile gloves, mask, and gown), although some agency policies do not include sterile gown

2. 3.

4. 5.

for the nurse. This is correct. This is an invasive procedure, so informed consent is required. The nurse should confirm that this has been obtained. This is incorrect. The scrub is not done with antibacterial soap. The scrub is done with chlorhexidine–alcohol solution or, alternatively, first with 70% alcohol and then with povidone detergent. This is incorrect. The client is placed in Trendelenburg position with a rolled towel between the shoulders for best site access. This is correct. The client should wear a mask or turn their head, if done at the bedside, as this is a sterile procedure.

PTS: 1 CON: Safety 48. ANS: 1, 4, 5 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Apply the nursing process to clients with fluid, electrolyte, and acid–base imbalances. Page: 1029 (V1) Heading: Table 38-7 Acid–Base Imbalances Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Acid–Base Balance Difficulty: Moderate

2. 3.

4. 5.

Feedback This is correct. Treatment for metabolic acidosis is aimed at correcting the underlying problem, which includes glucose regulation; that would be achieved by administering insulin. This is incorrect. Tylenol will not resolve the client’s headache unless the metabolic acidosis is also resolved. This is incorrect. Mechanical ventilation is not indicated, because while metabolic acidosis exists, the breathing pattern helps to compensate; correction of metabolic acidosis will correct the breathing pattern. This is correct. Dialysis for kidney failure is aimed at treating an underlying cause of the metabolic acidosis and would be anticipated. This is correct. Bicarbonate administration can reduce pH and begin the process of resolving the problem.

PTS: 1 CON: Acid–Base Balance 49. ANS: 1, 3, 4 Chapter: Chapter 38 Fluids, Electrolytes, & Acid–Base Balance Objective: Describe the body mechanisms for maintaining fluid and electrolyte balance & Summarize the major fluid and electrolyte balance disorders.

Page: 1032 (V1) Heading: Planning Outcomes/Evaluation > Example Problem: Fluids, Electrolytes, and Acid–Base Imbalances Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Fluid and Electrolyte Balance Difficulty: Difficult

1. 2.

Feedback This is correct. Urine output within normal limits (e.g., 35 mL/hr) would indicate the client’s fluid status has returned to homeostasis. This is incorrect. Elevated antidiuretic hormone levels do not indicate fluid homeostasis: Antidiuretic hormone causes the kidneys to retain fluid, which would be seen while the client was dehydrated but should return to normal levels with homeostasis, rather than being elevated. This is correct. Renin converts angiotensinogen to angiotensin II to retain sodium and water. Absence of renin would indicate water is no longer being reabsorbed and fluid homeostasis has been reached; therefore, a reduced renin production would indicate “return” to fluid homeostasis. This is correct. Aldosterone promotes reabsorption of sodium resulting in passive reabsorption of water and will be elevated during periods of dehydration. Production will decline with return to fluid homeostasis. This is incorrect. Formed stools will occur when the bowel returns to normal function, but this is not an indicator of fluid homeostasis.

PTS:

CON: Fluid and Electrolyte Balance

Chapter 39. Perioperative Care Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The preoperative phase encompasses which period of time? 1. Entry to the operating suite until admission to postanesthesia care 2. Entry into the operating suite until discharge from the hospital 3. The decision to have surgery until admission to postanesthesia care 4. The decision to have surgery until entry to the operating suite 2. A 2-year-old child is scheduled for a tonsillectomy. When determining the plan of care, what should the nurse do? 1. Include the parents or caregivers in the plan of care. 2. Explain to the child that she will have a sore throat after surgery. 3. Tell the child that she can have her favorite foods for the first 24 hours after surgery. 4. Prepare the child for discharge from the hospital as soon as she is alert. 3. The nurse is preparing client care for several surgical cases. The nurse is aware that knowing the type of surgery helps identify needs to plan client care. Which of the following surgeries would pose a higher risk for infection? 1. Repair of a stab wound to the lower leg 2. Tonsillectomy of a preschool-age client 3. Cardiac catheterization via the femoral artery 4. Laparoscopic cholecystectomy 4. The nurse is providing care to the client in the preoperative phase. Which of the following are the nurse’s activities related to this phase? 1. Admit the client to the surgical suite. 2. Prepare the client mentally and physically for surgery. 3. Set up the sterile field in the operating room. 4. Perform the primary surgical scrub to the surgical site. 5. The nurse is gathering preoperative data on a client that is scheduled for abdominal surgery tomorrow. The nurse learns that the client takes the following medications daily: warfarin, a multivitamin, and vitamin E. The client reports that he stopped taking the anticoagulant 4 days ago, as instructed by the surgeon. He has continued to take the multivitamin and vitamin E. Based on the information given, why does the nurse notify the surgeon? 1. Needs an order to restart the anticoagulant 2. Is concerned about continued use of the multivitamin 3. Is concerned about the vitamin E 4. Has canceled the surgery to evaluate lab values

6. The nurse is assessing a client admitted for a total hip arthroplasty under general anesthesia. The client reports that her spouse had a “nasty cold” last week and states she now has a cough and “little tickle” in their throat. The nurse notes mild rhonchi in both bases of the lung fields. Which of the following nursing diagnoses would best explain why the nurse contacted the surgeon and anesthesiologist for a possible postponement of the surgery? 1. Risk for pneumonia due to cough and rhonchi in lungs 2. Risk for infection related to exposure to infection and cough 3. Risk for noncompliance related to inability to follow instructions 4. Risk for caregiver role strain due to spouse’s acute illness 7. A client is admitted from a local skilled nursing facility to the outpatient surgery center for surgical debridement of a stage 4 sacral pressure ulcer. The perioperative nurse discovers that the client does not have a signed consent form for the surgery on the chart or in the surgery center. The client says that she has not talked to the surgeon and that she has many questions regarding her surgery. When informed of this, the surgeon tells the nurse to have the client sign the informed consent form, and he will review it prior to the surgery. What should the nurse do? 1. Follow the surgeon’s orders, and ask the client to sign the surgical consent form. 2. Inform the surgeon that she will have the client sign after he discusses the surgery with the client. 3. Ensure that the signed surgical consent is witnessed by two nurses because the surgeon is not available. 4. Cancel the surgery and transfer the client back to the long-term care facility. 8. Identify the type of surgery a terminally ill client will undergo if the purpose is removal of tissue to relieve pain. 1. Procurement 2. Ablative 3. Palliative 4. Diagnostic 9. A client had a hiatal hernia repair earlier today and is now in the postanesthesia care unit (PACU). The family asks the nurse why the client is in the PACU rather than back in his room on the postsurgical unit. What should the nurse inform the family? 1. Clients who have had surgical complications are observed in the PACU until they are stable enough to return to the floor. 2. Clients recover from the effects of anesthesia in the PACU and then return to the postsurgical unit for further care. 3. The PACU is a holding area for clients awaiting a surgical unit bed or awaiting adequate staff to provide care on the postsurgical unit. 4. The nurse will ask the surgeon to explain to them why the client is not on the postsurgical unit as per usual procedure.

10. The client is scheduled for a bronchoscopy. The client states that they are mildly anxious but is afraid of “going to sleep and never waking up.” Which type of anesthesia would be most appropriate for the client? 1. General anesthesia 2. Peripheral block 3. Regional block 4. Conscious sedation 11. A client has chronic confusion secondary to dementia. As a result, he is unable to sign an informed consent for surgery. What is required in this situation? 1. An informed consent is not needed. 2. Two nurses may witness the client’s signature. 3. The surgeon must sign the informed consent. 4. The person with power of attorney should sign the informed consent. 12. The client tells the nurse, “I’m so nervous. I want to be knocked out for the surgery so that I don’t know what is going on.” When the nurse communicates with the surgeon and anesthetist, she tells them that the client desires which type of anesthesia? 1. Conscious sedation 2. General anesthesia 3. Local anesthesia 4. Regional anesthesia 13. A client is to have a sequential compression device (SCD) applied on the postoperative unit. The client is wearing knee-high elastic (antiembolism) stockings. When applying the SCD, what should the nurse do? 1. Remove the antiembolism stockings and not replace them. 2. Replace the knee-high stockings with thigh-high stockings. 3. Notify the surgeon that the client is wearing antiembolism stockings. 4. Apply the SCD over the knee-high antiembolism stockings. 14. To promote deep breathing, coughing, and turning by a postoperative client on the first postoperative day, what would be the best action by the nurse? 1. Teach the client the purpose of respiratory care and ambulation. 2. Provide constant reinforcement for accomplishing these activities. 3. Assess the client’s pain level before these activities. 4. Emphasize the complications of immobility and poor cough effort. 15. The nurse is assessing the client who is status 4 hours post total knee arthroplasty. The assessment is as follows: blood pressure (BP) 90/60 mm Hg, pulse (P) 94 beats/min; respirations (R) 16 breaths/min; temperature (T) 98.6F, dressing is saturated with frank red blood. The nurse reinforces the dressing and contacts the surgeon. What is the nurse’s main concern regarding this client? 1. The client may be hemorrhaging. 2. The client may be hypovolemic.

3. The client is developing an infection. 4. The client is developing a thrombus. 16. The nurse is providing care to a client scheduled for repair of a torn rotator cuff. The nurse understands that this surgery will be classified as what? 1. Reconstructive, minor, elective 2. Cosmetic, minor, urgent 3. Ablative, major, emergent 4. Reconstructive, major, urgent 17. The preoperative nurse is preparing clients for surgery. Which client does the nurse classify as facing the highest surgical risk? 1. A 40-year-old with hepatitis secondary to past IV drug use 2. An 83-year-old smoker with medically controlled hypertension 3. A 6-month-old with congenital heart anomaly and early stage liver disease 4. A 28-year-old taking anticoagulants secondary to mitral valve prolapse 18. The client asks the preoperative nurse why all of the team members took a time-out before starting the procedure. Which of the following is the nurse’s best response? 1. “This is one of our safety steps to verify you and your surgical procedure.” 2. “This gives the team a chance to rest before performing your procedure.” 3. “This is one way that we prevent complications prior to your surgery.” 4. “This verifies that you have signed the consent form and agree to the surgery.” 19. The client is scheduled for outpatient cholecystectomy (gall bladder removal) in 2 weeks. Based on the client’s history, the nurse includes which of the following in the preoperative plan of care? 1. Tell the client to avoid smoking on the day of surgery. 2. Use a safety razor to shave the abdomen the day before surgery. 3. Ask the surgeon to prescribe antibiotics to be given preoperatively. 4. Tell the client to inform the surgeon of allergies and chronic health conditions. 20. The staff RN is assigned to an operation with an operating room LPN. The physician employs another RN who will be first assistant for the operation. What role will the staff RN play? 1. Scrub nurse 2. Anesthesiologist 3. Circulating nurse 4. Technician 21. In the emergency department (ED), the client is diagnosed with a dislocated humerus. What type of anesthesia would the nurse anticipate will be used to repair the dislocation in the ED? 1. General 2. Epidural 3. Conscious sedation 4. Local

22. The intraoperative nurse observes the anesthesiologist administer general anesthesia, insert the endotracheal tube, and take control of the airway. The nurse understands that the next important nursing intervention for this client is to: 1. Prepare the surgical site. 2. Shave the surgical site. 3. Position the client. 4. Pad bony prominences. 23. The postoperative client is admitted to the postanesthesia care unit (PACU) with an oral airway in place, an indwelling urinary catheter, IV fluid infusing via two different sites, and a Jackson-Pratt drain pinned to the gown near the wound dressing. What is the nurse’s priority action after the client is moved to the bed? 1. Check the wound dressing. 2. Obtain vital signs. 3. Turn the client’s head to the side. 4. Hang the urinary drainage bag on the bed frame. 24. The postoperative client returned to the surgical nursing unit at 1:30 p.m. The evening shift nurse receives the report and begins working at 3:30 p.m. How often will the evening shift nurse take this client’s vital signs? 1. Immediately, then every 30 minutes for the next 2 hours 2. Immediately, then every hour for the next 4 hours 3. Every hour beginning 30 minutes from now until end of shift 4. Immediately, then every 30 minutes 2 more times, then hourly 25. The nurse is caring for a client with a Salem-sump double-lumen nasogastric (NG) tube to suction. The client complains of nausea and has mild abdominal distention. What is the nurse’s priority action? 1. Administer an antiemetic. 2. Replace the nasogastric tube. 3. Check placement of the NG tube. 4. Irrigate the NG tube. 26. The nurse admits a client who is scheduled for surgery tomorrow morning. The nursing admission assessment indicates that the client is mildly anxious about the procedure, does not drink alcohol or smoke, is married with two children, and is allergic to kiwi, avocados, and penicillin. The nurse identifies the priority nursing diagnosis for this client as: 1. Fear 2. Anxiety 3. Risk for Latex Allergy Response 4. Ineffective Airway Clearance 27. The nurse admits a client to the postoperative unit following gastric bypass surgery for weight loss. Based on the client’s history, what is the priority nursing diagnosis for this client? 1. Risk for Infection

2. Delayed Surgical Recovery 3. Chronic Pain 4. Risk for Deficient Fluid Volume Multiple Response Identify one or more choices that best complete the statement or answer the question. 28. The surgical nurse manager is preparing the schedule based on classification. Surgeries are commonly classified by which of the following? Select all that apply. 1. Acuity 2. Level of urgency 3. Length of surgery 4. Body system 5. Type of anesthesia 29. Which of the following describes the Perioperative Nursing Data Set (PNDS)? Select all that apply. 1. A standardized tool for assessing high-risk surgical clients 2. A standardized vocabulary encompassing all surgical client outcomes 3. The first specialized nursing language recognized by the American Nurses Association (ANA) 4. A standardized language designed to describe the care of perioperative clients 5. The standard for safety in staffing levels of perioperative nurses 30. The nurse is caring for a client who had abdominal surgery 3 days ago and will be discharged home later today. The nurse will know that teaching is effective if the client does which of the following? Select all that apply. 1. Describes clinical findings associated with infection 2. Performs the dressing change as prescribed 3. Demonstrates absence of surgical incision pain 4. Completes the regimen of prescribed antibiotics 5. Completes bowel management regimen 31. The circulating nurse is providing care to the surgical client during the interoperative phase. Which of the following are components of the circulating nurse’s focus to prevent complications during the surgery? Select all that apply. 1. Monitor the client’s intake and output. 2. Create the operative field, cleanse the site. 3. Maintain the “nontouch” field prior to surgery. 4. Send the pathology specimens to the laboratory. 5. Apply antiembolism stockings in recovery. 32. The nurse is preparing the client for general anesthesia. The client asks what the desired effects of general anesthesia are. Select all that apply.

1. 2. 3. 4. 5.

Risk reduction Analgesia Amnesia Muscle relaxation Reduced Infection

33. The preoperative nurse is preparing a client for surgery. Identify the interventions the nurse will perform. Select all that apply. 1. Inform the family to wait in the surgical waiting room. 2. Prepare the surgical suite for the operation. 3. Remove the client’s dentures and contact lenses. 4. Assist the client to complete a living will. 5. Describe who will be in the operating suite. 34. A client had a colon resection for removal of a cancerous tumor. Postoperatively, on the surgical floor, which of the following activities would the nurse perform for the purpose of decreasing the risk of postoperative complications? Select all that apply. 1. Assist the client to turn, breathe deeply, and cough every 2 hours. 2. Teach the client about the type of tumor removed. 3. Assess the drainage from the surgical site. 4. Monitor vital signs on a regular basis. 5. Instruct how to change the sterile dressings. 35. A client returns from surgery with a nasogastric tube and intermittent gastric suction to provide abdominal decompression. Which of the following are correct nursing activities for managing the equipment and drainage? Select all that apply. 1. Wear nonsterile gloves when emptying the drainage container. 2. When irrigating the nasogastric tube, use sterile water. 3. Wear sterile gloves when irrigating the nasogastric tube. 4. Apply water-soluble lubricant if the client’s lips are dry. 5. Document the consistency and amount of drainage. 36. The perioperative nurse maintains the safety of the client during surgery with which of the following goals? Select all that apply. 1. Preventing infection 2. Improving the accuracy of client identification 3. Preventing mistakes in surgery 4. Obtaining signed consent for surgery 5. Keeping the family informed of the client’s status 37. The nurse is caring for a client who is wearing antiembolism compression stockings. The client repeatedly complains of discomfort caused by the stockings. What actions will the nurse take to improve comfort? Select all that apply. 1. Assess to determine whether the stockings are the correct size. 2. Remove the stockings for the remainder of the shift.

3. Ensure there are no wrinkles or rolled areas in the stockings. 4. Check that the stockings are on straight and the heel is in the right place. 5. Make sure the closed toe is molded to the toes.

Chapter 39. Perioperative Care Answer Section MULTIPLE CHOICE 1. ANS: 4 Chapter: Chapter 39 Perioperative Care Objective: Name and differentiate the three phases of the perioperative period. Page: 1059 (V1) Heading: Perioperative Nursing > Preoperative Care Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Easy Feedback 1 This is incorrect. The intraoperative phase begins when the client enters the operating suite and ends when the client is admitted to the postanesthesia care unit. 2 This is incorrect. This is not a phase of perioperative care. 3 This is incorrect. This is a combination of the perioperative and intraoperative phases. 4 This is correct. The preoperative phase begins with the decision to have surgery and ends when the client enters the operating room. PTS: 1 CON: Patient-Centered Care 2. ANS: 1 Chapter: Chapter 39 Perioperative Care Objective: Use nursing diagnoses appropriately to describe a patient’s unique needs during the preoperative, intraoperative, and postoperative periods. Page: 1060 (V1) Heading: What Factors Affect Surgical Risk? > Age: Toddlers Integrated Processes: Caring Client Need: Psychosocial Integrity Cognitive Level: Synthesis [Creating] Concept: Growth and Development Difficulty: Moderate Feedback 1 This is correct. It is developmentally normal for toddlers to experience anxiety with separation from parents or caregivers. Be sure to include these people in the plan of care. 2 This is incorrect. Developmentally, a 2-year-old lives in the “here and now” and

wouldn’t grasp an intangible concept, such as pain in the future. This is incorrect. The toddler would take liquids and soft foods within the first 24 hours when her throat is sore during swallowing. She should not eat foods that are rough and crunchy because they may scratch her throat and cause bleeding. This is incorrect. After a tonsillectomy, the child will need to be monitored for bleeding and stable vital signs; therefore, she will not be discharged as soon as she is alert.

PTS: 1 CON: Growth and Development 3. ANS: 1 Chapter: Chapter 39 Perioperative Care Objective: Describe ways in which surgeries can be classified. Page: 1059 (V1) Heading: How Are Surgeries Classified? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Safety Difficulty: Difficult

Feedback This is correct. The body system classification is useful for determining the postoperative risk of infection. For example, surgical incisions that enter the gastrointestinal, respiratory, or genitourinary tract have a higher risk for infection than does surgery of other body systems. However, if an organ ruptures or surgery is required to repair a penetrating injury, the risk of infection is very high regardless of the body system involved. This is incorrect. The body system classification is useful for determining the postoperative risk of infection. For example, surgical incisions that enter the gastrointestinal, respiratory, or genitourinary tract have a higher risk for infection than does surgery of other body systems. Although this is a high risk for infection, the penetrating wound is at a higher risk. This is incorrect. This is at a lower risk for infection than the penetrating wound. Diagnostic (exploratory) surgery is done to confirm or rule out a diagnosis. Examples include biopsy, fine-needle aspiration, or invasive testing, such as a cardiac catheterization. This is incorrect. Ablative surgery involves removal of a diseased body part. For example, a cholecystectomy removes a diseased gallbladder and holds a lower risk of infection. PTS:

CON: Safety

4. ANS: 2 Chapter: Chapter 39 Perioperative Care Objective: Describe nursing actions associated with the preoperative phase, including physical preparations for surgery, preoperative teaching, and surgical consent forms. Page: 1059 (V1) Heading: Preoperative Care Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Easy

1 2 3 4

Feedback This is incorrect. The client is in the intraoperative phase when admitted to the surgical suite. This is correct. The nursing focus in the preoperative phase is to prepare the client mentally and physically for surgery. This is incorrect. The sterile field and the surgical scrub would be performed in the surgery suite during the intraoperative phase. This is incorrect. This is a component of intraoperative nursing.

PTS: 1 CON: Patient-Centered Care 5. ANS: 3 Chapter: Chapter 39 Perioperative Care Objective: Discuss the importance of perioperative safety & Discuss factors that affect the degree of risk of surgery. Page: 1060 (V1) Heading: What Factors Affect Surgical Risk? Medications Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Difficult Feedback 1 This is incorrect. Generally, the surgeon or the anesthesiologist instructs clients to continue or discontinue taking their prescribed medicines. However, it is important to assess use of supplements and over-the-counter medicines. 2 This is incorrect. The use of a multivitamin, such as vitamin E, does not pose a risk for complications. 3 This is correct. Both prescribed and over-the-counter medications may increase surgical risks. Many herbs can cause potassium loss and increase the risk for cardiac arrhythmias. Vitamin E may increase the risk for bleeding. This client’s

use of vitamin E daily should be discontinued 2 weeks prior to surgery, so the nurse should inform the surgeon of the vitamin E intake. This is incorrect. The nurse cannot cancel surgery without an order from the surgeon, who determines whether the surgery should be delayed or whether it is so urgent that it needs to continue as scheduled, even in the presence of a risk factor (e.g., vitamin E intake).

PTS: 1 CON: Safety 6. ANS: 2 Chapter: Chapter 39 Perioperative Care Objective: Use nursing diagnoses appropriately to describe a patient’s unique needs during the preoperative, intraoperative, and postoperative periods. Page: 1063 (V1) Heading: Focused Physical Assessment Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Difficult Feedback 1 This is incorrect. There is no indication that the client has pneumonia, which is a medical diagnosis, not a nursing diagnosis. 2 This is correct. If the client states she had a cough last week, perform a focused assessment of the ear, nose, throat, and lungs to determine how the cough may affect the patient’s risk. If the patient has lower airway congestion, as evidenced by rhonchi and productive cough, communicate these findings to the surgeon and the anesthesia team; if general anesthesia is planned, it may be necessary to delay the surgery. 3 This is incorrect. There is no indication that the client did not follow any preoperative instructions. 4 This is incorrect. Although the spouse may still be ill with a “nasty cold,” it does not provide enough information to state that there will be any strain on the spouse or client as far as care. PTS: 1 CON: Safety 7. ANS: 2 Chapter: Chapter 39 Perioperative Care Objective: Describe nursing actions associated with the preoperative phase, including physical preparations for surgery, preoperative teaching, and surgical consent forms. Page: 1066 (V1) Heading: Planning Interventions/Implementation > Confirm That Surgical Consent Has Been Obtained

Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Cognitive Level: Application [Applying] Concept: Legal Difficulty: Moderate Feedback 1 This is incorrect. Obtaining informed consent is the surgeon’s responsibility. The surgeon is responsible for giving the client the necessary information and determining the client’s competence to make an informed decision about the surgery. 2 This is correct. Informed surgical consent requires that the surgeon communicates information about the surgery to the client, that the client understands the communication and agrees to the surgery, and that the client has not been coerced to give consent. As a client advocate, the nurse should verify with the client that the surgeon has explained the procedure and answered all her questions. The surgeon is responsible for giving the client the necessary information and determining the client’s competence to make an informed decision about the surgery. 3 This is incorrect. Informed surgical consent requires that the surgeon communicates information about the surgery to the client, that the client understands the communication and agrees to the surgery, and that the client has not been coerced to give consent. The surgeon is responsible for giving the client the necessary information and determining the client’s competence to make an informed decision about the surgery. 4 This is incorrect. The nurse does not have the authority to cancel the surgery, but as a client advocate, must notify the surgeon and delay sending the client to the surgery until informed consent is obtained. PTS: 1 CON: Legal 8. ANS: 3 Chapter: Chapter 39 Perioperative Care Objective: Describe ways in which surgeries can be classified. Page: 1063 (V1) Heading: Preoperative Care > How Are Surgeries Classified? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Knowledge [Remembering] Concept: Patient-Centered Care Difficulty: Easy Feedback 1 This is incorrect. Procurement surgery occurs when an organ or tissue is harvested for transplantation into another.

2 3 4

This is incorrect. Ablative surgery involves removal of a body part. This is correct. Palliative surgery alleviates discomfort or other disease symptoms without producing a cure. This is incorrect. Diagnostic surgery confirms or rules out a diagnosis.

PTS: 1 CON: Patient-Centered Care 9. ANS: 2 Chapter: Chapter 39 Perioperative Care Objective: Use nursing diagnoses appropriately to describe a patient’s unique needs during the preoperative, intraoperative, and postoperative periods. Page: 1077 (V1) Heading: Recovery from Anesthesia Integrated Processes: Safe and Effective Care Environment: Management of Care Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Admission to the PACU does not indicate surgical complications. 2 This is correct. A client remains in the PACU until he has recovered from the effects of anesthesia. In the PACU, the client is assessed every 5 to 15 minutes so that the nurse may quickly identify surgical or anesthesia-related problems. Most surgical units routinely admit clients to the PACU for a period of observation. 3 This is incorrect. Admission to the PACU does not imply that a holding area is required. 4 This is incorrect. There is no reason the surgeon would need to explain this to the family, as the nurse could communicate the procedure. It is not usual procedure for a client to be transferred directly from surgery to the postsurgical unit. PTS: 1 CON: Safety 10. ANS: 4 Chapter: Chapter 39 Perioperative Care Objective: Compare and contrast general anesthesia, local anesthesia, regional anesthesia, and conscious sedation. Page: 1072 (V1) Heading: Types of Anesthesia Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Comprehension [Understanding]

Concept: Safety Difficulty: Easy Feedback 1 This is incorrect. General anesthesia produces rapid unconsciousness and loss of sensation. The anesthesiologist or nurse–anesthetist administers inhaled and intravenous medications that depress the patient’s central nervous system and relax the musculature. Muscle relaxants, paralyzing agents, narcotics, barbiturates, and inhaled gases are some of the agents used during general anesthesia. 2 This is incorrect. Peripheral nerve block is injection of an anesthetic into and around a nerve or group of nerves (e.g., the facial nerve). A Bier (intravenous) block is a nerve block technique in which the anesthetist places a tourniquet on an arm or leg and then injects a local anesthetic agent intravenously below the level of the tourniquet. The tourniquet is maintained at a pressure that limits venous return but continues to allow arterial circulation. The patient feels no pain in the extremity as long as the tourniquet is in place. 3 This is incorrect. Regional anesthesia prevents pain by interrupting nerve impulses to and from the area of the procedure. The patient remains alert, but is numb in the involved area. Regional anesthesia may be administered by infiltration of the surgical site and surrounding tissue with local anesthetics, such as lidocaine or bupivacaine. These medications may also be injected into and around specific nerves to depress the sensory, motor, and/or sympathetic impulses of a limited area of the body. This is not the best type of anesthesia for bronchoscopy. 4 This is correct. Conscious sedation is an alternative form of anesthesia that provides intravenous sedation and analgesia without producing unconsciousness. During conscious sedation, the patient may feel sleepy but is aware of his surroundings, can be easily aroused by touch or speech, and can talk with the surgical team. Nevertheless, blood pressure, heart rate, respiratory rate, and oxygen saturation are monitored, and the patient usually receives oxygen via nasal cannula during the procedure. Because of the amnesic effect of many of the medications, the patient may not recall aspects of the procedure afterward. Conscious sedation is used for certain procedures, such as bronchoscopy and cosmetic surgery. PTS: 1 CON: Safety 11. ANS: 4 Chapter: Chapter 39 Perioperative Care Objective: Use nursing diagnoses appropriately to describe a patient’s unique needs during the preoperative, intraoperative, and postoperative periods. Page: 1076 (V1) Heading: Planning Interventions/Implementation > What Is Informed Consent?

Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Application [Applying] Concept: Legal Difficulty: Moderate

2 3 4

Feedback This is incorrect. Informed consent must be given prior to any invasive procedure, Before a surgical procedure is performed, professional standards and the law require the surgeon to obtain the patient’s informed consent. The signed consent form verifies that the surgeon and patient have communicated adequately about the surgery (Dale, Rothrock, & McEwen, 2018). Once signed and witnessed, the consent form is part of the patient’s record and accompanies him to the operating room. This is incorrect. The nurse may witness the client’s and surgeon’s signatures of the informed consent, but two nurses may not sign for the client. This is incorrect. Both the client and surgeon sign the consent form that verifies that the procedure has been discussed. This is correct. In most states, a family member, conservator, or legal guardian may give consent for a procedure if a client is not capable of giving an informed consent or if the client is a minor.

PTS: 1 CON: Legal 12. ANS: 2 Chapter: Chapter 39 Perioperative Care Objective: Compare and contrast common nursing interventions during the intraoperative phase, including skin preparation, positioning for surgery, and intraoperative safety measures. Page: 1072 (V1) Heading: Types of Anesthesia Integrated Processes: Caring Client Need: Safe and Effective Care Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Easy Feedback 1 This is incorrect. During conscious sedation, the client feels sleepy but is easily aroused by touch or speech. 2 This is correct. General anesthesia produces rapid unconsciousness and loss of sensation. 3 This is incorrect. Local anesthesia produces loss of pain sensation at the desired site and is typically used for minor procedures. The client remains alert during local anesthesia.

This is incorrect. Regional anesthesia interrupts nerve impulses to and from the affected area, but the client remains alert.

PTS: 1 CON: Patient-Centered Care 13. ANS: 4 Chapter: Chapter 39 Perioperative Care Objective: Provide nursing care to prevent postoperative complications, including application of elastic and sequential compression devices, use of incentive spirometry, and management of gastric suction. Page: 1066 (V1) Heading: Planning Interventions/Implementation > Sequential Compression Devices (SCDs)?4 Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback 1 This is incorrect. If elastic stockings have been ordered with the sequential compression device, leave them in place. 2 This is incorrect. Knee-high stockings do not need to be replaced with thighhigh stockings. Some research has shown knee-high stockings to be equally effective. 3 This is incorrect. There is no need to notify the surgeon because clients commonly return from surgery wearing antiembolism stockings, as prescribed. 4 This is correct. If elastic stockings have been ordered with the sequential compression device, leave them in place; if the client is not yet wearing them, obtain them and put them on the client. PTS: 1 CON: Perfusion 14. ANS: 3 Chapter: Chapter 39 Perioperative Care Objective: Provide nursing care to prevent postoperative complications, including application of elastic and sequential compression devices, use of incentive spirometry, and management of gastric suction. Page: 1067 (V1) Heading: Postoperative Teaching > Incentive Spirometry Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate Feedback

This is incorrect. Teaching the client about these interventions and the complications of failing to perform them should have been completed in the preoperative period. This is incorrect. Promoting deep breathing, coughing, moving in bed, and leg exercises helps to prevent thrombophlebitis, atelectasis, and pneumonia in the postoperative period, but another action should take priority. This is correct. Providing reinforcement may be helpful, but assessment of the client’s pain level is essential to provide pain relief and ensure the client’s full participation in the activities. This is incorrect. While promoting deep breathing, coughing, moving in bed, and leg exercises helps to prevent thrombophlebitis, atelectasis, and pneumonia in the postoperative period, this is not the best action for the nurse to take on the first postoperative day.

PTS: 1 CON: Health Promotion 15. ANS: 1 Chapter: Chapter 39 Perioperative Care Objective: Provide nursing care to prevent postoperative complications, including application of elastic and sequential compression devices, use of incentive spirometry, and management of gastric suction. Page: 1080 (V1) Heading: Table 39-4 Potential Postoperative Complications (Collaborative Problems) Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment Cognitive Level: Comprehension [Understanding] Concept: Perfusion Difficulty: Easy

2 3 4

Feedback This is correct. The signs for external hemorrhage include dressings saturated with bright red blood and increased output in drains or chest tubes. The signs of internal hemorrhage would be increased pain, increasing abdominal girth, ecchymosis or swelling around incision, tachycardia, hypotension. It appears that the client may be experiencing both internal (soaked dressing) and internal (hypotension) hemorrhage. This is incorrect. Although the client’s vital signs may indicate hypovolemia, the indications for hemorrhage are more correct. This is incorrect. There is no indication of an infection per the scenario (redness, increased pain, fever, etc.) This is incorrect. There is no indication of a thrombus, such as the limb being pale and edematous; aching and cramping in limb; and Homans’ sign (pain in calf when foot is dorsiflexion.

PTS: 1 CON: Perfusion 16. ANS: 1 Chapter: Chapter 39 Perioperative Care Objective: Provide nursing care to prevent postoperative complications, including application of elastic and sequential compression devices, use of incentive spirometry, and management of gastric suction. Page: 1059 (V1) Heading: Preoperative Care > How Are Surgeries Classified? Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is correct. Reconstructive surgery is performed to restore function. It is minor surgery and can be done on an outpatient basis; it is elective because life is not threatened if the repair is not done (although quality of life may decline). 2 This is incorrect. Cosmetic surgery is performed to improve appearance, which does not apply to this surgery; this client’s surgery is not considered an urgent surgery because life is not threatened by the torn rotator cuff. 3 This is incorrect. Ablative surgery involves removal of a diseased part (nothing will be removed during this client’s surgery); furthermore, this client’s surgery is not an emergency, and it is not major surgery (which involves essential body organs). 4 This is incorrect. Although this surgery is reconstructive, it is not a surgery that needs to be urgently performed, and it is not major surgery because it can be performed on an outpatient basis. PTS: 1 CON: Patient-Centered Care 17. ANS: 3 Chapter: Chapter 39 Perioperative Care Objective: Provide nursing care to prevent postoperative complications, including application of elastic and sequential compression devices, use of incentive spirometry, and management of gastric suction. Page: 1061 (V1) Heading: Box 39-2 Preexisting Conditions That Increase Surgical Risk Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Easy

Feedback This is incorrect. Although the 40-year-old client has an alteration in liver function, there are no other risk factors—and the client’s drug use occurred in the past. This is incorrect. Although the 83-year-old client has the risk factors of older age and hypertension, this is not the client with the highest risk because the infant has even more risk factors. This is correct. The 6-month-old client has the risks of very young age, cardiac problems, and liver disease, and can be assumed to take multiple medications, making this the client with the highest risk. This is incorrect. The 28-year-old client has two risk factors (anticoagulants and mitral valve prolapse) and is not the one with the highest risk.

PTS: 1 CON: Safety 18. ANS: 1 Chapter: Chapter 39 Perioperative Care Objective: Discuss the importance of perioperative safety. Page: 1058 (V1) Heading: Perioperative Safety > Take Measures to Prevent Wrong Patient, Wrong Site, Wrong Surgery Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 This is correct. This is a measure to prevent wrong patient, wrong site, and wrong surgery. 2 This is incorrect. Although the team may be fatigued, this is not the purpose of a time-out prior to the surgery. 3 This is incorrect. Although this may provide a chance to verify all preop care was provided prior to surgery, this is not the purpose of the time-out. 4 This is incorrect. Although this is done prior to surgery, it is not the purpose of the time-out. PTS: 1 CON: Safety 19. ANS: 4 Chapter: Chapter 39 Perioperative Care Objective: Describe nursing actions associated with the preoperative phase, including physical preparations for surgery, preoperative teaching, and surgical consent forms. Page: 1058 (V1)

Heading: Preoperative Care Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Applying [Application] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. The client should be encouraged to quit smoking immediately and not just on the day of surgery. 2 This is incorrect. Shaving the abdomen is not usually required. However, if the client has a great deal of hair requiring removal, it is normally done just before surgery rather than the day before. 3 This is incorrect. The nurse would not be the one to make a decision about whether antibiotics are needed. 4 This is correct. It is important for the client to inform the surgeon of all allergies, medications taken, and current health conditions. PTS: 1 CON: Safety 20. ANS: 3 Chapter: Chapter 39 Perioperative Care Objective: Compare and contrast general anesthesia, local anesthesia, regional anesthesia, and conscious sedation. Page: 1071 (V1) Heading: Intraoperative Care Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Analysis [Analyzing] Concept: Professionalism Difficulty: Difficult Feedback 1 This is incorrect. Because only an RN can act as circulating nurse, the roles of scrub nurse or technician would be assigned to the LPN. 2 This is incorrect. A physician acts as anesthesiologist, although an RN with advanced education (CRNA) could administer anesthesia. However, an RN could act as the CRNA; but the nurse in the question is not identified as a CRNA. 3 This is correct. The staff RN will act in the role of circulating nurse, which can be performed only by an RN. 4 This is incorrect. Because only an RN can act as circulating nurse, the roles of scrub nurse or technician would be assigned to the LPN. PTS:

CON: Professionalism

21. ANS: 3 Chapter: Chapter 39 Perioperative Care Objective: Compare and contrast general anesthesia, local anesthesia, regional anesthesia, and conscious sedation. Page: 1072 (V1) Heading: Types of Anesthesia Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. General anesthesia produces rapid unconsciousness and loss of sensation, but also depresses the client’s central nervous system (CNS) and relaxes the musculature. It produces more extensive effects than would be required for a procedure that will be performed in a few minutes. It also involves more risks than are justified in this case. 2 This is incorrect. An epidural anesthetic would not reduce pain or induce muscle relaxation as high up as the shoulder—if it did, it would also paralyze the muscles involved in breathing. 3 This is correct. Conscious sedation would relax the muscles and can be administered with an analgesic to allow repair of the dislocation with rapid return to consciousness following the procedure. 4 This is incorrect. A local anesthetic would not adequately relax muscles or anesthetize the shoulder joint. PTS: 1 CON: Safety 22. ANS: 3 Chapter: Chapter 39 Perioperative Care Objective: Compare and contrast common nursing interventions during the intraoperative phase, including skin preparation, positioning for surgery, and intraoperative safety measures. Page: 1072 (V1) Heading: Types of Anesthesia Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. The site is usually prepared after the client is positioned because some sites are not visible until after positioning. 2 This is incorrect. The surgical site is not normally shaved, but if it is required it

is usually done in preoperative holding. This is correct. The circulating nurse will position the client to maintain the client’s airway, to allow vital signs to be monitored, to maintain the client’s comfort and safety, and to make the operative site accessible. This is incorrect. Only after the client is positioned can the bony prominences be padded.

PTS: 1 CON: Safety 23. ANS: 3 Chapter: Chapter 39 Perioperative Care Objective: Provide nursing care to prevent postoperative complications, including application of elastic and sequential compression devices, use of incentive spirometry, and management of gastric suction. Page: 1077 (V1) Heading: Postoperative Care > Recovery From Anesthesia Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. Although assessing for drainage on the dressing is an important activity, it is not the first thing the nurse will do. 2 This is incorrect. Vital signs should be obtained, but that is not the first priority. 3 This is correct. Based on the fact that an oral airway remains in place, it can be concluded that the client’s sedation level is high. Guarding the airway by turning the client’s head to drain secretions or possible emesis is the highest priority action to be performed by the nurse. The only immediately life-threatening risk for this client would be a compromised airway. 4 This is incorrect. Ensuring proper drainage from the urinary catheter is important, but is not the first priority. PTS: 1 CON: Safety 24. ANS: 4 Chapter: Chapter 39 Perioperative Care Objective: Describe nursing assessments appropriate for surgical clients upon admission to the nursing unit. Page: 1077 (V1) Heading: Postoperative Care > Recovery From Anesthesia Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying]

Concept: Safety Difficulty: Difficult Feedback 1 This is incorrect. Vital signs would have been taken every 15 minutes for the first hour (1:30 to 2:30 p.m.), then every 30 minutes for the next 2 hours (2:30 to 4:30 p.m.). 2 This is incorrect. It is too soon to begin hourly vital signs. At this time, the client should be assessed more often than every hour. 3 This is incorrect. Vital signs would have been taken every 15 minutes for the first hour (1:30 to 2:30 p.m.), then every 30 minutes for the next 2 hours (2:30 to 4:30 p.m.); therefore, “immediately and every 30 minutes for the next 2 hours” is incorrect (on that schedule, the nurse would be taking vital signs at 3:30, 4:00, 4:30, 5:00, and 5:30 p.m.). 4 This is correct. It is now 3:30 p.m., so the nurse will take vital signs immediately, again at 4:00 p.m., and again at 4:30 p.m., at which time the nurse can begin to take hourly vital signs if the client’s vital signs are within acceptable and stable range. PTS: 1 CON: Safety 25. ANS: 3 Chapter: Chapter 39 Perioperative Care Objective: Provide nursing care to prevent postoperative complications, including application of elastic and sequential compression devices, use of incentive spirometry, and management of gastric suction. Page: 1080 (V1) Heading: Planning Interventions/Implementation > Gastrointestinal Suction Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. The client with a nasogastric tube should not require an antiemetic because the stomach should be emptied by suction; therefore, this is not the priority action. 2 This is incorrect. The nasogastric tube should not be replaced unless other actions are ineffective, and the tube is no longer functioning properly. 3 This is correct. The first action should be to check placement of the NG tube because it may have migrated out of the stomach into either the esophagus or the duodenum. 4 This is incorrect. Irrigating the tube would be the second action to take, but placement must be checked before taking this step.

PTS: 1 CON: Safety 26. ANS: 3 Chapter: Chapter 39 Perioperative Care Objective: Use nursing diagnoses appropriately to describe a patient’s unique needs during the preoperative, intraoperative, and postoperative periods. Page: 1079 (V1) Heading: Standardized Language > Nursing diagnosis: Latex Allergic Response Risk Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. The client is only mildly anxious, and there are no defining characteristics of Fear; therefore Fear would not be an appropriate diagnosis. 2 This is incorrect. Although the client does have mild Anxiety, this is not the priority diagnosis for this client. 3 This is correct. Risk for Latex Allergy Response is an appropriate diagnosis for clients who are allergic to bananas, avocados, kiwi, chestnuts, or poinsettia plants. This client has two of these allergies, so this is a priority diagnosis. 4 This is incorrect. There is no indication that this client will have, or currently has, Ineffective Airway Clearance. PTS: 1 CON: Safety 27. ANS: 1 Chapter: Chapter 39 Perioperative Care Objective: Use nursing diagnoses appropriately to describe a patient’s unique needs during the preoperative, intraoperative, and postoperative periods. Page: 1079 (V1) Heading: Analysis/Nursing Diagnosis Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Moderate

Feedback This is correct. This client is at Increased Risk for Infection because of a history of obesity and incision into the bowel to perform the surgery; therefore, this is an appropriate diagnosis. This is incorrect. Delayed Surgical Recovery would apply only if complications

arose or there was an indication the client was not recovering appropriately; it does not apply as a risk diagnosis. This is incorrect. While the client’s obesity may result in chronic pain due to stress on joints, it is not the priority. Also, there are no data in the scenario to indicate chronic pain. This is incorrect. There is no indication of excess bleeding or fluid loss in the question, so Risk for Deficient Fluid Volume would not be an appropriate diagnosis.

PTS:

CON: Safety

MULTIPLE RESPONSE 28. ANS: 1, 2, 4 Chapter: Chapter 39 Perioperative Care Objective: Describe the ways in which surgeries can be classified. Page: 1059 (V1) Heading: How Are Surgeries Classified? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is correct. Surgeries can be classified by body systems, purpose, level of urgency, and degree of seriousness (acuity). This is correct. The urgency may be used to classify surgeries. This is incorrect. Although the manager may need this information for staffing, the length of surgery and organ involved are not used for classifying surgeries. This is correct. The body system involved is a factor for classification of surgery. This is incorrect. Although it may affect the time frame for surgery, it is not a basis for classification.

PTS: 1 CON: Safety 29. ANS: 3, 4 Chapter: Chapter 39 Perioperative Care Objective: Compare and contrast common nursing interventions during the intraoperative phase, including skin preparation, positioning for surgery, and intraoperative safety measures. Page: 1063 (V1) Heading: Perioperative Nursing Data Set Integrated Processes: Communication and Documentation

Client Need: Safe and Effective Care Cognitive Level: Comprehension [Understanding] Concept: Informatics Difficulty: Difficult

1. 2. 3.

Feedback This is incorrect. The PNDS does not assess high-risk surgical clients. This is incorrect. This does not encompass all surgical outcomes. This is correct. The PNDS is a standardized vocabulary specifically designed to describe the care of perioperative clients. The current edition was updated to include 20 new interventions, 10 new outcomes (plus refining 10 existing outcomes for clarity), a new emphasis on the perioperative clinical workflow, recoding the PNDS to clearly express the perioperative plan of care (i.e., assessment, diagnosis, implementation, evaluation, outcome), and replacing the PNDS nursing diagnosis codes with their original NANDA International nursing diagnosis codes. This is correct. It was the first specialty language recognized by the ANA and is updated periodically to sustain validity and usefulness in the perioperative workplace. This is incorrect. This does not include safe staffing issues.

PTS: 1 CON: Informatics 30. ANS: 1, 2, 4 Chapter: Chapter 39 Perioperative Care Objective: Provide nursing care to prevent postoperative complications, including application of elastic and sequential compression devices, use of incentive spirometry, and management of gastric suction. Page: 1066 (V1) Heading: Planning Interventions/Implementation > Teaching Integrated Processes: Teaching and Learning Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate

1. 2. 3.

Feedback This is correct. The nurse would know that client teaching was effective if the client verbalizes signs and symptoms of infection. This is correct. The nurse would know that client teaching was effective if the client can perform the ordered dressing change. This is incorrect. Nurses cannot teach a client to be free of pain. Pain is subjective. The nurse can teach the client strategies to assist with pain, but they may not remove the pain completely.

4. 5.

This is correct. The nurse would know that client teaching was effective if the client completes the regimen of ordered antibiotics. This is incorrect. Although the client should know a bowel regimen, it is not necessary for the client to complete a bowel regimen in order to verify adequate teaching/learning.

PTS: 1 CON: Health Promotion 31. ANS: 1, 2, 3 Chapter: Chapter 39 Perioperative Care Objective: Compare and contrast common nursing interventions during the intraoperative phase, including skin preparation, positioning for surgery, and intraoperative safety measures. Page: 1080 (V1) Heading: Table 39-4 Potential Postoperative Complications (Collaborative Problems) Intraoperative Care: Clean Team Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Applying [Application] Concept: Collaboration Difficulty: Moderate

3. 4. 5.

Feedback This is correct. The circulating nurse works with the anesthesiologist to monitor the intake and output of the client for signs and symptoms of fluid imbalances, such as hemorrhage, fluid overload, etc. This is correct. This would prevent infections, the circulating nurse would “paint” the client with a surgical scrub to prevent contamination of the skin surface when incised. This is correct. This would prevent contamination and infection by maintaining a non-touch site on the client prior to surgery. This is incorrect. Although this may be a responsibility of the circulating nurse, it does not prevent complications from the surgery procedure. This is incorrect. The antiembolism stockings would be applied in recovery (PACU) by the PACU staff after surgery.

PTS: 1 CON: Collaboration 32. ANS: 2, 3, 4 Chapter: Chapter 39 Perioperative Care Objective: Compare and contrast general anesthesia, local anesthesia, regional anesthesia, and conscious sedation. Page: 1072 (V1) Heading: Interoperative Care: General Anesthesia Integrated Processes: Nursing Process

Client Need: Physiological Integrity Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is incorrect. Anesthesia is not used for the purpose of obtaining a reduction in risk potential; however, surgical risk is influenced by the type of anesthesia used. This is correct. General anesthesia is used to control pain (analgesia). This is correct. General anesthesia is used to promote amnesia. This is correct. General anesthesia is used to relax muscles. This is incorrect. There is no evidence that general anesthesia reduces infections.

PTS: 1 CON: Patient-Centered Care 33. ANS: 1, 3, 5 Chapter: Chapter 39 Perioperative Care Objective: Describe nursing actions associated with the preoperative phase, including physical preparations for surgery, preoperative teaching, and surgical consent forms. Page: 885 (V2) Heading: Assessment Guidelines and Tools & Example of a Preoperative Checklist, in Volume 2 Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Application [Applying] Concept: Collaboration Difficulty: Moderate

1. 2. 3.

4. 5.

Feedback This is correct. The nurse will also inform the client’s relatives where they may wait during the surgery. This is incorrect. The surgical suite will be prepared by the surgical team. It is not necessary to have the client prepare a living will prior to surgery. This is correct. Before being transported to the operating suite, the client must remove all artificial body parts, such as dentures, artificial limbs, or contact lenses. Wigs, eyeglasses, makeup, and jewelry must also be removed. This is incorrect. It is not necessary to have a living will prior to surgery. However, the nurse will ask the client whether there is one when obtaining the nursing history. This is correct. Describe who will be in the operating suite to decrease anxiety of the unknown.

PTS: 1 CON: Collaboration 34. ANS: 1, 3, 4 Chapter: Chapter 39 Perioperative Care

Objective: Provide nursing care to prevent postoperative complications, including application of elastic and sequential compression devices, use of incentive spirometry, and management of gastric suction. Page: 1077 (V1) Heading: Postoperative Care > Recovery From Surgery Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is correct. The nurse assists the client to turn, breathe deeply, and cough every 2 hours to decrease the risk of postoperative atelectasis or pneumonia. This is incorrect. The nurse may teach the client about cancerous tumors; however, this intervention will not decrease the risk of postoperative complications. This is correct. The nurse assesses the wound drainage to monitor for signs of bleeding, infection, or wound complications. This is correct. Vital signs are monitored to detect the potential for infection or hemorrhage, not to prevent them. This is incorrect. The nurse would not teach the client on sterile dressing changes immediately after the surgery. Often, the dressing is clean, not sterile, unless there are complications (infection).

PTS: 1 CON: Patient-Centered Care 35. ANS: 1, 4, 5 Chapter: Chapter 39 Perioperative Care Objective: Provide nursing care to prevent postoperative complications, including application of elastic and sequential compression devices, use of incentive spirometry, and management of gastric suction. Page: 878 (V2) Heading: Procedure 39-4 Managing Gastric Suction, in Volume 2. Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate

Feedback This is correct. Nonsterile procedure gloves are to protect the nurse and other clients against microorganisms that might be present in body fluids; wearing gloves is in observance of standard precautions.

2. 3. 4. 5.

This is incorrect. Sterile water is not used; saline compensates for electrolytes lost through NG drainage. This is incorrect. Sterile gloves are not needed for irrigating the NG tube because the nasal passages, esophagus, and stomach are not sterile. This is correct. For clients with an NG tube, frequent oral care, including watersoluble lubricant for dry lips, is important. This is correct. Monitoring and charting the amount and consistency of the drainage is a component of intake/output.

PTS: 1 CON: Safety 36. ANS: 1, 2, 3 Chapter: Chapter 39 Perioperative Care Objective: Name and differentiate the three phases of the perioperative period. Page: 1061 (V1) Heading: Perioperative Nursing > Perioperative Safety Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Easy

1. 2. 3. 4. 5.

Feedback This is correct. Preventing infection is an important safety requirement of nursing care of the perioperative client. This is correct. Making sure the right client has the right procedure is an important nursing concern when caring for the perioperative client. This is correct. Mistakes in surgery can have devastating long-term consequences and the nurse needs to do everything possible to prevent errors. This is incorrect. Although signed consent is necessary, it is not done to maintain safety but to make sure the client is able to make an informed decision. This is incorrect. Keeping the family informed is important for holistic care but is not necessarily a safety intervention.

PTS: 1 CON: Safety 37. ANS: 1, 3, 4 Chapter: Chapter 39 Perioperative Care Objective: Use nursing diagnoses appropriately to describe a patient’s unique needs during the preoperative, intraoperative, and postoperative periods. Page: 1068 (V1) Heading: Prepare the Patient Physically for Surgery > Antiembolism Stockings Integrated Processes: Nursing Process Client Need: Physiological Integrity

Cognitive Level: Application [Applying] Concept: Safety Difficulty: Difficult

1. 2. 3. 4.

Feedback This is correct. Discomfort can be caused by stockings that are too small, so it is important to make sure the stockings are correctly sized. This is incorrect. Stockings should be removed daily to wash the feet and legs, and then clean stockings should be reapplied. This is correct. Rolls and wrinkles can cause pressure sores and skin damage, so it would be important to make sure the stockings go on smoothly. This is correct. Compression stockings are designed to provide different amounts of pressure in different areas, so it is important to make sure the stockings are on straight and the heel is in the right place. In addition, having the heel and toe incorrectly placed would contribute to wrinkles and discomfort. This is incorrect. Some space should be left between the toes in the stockings and the client’s toe, so the toes of the stockings should not be molded over the toes.

PTS:

CON: Safety

Chapter 40. Leading & Managing Multiple Choice Identify the choice that best completes the statement or answers the question. 1. Physical therapy and nursing staff of a local rehabilitation hospital are in conflict over which department is responsible for transporting patients to and from therapy appointments. The physical therapy team members state they do not have sufficient time to come to the nursing unit to pick up the patients, who often are not ready to be transported. The nursing staff members state transporting patients creates a shortage of nursing personnel on the floor. Managers from both departments have attempted to resolve the conflict with input from the staff members. All attempts at conflict resolution have failed. To promote collaborative conflict resolution, the department managers take which step? 1. Instructing the nursing staff to identify patient transport solutions that have worked well in the past. 2. Advising the physical therapy staff they are responsible for transporting patients to and from therapy. 3. Asking the hospital administrator to make an unbiased decision. 4. Initiating informal negotiation between the two departments. 2. The nurse manager conducts an informal negotiation between two staff nurses who have had ongoing difficulty working together peacefully. During which step of the informal negotiation process does the nurse leader focus on managing the staff nurses’ emotions? 1. Setting the stage 2. Conducting the negotiation 3. Making offers and counteroffers 4. Agreeing on resolution of the conflict 3. The nurse observes an unlicensed assistive personnel (UAP) who fails to perform hand hygiene after placing a patient on a bedpan. When providing negative feedback to the UAP, the nurse should: 1. Conduct the conversation in a private setting. 2. Ask the unit manager to be present to document responses of both parties. 3. Address the issue of hand hygiene to all UAPs as a group. 4. Document the UAP’s actions for discussion during an upcoming annual review. 4. The nurse manager instructs a group of staff nurses to create a work schedule for the upcoming month. Conflict arises when several of the nurses express a desire to schedule vacation on the same dates. Which action by the nurse manager represents a laissez-faire leadership style? 1. Directing the group’s decisions about the scheduling process 2. Assuming responsibility for the group’s scheduling decisions 3. Taking over the process of developing the work schedule 4. Intervening if the group is unable to finalize the work schedule

5. The nurse manager meets with a team of staff nurses to discuss a proposed fall prevention plan. A staff nurse identifies a problem with the nurse manager’s proposed safety plan. Which action by the staff nurse represents effective followership? 1. Informing the nurse manager of the potential problem 2. Advising the other staff nurses that the fall prevention plan will not be effective 3. Requesting that the nurse manager identify a potential solution to the issue 4. Sharing only positive feedback while in a group setting 6. The staff nurse provides care to a stable patient who is newly diagnosed with diabetes. The patient has been authorized for discharge from the hospital. To promote efficiency, the staff nurse delegates care to an unlicensed assistive personnel (UAP). Which task must be completed by the staff nurse? 1. Teaching the patient about symptoms of hypoglycemia 2. Obtaining the patient’s pulse rate 3. Assisting the patient with ambulation to the bathroom 4. Measuring the patient’s blood pressure 7. The nurse is differentiating between the concepts of leadership and management. Which position does the nurse recognize as a position of leadership as opposed to a management role? 1. Charge nurse 2. Unit director 3. Mentor 4. Supervisor 8. Medical-surgical unit staff nurses discuss the nurse manager’s lack of involvement in unit activities. The nurse manager is rarely visible on the unit and rarely schedules staff meetings. The staff nurses determine the nurse manager’s behaviors are reflective of which leadership style? 1. Authoritarian 2. Democratic 3. Laissez-faire 4. Transformational 9. The charge nurse in an extended care facility responds to a Code Blue. Which leadership style will the charge nurse demonstrate when directing cardiopulmonary resuscitation measures for a patient who is apneic and pulseless? 1. Democratic 2. Laissez-faire 3. Transformational 4. Transactional 10. The staff nurse sits at a large table in the cafeteria with other nurses who are complaining about the hospital’s new policy regarding holiday scheduling. Which statement by the staff nurse demonstrates leadership qualities? 1. “It’s easy for management to make these rules because they’ll be off for the holidays.”

2. “You guys are just a bunch of complainers. You knew nursing required working holidays.” 3. “The new policy is not ideal. What ideas do you have for a better approach?” 4. “Why don’t you people stop criticizing our bosses and come up with a few solutions?” 11. The nurse manager notices nurse retention has steadily declined since she assumed the unit management position. Which action is most appropriate for the nurse manager to implement? 1. Assess the staff’s perception of the manager’s leadership style. 2. Throw monthly pizza parties for the unit. 3. Give each nurse on the unit a 5% raise in pay. 4. Consult the facility’s chief nursing officer for guidance. 12. The medical-surgical unit nurse manager instructs the novice nurse to choose a mentor. Which nurse does the novice nurse ask to accept a mentor position? 1. The nurse who serves as a charge nurse and part-time house supervisor 2. The nurse who recently graduated and who remembers the challenges of being a novice 3. The nurse who is often consulted by team members for guidance and support 4. The nurse who is most outspoken and interactive during nursing staff meetings 13. The newly-hired emergency department (ED) staff nurse has close friendships with several members of the hospital’s executive leadership council. As a result of personal relationships with institutional leaders, the staff nurse has power and influence in the ED. Which source of power is the staff nurse using? 1. Positional 2. Rewards 3. Legitimate 4. Referent 14. The nurse manager evaluates a staff nurse who has a history of frequent absences from work. Which strategy does the nurse manager implement to improve the staff nurse’s work attendance? 1. Provide negative feedback. 2. Share public feedback. 3. Praise desirable behaviors. 4. Reinforce constructive behaviors. 15. The nurse manager leads a staff meeting to inform team members about an upcoming unit reorganization. Which staff nurse’s behavior demonstrates passive resistance to the change? 1. Threatening to quit if the reorganization is put into action 2. Standing up during the meeting and stating, “This is stupid and won’t work!” 3. Listening quietly and making suggestions for implementation 4. Being silent at the meeting but frequently calling in sick during implementation

16. The nurse provides care to an older adult client who is diagnosed with Alzheimer’s disease. The nurse delegates the client’s bathing and hygiene care to an experienced certified nursing assistant. While shaving the client, the certified nursing assistant accidentally cuts the client’s chin. Who is legally liable for this injury? 1. The nurse who delegated the activity 2. The certified nursing assistant 3. Both the nurse and the certified nursing assistant 4. Both the nurse and the nurse’s supervisor 17. The nurse manager leads a staff development seminar about leadership styles. Which term does the nurse manager use to describe transformational leadership? 1. Directive 2. Individual performance 3. Traditional 4. Matrix communication 18. The nursing student plans future goals. Which goal represents a long-term goal? 1. Study every night for at least two hours 2. Find a babysitter for clinical days 3. Dress professionally for clinical 4. Specialize in care of sick newborns 19. To promote effective time management, the nurse creates a to-do list. Which action does the nurse implement first? 1. Prioritize the list items. 2. Question each item’s effectiveness. 3. Practice self-reliance. 4. Evaluate personal efficacy. Multiple Response Identify one or more choices that best complete the statement or answer the question. 20. Which characteristics must an effective nurse manager possess? Select all that apply. 1. Clinical expertise 2. Business sense 3. Graduate education 4. Leadership skills 5. Referent power 21. Safe, effective delegation of tasks must include implementation of which nursing actions? Select all that apply. 1. Supervising the patient care delivery 2. Determining the skill mix of unit personnel 3. Assessing the needs of the clients who are involved

4. Deciding which tasks to assign to a team member 5. Consulting with the charge nurse 22. The novice nurse is assigned a nurse mentor. As a mentee, what are the responsibilities of the novice nurse? Select all that apply. 1. Demonstrating an ability to move toward independence 2. Encouraging excellence in others 3. Using feedback to modify behaviors 4. Displaying flexibility and the ability to change 5. Exhibiting an eagerness to learn 23. The novice nurse creates a plan to promote personal empowerment. Which strategies does the novice nurse include in the empowerment plan? Select all that apply. 1. Attending seminars 2. Joining a unit-based committee 3. Serving as a mentor to a nursing student 4. Obtaining psychological counseling 5. Achieving a formal position of power 24. The unit manager evaluates the graduate nurse’s followership. Which statements by the graduate nurse reflect effective followership? Select all that apply. 1. “I was reading a nursing journal yesterday and found new evidence I’d like to share with you.” 2. “I understand what you are saying, but I don’t think you are seeing my perspective about the situation.” 3. “I have an idea to solve the weekend staffing problem. What if we started by finding nurses who prefer working weekends?” 4. “I think my time management skills are getting worse instead of better, so your solutions aren’t working. You need to offer effective solutions.” 5. “I would be happy to join the education committee to develop a handbook for newly hired nurses.”

Chapter 40. Leading & Managing Answer Section MULTIPLE CHOICE 1. ANS: 4 Chapter: Chapter 40 Leading & Managing Objective: Describe the major concepts of conflict, conflict resolution, and informal negotiation. Page: 1103 (V1) Heading: Conflict Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Application [Applying] Concept: Collaboration Difficulty: Moderate Feedback 1 This is incorrect. While it is natural for people to try to repeat something that worked well in the past, solutions that were previously successful may not work in the future. Instead, leaders should encourage people to search for innovative solutions. 2 This is incorrect. Assigning one group the responsibility for patient transportation is an authoritarian approach that does not represent a collaborative solution. 3 This is incorrect. Rather than delegating the responsibility for conflict resolution, the department managers must demonstrate leadership by actively identifying and implementing a solution. 4 This is correct. The responsibilities of a department manager include functioning as an informal negotiator when a resolution to conflict cannot be reached. The desired outcome is identification of a collaborative solution that is agreed upon by all parties. PTS: 1 CON: Collaboration 2. ANS: 2 Chapter: Chapter 40 Leading & Managing Objective: Describe the major concepts of conflict, conflict resolution, and informal negotiation. Page: 1103 (V1) Heading: Conflict Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Knowledge [Remembering] Concept: Collaboration Difficulty: Moderate

2 3 4

Feedback This is incorrect. Setting the stage, which is Step 2 of informal negotiation, may involve confronting the two parties or groups with their behavior toward one another, making direct statements designed to open communication, and challenging them to seek resolution of the situation. This is correct. Conducting the negotiation, which is Step 3 of informal negotiation, includes managing emotions. This is incorrect. Step 4 of informal negotiation involves making offers and counteroffers. This is incorrect. Step 5 of informal negotiation, which is the final step in the process, centers on agreeing on a resolution to the conflict.

PTS: 1 CON: Collaboration 3. ANS: 1 Chapter: Chapter 40 Leading & Managing Objective: Discuss the importance of effective communication skills to nurse leaders and managers. Page: 1099 (V1) Heading: Communicating Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Application [Applying] Concept: Collaboration Difficulty: Moderate Feedback 1 This is correct. Negative feedback should be given in private. 2 This is incorrect. It is not necessary for the nurse manager to be present because staff nurses are responsible for delegating to and supervising UAPs. 3 This is incorrect. The nurse should not call a meeting of the entire group of UAPs. For the NAPs who are adhering to hand hygiene protocols, the meeting would not be the most efficient use of time. Instead, the nurse should address the issue with the NAP who is in need of correction. 4 This is incorrect. Failure to immediately correct the UAP’s inadequate hand hygiene practices could pose a threat to patient safety and increase the risk of transmitting infectious microbes. PTS: 1 CON: Collaboration 4. ANS: 4 Chapter: Chapter 40 Leading & Managing Objective: Compare and contrast authoritarian, democratic, and laissez-faire leadership styles. Page: 1089 (V1) Heading: What Is Leadership?

Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Comprehension [Understanding] Concept: Leadership and Management Difficulty: Moderate Feedback 1 This is incorrect. Directing the group’s decisions is representative of an authoritarian leadership style. 2 This is incorrect. An authoritarian leader bears most of the responsibility for outcomes. 3 This is incorrect. Making a group’s final decisions is reflective of authoritarian leadership style. 4 This is correct. Laissez-faire leadership gives followers the majority of control in the decision-making process. A laissez-faire leader has a relatively inactive style and intervenes only when goals have not been met or a problem arises. PTS: 1 CON: Leadership and Management 5. ANS: 1 Chapter: Chapter 40 Leading & Managing Objective: Discuss the qualities, behaviors, and strategies that contribute to effective leadership and followership. Page: 1096 (V1) Heading: What Is Followership? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Analysis [Analyzing] Concept: Collaboration Difficulty: Moderate Feedback 1 This is correct. Effective followership includes suggesting ways to improve patient care. If a problem is identified, the team leader should be informed right away. 2 This is incorrect. Discussing the potential problem with other staff members does not promote resolution of the problem. Potential problems should be immediately reported to the team leader. 3 This is incorrect. Important qualities and behaviors that should be demonstrated by followers include informing a team leader when a problem is identified, as well as proposing a potential solution. 4 This is incorrect. An effective follower provides honest feedback and constructive criticism, even if it means politely challenging the leader’s ideas. Privacy is necessary if a “heated” discussion with the leader is anticipated.

PTS: 1 CON: Collaboration 6. ANS: 1 Chapter: Chapter 40 Leading & Managing Objective: Describe the major concepts of safe and effective delegation. Page: 1100 (V1) Heading: Delegating Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Application [Applying] Concept: Collaboration Difficulty: Easy Feedback 1 This is correct. Health teaching must be completed by the nurse. Interventions that require professional nursing knowledge, decisions, or skills may not be delegated. 2 This is incorrect. For a stable patient, the UAP may measure vital signs, including the patient’s pulse rate. 3 This is incorrect. Activities of daily living, including assisting the patient with ambulating to the bathroom, may be delegated to the UAP. 4 This is incorrect. For a stable patient, the UAP may measure vital signs, including the patient’s blood pressure. PTS: 1 CON: Collaboration 7. ANS: 3 Chapter: Chapter 40 Leading & Managing Objective: Discuss the qualities of preceptors and mentors. Page: 1093 (V1) Heading: How Can I Prepare to Become a Leader and Manager? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Comprehension [Understanding] Concept: Leadership and Management Difficulty: Easy Feedback 1 This is incorrect. The charge nurse position is one the nurse is hired to fulfill, holding a position of conferred power over other staff, so this position is a lower-level management position. The mentor position is a leadership position. 2 This is incorrect. The unit director position is one the nurse is hired to fulfill, holding a position of conferred power over other staff, so this position is a middle-level management position. The mentor position is a leadership position. 3 This is correct. The mentor position is a leadership position, assisting less experienced nurses to meet their goals and objectives because the mentor has

charisma, knowledge, experience, and leadership skills. This is incorrect. The supervisor position is one the nurse is hired to fulfill, holding a position of conferred power over other staff, so this position is a middle-level management position. The mentor position is a leadership position.

PTS: 1 CON: Leadership and Management 8. ANS: 3 Chapter: Chapter 40 Leading & Managing Objective: Compare and contrast authoritarian, democratic, and laissez-faire leadership styles. Page: 1089 (V1) Heading: What Is Leadership? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Application [Applying] Concept: Leadership and Management Difficulty: Easy

1 2 3

Feedback This is incorrect. Authoritarian leaders are highly involved in directing staff activity, so this does not describe this manager’s style. This is incorrect. A democratic leadership style is a participative leadership approach and is not descriptive of the manager in the question. This is correct. A laissez-faire style is also known as permissive or nondirective, with the leader allowing staff to function with little intervention; this describes this manager’s approach. This is incorrect. A transformational leader inspires and motivates followers creating a supportive climate, which does not describe the manager in the question.

PTS: 1 CON: Leadership and Management 9. ANS: 4 Chapter: Chapter 40 Leading & Managing Objective: Discuss the qualities, behaviors, and strategies that contribute to effective leadership and followership. Page: 1089 (V1) Heading: What Is Leadership? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Analysis [Analyzing] Concept: Leadership and Management Difficulty: Difficult Feedback

This is incorrect. During a Code Blue, all team members must understand their roles and responsibilities, and they must take appropriate actions. There is no time for a democratic discussion, so a democratic leadership style would not be the most appropriate one. This is incorrect. The nurse who is directing a code must be actively engaged with all team members. A laissez-faire approach, which involves limited interaction with team members, would not be appropriate. This is incorrect. The transformational leadership style focuses on engaging, inspiring, and empowering others to accomplish a mission. The transformational leadership style emphasizes building relationships as a precursor to accomplishing tasks. Cardiopulmonary resuscitation is a task-oriented process that requires effective engagement from all team members. Inspiring and motivating followers is not the focus during cardiopulmonary resuscitation, so the transformational leadership style would not be ideal. This is correct. Transactional leaders may be task-oriented, enforce rules, and provide guidance to workers A transactional leader would direct everyone to play a part in resuscitating the patient, so transactional leadership would be the most effective style in this scenario.

PTS: 1 CON: Leadership and Management 10. ANS: 3 Chapter: Chapter 40 Leading & Managing Objective: Discuss the qualities, behaviors, and strategies that contribute to effective leadership and followership. Page: 1103 (V1) Heading: Conflict Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Comprehension [Understanding] Concept: Collaboration Difficulty: Easy Feedback 1 This is incorrect. Presuming management personnel are uninterested in the nursing team’s dissatisfaction about the holiday scheduling implies there is no possibility of a solution. A leader is open to problem-solving and seeks solutions, as opposed to simply joining in with individuals who are complaining. 2 This is incorrect. Criticizing the group for complaining minimizes the problem and will not resolve the situation and does not demonstrate leadership skills. 3 This is correct. Professionally acknowledging the issue and encouraging the development of solutions demonstrate leadership. 4 This is incorrect. While the idea behind the statement (“come up with new solutions”) is good, the words themselves (i.e., “Why don’t you people stop

complaining …”) may be perceived as hostile and do not show leadership skills. PTS: 1 CON: Collaboration 11. ANS: 1 Chapter: Chapter 40 Leading & Managing Objective: Discuss the qualities and activities that contribute to effective management. Page: 1091 (V1) Heading: What Is Management? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Analysis [Analyzing] Concept: Leadership and Management Difficulty: Moderate Feedback 1 This is correct. Because the problem began when the nurse took the management position, it is important to assess the staff’s perception of the manager’s leadership approach to help identify the problem. 2 This is incorrect. Monthly pizza parties may be one part of a solution aimed at increasing staff retention. However, before formulating solutions, the problem needs to be identified. 3 This is incorrect. It is not within the scope of the unit manager’s position to give across-the-board raises. 4 This is incorrect. If the nurse manager is unable to effectively problem-solve the issue, consulting executive leadership may be necessary. However, reaching out to executive leadership would not be an appropriate first step in the process. PTS: 1 CON: Leadership and Management 12. ANS: 3 Chapter: Chapter 40 Leading & Managing Objective: Discuss the qualities of preceptors and mentors. Page: 1093 (V1) Heading: How Can I Prepare to Become a Leader and Manager? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Application [Applying] Concept: Leadership and Management Difficulty: Moderate Feedback 1 This is incorrect. While serving as a charge nurse and a part-time house supervisor are indicators of clinical expertise, the individual’s current responsibilities and commitments must be taken into account. A fellow staff nurse who has fewer commitments is more likely to be available to dedicate

time to the development of a novice nurse. This is incorrect. Although the recent graduate may be empathetic, this individual may not yet be prepared to serve as a mentor. Rather, the recent graduate would likely benefit from being mentored, as well. This is correct. Frequent consultation by fellow nurses likely indicates that the nurse possesses clinical expertise. Willingness to guide others suggests the nurse is committed to helping team members. The nurse who is consulted by other nurses would be the best choice if this nurse is willing to act as a mentor to the student. This is incorrect. Being outspoken and interactive may or may not be desirable qualities in a mentor. Ideally, a mentor is someone more experienced who provides career development assistance, such as coaching, sponsoring advancement, providing challenging assignments, protecting protégés from adversity, and promoting positive visibility.

PTS: 1 CON: Leadership and Management 13. ANS: 4 Chapter: Chapter 40 Leading & Managing Objective: Describe several ways to empower nurses. Page: 1097 (V1) Heading: What Are Power and Empowerment? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Comprehension [Understanding] Concept: Leadership and Management Difficulty: Moderate Feedback 1 This is incorrect. Positional power, which is also known as legitimate power, occurs when an individual derives authority from an official position in the organization’s hierarchy. The person at the top has the most power. 2 This is incorrect. Power derived through rewards involves the ability of an individual to control or allocate incentives (e.g., promotion, salary increases, recognition, or other benefits). 3 This is incorrect. Legitimate power, which is also known as positional power, occurs when an individual derives authority from an official position in the organization’s hierarchy. The person at the top has the most power. 4 This is correct. Referent power is informal power that is created through relationships with people within the organization. PTS: 1 CON: Leadership and Management 14. ANS: 1 Chapter: Chapter 40 Leading & Managing

Objective: Discuss the importance of effective communication skills to nurse leaders and managers. Page: 1099 (V1) Heading: Communicating Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Analysis [Analyzing] Concept: Leadership and Management Difficulty: Moderate Feedback 1 This is correct. Negative feedback is the process of pointing out what someone is not doing well and telling him how he can change it. Communicated in a constructive manner and not overused, negative feedback prompts the person to correct inappropriate behavior. Negative feedback should be given in private. 2 This is incorrect. Public sharing of positive feedback may be appropriate. However, in this case, negative feedback is indicated. Negative feedback should be shared privately. 3 This is incorrect. Praise is an excellent motivator and is indicated when addressing desirable behaviors. However, to modify an undesirable behavior, negative feedback is indicated. 4 This is incorrect. Reinforcing constructor behaviors is appropriate. However, for the purposes of addressing the problem behavior (frequent absences), negative feedback is needed. PTS: 1 CON: Leadership and Management 15. ANS: 4 Chapter: Chapter 40 Leading & Managing Objective: Describe the change process, including methods to decrease resistance to change. Page: 1101 (V1) Heading: Managing Change Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Comprehension [Understanding] Concept: Collaboration Difficulty: Moderate

1 2 3

Feedback This is incorrect. Threatening to quit is reflective of active resistance to change. This is incorrect. Open expressions of destructive and/or hostile criticism (“This is stupid …”) represent active resistance. This is incorrect. The nurse who listens to the planned changes and makes suggestions to support successful implementation of the changes is

demonstrating leadership characteristics. This is correct. Passive resistance involves avoidance, such as canceling appointments to discuss implementing the change; being “too busy” to implement the change; or agreeing to the change, but citing numerous barriers to it. Frequent absences during implementation of the reorganization may represent resistance to the change. Because the resistance is not overtly expressed, the resistance is passive in nature.

PTS: 1 CON: Collaboration 16. ANS: 2 Chapter: Chapter 40 Leading & Managing Objective: Describe the major concepts of safe and effective delegation. Page: 1100 (V1) Heading: Delegating Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Application [Applying] Concept: Collaboration Difficulty: Difficult Feedback 1 This is incorrect. The delegating nurse will not be held legally liable because the nursing assistant is qualified to perform this task. The courts have usually ruled that nurses are not liable for the negligence of other workers, provided that the nurse delegated appropriately. This was an appropriate delegation, so the nursing assistant will be held responsible. 2 This is correct. The courts have usually ruled that nurses are not liable for the negligence of other workers, provided that the nurse delegated appropriately. This was an appropriate delegation, so the nursing assistant will be held responsible. 3 This is incorrect. As a general rule, the courts have typically found that nurses are not liable for the negligence of other workers, provided that the nurse delegated appropriately. This was an appropriate delegation, so the nursing assistant will be held responsible. The delegating nurse will not be held legally liable because the nursing assistant is qualified to perform this task. 4 This is incorrect. The nursing supervisor was not involved in the delegation process or the delivery of patient care and will not be held liable. When the nurse’s act of delegation is appropriate, the courts have generally ruled that nurse is not liable for the negligence of other members of the healthcare team. PTS: 1 CON: Collaboration 17. ANS: 4 Chapter: Chapter 40 Leading & Managing

Objective: Explain the differences between transactional and transformational theories. Page: 1089 (V1) Heading: What is Leadership? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Comprehension [Understanding] Concept: Leadership and Management Difficulty: Difficult Feedback 1 This is incorrect. Transactional leadership is directive in nature. By contrast, transformational leadership is participative. 2 This is incorrect. While transactional leadership emphasizes individual performance, transformational leadership focuses on team and relationships. 3 This is incorrect. Transactional leadership is described as traditional. Transformational leadership is described as contemporary. 4 This is correct. Transformational leadership uses matrix communication. However, transactional leadership uses hierarchical communication. PTS: 1 CON: Leadership and Management 18. ANS: 4 Chapter: Chapter 40 Leading & Managing Objective: Establish short- and long-term personal and career goals. Page: 1105 (V1) Heading: Time Management Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment Cognitive Level: Comprehension [Understanding] Concept: Professionalism Difficulty: Easy Feedback 1 This is incorrect. Studying every night is a short-term goal because this action may be implemented immediately. 2 This is incorrect. Finding a babysitter is a short-term goal that needs to be met soon. 3 This is incorrect. Dressing professionally is a short-term goal that will be ongoing throughout the student’s career. It is short term because it will begin, one assumes, in the near future. 4 This is correct. Specializing in care of newborns is a long-term goal because the nurse must first complete nursing school and obtain specialty training to fulfill the goal. PTS:

CON: Professionalism

19. ANS: 1 Chapter: Chapter 40 Leading & Managing Objective: Develop effective time management strategies. Page: 1105 (V1) Heading: Time Management Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Application [Applying] Concept: Professionalism Difficulty: Moderate Feedback This is correct. The nurse’s initial step is prioritizing the list items. Prioritization is necessary to determine the order in which the items should be completed. This is incorrect. The nurse cannot question the effectiveness of an item until the task is performed. The first step is prioritization of the items on the list. This is incorrect. Practicing self-reliance will be the second step. As a first step, the nurse must prioritize the items on the list. This is incorrect. Evaluating personal efficacy involves asking whether or not the individual has the skill and ability to obtain the desired effect. Prior to evaluation of efficacy, the items in the list must be prioritized.

1 2 3 4

PTS:

CON: Professionalism

MULTIPLE RESPONSE 20. ANS: 1, 2, 4 Chapter: Chapter 40 Leading & Managing Objective: Discuss the qualities and activities that contribute to effective management. Page: 1091 (V1) Heading: What is Management? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Comprehension [Understanding] Concept: Leadership and Management Difficulty: Moderate

Feedback This is correct. An effective nurse manager possesses a combination of qualities: leadership skills, clinical expertise, and business sense. In combination, these qualities prepare the individual for the complex task of managing a group or team of healthcare providers.

This is correct. An effective nurse manager possesses a combination of qualities: leadership skills, clinical expertise, and business sense. In combination, these qualities prepare the individual for the complex task of managing a group or team of healthcare providers. This is incorrect. An individual’s academic training does not necessarily determine effectiveness as a manager. Graduate-level education is not a requirement to be an effective nurse manager. This is correct. An effective nurse manager possesses a combination of qualities: leadership skills, clinical expertise, and business sense. In combination, these qualities prepare the individual for the complex task of managing a group or team of healthcare providers. This is incorrect. Referent power refers to informal power created through relationships with people within the organization. Referent power is not critical to an individual’s effectiveness as a nurse manager.

PTS: 1 CON: Leadership and Management 21. ANS: 1, 2, 3, 4 Chapter: Chapter 40 Leading & Managing Objective: Describe the major concepts of safe and effective delegation. Page: 1100 (V1) Heading: Delegating Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Comprehension [Understanding] Concept: Leadership and Management Difficulty: Difficult

1. 2.

Feedback This is correct. The nurse is responsible for supervising patient care to ensure that it is competently delivered. This is correct. When delegating tasks, the nurse must take into consideration the skills and competency of the team members as well as the condition and needs of the clients receiving care. This is correct. Delegation of patient care tasks to other healthcare workers is one of the most important responsibilities of the registered nurse. When delegating tasks, the nurse must take into consideration the skills and competency of the team members as well as the condition and needs of the clients receiving care. This is correct. Delegation of patient care tasks to other healthcare workers is one of the most important responsibilities of the registered nurse. When delegating tasks, the nurse must take into consideration the skills and competency of the team members as well as the condition and needs of the clients receiving care. The nurse is also responsible for supervising patient care to ensure that it is competently

delivered. This is incorrect. Consultation with the charge nurse is not required in order to safely and effectively delegate tasks.

PTS: 1 CON: Leadership and Management 22. ANS: 1, 3, 4, 5 Chapter: Chapter 40 Leading & Managing Objective: Discuss the qualities of preceptors and mentors. Page: 1093 (V1) Heading: How Can I Prepare to Become a Leader and Manager? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Cognitive Level: Comprehension [Understanding] Concept: Leadership and Management Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is correct. Responsibilities of the mentee include demonstrating an ability to move toward independence. This is incorrect. The mentor’s responsibilities include encouraging excellence in others. This is correct. Responsibilities of the mentee include using feedback to modify behaviors. This is correct. Responsibilities of the mentee include displaying flexibility and the ability to change. This is correct. Responsibilities of the mentee include exhibiting an eagerness to learn.

PTS: 1 CON: Leadership and Management 23. ANS: 1, 2, 3 Chapter: Chapter 40 Leading & Managing Objective: Describe several ways to empower nurses. Page: 1097 (V1) Heading: What Are Power and Empowerment? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Application [Applying] Concept: Professionalism Difficulty: Moderate

Feedback This is correct. Improving competence (e.g., by attending seminars) can increase

2. 3. 4. 5.

feelings of empowerment. This is correct. Joining a committee increases one’s impact, which can be empowering. This is correct. Acting as a mentor can increase one’s impact, which can also be empowering. This is incorrect. Psychological counseling is not necessary for most people to feel empowered. This is incorrect. Achieving a formal position of power does not necessarily produce a sense of empowerment. It is possible to be powerful and yet not feel empowered.

PTS: 1 CON: Professionalism 24. ANS: 1, 2, 3, 5 Chapter: Chapter 40 Leading & Managing Objective: Distinguish between leadership, followership, and management. Page: 1096 (V1) Heading: What Is Followership? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Comprehension [Understanding] Concept: Leadership and Management Difficulty: Easy

1. 2.

3. 4.

Feedback This is correct. Sharing new evidence provides the opportunity to improve patient care, which is an important part of followership. This is correct. “I understand what you are saying, but …” is a statement that demonstrates honesty, respect, and careful listening, which are important parts of followership. This is correct. Creativity and innovation, as demonstrated in “… I have an idea to solve …” is an important part of followership. This is incorrect. The actions of stating that a problem is getting worse and suggesting the nurse manager’s solutions are not working represent criticism. While politely challenging a leader’s ideas is generally appropriate, the challenges should be framed in a constructive manner, and alternative solutions should be offered. This is correct. Accepting responsibility when offered (e.g., by agreeing to join the education committee) is an important means of demonstrating effective followership.

PTS:

CON: Leadership and Management

Chapter 41. Nursing Informatics Multiple Choice Identify the choice that best completes the statement or answers the question. 1. In informatics, raw, unprocessed numbers, symbols, or words that have no meaning by themselves are called which of the following? 1. Information 2. Data 3. Knowledge 4. Wisdom 2. Which informatics concept concerns the appropriate use of knowledge in managing or solving human problems? 1. Wisdom 2. Data 3. Knowledge 4. Information 3. The nurse is writing a blog on caring for patients with chronic illness. Which posting can be identified as a breach of the Health Insurance Portability and Accountability Act (HIPAA)? 1. A male with a glucose in the 200 range 2. A female reporting chronic headaches 3. A patient in their 30s with a history of lymphoma 4. A 24-year-old female in intensive care unit bed 4 with lupus 4. The seasoned nurse is precepting a novice nurse at the local hospital. The novice nurse needs to access a patient’s electronic health record (EHR) to retrieve laboratory results but does not yet have a password. Which action would the seasoned nurse take? 1. Share a password with the novice nurse until they receive a password. 2. Log on and remain with the novice nurse while the record is viewed. 3. Notify the supervisor that the new employee needs a password. 4. Inform the novice nurse that a password will not be given until orientation is complete. 5. CINAHL is a(n): 1. Popular periodical 2. Internet site 3. Scholarly journal 4. Literature database

6. A nurse is entering a pharmacy request for patient medication in the patient’s electronic health record (EHR) while seated at a computer in the nursing station. A physician approaches the nurse and asks for them to access another patient’s EHR to review laboratory values. Which of the following is the best action for the nurse to take? 1. Access the lab report for the physician. 2. Log off the computer before proceeding. 3. Quickly finish the pharmacy requisition before the physician logs on. 4. Allow the physician to access the laboratory report immediately. 7. Which is the primary benefit of computerized physician order entry (CPOE)? 1. Increased privacy 2. Improved access to patient data 3. Cost savings 4. Reduced medication errors 8. The nurse reviews the patient’s laboratory results. Which component of informatics is the nurse viewing? 1. Data 2. Information 3. Knowledge 4. Wisdom 9. Which classification system promotes standardized language that will improve computer interoperability in nursing? 1. NANDA-I nursing diagnoses 2. National Patient Safety Goals 3. QSEN competencies 4. Patient Bill of Rights 10. The Health Information Technology for Economic and Clinical Health (HITECH) encouraged implementation of electronic health records (EHR) by which means? 1. Fining facilities that did not convert to EHRs by 2015 2. Mandating that all facilities implement EHRs within the year 3. Providing incentive payments to facilities that converted to EHRs 4. Restricting providers’ access to traditional patient health records 11. Which patient may benefit the most from the use of telehealth? 1. A patient requiring a splenectomy 2. A patient who needs to see a cardiac specialist 3. A patient receiving daily chemotherapy for 3 weeks 4. A patient 41 weeks pregnant ready to deliver a third baby 12. The nurse is caring for a patient newly diagnosed with diabetes. The patient tells the nurse, “After searching the Internet, I found out that I don’t need insulin. All I need to do to control blood sugar is drink a mixture of vinegar and apple juice.” Which teaching would the nurse provide?

1. Show the patient how to choose reputable, trustworthy healthcare Web sites. 2. Instruct the patient on the importance of adhering to the prescriber’s instructions. 3. Inform the patient that the healthcare provider is always right and should be trusted. 4. Have the patient return to the Web site to obtain more detailed information. 13. The nurse organizing an evidence-based practice committee has a computer with Internet access. Which would be most important to the committee when searching for the most current scientific evidence? 1. Medical and nursing textbooks 2. Database of health journals 3. Subscriptions to scholarly journals 4. Librarian in the facility 14. The nurse is preparing to conduct a literature search to find evidence related to care of a patient with diabetes experiencing neuropathy. Which of the following keywords would the nurse use to best identify the information searched for? 1. Caring for diabetics 2. Nursing care of neuropathy 3. Diabetic neuropathy 4. Complications of diabetes 15. Which of the following sources provides the most current information regarding a medication newly approved by the U.S. Food and Drug Administration (FDA)? 1. The worldwide Web 2. Popular periodicals 3. Textbooks 4. Scholarly journals 16. The nurse is looking for the most current evidence related to safe medication administration. Which source provides the most reliable information? 1. Peer-reviewed scholarly journals 2. Popular periodicals 3. Social media Internet sites 4. Online drug reference 17. Which database would the nurse use to restrict the search to nursing articles only? 1. MEDLINE 2. CINAHL 3. PsycINFO 4. ProQuest 18. The nurse is conducting a literature search. In which instance might the nurse question the reliability of the health information? 1. The author has a DNP degree.

2. The article has a list of references. 3. The Web address ends in .net. 4. The Publication date is 3 years old. Multiple Response Identify one or more choices that best complete the statement or answer the question. 19. Which of the following are main functions of a computer? Select all that apply. 1. Process 2. Storage 3. Memory 4. Output 5. Input 20. Which of the following aspects of a computer determine its power? Select all that apply. 1. User-friendliness 2. Speed of operations 3. Accessibility for the user 4. Data storage capacity 5. Accuracy and reliability of operations 21. Which of the following health information is protected in the electronic health record? Select all that apply. 1. Social Security number 2. Insurance information 3. Physician’s name 4. Laboratory results 5. Patient’s gender 22. The nurse practitioner dispenses a drug to administer to the patient and the electronic health record (EHR) flags the medication. For which reason might this occur? Select all that apply. 1. The medication has a similar name to another medication (sound-alike-look-alikedrug [SALAD]). 2. The medication ordered is higher than the normal recommended dose. 3. The pharmacist feels there is a better medication for the patient. 4. The drug is incompatible with another medication the patient is taking. 5. The patient has reported a drug allergy to the medication. 23. The nurse is using an electronic health record (EHR) system. Which feature does not improve the safety of patient care delivered by the nurse? Select all that apply. 1. Physician order entry 2. Decision support tools 3. Elimination of poor handwriting 4. Improved accessibility

5. Cost-effectiveness 24. The nurse is administering medications to patients by using a barcode–scanning device that scans the patient’s identification bracelet and the medication to be administered to avoid a medication error. Which types of errors does this barcode–scanning device prevent? Select all that apply. 1. Errors of commission 2. Errors of omission 3. Errors in planning 4. Errors in execution 5. Errors in assessment 25. Which describes a best practice when communicating professionally? Select all that apply. 1. Text messages should be elaborate. 2. Use abbreviations when possible. 3. Avoid using all caps. 4. Use proper grammar and spelling 5. Inform the receiver when you expect to reply

Chapter 41. Nursing Informatics Answer Section MULTIPLE CHOICE 1. ANS: 2 Chapter: Chapter 41 Nursing Informatics Objective: Define informatics and its four components. Page: 1110 (V1) Heading: Data Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Knowledge [Remembering] Concept: Informatics Difficulty: Easy Feedback 1 This is incorrect. Information consists of groupings of data processed into a meaningful, structured form. 2 This is correct. Data are raw, unprocessed numbers, symbols, or words that have no meaning by themselves. 3 This is incorrect. Knowledge is formed when data are grouped, creating meaningful information and relationships, which are then added to other structured information. 4 This is incorrect. Wisdom is the appropriate use of knowledge in managing or solving human problems. PTS: 1 CON: Informatics 2. ANS: 1 Chapter: Chapter 41 Nursing Informatics Objective: Define informatics and its four components. Page: 1110 (V1) Heading: Wisdom Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Knowledge [Remembering] Concept: Informatics Difficulty: Easy Feedback 1 This is correct. Wisdom is the appropriate use of knowledge in managing or solving human problems. 2 This is incorrect. Data are raw, unprocessed numbers, symbols, or words that have no meaning by themselves.

3 4

This is incorrect. Information consists of groupings of data processed into a meaningful, structured form. This is incorrect. Knowledge is formed when data are grouped, creating meaningful information and relationships, which are then added to other structured information.

PTS: 1 CON: Informatics 3. ANS: 4 Chapter: Chapter 41 Nursing Informatics Objective: Describe the importance of protecting personal health information. Page: 1111 (V1) Heading: Social Networking Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Informatics Difficulty: Moderate Feedback 1 This is incorrect. Only providing a gender and diagnosis does not provide enough information to easily identify a specific patient. 2 This is incorrect. This posting only states a gender and diagnosis, which does not make it easy to identify the patient. 3 This is incorrect. This posting does not provide a specific age or location and does not easily identify the patient. 4 This is correct. This posting provides which unit the patient is on, the bed number, gender, age, and diagnosis. Posting all of this information can easily identify the exact patient and would be a HIPAA violation. PTS: 1 CON: Informatics 4. ANS: 3 Chapter: Chapter 41 Nursing Informatics Objective: Describe the importance of protecting personal health information. Page: 1116 (V1) Heading: Box 41-1 Some Simple Tips for Password Management Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Informatics Difficulty: Moderate

Feedback This is incorrect. Never share your password with another person.

2 3 4

This is incorrect. Never log on to a computer to allow another access to information. This is correct. Notify your supervisor that the new employee needs a password. This is incorrect. In most hospitals, nurses are given a password during their orientation.

PTS: 1 CON: Informatics 5. ANS: 4 Chapter: Chapter 41 Nursing Informatics Objective: Describe the process of literature database searching. Page: 1121 (V1) Heading: Table 41-2 Selected Databases for Health Literature Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Informatics Difficulty: Easy Feedback 1 This is incorrect. CINAHL is not a periodical, but a literature database which may consist of periodicals. 2 This is incorrect. CINAHL may be accessed by the Internet or in hard copy in most libraries. 3 This is incorrect. CINAHL is a literature database consisting of scholarly journals. 4 This is correct. CINAHL—Cumulative Index of Nursing and Allied Health Literature—is a literature database covering nursing, allied health, biomedical, and consumer health journal articles. PTS: 1 CON: Informatics 6. ANS: 2 Chapter: Chapter 41 Nursing Informatics Objective: Describe the importance of protecting personal health information. Page: 1119 (V1) Heading: Box 41-1 Some Simple Tips for Password Management Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Informatics Difficulty: Difficult

Feedback This is incorrect. Accessing information that is not relevant to the care that the

2 3

nurse is providing is a HIPAA violation. This is correct. The nurse would log off the computer and then allow the physician to log on under their own password. This is incorrect. Rushing to complete a pharmacy request for patient medication is a situation of risk for medication error. The nurse would never hurriedly order or administer medication because that is when errors are more likely to occur. This is incorrect. The nurse should never allow anyone to use her password to access information. The nurse must log off before any other provider uses the terminal for accessing patient data.

PTS: 1 CON: Informatics 7. ANS: 4 Chapter: Chapter 41 Nursing Informatics Objective: Discuss the benefits of the electronic health record. Page: 1114 (V1) Heading: Computerized Physician Order Entry (CPOE) Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Informatics Difficulty: Difficult Feedback 1 This is incorrect. CPOE does help protect patient health information, but the primary benefit is to reduce errors. 2 This is incorrect. Likewise, orders entered into the computer are more conveniently accessed by nurses and pharmacists, but the most important benefit of CPOE is to reduce errors. 3 This is incorrect. Although the efficiencies of the CPOE reduce costs, it is not the primary benefit of the system. 4 This is correct. CPOE is technology that allows healthcare providers to enter orders into a computerized prescribing system instead of handwriting them. Orders are integrated with patient information, including allergy history and laboratory and other prescription data. The new order is then automatically checked for potential errors or problems. This reduces prescription errors resulting from illegible penmanship. It can detect dosing errors by flagging medication dilution or dosages that fall outside normal dosing standards. The system warns about the possibility of a drug interaction, allergy, or incorrect dose. As some drug names sound like other drugs, CPOE can alert prescribers and potentially avoid a drug error that could be serious or fatal. PTS:

CON: Informatics

8. ANS: 2 Chapter: Chapter 41 Nursing Informatics Objective: Define informatics and its four components. Page: 1110 (V1) Heading: Information Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Informatics Difficulty: Moderate Feedback 1 This is incorrect. Data (raw numbers) alone have no meaning without associating the values with the patient’s health status. 2 This is correct. The material reviewed on the laboratory report is information because they correspond to the patient’s physiological condition. 3 This is incorrect. The laboratory results become knowledge when the nurse interprets the laboratory readings to understand the patient’s condition. 4 This is incorrect. The nurse uses wisdom when applying the laboratory values to findings to determine an appropriate plan of care for the patient. PTS: 1 CON: Informatics 9. ANS: 1 Chapter: Chapter 41 Nursing Informatics Objective: Explain the role of interoperability and standardized languages within the electronic health record system for exchanging health information. Page: 909 (V2) Heading: Standardized Language Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Informatics Difficulty: Moderate

Feedback This is correct. Standardizing the language of nursing diagnoses (NANDA International taxonomy) improves interoperability among computer systems and software programs. This is incorrect. Although improving interoperability and interprofessional communication through the use of standardized languages indirectly improves patient safety, the primary purpose of the National Patient Safety Goals is to improve patient safety. This is incorrect. The Quality and Safety Education for Nurses (QSEN)

Initiative was designed to guide future nurses with the knowledge, skills, and attitudes (KSAs) necessary to provide quality and safe patient care within the healthcare systems in which they work. This is incorrect. The Patient Bill of Rights advocates for protection of patient information, fair treatment, and autonomy over medical decisions, among other rights—rather than standardizing nursing language.

PTS: 1 CON: Informatics 10. ANS: 3 Chapter: Chapter 41 Nursing Informatics Objective: Discuss the impact of legislative efforts to encourage electronic health record adoption. Page: 1116 (V1) Heading: Electronic Health Records Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Informatics Difficulty: Easy Feedback 1 This is incorrect. The HITECH did not fine organizations failing to implement an EHR system. 2 This is incorrect. HITECH did not mandate implementation of an EHR system. 3 This is correct. Incentive payments were offered by the HITECH to promote implementation of EHR systems by helping the organization to pay for start-up costs. 4 This is incorrect. HITECH does not restrict providers’ access to traditional patient health records. PTS: 1 CON: Informatics 11. ANS: 2 Chapter: Chapter 41 Nursing Informatics Objective: Explain the role of interoperability and standardized languages within the electronic health record system for exchanging health information. Page: 1112 (V1) Heading: Telehealth Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Informatics Difficulty: Moderate Feedback

1 2

This is incorrect. A patient requiring surgery would need to be admitted to a facility to undergo surgery and is not a good candidate for telehealth. This is correct. A patient needing to see a cardiac specialist would be a good candidate for telehealth. The specialist can review lab results, x-rays, and other diagnostic results without the patient present. This is incorrect. This patient is not a good candidate for telehealth since they are receiving chemotherapy which comes with additional side effects, such as nausea and vomiting, diarrhea, stomatitis, and blood dyscrasias. This is incorrect. This patient is not a good candidate for telehealth since they are past a due date and multipara.

PTS: 1 CON: Informatics 12. ANS: 1 Chapter: Chapter 41 Nursing Informatics Objective: Describe the process of literature database searching. Page: 1114 (V1) Heading: Aiding Patients in Self-Care Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Informatics Difficulty: Easy Feedback 1 This is correct. Not all information available on the Internet is reliable. The nurse would teach the patient how to search authority sources, professional organization Web sites, nursing literature databases, and key government guidelines for trustworthy information. 2 This is incorrect. Although following the prescriber’s instructions is important, if the patient believes the mixture of vinegar and apple juice will prevent needing daily injections of insulin, he will be unlikely to follow the prescriber’s instructions. 3 This is incorrect. Saying the healthcare provider is always right is patronizing and does not promote the patient’s active participation in his own healthcare. 4 This is incorrect. The information the patient obtained from the Web site is not reliable and is not suitable heath advice. PTS: 1 CON: Informatics 13. ANS: 2 Chapter: Chapter 41 Nursing Informatics Objective: Describe the process of literature database searching. Page: 1122 (V1) Heading: Literature Databases

Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Informatics Difficulty: Moderate Feedback 1 This is incorrect. Textbooks are not the most current evidence because they require time to write and publish. 2 This is correct. The most important resource for an evidence-based practice committee would be access to a database of medical, nursing, and allied health journals, such as CINHAL (Cumulative Index to Nursing and Allied Health Literature) and ProQuest. 3 This is incorrect. Although scientific research is published in peer-reviewed, scholarly journals, having various subscriptions of hard-copy journals is not practical because the nurse would have to read through each journal to find information, and the number of articles available would be limited using this approach. 4 This is incorrect. The librarian can be helpful, but this would not be as important as another option. PTS: 1 CON: Informatics 14. ANS: 3 Chapter: Chapter 41 Nursing Informatics Objective: Describe the process of literature database searching. Page: 1117 (V1) Heading: Standardized Languages Support Evidence-Based Practice Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Informatics Difficulty: Moderate Feedback 1 This is incorrect. Searching “care for diabetics” is too broad and would not focus on neuropathy. 2 This is incorrect. Searching “nursing care of neuropathy” is too broad and would provide journal articles containing subject matter unrelated to the search topic of interest. 3 This is correct. Searching the keywords “diabetic neuropathy” will bring up the most relevant content. 4 This is incorrect. There are many complications of diabetes other than neuropathy; therefore, searching “complications of diabetes” will provide many articles not relevant to the nurse’s interests.

PTS: 1 CON: Informatics 15. ANS: 1 Chapter: Chapter 41 Nursing Informatics Objective: Describe the process of literature database searching. Page: 1122 (V1) Heading: The World Wide Web Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Informatics Difficulty: Easy Feedback 1 This is correct. The most recently published information is available via the worldwide Web because content can be uploaded quickly. 2 This is incorrect. Popular periodicals may provide current information, but it is not likely to be as reliable as other sources. 3 This is incorrect. Textbooks require time to write and publish. By the time they are purchased, the material contained within a textbook is 1 to 2 years old, so it does not contain the most current information. 4 This is incorrect. Scholarly journals are the second most current source of information and are generally very reliable, although all information needs to be evaluated for application to the nurse’s practice. PTS: 1 CON: Informatics 16. ANS: 4 Chapter: Chapter 41 Nursing Informatics Objective: Describe the process of literature database searching. Page: 1115 (V1) Heading: Supporting Healthcare Professionals Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Informatics Difficulty: Moderate Feedback 1 This is incorrect. Peer-reviewed journal articles are read by experts in the field and critiqued before they are published to check for reliability. They are a good source of reliable information, although they would be a secondary source. 2 This is incorrect. Popular periodicals are secondary sources of information; they are not scholarly, technical, peer-reviewed, or verified by an authoritative source.

3 4

This is incorrect. Social media sites are largely merely a sharing of opinions and lack reliability. This is correct. Online drug references published by authoritative sources are reliable and current, for example, the U.S. FDA’s Medication Guides or the Physicians’ Desk Reference (PDR).

PTS: 1 CON: Informatics 17. ANS: 2 Chapter: Chapter 41 Nursing Informatics Objective: Describe the process of literature database searching. Page: 1123 (V1) Heading: Cumulative Index for Nursing and Allied Health Literature (CINAHL) Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Informatics Difficulty: Easy Feedback 1 This is incorrect. MEDLINE contains the largest biomedicine and healthcare medical library and is not specific to nursing. 2 This is correct. CINAHL covers nursing, allied health, biomedical, and consumer health journals that are more specific to nursing than any other database. 3 This is incorrect. PsycINFO covers worldwide literature in psychology and related disciplines and is not nursing specific. 4 This is incorrect. ProQuest is a general database containing information from many sources other than healthcare. PTS: 1 CON: Informatics 18. ANS: 3 Chapter: Chapter 41 Nursing Informatics Objective: Describe the process of literature database searching. Page: 1119 (V1) Heading: Box 41-4 How to Evaluate Health Information on the Internet Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Informatics Difficulty: Moderate Feedback 1 This is incorrect. A doctorate in nursing practice (DNP) degree indicates the author has a good educational basis and can be considered an expert. This would

not make the nurse question the reliability of the writing. This is incorrect. Articles with a reference list indicate the writing is based on other sources and would not make the nurse question the reliability of the writing. This is correct. Web addresses ending in .net would make the nurse doublecheck the reliability of the information to make sure it is accurate by looking for other sources to support the claims. A Web address ending in .net indicates a network of computers. This is incorrect. Information that is less than 5 years old is considered up to date; some classic content, original theory, or research may be even older and still remain relevant.

PTS:

CON: Informatics

MULTIPLE RESPONSE 19. ANS: 1, 2, 4, 5 Chapter: Chapter 41 Nursing Informatics Objective: Define informatics and its four components. Page: 1111 (V1) Heading: Computer Basics Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Knowledge [Remembering] Concept: Informatics Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is correct. The four main functions of a computer are input, process, output, and storage. This is correct. The four main functions of a computer are input, process, output, and storage. This is incorrect. Memory refers to the amount of space available for storage of digital information on a computer. This is correct. The four main functions of a computer are input, process, output, and storage. This is correct. The four main functions of a computer are input, process, output, and storage.

PTS: 1 CON: Informatics 20. ANS: 2, 4, 5 Chapter: Chapter 41 Nursing Informatics

Objective: Define informatics and its four components. Page: 1111 (V1) Heading: Computer Basics Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Knowledge [Remembering] Concept: Informatics Difficulty: Difficult

1. 2. 3. 4. 5.

Feedback This is incorrect. Although ease of use and accessibility are important features for users, these factors do not determine the power of a computer. This is correct. The power of a computer is determined by its speed, accuracy, reliability, and data storage and processing capabilities. This is incorrect. Although ease of use and accessibility are important features for users, these factors do not determine the power of a computer. This is correct. The power of a computer is determined by its speed, accuracy, reliability, and data storage and processing capabilities. This is correct. The power of a computer is determined by its speed, accuracy, reliability, and data storage and processing capabilities.

PTS: 1 CON: Informatics 21. ANS: 1, 2, 4 Chapter: Chapter 41 Nursing Informatics Objective: Describe the importance of protecting personal health information. Page: 1111 (V1) Heading: Protecting Privacy Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Knowledge [Remembering] Concept: Informatics Difficulty: Moderate

2. 3. 4. 5.

Feedback This is correct. A social security number is identifiable information and must be protect. Federal regulations govern what information must be protected. Penalties will be levied for each breach of privacy. This is correct. Insurance information is covered under protected information. This is incorrect. A physician’s name does not identify the patient and is not protected information. This is correct. A patient’s laboratory results are protected information. This is incorrect. A patient’s gender is not identifiable and, therefore, is not protected information.

PTS: 1 CON: Informatics 22. ANS: 1, 2, 4, 5 Chapter: Chapter 41 Nursing Informatics Objective: Identify at least two ways that automation decreases error in healthcare. Page: 1113 (V1) Heading: Reducing Error with Automation Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Informatics Difficulty: Difficult

2. 3.

Feedback This is correct. The EHR may flag a medication to alert the nurse practitioner if a medication is a SALAD medication (sounds or looks similar to another medication), such as bupropion and buspirone. This is correct. A medication may be flagged by the EHR if the recommended dose range is higher or lower than the prescribed dose. This is incorrect. A medication is not flagged if the pharmacist feels there is a medication more suitable for the patient. The pharmacist may call the healthcare provider. This is correct. If the patient is taking a medication that will interact with the prescribed medication, the EHR may flag the medication for the nurse practitioner to review. This is correct. In order to prevent serious error, a medication that the patient reports an allergic response to may be flagged.

PTS: 1 CON: Informatics 23. ANS: 1, 2, 3 Chapter: Chapter 41 Nursing Informatics Objective: Discuss the benefits of the electronic health record. Page: 1117 (V1) Heading: Benefits of an Electronic Health Record Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Informatics Difficulty: Moderate

Feedback This is correct. EHRs allow for secure communication of patient information among

2. 3. 4. 5.

various healthcare providers, which can reduce costly redundant tests and duplication in care. Physician order entry improves patient safety because it prevents missed orders or misunderstood telephone orders. This is correct. Decision support tools help to maintain patient safety by reducing errors in calculating medication dosages. This is correct. Eliminating poor handwriting with typed text reduces errors caused by misinterpreting the written word. This is incorrect. Although an EHR does improve accessibility, this is convenient for those using the EHR and not a feature that improves patient safety. This is incorrect. Although EHRs are cost effective, the price does not promote patient safety.

PTS: 1 CON: Informatics 24. ANS: 1, 4 Chapter: Chapter 41 Nursing Informatics Objective: Discuss the benefits of the electronic health record. Page: 1113 (V1) Heading: Reducing Error with Automation Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Informatics Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is correct. A medication error is an error of commission because it is something that is done incorrectly. This is incorrect. A barcode scanner would not prevent the nurse from missing an order or forgetting to give a medication, which would be errors of omission. This is incorrect. The nurse administering medication is not planning care. This is correct. Making a medication error would be an error in execution. This is incorrect. There is no such thing as an error in assessment.

PTS: 1 CON: Informatics 25. ANS: 3, 4, 5 Chapter: Chapter 41 Nursing Informatics Objective: Explain the role of interoperability and standardized languages within the electronic health record system for exchanging health information. Page: 1111 (V1) Heading: Communicating Professionally Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care

Cognitive Level: Application [Applying] Concept: Informatics Difficulty: Difficult

1. 2. 3. 4. 5.

Feedback This is incorrect. Text messages and emails should be concise and to the point. This is incorrect. Abbreviations should be avoided when possible. The individual receiving the communication may not understand the abbreviations being used. This is correct. The sender should avoid using all caps because this can come across as yelling to the receiver. This is correct. The sender should use proper grammar and spelling in all professional communication. This is correct. If you are unable to respond immediately, at least alert the receiver of when they may expect a response. Not responding relays the message they are not important.

PTS:

CON: Informatics

Chapter 42. Promoting Health Multiple Choice Identify the choice that best completes the statement or answers the question. 1. A client informs the nurse that he has quit smoking because his father died of lung cancer 3 months ago. Based on his motivation, smoking cessation should be recognized as an example of which of the following? 1. Healthy living 2. Health promotion 3. Wellness behaviors 4. Health protection 2. A patient with morbid obesity was enrolled in a weight loss program last month and has attended four weekly meetings. But now he believes he no longer needs to attend meetings because he has “learned what to do.” He informs the nurse facilitator about his decision to quit the program. What should the nurse tell him? 1. “By now, you have successfully completed the steps of the change process. You should be able to successfully lose the rest of the weight on your own.” 2. “Although you have learned some healthy habits, you will need at least another 6 weeks before you can quit the program and have success.” 3. “You have done well in this program. However, it is important to continue in the program to learn how to maintain weight loss. Otherwise, you are likely to return to your previous lifestyle.” 4. “You have entered the ‘determination stage’ and are ready to make positive changes that you can keep for the rest of your life. If you need additional help, you can come back at a later time.” 3. The school nurse at a local elementary school is performing physical fitness assessments on the third grade children. When assessing students’ cardiorespiratory fitness, the most appropriate test is to have the students: 1. Step up and down on a 12-inch bench 2. Perform the sit-and-reach test 3. Run a mile without stopping, if they can 4. Perform range-of-motion exercises 4. A 55-year-old man suffered a myocardial infarction (heart attack) 3 months ago. During his hospitalization, he had stents inserted in two sites in the coronary arteries. He was also placed on a cholesterol-lowering agent and two antihypertensives. What type of care is he receiving? 1. Primary prevention 2. Secondary prevention 3. Tertiary prevention 4. Health promotion

5. A mother of three young children is newly diagnosed with breast cancer. She is intensely committed to fighting the cancer. She believes she can control her cancer to some degree with a positive attitude and feelings of inner strength. Which of the following traits is she demonstrating that is linked to health and healing? 1. Invincibility 2. Hardiness 3. Baseline strength 4. Vulnerability 6. Which type of health promotion programs seeks to raise the level of knowledge and awareness of individuals and groups about health habits? 1. Environmental evaluation and protection 2. Information dissemination 3. Wellness assessment and appraising health risk 4. Lifestyle and behavior changes 7. The nurse is caring for a patient with a nursing diagnosis of Activity Intolerance secondary to cardiac disease that causes the patient to produce less energy than is expended with activity. Which theory of health and wellness would support this nursing diagnosis? 1. World Health Organization (WHO) 2. Jean Watson 3. Betty Neuman 4. Myers, Sweeney, and Witmer 8. The nurse teaches a class for the community discussing routine screening tests for different types of cancer. What level of health prevention would the nurse classify this activity? 1. Primary 2. Secondary 3. Tertiary 4. Maintenance 9. The nurse working in an acute care setting provides what level of health prevention most often? 1. Primary 2. Secondary 3. Tertiary 4. Assessment 10. The nurse is working with a client who is obese and reports having a sedentary lifestyle. What is the nurse’s first action to promote this client’s health? 1. Teach the client how to follow a low-calorie diet. 2. Assist the client in a plan to increase his activity level. 3. Explain the risks associated with the client’s weight and lifestyle. 4. Help the client identify goals for promoting health.

11. The nurse is teaching a class for diabetics and tells them, “Maintaining your blood glucose within normal limits helps reduce the risk for complications of diabetes.” What type of activity does this class represent? 1. Health promotion 2. Health protection 3. Primary prevention 4. Tertiary prevention 12. A group of nursing students have been discussing the benefits of forming a study group. They realize that reviewing disease processes and treatments together may be more helpful in retaining new information and applying it to the clinical setting than if they continued to study individually. According to Prochaska and DiClemente’s Transtheoretical Model of Change, which stage of behavior change are they exemplifying? 1. Precontemplation 2. Contemplation 3. Preparation 4. Action Stage 13. The nurse meets with patients who have quit smoking or are planning to quit. Which statement made by a patient would lead the nurse to conclude that that patient is in the maintenance stage of change? 1. “I haven’t smoked in 2 weeks, but I have to constantly resist the urge to light a cigarette.” 2. “I don’t even think about cigarettes anymore. I really don’t miss smoking.” 3. “Each day I don’t smoke, I put money that I would have spent in a jar to pay for a vacation.” 4. “I am chewing gum and eating carrot sticks to keep myself from lighting a cigarette.” 14. The nurse is planning a health promotion class for young adult women. What topic would be most important for the nurse to include for this group? 1. Immunizations 2. Papanicolaou (Pap) test every 2 or 3 years 3. Annual mammograms 4. Screening colonoscopies 15. The nurse is planning a health promotion class for adolescents. The presentation is too long. Which topic would be least important and therefore appropriate for the nurse to delete? 1. Stranger danger 2. Motor vehicle safety 3. Firearm safety 4. Alcohol and drug use 16. Which would be an appropriate topic for the elementary school nurse to include in health promotion activities for students?

1. 2. 3. 4.

Housing conditions Poor sanitation Stranger danger Preventing sexually transmitted infections (STIs)

17. The new mother who just gave birth tells the nurse, “I don’t know anything about babies, so I want you to teach me everything you can to help me be a good mother.” What nursing diagnosis would be most appropriate for this patient? Readiness for Enhanced: 1. Breastfeeding 2. Communication 3. Family Coping 4. Parenting 18. The nurse conducts an assessment of a 38-year-old patient’s fitness using the step test. At the end of the test, which heart rate would indicate the patient is in very poor physical condition? 1. 96 beats/min 2. 106 beats/min 3. 114 beats/min 4. 134 beats/min Multiple Response Identify one or more choices that best complete the statement or answer the question. 19. According to Pender’s Health Promotion Model, which variables must be considered when planning a health promotion program for a client? Select all that apply. 1. Individual characteristics and experiences 2. Levels of prevention 3. Behavioral outcomes 4. Behavior-specific cognition and affect 5. Health is compared to the spokes of a wheel 20. Goals for Healthy People 2020 include which of the following? Select all that apply. 1. Eliminate health disparities among various groups. 2. Decrease the cost of healthcare related to tobacco use. 3. Increase the quality and years of healthy life. 4. Decrease the number of inpatient days annually. 5. Promote hospice care to the elderly 21. The nurse is implementing a wellness program based on data gathered from a group of low-income seniors living in a housing project. He is using the Wheels of Wellness as a model for his planned interventions. Which of the following interventions would be appropriate based on this model? Select all that apply. 1. Creating a weekly discussion group focused on contemporary news 2. Facilitating a relationship between local pastors and residents of subsidized

housing 3. Coordinating a senior tutorial program for local children at the housing center 4. Establishing an on-site healthcare clinic operating 1 day per week 5. Providing free housing for seniors 22. The nurse working in an ambulatory care program asks questions about the client’s locus of control as a part of his assessment because of which of the following? Select all that apply. 1. People who feel in charge of their own health are the easiest to motivate toward change. 2. People who feel powerless about preventing illness are least likely to engage in health promotion activities. 3. People who respond to direction from respected authorities often prefer a health promotion program supervised by a health provider. 4. People who feel in charge of their own health are less motivated by health promotion activities. 5. People who are not in control of their health decisions will be more motivated by positive change. 23. Identify interventions that would be effective when assisting a client in making behavior changes that would reduce his health risk factors. Select all that apply. 1. Ask the client to follow a plan you wrote for him. 2. Have the client identify two or three goals for change. 3. Help the client to understand the benefits of change. 4. Allow the client to identify available support and resources within the community. 5. Ask the family members to create a plan according to family values and rules. 24. The nurse is admitting an elderly resident to an assisted living facility. In order to determine the resident’s level of physical fitness upon admission, which of the following components should be included in the assessment? 1. Cardiorespiratory fitness 2. Hardiness 3. Muscular fitness 4. Flexibility 5. Nutritional status 25. The nurse is conducting a risk appraisal related to the patient’s lifestyle choices. What questions would be appropriate for the nurse to ask? Select all that apply. 1. “What is your job?” 2. “What is your marital status?” 3. “What are your hobbies?” 4. “Are you sexually active?” 5. “Have you moved recently?” 26. What teaching points will the nurse develop to address Healthy People 2020 goals? Select all that apply.

1. 2. 3. 4. 5.

How to assess developmental milestones How to file for Medicaid How to maintaining a safe home and neighborhood How to develop and maintain a healthy lifestyle How to develop a low-fat, low-calorie diet

27. The nurse, working in a substance abuse rehabilitation facility, is talking with a resident who says, “I’m just here to avoid going to jail. I’m not addicted to alcohol. I just enjoy it, but I’m going to quit to avoid getting arrested again.” Which of Pender’s Health Promotion Model assumptions is this resident demonstrating? Select all that apply. 1. Health professionals are part of the person’s interpersonal environment. 2. The capacity for self-awareness includes assessing one’s own competencies. 3. The person values positive growth and attempts to balance change and stability. 4. The person seeks to actively regulate his own behavior. 5. The person relies on family members to reconfigure person–environment interactive patterns.

Chapter 42. Promoting Health Answer Section MULTIPLE CHOICE 1. ANS: 4 Chapter: Chapter 42 Promoting Health Objective: Define health, health promotion, and health protection. Page: 1127 (V1) Heading: Health Promotion Versus Health Protection Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Health Promotion Difficulty: Moderate Feedback 1 This is incorrect. Healthy living is not the reason that the client gives for smoking cessation. The client states a desire to avoid illness. 2 This is incorrect. Health promotion is motivated by the desire to increase wellbeing; the motivation of the client in this scenario is to avoid lung cancer. 3 This is incorrect. Smoking cessation may be a wellness behavior, but it does not address motivation. 4 This is correct. Health protection is motivated by the desire to avoid illness, which is the reason that the client stated in this scenario. PTS: 1 CON: Health Promotion 2. ANS: 3 Chapter: Chapter 42 Promoting Health Objective: Identify Prochaska and DiClemente’s four stages of change. Page: 1130 (V1) Heading: Transtheoretical Model of Change Integrated Processes: Teaching and Learning Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate Feedback 1 This is incorrect. Prochaska and DiClemente identified four stages of change: the contemplation stage, the determination stage, the action stage, and the maintenance stage. 2 This is incorrect. The patient demonstrates behaviors typical of the action stage. 3 This is correct. If a participant exits a program before the end of the

maintenance stage, relapse is likely to occur as the individual resumes his previous lifestyle. This is incorrect. There is no determination stage. The individual needs to progress through all the stages and continue with the maintenance stage to ensure that change will be permanent.

PTS: 1 CON: Health Promotion 3. ANS: 3 Chapter: Chapter 42 Promoting Health Objective: Identify health promotion strategies (including immunizations and screenings) across the life span. Page: 1133 (V1) Heading: Assessment > Physical Fitness Assessment Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate Feedback 1 This is incorrect. The step test is appropriate for adults. The 12-inch bench height is too high for young children. 2 This is incorrect. The sit and reach test assesses flexibility. 3 This is correct. Field tests are good for children and can be used when assessing cardiorespiratory fitness. 4 This is incorrect. The range-of-motion test assesses flexibility. PTS: 1 CON: Health Promotion 4. ANS: 3 Chapter: Chapter 42 Health Promotion Objective: Identify health prevention activities and categorize them as primary, secondary, or tertiary levels of prevention. Page: 1127 (V1) Heading: Health Promotion Versus Health Protection > Levels of Prevention Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Primary prevention activities are designed to prevent or slow the onset of disease. Activities such as eating healthy foods, exercising, wearing sunscreen, obeying seat-belt laws, and getting immunizations are examples of

primary level interventions. This is incorrect. Secondary prevention activities detect illness so that it can be treated in the early stages. Examples of these activities are physical exams, screenings, and tests. This is correct. Tertiary prevention focuses on stopping the disease from progressing and returning the individual to the pre-illness phase. The patient has an established disease and is receiving care to stop the disease from progressing. This is incorrect. Health promotion is not a specific type of care. The World Health Organization (WHO) has defined health promotion as the process of equipping people to have control over, and to improve, physical, emotional, and social health (WHO, 1986).

PTS: 1 CON: Patient-Centered Care 5. ANS: 2 Chapter: Chapter 42 Promoting Health Objective: Identify the areas of assessment in relation to developing a health promotion plan. Page: 1134 (V1) Heading: Stressful Life Change Events > Hardiness Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Invincibility is the belief that one is not susceptible to illness and the resulting lack of participation in screenings and health promotion behaviors recommended by healthcare providers (HCP’s). 2 This is correct. One of the characteristics of a hardy person is the belief in the ability to control the experience. 3 This is incorrect. Baseline strength is not a specific trait since it does not address whether the individual is vulnerable and lacks strength, or hardy which indicates strength. 4 This is incorrect. A vulnerable individual is one who lacks the defenses to maintain health and is more likely to experience illnesses along with complications. PTS: 1 CON: Patient-Centered Care 6. ANS: 2 Chapter: Chapter 42 Promoting Health Objective: Discuss nurses’ role in health promotion, list health promotion activities that a nurse may conduct in acute care facilities, the workplace, local communities, and schools. Page: 1130 (V1)

Heading: Health Promotion Programs > Disseminating information Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Knowledge [Remembering] Concept: Health Promotion Difficulty: Moderate Feedback 1 This is incorrect. Environmental evaluation and protection are an assessment, not a health promotion program. 2 This is correct. Disseminating information at the individual, group, or community level will help a person recognize a problem and understand options for change. It increases knowledge of health habits for any level; therefore, these are examples of health promotion programs. 3 This is incorrect. Wellness assessment and appraising health risk are not health promotion programs. 4 This is incorrect. Lifestyle and behavior changes can be the result of health promotion programs but are not a health promotion program. PTS: 1 CON: Health Promotion 7. ANS: 3 Chapter: Chapter 42 Promoting Health Objective: Define health, health promotion, and health protection. Page: 1127 (V1) Heading: What is Health Promotion? > Betty Neuman Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Evidenced-Based Practice Difficulty: Moderate Feedback 1 This is incorrect. The WHO definition is not a theory of health and wellness. The WHO defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” That definition does not involve energy expenditure, so it is irrelevant to the patient’s nursing diagnosis. 2 This is incorrect. Jean Watson’s definition involves a high level of overall physical, mental, and social functioning; a general adaptive–maintenance level of daily functioning; and the absence of illness, but does not address energy expenditure. 3 This is correct. Betty Neuman’s theory defines health as more energy generated than expended, and illness, possibly even death, as more energy expended than generated. This theory describes health as an expression of living energy

displayed as a continuum, with high energy being wellness at one end and low energy (illness) at the other end. This is incorrect. Myers, Sweeney, and Witmer defined wellness as a way of life oriented toward optimal health and well-being in which body, mind, and spirit are integrated; with no mention of energy balance, this theory is not relevant to the nursing diagnosis.

PTS: 1 CON: Evidence-Based Practice 8. ANS: 2 Chapter: Chapter 42 Promoting Health Objective: Identify health prevention activities and categorize them as primary, secondary, or tertiary. Page: 1127 (V1) Heading: Levels of Prevention > Secondary Prevention Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate Feedback 1 This is incorrect. Primary prevention activities are designed to prevent disease. It does not include screening. 2 This is correct. The nurse is providing secondary health prevention because the individuals are being taught to get screened for existing disease. 3 This is incorrect. Tertiary prevention would focus on halting the progress of the cancer. These individuals in the scenario are not receiving cancer treatment, so it is not a tertiary activity. 4 This is incorrect. Maintenance is a stage in the transtheoretical model of change and is not a level of health prevention. PTS: 1 CON: Health Promotion 9. ANS: 3 Chapter: Chapter 42 Promoting Health Objective: Identify health prevention activities and categorize them as primary, secondary, or tertiary. Page: 1127 (V1) Heading: Levels of Prevention > Tertiary prevention Integrated Processes: Communication and Documentation Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate

Feedback This is incorrect. Primary care prevention activities are designed to prevent disease. Although the nurse delivers some primary health prevention when, for example, teaching patients about activity and healthy eating, this is not the type of care most often provided. This is incorrect. Although the nurse delivers some secondary care, screening patients for disease and educating for detection of complications or problems in the early stages, this is not the level of care provided most often. This is correct. Patients who are admitted to the hospital are usually admitted for tertiary prevention, which focuses on stopping the disease from progressing and helping to return the individual to pre-illness health. This is the type of care most often provided. This is incorrect. Assessment is not a “type” of prevention, so does not fit this scenario.

PTS: 1 CON: Patient-Centered Care 10. ANS: 4 Chapter: Chapter 42 Promoting Health Objective: Apply Pender’s Health Promotion Model to plan activities designed to change unhealthy behavior Page: 1128 (V1) Heading: Health Promotion Models > Pender’s Health Promotion Model Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Health Promotion Difficulty: Moderate Feedback 1 This is incorrect. Teaching the client how to follow a low calorie diet is not the first action to promote this client’s health, although it could occur later after the client identifies weight loss as a goal. 2 This is incorrect. Assisting the client with a plan to increase activity is not the first action for health promotion for this client. It could occur later after the client identifies weight loss as a goal. 3 This is incorrect. Explaining risks associated with the client’s weight and lifestyle is not the first action to promote this client’s health. The risks can be explained after identifying the client’s goals. 4 This is correct. Before instituting any interventions, such as diet teaching, creating a plan for increasing activity, or discussing risks associated with weight and lifestyle, the nurse must first help the patient identify goals. Most health promotion strategies must be implemented by clients, not by healthcare providers, so the client’s goals are essential in planning actions that are likely to

be successful. Recall that in the nursing process, interventions are developed on the basis of goals. If the nurse immediately starts teaching about diet and activity, it may be discovered that this patient may not be interested in exercising or increasing activity level. PTS: 1 CON: Health Promotion 11. ANS: 2 Chapter: Chapter 42 Promoting Health Objective: Define health, health promotion, and health protection. Page: 1127 (V1) Heading: Health Promotion Versus Health Protection. Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Difficult Feedback 1 This is incorrect. Health promotion is motivated by the desire to increase wellbeing. In this scenario, the diabetic clients are being motivated to avoid illness by maintaining blood glucose. 2 This is correct. Health protection is motivated by a desire to avoid illness. 3 This is incorrect. Primary prevention activities are designed to prevent or delay the onset of disease; in this scenario, the clients already have a disease (diabetes). 4 This is incorrect. Tertiary prevention focuses on halting the progress of a disease and returning the person to pre-illness. This cannot be done for diabetes, which is a chronic disease. PTS: 1 CON: Health Promotion 12. ANS: 2 Chapter: Chapter 42 Promoting Health Objective: Identify Prochaska and DiClemente’s four stages of change. Page: 1130 (V1) Heading: Transtheoretical Model of Change > Stage 2 Contemplation Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate Feedback 1 This is incorrect. In the precontemplation stage, the individual has no intention to change in the foreseeable future.

This is correct. During the contemplative stage, the individual acknowledges the problem, considers changing a specific behavior, actively gathers information and verbalizes plans to change. Discussing benefits of a study group would fall into this stage. This is incorrect. In the preparation stage, the individual has created an action plan or is making other small steps in preparation for taking action within the month. In this scenario, there is no concrete plan regarding the study group. The nursing students only agreed that they would benefit from one. This is incorrect. In the action stage, the individual actively implements strategies to discontinue a previous behavior and adopt new one. In this scenario, there has been no change implemented.

PTS: 1 CON: Health Promotion 13. ANS: 3 Chapter: Chapter 42 Promoting Health Objective: Identify Prochaska and DiClemente’s four stages of change Page: 1130 (V1) Heading: Transtheoretical Model of Change > Stage 5 Maintenance Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Health Promotion Difficulty: Difficult Feedback 1 This is incorrect. The client who is in the action stage still has to apply considerable amount of time and energy while implementing the plan for change. 2 This is incorrect. A patient who no longer thinks about cigarettes and doesn’t miss smoking is in the termination stage; there is little risk of relapse 3 This is correct. Rewarding and reinforcing ongoing success by putting money in a jar to pay for vacation is demonstrating the maintenance stage. 4 This is incorrect. A patient who has implemented the plan to quit smoking but still requires considerable time and energy to maintain the change is in the action stage (i.e., “I haven’t smoked in 2 weeks …” and “I am chewing gum and eating carrot sticks …”). PTS: 1 CON: Health Promotion 14. ANS: 2 Chapter: Chapter 42 Promoting Health Objective: Identify specific health promotion strategies (including immunizations and screenings) across the life span. Page: 1135 (V1)

Heading: Health Screening Activities > Cervical Cancer Screening Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate Feedback 1 This is incorrect. While adult women may require booster tetanus immunizations or other specific immunizations if they travel abroad, this is not a priority concern for most young women. 2 This is correct. Women should begin having Pap tests by age 21 and have repeat tests every 2 to 3 years; therefore, this would be an appropriate topic to include in a health promotion class. 3 This is incorrect. Annual mammograms are not recommended for healthy young adult women unless they have a specific risk factor, such as a history of breast cancer at a young age in their family; therefore, this topic is less important overall. 4 This is incorrect. Screening colonoscopies are recommended to begin at age 50, so that is not a topic that needs to be included in this class. PTS: 1 CON: Health Promotion 15. ANS: 1 Chapter: Chapter 42 Promoting Health Objective: Identify specific health promotion strategies (including immunizations and screenings) across the life span. Page: 1131 (V1) Heading: Health Promotion Throughout the Life Span > Adolescence Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate Feedback 1 This is correct. Stranger danger is more appropriate for school-age children, so this topic could be safely eliminated. 2 This is incorrect. Risks related to motor vehicle accidents are high in the adolescent population and should not be eliminated. 3 This is incorrect. Firearm danger is significant for adolescents, so this topic should not be deleted. 4 This is incorrect. Alcohol and drug use pose a significant risk for adolescents, so this topic should not be deleted.

PTS: 1 CON: Health Promotion 16. ANS: 3 Chapter: Chapter 42 Promoting Health Objective: Identify specific health promotion strategies (including immunizations and screenings) across the life span Page: 1131 (V1) Heading: Health Promotion Throughout the Life Span > School Age Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Easy Feedback 1 This is incorrect. Elementary school students would not be the best audience for the topic “housing conditions.” 2 This is incorrect. Although elementary school students may be taught about handwashing, sanitation would be too mature a topic for this audience. 3 This is correct. Stranger danger is a risk for harm for elementary school students, so this would be an appropriate topic for discussion to promote health. 4 This is incorrect. STIs would be too mature a topic for elementary school students. PTS: 1 CON: Health Promotion 17. ANS: 4 Chapter: Chapter 42 Promoting Health Objective: Construct a health promotion plan of care using the nursing process, NANDA-1 taxonomy, Nursing Outcomes Classification, and Nursing Interventions Classification. Page: 1136 (V1) Heading: Analysis/Nursing Diagnosis Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Health Promotion Difficulty: Moderate Feedback 1 This is incorrect. The mother requested to be educated about parenting, not feeding. Although breastfeeding may be part of parenting, this diagnosis is too specific for the information in this scenario. 2 This is incorrect. Communication certainly is important to good parenting. However, the patient is asking for more than just information about communication. 3 This is incorrect. Coping skills are not what this patient is requesting help with,

although parenting may involve these skills. This is correct. Readiness for Enhanced Parenting is the best nursing diagnosis for this patient, who is seeking information to improve her ability to care for her child (i.e., to nurture growth and development of the child).

PTS: 1 CON: Health Promotion 18. ANS: 4 Chapter: Chapter 42 Promoting Health Objective: Identify the areas of assessment in relation to developing a health promotion plan. Page: 1133 (V1) Heading: Assessment > Physical Fitness Assessment Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. A heart rate of 96 beats/min indicates that the patient is in above average physical condition. 2 This is incorrect. A heart rate of 106 beats/min indicates that the patient is in average physical condition. 3 This is incorrect. A heart rate of 114 beats/min indicates that the patient is in below average physical condition. 4 This is correct. A heart rate higher than 130 beats/min indicates the patient is in very poor physical condition. PTS:

CON: Patient-Centered Care

MULTIPLE RESPONSE 19. ANS: 1, 3, 4 Chapter: Chapter 42 Promoting Health Objective: Apply Pender’s Health Promotion Model to plan activities designed to change unhealthy behavior. Page: 1128 (V1) Heading: Health Promotion Models > Pender’s Health Promotion Model Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Moderate

1. 2.

3. 4. 5.

Feedback This is correct. Individual characteristics and experiences are considered when applying Pender’s health promotion model (HPM). This is incorrect. Levels of prevention were identified by Leavell and Clark; three levels relate to health protection. The levels differ based on their timing in the illness cycle. This is correct. Behavioral outcomes are considered when applying Pender’s HPM. This is correct. Behavior-specific cognition and affect are considered when applying Pender’s HPM. This is incorrect. Comparing health to the spokes of a wheel is not part of Pender’s HPM. Myers, Sweeney, and Witmer have likened the different facets of health to the spokes of a wheel in their Wheel of Wellness HPM.

PTS: 1 CON: Patient-Centered Care 20. ANS: 1, 3 Chapter: Chapter 42 Promoting Health Objective: Discuss the Healthy People 2020 report in relation to the leading causes of death and to health promotion strategies: nutrition, exercise, lifestyle, and environment. Page: 1136 (V1) Heading: Planning Outcomes/Evaluation > Healthy People 2020 Goals Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Knowledge [Remembering] Concept: Health Promotion Difficulty: Easy

1. 2. 3. 4. 5.

Feedback This is correct. Eliminating health disparities and improving health of all groups is a Healthy People 2020 goal. This is incorrect. Decreasing the cost of healthcare is not a Healthy People 2020 goal. This is correct. Increasing the quality and years of healthy life is a goal of Health People 2020. This is incorrect. Decreasing the number of inpatient days is not a goal of Healthy People 2020. This is incorrect. Promoting hospice care for the elderly is not a goal of Healthy People 2020.

PTS: 1 CON: Health Promotion 21. ANS: 1, 2, 3, 4 Chapter: Chapter 42 Promoting Health

Objective: Discuss nurses’ role in health promotion, and list health promotion activities that a nurse may conduct in acute care facilities, the workplace, local communities, and schools. Page: 1129 (V1) Heading: Health Promotion Models > Wheel of Wellness Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Health Promotion Difficulty: Difficult

2. 3. 4. 5.

Feedback This is correct. The Wheels of Wellness model identifies the following dimensions of health: emotional, intellectual, physical, spiritual, social/family, and occupational. A weekly discussion group stimulates intellectual health. This is correct. A relationship between local pastors and those living in subsidized housing creates a climate for spiritual health. This is correct. A tutorial program offered by seniors to local children will facilitate occupational health. This is correct. An on-site healthcare clinic addresses physical health. This is incorrect. Providing free housing for seniors is not an intervention for this model.

PTS: 1 CON: Health Promotion 22. ANS: 1, 2, 3 Chapter: Chapter 42 Promoting Health Objective: Identify the areas of assessment in relation to developing a health promotion model. Page: 1134 (V1) Heading: Health Beliefs > Locus of Control Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Knowledge [Remembering] Concept: Patient-Centered Care Difficulty: Moderate

2. 3.

Feedback This is correct. Identifying a person’s locus of control helps the nurse determine how to approach a client about health promotion. Clients who feel in charge of their own health are the easiest to motivate toward positive change. This is correct. People who feel powerless about preventing illness are least likely to engage in health promotion activities. This is correct. People who respond to direction from respected authorities often prefer a health promotion program that is supervised by a health provider.

4. 5.

This is incorrect. People who feel in charge of their own health more likely to engage in and be motivated by health promotion activities. This is incorrect. People who are in control of their health decisions will be more motivated toward positive change.

PTS: 1 CON: Patient-Centered Care 23. ANS: 2, 3, 4 Chapter: Chapter 42 Promoting Health Objective: Discuss nurses’ role in health promotion, and list health promotion activities that a nurse may conduct in acute care facilities, the workplace, local communities, and schools: Page: 1136 (V1) Heading: Planning Interventions/Implementation Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Difficult

2. 3. 4. 5.

Feedback This is incorrect. Nurses have been recognized as leaders in health promotion for a long time. The nurse’s role is to motivate clients and facilitate change; however, it is essential that the goals belong to the clients. This is correct. The nurse will need to help clients to identify goals that are individualized. This is correct. The client will need to understand the benefits of change. This is correct. The client will need support and resources to create positive change. This is incorrect. Although family support will facilitate change, it is essential that the goals are created by the client.

PTS: 1 CON: Health Promotion 24. ANS: 1, 3, 4 Chapter: Chapter 42 Promoting Health Objective: Identify the areas of assessment in relation to developing a health promotion plan. Page: 1133 (V1) Heading: Physical Fitness Assessment Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Difficult Feedback

1. 2. 3. 4.

This is correct. Cardiorespiratory fitness is included in a physical fitness assessment. This is incorrect. Evaluating hardiness is not part of a physical fitness assessment. This is correct. Muscular fitness is a part of a physical fitness assessment. Muscle strength and endurance are measured during this part of the assessment. This is correct. Flexibility is included in a physical fitness assessment. Although flexibility measures the ability to move a joint through its range of motion, the most common part of this assessment is to evaluate low back and hip (trunk) flexion. This is incorrect. A nutritional assessment is a key component of an overall wellness assessment, not a physical fitness assessment.

PTS: 1 CON: Patient-Centered Care 25. ANS: 1, 2, 3, 4 Chapter: Chapter 42 Promoting Health Objective: Identify areas of assessment in relation to developing a health promotion plan. Page: 1133 (V1) Heading: Lifestyle Risk Appraisal Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Health Promotion Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is correct. A person’s occupation is a significant component of his lifestyle, so this would be an important question to ask. This is correct. Marital status plays an important role in lifestyle, so this is an appropriate question to ask. This is correct. Hobbies should be assessed to determine specific lifestyle risks for this patient. This is correct. Even married people should be asked about sexual activity because sexual activity can have a significant impact on health and risk for health problems. This is incorrect. A question about a recent move would not be a question related to lifestyle.

PTS: 1 CON: Health Promotion 26. ANS: 2, 3, 4 Chapter: Chapter 42 Promoting Health Objective: Discuss the Healthy People 2020 report in relation to leading causes of death and to health promotion strategies: nutrition, exercise, lifestyle, and environment. Page: 1137 (V1) Heading: Healthy People 2020 Goals Integrated Processes: Teaching and Learning

Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate

1. 2.

Feedback This is incorrect. Assessing is not a teaching point, although promoting healthy development is a Healthy People 2020 goal. This is correct. Improving access to healthcare is a goal of Healthy People 2020, so teaching patients how to file an application for Medicaid would be an appropriate teaching point. This is correct. Maintaining a social and physical environment that promotes good health is a Healthy People 2020 goal, so teaching patients how to maintain a safe home environment would be an appropriate teaching point. This is correct. Teaching patients to develop and maintain a healthy lifestyle would meet the Healthy People 2020 goal of promoting quality of life, healthy development, and healthy behaviors in all stages of the life span. This is incorrect. A low-fat, low-calorie diet is not appropriate for all people, so this would not be a teaching point to be included in meeting Healthy People 2020 goals.

PTS: 1 CON: Health Promotion 27. ANS: 1, 3, 4 Chapter: Chapter 42 Promoting Health Objective: Apply Pender’s Health Promotion Model to plan activities designed to change unhealthy behavior. Page: 1128 (V1) Heading: Health Promotion Models > Pender’s Health Promotion Model Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Difficult

1. 2. 3. 4.

Feedback This is correct. The resident is aware of the nurse as someone in the environment, so this assumption is demonstrated. This is incorrect. The resident lacks self-awareness by denying the addiction; this assumption is not being demonstrated. This is correct. The resident evidently values growth because he has agreed to enter a treatment facility to improve his addiction issue. This is correct. The resident is trying to regulate his behavior while in the treatment facility.

This is incorrect. According to Pender’s health promotion model (HPM), selfinitiated reconfiguration of person–environment interactive patterns is essential to behavior change.

PTS:

CON: Patient-Centered Care

Chapter 43. Community & Home Health Nursing Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The inhabitants of Yulupa, California, form which of the following? 1. Aggregate 2. Community 3. Population 4. Vulnerable population 2. A community health nurse has been assigned census tracts 131 and 132 as a new assignment. This large area crosses the border of two towns and includes 4,000 people. Which components of the community must the community health nurse assess prior to beginning the new assignment? 1. Income levels, health status, and relationships among groups 2. Structure of the tracts, effectiveness of the community, and current status 3. Number of clients with health problems compared with the number of healthcare providers 4. Community organizations and beliefs about their role in the community 3. A community health nurse is evaluating the current health programs in the community. Which of these outcomes would indicate a healthy community? 1. Ninety percent of members report adequate access to primary care services. 2. Immunization services are available at hospitals and clinics. 3. Affordable housing in the community is under construction. 4. Mortality rates have been stable over the past 5 years. 4. Which type of nursing has a focus on the community as a whole and the health status of individuals as an aggregate? 1. School nursing 2. Community health nursing 3. Community-oriented nursing 4. Public health nursing 5. The community health nurse is working with the residents of government-subsidized senior housing. Regular meetings are scheduled to discuss concerns and evaluate whether they receive healthcare that meets their needs. Which of the following nursing roles best describes these actions? 1. Case manager 2. Client advocate 3. Collaborator 4. Counselor

6. Which statement made by the novice nurse requires further teaching regarding the role of a community health nurse? 1. “As a community health nurse, I will assist in providing free prenatal care for lowincome women.” 2. “I have planned to teach teenagers about preventing sexually transmitted infections (STIs) weekly.” 3. “I have scheduled a tuberculosis screening event at the homeless shelter.” 4. “I gave an older adult an injection of insulin yesterday.” 7. The community health nurse has gathered data about the community, including identifying many weaknesses in the community health systems that contribute to poor health outcomes. Which would be her next step? 1. Analyze the data. 2. Implement interventions. 3. Evaluate the effectiveness of the interventions. 4. Plan the care. 8. The similarity between the Omaha System and the NANDA-I taxonomy is that both contain which of the following? 1. Evaluation tools expressed in standardized language 2. Nursing diagnoses expressed in standardized language 3. Diagnoses, outcomes, and interventions 4. Labels that are intended for use in any healthcare setting 9. A nurse serving the community in a public health role would likely perform which of the following functions within a particular community? 1. Tracking the prevalence of gonorrhea between January and June 2. Screening for scoliosis among 12- to 14-year-old girls in middle school 3. Weighing premature infants receiving phototherapy at home 4. Giving the H1N1 influenza vaccine to fire fighters and police personnel 10. A community health nurse planning a new program for teen pregnancy prevention designs a community assessment covering the structure of the target. Which of the following areas would be included? 1. Number of residential and commercial buildings 2. Demographic data of residents in the community 3. Morbidity and mortality rates of the population 4. Common strategies for conflict resolution 11. Which activity by the student nurse indicates an understanding regarding secondary prevention? 1. Educating high school students about sexually transmitted infection (STI) prevention 2. Providing a screening for scoliosis for high school athletes 3. Lobbying congress regarding cancer treatment coverage for the uninsured 4. Referring a terminally ill patient for hospice care

12. Today is the last day of work on the medical-surgical unit for a nurse who has decided to work in home care. A patient asks her why the nurse is leaving to work in home care. Select a response that best illustrates the advantages of home care. 1. “Care is much more comprehensive and unhurried in the home; it is more enjoyable for nurses to work in home care.” 2. “Home care is much more organized than hospital care; you have access to the whole team, and there is less interference from others.” 3. “A home health nurse has more autonomy and skills than a hospital nurse does; I’ll get to do more.” 4. “In home care, I can see my patients in their personal environment; this will help me understand them more and allow me to give personalized care.” 13. A 56-year-old patient is hospitalized because of poorly controlled diabetes and a leg ulcer that developed as a complication of diabetes. The patient is awake, alert, and oriented but fatigued and in need of wound care. In the hospital, insulin and a variety of oral medications were prescribed. The patient is learning how to check their blood sugar and administer insulin. The patient has never given himself insulin and does not understand how to interpret blood sugar readings. The physician has prescribed discharge from the hospital with home health follow-up. Is this an appropriate referral? 1. Yes; the patient is in need of skilled services and, therefore, eligible for home care services. 2. Yes; the patient has been unable to control the diabetes, is noncompliant, and needs to be monitored. 3. No; the patient would remain hospitalized; there are too many needs for home care services. 4. No; the patient is relatively young and oriented and would be able to provide their own care. 14. A home health nurse is working with a physical therapist and home health aides to work out a schedule for their visits that will best address the patient’s needs. Which nursing role does this demonstrate? 1. Direct care provider 2. Client and family educator 3. Client advocate 4. Care coordinator 15. A home health nurse has called the patient to arrange an initial home visit and has driven to the home. Which is the nurse’s objective in the first few minutes of the visit? 1. Develop rapport and trust with the patient and family. 2. Gather demographic data and complete the referral form. 3. Assess the patient’s most important health needs. 4. Determine the patient’s needs for ongoing care.

16. Documentation in home healthcare may take many forms. Some nurses use NANDA-I terminology for diagnoses, whereas others use the Clinical Care Classification (CCC) system. The chief benefit of the CCC system is that it: 1. Contains diagnoses specific to home care, whereas NANDA-I does not. 2. Is simpler to use and more readily understood by other disciplines. 3. Is linked to the OASIS (Online Acquittal Support Information System) reporting forms required by Medicare. 4. Uses standardized terminology, whereas NANDA-I does not. 17. A 56-year-old patient provides care to their 91-year-old widowed father. The patient frequently reports fatigue and that there is no time to socialize with friends. “I’m so busy taking care of my dad. It’s really hard work because he is bedridden. Sometimes it breaks my heart when I have to feed and bathe him. He always seemed so strong when I was a child.” The most appropriate nursing diagnosis for this patient is: 1. Caregiver Role Strain 2. Impaired Home Maintenance 3. Interrupted Family Processes 4. Risk for Caregiver Role Strain 18. The nurse is visiting a patient who lives in a single-room occupancy hotel. The patient requires wound care and medication management. There is no running water in the room, and the bathroom down the hall is in disrepair and filthy. The patient’s room is not clean. Which supplies would be essential for the nurse to bring with him when visiting this client? 1. All wound care supplies needed for the duration of the care 2. Reclosable plastic bags for disposal of old dressings 3. Small, biohazard sharps container to be left in the room 4. Waterless, antibacterial hand sanitizer solution 19. Which of the following unique aspects of home care do Medicare reimbursement regulations require that the nurse include in documentation? 1. Patient assessment data and interventions performed 2. Patient response to care and assessment of environment 3. Evidence of homebound status and continued need for skilled care 4. Skilled care delivered and communication with other providers 20. At a home visit, the nurse asks the patient, “Have you taken your blood pressure medicine today?” The patient replies, “I don’t remember. Maybe.” On the table are several bottles of medication, some open, some not. They have all been prescribed for the patient. The patient cannot say how often to take each one, when asked. A compartmentalized medication organizer is on the table, with a few capsules in it, and some compartments left open. Which action would the nurse take? 1. Show the patient how to put the medications in the organizer for the next 2 days; observe while he fills the rest of the organizer. 2. Arrange for a home health aide to come each day to show the patient which pills to take.

3. Administer today’s medications and arrange for the pharmacy to put medications in easy-to-open containers in the future. 4. Fill the organizer for each day of the week; explain how to use it; and return in a day or two to evaluate. 21. A family caregiver is learning to administer insulin injections to a homebound family member. Which would the nurse advise the caregiver to do with the used needles? 1. “Discard the needle and syringe in a thick plastic milk jug with a lid.” 2. “Securely recap them and place them in a paper bag in the household trash.” 3. “Remove the needle and put it in a coffee can with a lid; put the syringe in the trash.” 4. “Do not recap the needle; break it by bending it on the tabletop.” Multiple Response Identify one or more choices that best complete the statement or answer the question. 22. A community health nurse prepares for a new assignment and has been assigned census tracts 131 and 132. This large area crosses the border of two towns and includes 4,000 people. The nurse recognizes that which is true regarding census tracts? Select all that apply. 1. They define the geopolitical boundaries of a community. 2. They are made up of persons who share a common heritage and customs. 3. They divide populations into smaller groups that can be assessed more readily. 4. They are natural divisions in communities that are based on voting patterns. 5. Rural census tracts are very small in size. 23. Which interventions would the nurse implement in the home of an elderly patient to promote safety? Select all that apply. 1. Encourage dim lighting throughout the home. 2. Change batteries in all smoke detectors. 3. Fix loose railings up the stairs. 4. Ensure rugs in the home are loose. 5. Check that all medications are tightly sealed and out of the patient’s reach. 24. Which of the following groups represents a vulnerable population? Select all that apply. 1. Homeless persons with no known illnesses 2. Women who have experienced domestic violence 3. Ninth grade students at the local high school 4. Persons with type 1 diabetes mellitus 5. An elderly individual with heart failure 25. Which of the following is a primary intervention? Select all that apply. 1. Immunization of college-bound students against meningitis 2. Safer sex education for high school students 3. Lobbying for health education in the schools

4. Tuberculosis (TB) screening via purified protein derivative (PPD) testing 5. Cardiac rehabilitation for post-operative patients 26. Identify the nurse who is acting as a community health nurse. Select all that apply. 1. A nurse who provides screening and direct care in the elementary school 2. A nurse who offers health education after services each Sunday 3. Nurse who works for the Red Cross by providing disaster relief 4. A nurse administering vaccines to inmates in a correctional facility 5. A nurse who starts an intravenous (IV) line on a patient admitted to the hospital with dehydration 27. Which of the following interventions has a public health focus? Select all that apply. 1. Controlling the blood sugar of a diabetic client with cardiovascular disease 2. Assisting with the launch of an after-school program in a high-crime neighborhood 3. Providing an influenza vaccination program for seniors and persons with chronic illness 4. Offering counseling to the family of a child with severe cognitive deficits 5. Providing food nutrition classes to obese adults in a rural area 28. Which of the following clients would most likely require home health services? Select all that apply. 1. A 45-year-old with an injured rotator cuff that requires surgery 2. A 32-year-old terminally ill individual with a supportive family 3. A 92-year-old living independently with multiple medical problems 4. A 6-year-old with a fractured hip requiring a leg and pelvic cast 5. An 18-year-old who lives with their parents with newly diagnosed type I diabetes 29. Which of the following services are provided by home health agencies? Select all that apply. 1. Direct care of clients in the home, performing treatments 2. Indirect care, such as provision of medication and supplies 3. Acute care services for clients with complex diseases 4. Respite care of clients to relieve family caregivers 5. Teaching patients or caregivers to perform services 30. Home healthcare and home hospice care are two different types of home health services. Which statements describe the differences between these services? Select all that apply. 1. Home healthcare promotes independence in clients; home hospice care promotes comfort and quality of life. 2. Home healthcare promotes comfort and symptom management; hospice care promotes self-care. 3. Home healthcare is focused on teaching self-care; home hospice care is focused on teaching skilled care to caregivers. 4. Home healthcare is focused on fostering independence; home hospice care is focused on managing symptoms. 5. Home healthcare is provided in the home; hospice care is only provided in a

hospital setting. 31. The nurse has been assigned to a caseload of home health clients. Before making home visits, which two planning activities must she perform first? 1. Order supplies for the home care services. 2. Review the cases to determine the reasons for the visits. 3. Contact the clients to arrange for the visits. 4. Develop a schedule for the day so that all visits can be made. 5. Plan for caregiver respite care. 32. The nurse is visiting a client who resides in a single-room-occupancy hotel. Groups of people are leaning against the building and smoking on the steps. There is obvious substance abuse occurring in the lobby and halls of the building. There is no running water in the room, and the bathroom down the hall is in disrepair and filthy. A primary concern that the nurse must consider when making this visit is safety. Which of the following actions are appropriate safety measures? Select all that apply. 1. Notify the police that the nurse plans to visit this site. 2. Carry something that can be used as a weapon, if necessary. 3. Inform the home health agency of the nurse’s route and time of visit. 4. Do not visit if the nurse senses danger when arriving at the site. 5. Assess the surroundings for stores, community resources, or police department. 33. The nurse is visiting a patient who lives alone in a two-room house. The patient requires wound care and medication management, but their health is not expected to improve much, even with care. There is no running water in the house, and the bathroom is in disrepair and filthy. At the first home visit, which of the following would the nurse assess? Select all that apply. 1. Wound status 2. Patient concerns 3. Ability to perform care independently 4. End-of-life planning 5. Review of medications

Chapter 43. Community & Home Health Nursing Answer Section MULTIPLE CHOICE 1. ANS: 3 Chapter: Chapter 43 Community & Home Health Nursing Objective: Define the meaning of community. Page: 1144 (V1) Heading: Understanding the Concept of Community Integrated Processes: Culture and Spirituality Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Health Promotion Difficulty: Moderate

1 2 3 4

Feedback This is incorrect. An aggregate is a group that has at least one shared characteristic. This is incorrect. A community is a group of like-minded individuals or one whose members have a common purpose. This is correct. A population is all of the people inhabiting a specified area. This is incorrect. A vulnerable population is an aggregate with increased risk for poor health outcomes.

PTS: 1 CON: Health Promotion 2. ANS: 2 Chapter: Chapter 43 Community & Home Health Nursing Objective: Describe the roles of nurses in the community setting. Page: 1144 (V1) Heading: Understanding the Concept of Community Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Health Promotion Difficulty: Difficult Feedback 1 This is incorrect. Income level and demographic data, such as community organizations and healthcare providers, are included in the assessment of the community structure. 2 This is correct. To understand a community and its needs, the nurse must assess the community’s structure, status (the biological, social, and emotional outcome

3 4

components of the community), and process (overall effectiveness of the community). This is incorrect. The number of clients with health problems is only a part of the assessment of the community status. This is incorrect. Community organizations and beliefs about their role are part of the community assessment.

PTS: 1 CON: Health Promotion 3. ANS: 1 Chapter: Chapter 43 Community & Home Health Nursing Objective: Identify at least four factors by which you can recognize a healthy community. Page: 1146 (V1) Heading: What Makes a Community Healthy? Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate Feedback 1 This is correct. Evidence of health in a community can be judged by examining progress in the focus areas delineated in Healthy People 2020. Access to primary care services is a measurable outcome that provides evidence of effectiveness of health programs. 2 This is incorrect. The availability of immunization services at the hospital or at many offices does not provide evidence that these services are being used. 3 This is incorrect. The fact that affordable housing is under construction does not mean that it is being accepted and used nor that enough is being built. 4 This is incorrect. Mortality rates may be stable but could be quite high and within unacceptable parameters. PTS: 1 CON: Health Promotion 4. ANS: 4 Chapter: Chapter 43 Community & Home Health Nursing Objective: Compare and contrast community-based care, community health nursing, public health nursing, and community-oriented nursing. Page: 1147 (V1) Heading: Public Health Nursing Integrated Processes: Caring Client Need: Health Promotion and Maintenance Cognitive Level: Knowledge [Remembering] Concept: Health Promotion Difficulty: Easy

1 2

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Feedback This is incorrect. School nursing focuses on optimizing health for a community of students in a school setting. This is incorrect. Community health nursing focuses on the health of individuals, families, and groups and on how their health affects the health of the community. This is incorrect. Community-oriented care combines elements of community health nursing and public health. This is correct. Public health nursing focuses on the community at large and the eventual effect of the community’s health status on the health of individuals, families, and groups.

PTS: 1 CON: Health Promotion 5. ANS: 3 Chapter: Chapter 43 Community & Home Health Nursing Objective: Describe the roles of nurses in the community setting. Page: 1149 (V1) Heading: Collaborator Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate Feedback 1 This is incorrect. As a case manager, the nurse makes referrals to or collaborates with other healthcare and social agencies. 2 This is incorrect. In the client advocate role, the nurse supports the identified or voiced concerns of the client or community. 3 This is correct. As a collaborator, the nurse forges partnerships and coalitions that can effectively address common concerns among different communities. In this role, the nurse facilitates discussion to work toward problem resolution. 4 This is incorrect. A counselor offers practical solutions to resolve problems. PTS: 1 CON: Health Promotion 6. ANS: 4 Chapter: Chapter 43 Community & Home Health Nursing Objective: Describe the roles of nurses in the community setting. Page: 1147 (V1) Heading: Understanding the Concept of Community-Based Care Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Analyzing [Analysis]

Concept: Health Promotion Difficulty: Moderate Feedback 1 This is incorrect. Offering free prenatal care for low income women is the role of the community nurse and indicates an understanding of the teaching. 2 This is incorrect. Teaching teens about STI prevention is an example of the role of the community nurse and indicates the novice nurse understands this role. 3 This is incorrect. This statement indicates an understanding of the role of a community nurse because it demonstrates care for a community. 4 This is correct. This statement indicates a need for further teaching; this does not demonstrate care for a community. PTS: 1 CON: Health Promotion 7. ANS: 1 Chapter: Chapter 43 Community & Home Health Nursing Objective: Describe the roles of nurses in the community setting. Page: 1154 (V1) Heading: Applying the Nursing Process in Community-Based Care Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate Feedback 1 This is correct. After a thorough assessment, the nurse compiles a list of community strengths and weaknesses. Once this list is in place, the nurse must analyze the data. 2 This is incorrect. Implementing interventions occurs after planning the care. 3 This is incorrect. Evaluating the effectiveness of interventions is not the second step of the nursing process in community-based care; it is the final step. 4 This is incorrect. The process of planning care occurs after analyzing the data. PTS: 1 CON: Health Promotion 8. ANS: 2 Chapter: Chapter 43 Community & Home Health Nursing Objective: Use standardized nursing language taxonomies (NANDA-I, NOC, NIC, Omaha, and CCC) to describe care planning in community and home care. Page: 1161 (V1) Heading: Analysis/Nursing Diagnosis Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing]

Concept: Health Promotion Difficulty: Moderate Feedback 1 This is incorrect. The NANDA-I taxonomy is not an evaluation tool. The Omaha System provides standardized terms for outcomes. 2 This is correct. The NANDA-I taxonomy and the Omaha System both contain nursing diagnoses expressed in standardized language. 3 This is incorrect. The Omaha System also contains outcomes and interventions. 4 This is incorrect. The Omaha System was developed for use in community settings, whereas the NANDA-I taxonomy may be used in all settings. PTS: 1 CON: Health Promotion 9. ANS: 1 Chapter: Chapter 43 Community & Home Health Nursing Objective: Compare and contrast community-based care, community health nursing, public health nursing, and community-oriented nursing. Page: 1147 (V1) Heading: Public Health Nursing Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate Feedback 1 This is correct. Public health nursing focuses on the community at large and the eventual effect of the community’s health status on the health of individuals, families, and groups. The goal of public health is to prevent individual disease and disability, in addition to promoting and protecting the health of the community as a whole, such as tracking the prevalence of disease. Activities such as scoliosis screening, home care, and vaccination program are examples of community health nursing. 2 This is incorrect. Screening for scoliosis is an example of community health nursing. 3 This is incorrect. Weighing premature infants receiving phototherapy at home is the role of a community health nurse. 4 This is incorrect. Giving the H1N1 influenza vaccine to emergency personnel is the role of a community health nurse. PTS: 1 CON: Health Promotion 10. ANS: 2 Chapter: Chapter 43 Community & Home Health Nursing Objective: Discuss at least three strategies that nurses use to gather community data.

Page: 1145 (V1) Heading: What Are the Components of a Community? Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate

1 2

3 4

Feedback This is incorrect. The number of residential and commercial buildings are not included in the structure portion of an assessment. This is correct. Structure refers to the general characteristics of a community. These include demographic data, such as gender, age, ethnicity, and educational and income levels, as well as data about healthcare services, such as the number of primary care providers or emergency departments in the area. This is incorrect. The morbidity and mortality would be examined for a community when assessing status. This is incorrect. Strategies for conflict resolution are reviewed when assessing the process.

PTS: 1 CON: Health Promotion 11. ANS: 2 Chapter: Chapter 43 Community & Home Health Nursing Objective: Distinguish primary, secondary, and tertiary interventions in regard to a community health scenario. Page: 1149 (V1) Heading: How Are Community Nursing Interventions Classified? Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Health Promotion Difficulty: Moderate

1 2 3 4

Feedback This is incorrect. This is an example of primary prevention. This is correct. Screening high school athletes for scoliosis demonstrates secondary prevention. This is incorrect. Lobbying demonstrates primary prevention. This is incorrect. Referring a patient for care demonstrates tertiary prevention.

PTS: 1 12. ANS: 4

CON: Health Promotion

Chapter: Chapter 43 Community & Home Health Nursing Objective: Describe ways in which home healthcare differs from hospital nursing. Page: 1156 (V1) Heading: Home Healthcare Helps You to Better Understand the Concept of Client Integrated Processes: Caring Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate Feedback 1 This is incorrect. Care, in the home and hospital, is comprehensive. In both locations, the nurse has obligations to other patients and will need to watch her schedule. The level of enjoyment a nurse has with her job is dependent on many factors. 2 This is incorrect. A disadvantage to home care is the lack of immediate assistance from other members of the health team. 3 This is incorrect. Home care nurses may be more autonomous than hospital nurses; however, their scope of practice is identical. 4 This is correct. The home is the client’s personal environment: a window into the patient’s life. The nurse is able to see how the patient lives, interacts, and negotiates the world. PTS: 1 CON: Health Promotion 13. ANS: 1 Chapter: Chapter 43 Community & Home Health Nursing Objective: Identify the primary goal of home care. Page: 1155 (V1) Heading: Nursing care in the home differs from hospital nursing Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Health Promotion Difficulty: Difficult Feedback 1 This is correct. A client must require skilled services to be eligible for home care services. This patient needs wound care, to be taught about diabetes care, and to be monitored. These are all skilled services. All of these needs can be met with home care services. He is alert and oriented, which is important for planning teaching sessions. 2 This is incorrect. The reason for being eligible for home health services is the need to receive skilled services. Just because a patient is noncompliant does not mean they are eligible for services.

3 4

This is incorrect. The patient’s needs can be met at home by a home health-care provider. This is incorrect. The patient may be alert and oriented but needs to receive follow-up and monitoring for the diabetes.

PTS: 1 CON: Health Promotion 14. ANS: 4 Chapter: Chapter 43 Community & Home Health Nursing Objective: Describe the roles of nurses in the community setting. Page: 1149 (V1) Heading: Care Coordinator Integrated Processes: Caring Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Easy Feedback 1 This is incorrect. Direct care involves hands-on tasks, such as dressing wounds and administering medications. 2 This is incorrect. The educator role involves communicating with clients and families to help them develop the skill involved to administer self-care. 3 This is incorrect. A client advocate supports the client’s right to make decisions and protects the client from harm if he is unable to make decisions. 4 This is correct. A care coordinator manages and coordinates the services of members of the healthcare team and develops a plan of care that addresses the client’s needs. PTS: 1 CON: Health Promotion 15. ANS: 1 Chapter: Chapter 43 Community & Home Health Nursing Objective: Identify the primary goal of home care. Page: 1161 (V1) Heading: At the Visit Integrated Processes: Caring Client Need: Health Promotion and Maintenance Cognitive Level: Synthesis [Creating] Concept: Health Promotion Difficulty: Moderate Feedback 1 This is correct. All of these objectives are appropriate for the home health visit. However, the first few minutes of the initial visit set the tone for the relationship among client, nurse, family, and agency. In that time, the nurse focuses on

2 3 4

developing rapport and trust. This is incorrect. Gathering demographic data and completing a referral form are completed once rapport has been established. This is incorrect. The nurse will first develop rapport prior to assessing the patient’s health needs. This is incorrect. The nurse will determine the patient’s needs for ongoing care after establishing rapport.

PTS: 1 CON: Health Promotion 16. ANS: 3 Chapter: Chapter 43 Community & Home Health Nursing Objective: Use standardized nursing language taxonomies (NANDA-I, NOC, NIC, Omaha, and CCC) to describe care planning in community and home care. Page: 931 (V2) Heading: Standardized Terminology for Home Health Nursing Diagnoses Integrated Processes: Communication and Documentation Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Health Promotion Difficulty: Moderate Feedback 1 This is incorrect. Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC) have some interventions and outcomes that are specific to home care use. 2 This is incorrect. The Clinical Care Classification (CCC) was developed using standardized nursing language. 3 This is correct. Home care nurses more commonly use the CCC because it is linked to the OASIS reporting forms required by Medicare. The CCC was developed for use in home care; however, the diagnoses themselves are not specific to home care. They can be used in any setting. 4 This is incorrect. NANDA-I, NIC, and NOC all use standardized language that may be used in any setting, including home healthcare. PTS: 1 CON: Health Promotion 17. ANS: 1 Chapter: Chapter 43 Community & Home Health Nursing Objective: Describe the nurse’s role in treating caregiver strain. Page: 1161 (V1) Heading: Caregiver Role Strain and Risk for Caregiver Role Strain Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying]

Concept: Health Promotion Difficulty: Moderate Feedback 1 This is correct. This caregiver is experiencing fatigue, isolation, and difficulty adjusting to role changes. These are signs of Caregiver Role Strain. 2 This is incorrect. There is no evidence of Impaired Home Maintenance. 3 This is incorrect. Although family processes have been altered, this is not the best nursing diagnosis based on the defining characteristics given. 4 This is incorrect. Since the patient is experiencing symptoms, this is an actual problem and not a potential problem. PTS: 1 CON: Health Promotion 18. ANS: 4 Chapter: Chapter 43 Community & Home Health Nursing Objective: Describe how infection control measures differ in the home and in the hospital. Page: 1164 (V1) Heading: Controlling Infection in the Home Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate Feedback 1 This is incorrect. The nurse would limit the supplies brought into the home if the conditions are not clean. Wound care supplies, for example, would be ordered and kept in the home. 2 This is incorrect. Old dressings would be double-bagged to prevent leakage and discarded in the home. 3 This is incorrect. There is no evidence that a sharps disposal container is needed. 4 This is correct. The nurse would use a waterless antibacterial hand sanitizer in place of soap and water because there is no sink and conditions are filthy. PTS: 1 CON: Health Promotion 19. ANS: 3 Chapter: Chapter 43 Community & Home Health Nursing Objective: List at least four criteria clients must meet for home care to be reimbursed by Medicare. Page: 1161 (V1) Heading: After the Visit Integrated Processes: Communication and Documentation Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion

Difficulty: Moderate Feedback 1 This is incorrect. Patient assessment and interventions performed would be documented, but the unique requirements of home care include documentation of homebound status and the continued need for skilled care. 2 This is incorrect. Patient response to care and assessment of the environment are documented, but the unique requirements of home health care include documentation of homebound status and continued need for skilled care. 3 This is correct. All of the aspects mentioned would be documented. However, the unique requirements of home care include documentation of homebound status and the continued need for skilled care. 4 This is incorrect. Skilled care delivered and communication with other providers is documented, but the requirements unique to home health are homebound status and continued need for skilled care. PTS: 1 CON: Health Promotion 20. ANS: 4 Chapter: Chapter 43 Community & Home Health Nursing Objective: Explain the role of the nurse in helping clients and families manage medications and treatments in the home setting. Page: 1163 (V1) Heading: Assisting With Medication Management Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Difficult Feedback 1 This is incorrect. Showing the patient how to load the organizer solves part of the problem; however, this would not allow the nurse to evaluate whether the patient would then know to take the medications each day. 2 This is incorrect. Home health aides cannot be responsible for patient medications. 3 This is incorrect. There is no indication that the patient is having difficulty opening his medication containers, so there is no need to talk to the pharmacy. 4 This is correct. From the cues given, it seems likely the patient would not be able to accurately load the medication organizer—and, in fact, may not be able to use it properly to take the correct medications at the correct time. The nurse would need to return every day or so until he is certain that the patient can actually administer his own meds after someone else loads the organizer. PTS:

CON: Health Promotion

21. ANS: 1 Chapter: Chapter 43 Community & Home Health Nursing Objective: Describe how infection control measures differ in the home and in the hospital. Page: 1164 (V1) Heading: Clean and Sterile Technique Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate Feedback 1 This is correct. The caregiver would discard the syringe and needle in a thick plastic milk jug with a lid, a metal coffee can with a lid, or a commercial sharps container. 2 This is incorrect. Patients and caregivers should not recap used needles. 3 This is incorrect. The nurse should not advise the caregiver to remove the needle; this can cause needlestick injury. 4 This is incorrect. The caregiver should not break the needle; this can lead to a needlestick injury. PTS:

CON: Health Promotion

MULTIPLE RESPONSE 22. ANS: 1, 3 Chapter: Chapter 43 Community & Home Health Nursing Objective: Describe the roles of nurses in the community setting. Page: 1144 (V1) Heading: Understanding the Concept of Community Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Health Promotion Difficulty: Moderate

1. 2. 3.

Feedback This is correct. Census tracts show geopolitical boundaries that are useful to anyone who studies the characteristics and concerns of smaller groups of people. This is incorrect. Although some individuals within a census tract have a sense of belonging, a tract is not made up of individuals with common customs and heritage. This is correct. Census tracts are derived from the national census. They typically include 1,500 to 8,000 people. The area of the tract varies based on the density.

4. 5.

This is incorrect. Divisions are not based on voting patterns. This is incorrect. Rural tracts are large in size.

PTS: 1 CON: Health Promotion 23. ANS: 2, 3 Chapter: Chapter 43 Community & Home Health Nursing Objective: State two important safety concerns in home care that arise out of The Joint Commission 2019 home care safety goals. Page: 1165 (V1) Heading: Unhealthy Home May Mean Poor Health Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is incorrect. Dim lighting should be avoided to ensure the patient can see well. This is correct. It is important to change batteries in smoke detectors to ensure they are working properly. This is correct. Loose railings should be secured to avoid injury. This is incorrect. Rugs should not be used in the home, but should be secured if they are present. This is incorrect. The individual should be able to reach and open the medication.

PTS: 1 CON: Health Promotion 24. ANS: 1, 2, 4, 5 Chapter: Chapter 43 Community & Home Health Nursing Objective: Discuss factors that create vulnerability for a population. Page: 1146 (V1) Heading: What Makes a Population Vulnerable? Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Health Promotion Difficulty: Moderate

1. 2.

Feedback This is correct. Individuals with limited economic or social resources are a vulnerable population. This is correct. An individual who experienced abuse or trauma is a vulnerable population.

3. 4. 5.

This is incorrect. This age group is not a vulnerable population. The very young and very old are at risk. This is correct. An individual with chronic disease is a vulnerable population. This is correct. The very young and very old are considered vulnerable populations.

PTS: 1 CON: Health Promotion 25. ANS: 1, 2, 3 Chapter: Chapter 43 Community & Home Health Nursing Objective: Distinguish primary, secondary, and tertiary interventions in regard to a community health scenario. Page: 1149 (V1) Heading: Primary Prevention Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate

2. 3. 4. 5.

Feedback This is correct. Immunizations are an example of primary prevention. Primary interventions are interventions that occur before disease appears. The goal of primary interventions is to promote health and prevent disease. Secondary interventions aim to reduce the impact of the disease process by early detection and treatment. Tertiary interventions aim to halt disease progression and restore client functioning. This is correct. Sex education is an example of primary prevention. This is correct. Lobbying for health education is primary prevention. This is incorrect. Screening for TB is an example of secondary prevention. This is incorrect. Cardiac rehabilitation is an example of tertiary prevention.

PTS: 1 CON: Health Promotion 26. ANS: 1, 2, 3, 4 Chapter: Chapter 43 Community & Home Health Nursing Objective: Compare and contrast community-based care, community health nursing, public health nursing, and community-oriented nursing. Page: 1147 (V1) Heading: Public Health Nursing Integrated Processes: Caring Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Health Promotion Difficulty: Easy

1. 2. 3. 4. 5.

Feedback This is correct. This describes a nurse working in a community health setting as a school nurse. This is correct. This describes a nurse working in a community health setting as a parish nurse. This is correct. This describes a nurse working in a community health setting as a disaster nurse. This is correct. This describes a nurse working in a community health setting as a prison nurse. This is incorrect. This does not describe a community health nurse, but a hospital staff nurse.

PTS: 1 CON: Health Promotion 27. ANS: 2, 3, 5 Chapter: Chapter 43 Community & Home Health Nursing Objective: Compare and contrast community-based care, community health nursing, public health nursing, and community-oriented nursing. Page: 1147 (V1) Heading: Public Health Nursing Integrated Processes: Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate

2. 3. 4. 5.

Feedback This is incorrect. Diabetic care is focused on individual health. Public health nursing focuses on the community at large and the eventual effect of the community’s health status on the health of individuals and families. This is correct. An intervention for a neighborhood focuses on the community and is an example of public health nursing. This is correct. Providing a flu clinic for seniors and individuals with chronic illness focuses on the community at large and is an example of public health nursing. This is incorrect. Family counseling is focused on family health. This is correct. Offering nutrition courses to obese individuals in a rural area focuses on the health of the community and is an example of public health nursing.

PTS: 1 CON: Health Promotion 28. ANS: 2, 3 Chapter: Chapter 43 Community & Home Health Nursing Objective: Identify the primary goal of home care.

Page: 1155 (V1) Heading: Distinctive Features of Home Healthcare Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is incorrect. This individual is young and undergoing a surgery that would not require home health services. This is correct. Though this individual is young with supportive family, they are terminal and would benefit from a home health service such as hospice. This is correct. This individual is older with multiple medical problems and would benefit from home health monitoring to avoid placement in a skilled nursing facility. This is incorrect. This individual is young and lives with parents who can manage their care. This is incorrect. This individual has family support, is young, and lives at home. The family can receive outpatient diabetes education to manage the illness.

PTS: 1 CON: Health Promotion 29. ANS: 1, 2, 4, 5 Chapter: Chapter 43 Community & Home Health Nursing Objective: Identify the primary goal of home care. Page: 1156 (V1) Heading: Box 43-3 Skilled Nursing Services Integrated Processes: Caring Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Health Promotion Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is correct. Providing direct care to clients in the home is an example of a service provided by a home health agency. This is correct. Indirect care is a type of service provided by a home health agency. This is incorrect. Acute care services are provided in the hospital. This is correct. Home health agencies can provide respite care for caregivers. This is correct. Home health nurses teach patients or family members the skills for self-care and medication administration.

PTS:

CON: Health Promotion

30. ANS: 1, 4 Chapter: Chapter 43 Community & Home Health Nursing Objective: Describe how the nurse’s emphasis differs in hospice nursing as compared to home health nursing. Page: 1157 (V1) Heading: Hospice Care Integrated Processes: Caring Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Health Promotion Difficulty: Moderate

3. 4. 5.

Feedback This is correct. The purpose of home healthcare is to promote self-care and foster independence. The purpose of home hospice care is to promote comfort and quality of life by managing symptoms. This is incorrect. The purpose of home healthcare is to promote self-care and foster independence. The purpose of home hospice care is to promote comfort and quality of life by managing symptoms. This is incorrect. The purpose of home healthcare is both home care and teaching family members to perform skills. This is correct. Home healthcare focuses on fostering independence, whereas the purpose of hospice care is to provide symptom management. This is incorrect. Home healthcare is provided in the place of residence, and hospice care can be provided in the home or a facility.

PTS: 1 CON: Health Promotion 31. ANS: 2, 3 Chapter: Chapter 43 Community & Home Health Nursing Objective: Apply the nursing process to the care of patients in the home and community. Page: 1159 (V1) Heading: How Do I Make a Home Visit? Integrated Processes: Caring Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Difficult

1. 2.

Feedback This is incorrect. The nurse should not order supplies until after reviewing the reason for the visit to determine which supplies are required. This is correct. However, it is essential to first determine the nature of the visits and

4. 5.

to secure permission for visiting before the nurse can order supplies and plan her day. This is correct. However, it is essential to first determine the nature of the visits and to secure permission for visiting before the nurse can order supplies and plan her day. This is incorrect. The nurse would first contact the patient before planning a schedule for visits. This is incorrect. The nurse would first determine if respite care is needed by making a home visit.

PTS: 1 CON: Health Promotion 32. ANS: 3, 4, 5 Chapter: Chapter 43 Community & Home Health Nursing Objective: Outline the steps required to prepare for a home visit, including considerations for the nurse’s safety. Page: 1155 (V1) Heading: Distinctive Features of Home Healthcare Integrated Processes: Caring Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is incorrect. The nurse should notify the police if danger is sensed but not to tell them of a planned visit. This is incorrect. The nurse would always carry a cell phone to alert police when security is threatened. It is not recommended that the nurse carry a weapon. This is correct. Safety is a primary consideration in home care. The nurse would file a route and planned schedule with the agency. This is correct. In addition, the nurse would not enter the building if they feel they may be in danger. This is correct. It is important for the nurse to assess their surroundings for safe locations, such as a store, a community resource, or police department.

PTS: 1 CON: Health Promotion 33. ANS: 1, 2, 3, 5 Chapter: Chapter 43 Community & Home Health Nursing Objective: Discuss ways in which the assessment process is unique in home care. Page: 1152 (V1) Heading: Assessment Integrated Processes: Nursing Process

Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Easy

2. 3. 4. 5.

Feedback This is correct. The nurse would assess the patient’s wound status at the first home visit to determine care and supplies needed. The nurse would assess the patient’s status, condition of the wound, concerns, and ability to perform care independently. This is correct. Patient concerns are assessed the first home visit. This is correct. It is important to determine the patient’s ability to perform care independently at the first visit to determine the level of care and monitoring required. This is incorrect. End-of-life care is a topic the nurse may wish to explore after a relationship has developed. This is correct. A review of medications is done at the first home visit.

PTS:

CON: Health Promotion

Chapter 44. Ethics & Values Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The emergency department nurse is providing discharge teaching to a patient. The patient asks the nurse, “I appreciate everything you’ve done for me and I really like you. Can I take you out for dinner?” Which response does the nurse choose? 1. “Yes, that would be nice. It is really great to be appreciated.” 2. “No, and please do not ask again. Your request is inappropriate.” 3. “I appreciate your kindness, but I will have to decline your offer.” 4. “We cannot socialize until 3 days following your hospital discharge.” 2. Which concept refers to conflicts that arise between two or more ethical principles in patient care scenarios? 1. Nursing ethics 2. Bioethics 3. Ethical dilemma 4. Moral distress 3. The nurse provides care to an alert, oriented patient who is prescribed a blood transfusion for treatment of severe anemia. The patient refuses the treatment. The primary care provider explains to the patient that the blood transfusion is necessary for survival; however, the patient continues to refuse the transfusion. Which action does the nurse anticipate implementing? 1. Document the patient’s confusion and administer the blood. 2. Request a psychological evaluation to ensure that the patient understands the risks. 3. Ask family members to persuade the patient to consent to receiving blood. 4. Follow the patient’s wishes and do not administer the blood. 4. The postoperative care unit (PACU) nurse provides care to a patient who underwent a total hip replacement. The nurse is aware that the patient is a practicing Jehovah’s Witness. The primary care provider orders administration of blood for treatment of severe postoperative anemia. The patient is still very drowsy following general anesthesia and is unable to discuss the plan of care. The nurse understands the blood transfusion is necessary for the patient’s survival. However, the nurse is also aware that the patient’s religious beliefs may prohibit the patient from receiving blood products. Which term best describes the conflict the nurse is experiencing? 1. Ethical agency 2. Ethical dilemma 3. Moral outrage 4. Moral distress 5. Confidentiality will be maintained by the nurse who believes in and values the ethical principle of: 1. Fidelity 2. Veracity

3. Beneficence 4. Autonomy 6. The primary care provider orders limited treatments for patients who are diagnosed with a terminal illness and distributes the majority of resources to patients who have a high likelihood of survival. The primary care provider’s intention is to serve the greater good. Which ethical principle best describes the primary care provider’s approach to allocation of resources? 1. Ethics of care 2. Utilitarianism 3. Deontology 4. Categorical imperative 7. The nurse admits a patient to the hospital medical-surgical unit of the hospital. During the admission process, the nurse asks whether or not the patient has an advance directive. The basis for the nurse’s inquiry is: 1. The International Council of Nurses (ICN) Code of Ethics for Nurses 2. Values clarification 3. Patient advocacy 4. The Health Insurance Portability and Accountability Act (HIPAA) 8. Which action is included in Step 3 of the MORAL decision-making model? 1. Realizing information gaps 2. Resolving the dilemma 3. Requesting a review of opposing viewpoints 4. Recognizing the values and options of all major players 9. The nurse provides care to a patient who is admitted to the hospital for management of severe migraines. After administering a prescribed pain medication, the nurse states, “I will return in 20 minutes to reassess your pain.” By following through on the commitment to return at the specified time, which ethical principle does the nurse display? 1. Nonmaleficence 2. Autonomy 3. Beneficence 4. Fidelity 10. An alert, oriented, competent 87-year-old patient requests a Do Not Attempt Resuscitation/Allow Natural Death (AND) prescription. The patient’s family members oppose the patient’s decision and ask the hospital’s ethics committee to intervene on their behalf. Which framework is the ethics committee most likely as a guide for their decision making process? 1. Social justice 2. Patient benefit 3. Autonomy 4. Consequentialist

11. A 60-year-old patient who is diagnosed with a treatable form of breast cancer chooses not to pursue radiation or chemotherapy. The nurse persuades the patient to receive treatment by continuing to remind the patient about her responsibilities toward her children and grandchildren. The nurse’s behavior best illustrates which principle? 1. Nonmaleficence 2. Autonomy 3. Paternalism 4. Beneficence 12. The nursing student asks the nurse educator to explain the American Nurses Association (ANA) Code of Ethics for Nurses. Which statement does the nurse educator include in the explanation? 1. “The ANA Code of Ethics is not subject to public scrutiny.” 2. “The ANA Code of Ethics is not legally binding.” 3. “Nursing codes cannot be used to determine the legality of nursing actions.” 4. “Laws related to nursing practice usually exceed ethical obligations.” 13. An alert, oriented, competent older adult patient is diagnosed with a terminal illness. The patient requests a Do Not Attempt Resuscitation/Allow Natural Death (AND) prescription. The patient’s family members oppose the patient’s decision and ask the healthcare team to ignore the request. Despite lengthy discussions among the patient, physician, nurse, and family, the conflict is unresolved. The nurse asks the hospital chaplain to help the family and healthcare team members understand each other’s opposing views. Which step of the MORAL model is the nurse implementing? 1. M—Massage the dilemma 2. O—Outline the options 3. R—Resolve the dilemma 4. L—Look back and evaluate 14. Which issue represents an internal constraint that may prevent the implementation of ethical decisions? 1. Nurse administrators are viewed by staff nurses as being primarily a source of punishment. 2. Nurses view other staff nurses as being unsupportive on ethical issues. 3. Nursing students are socialized to follow orders and not to question them. 4. Nurses fear retaliation from primary care providers who disagree with nursing decisions. 15. The nurse is assigned to provide care to a patient who developed septicemia following an abortion. The nurse believes abortion is murder of the unborn child. Which concept most specifically requires the nurse to provide high-quality patient care regardless of personal beliefs? 1. Ethics 2. Moral beliefs 3. Bioethics 4. Nursing ethics

16. The nurse is assigned to provide care to an unconscious, mechanically ventilated patient who is receiving palliative treatment. The patient is receiving an intravenous morphine infusion. The primary care provider’s orders include discontinuing the patient’s mechanical ventilation and increasing the morphine infusion rate, as needed, to maintain the patient’s comfort. The nurse refuses to implement the orders based on a belief that implementing the orders would be equivalent to killing the patient. The nurse’s decision illustrates which concept? 1. Ethical agency 2. Morals 3. Bioethics 4. Clinical decision making 17. The nursing student is delivering a classroom presentation about professional values identified by the American Association of Colleges of Nursing (AACN). Which example does the nursing student use to illustrate the value of integrity? 1. Acting in accordance with an appropriate code of ethics and standards of practice 2. Treating others fairly regardless of disability 3. Ensuring equal access to quality healthcare 4. Respecting the inherent worth and uniqueness of individuals and populations 18. The nurse states, “I believe nurses who do not regularly exercise should not talk to patients about the importance of physical activity. Nurses should practice what they teach.” Which term best relates to the content of the nurse’s statement? 1. Morals 2. Ethics 3. Values 4. Compromise 19. The nurse preceptor observes a novice nurse preparing to insert an intravenous (IV) access device into a patient’s antecubital vein. Prior to inserting the IV, the novice nurse tells the patient, “You won’t feel a thing.” The nurse preceptor recognizes the novice nurse’s violation of which ethical principle? 1. Beneficence 2. Nonmaleficence 3. Veracity 4. Confidentiality 20. The nurse manager’s goals include allowing staff members to schedule vacation while still ensuring that an adequate number of staff members are present to deliver safe patient care. To determine the minimum number of staff members who must be scheduled to work during holidays, the nurse manager performs a risk–benefit analysis. Which ethical framework best describes the nurse manager’s problem-solving approach? 1. Utilitarianism 2. Deontology 3. Categorical imperative

4. Feminist ethics 21. The emergency department nurse provides care to a 17-year-old patient who is diagnosed with cervical cancer secondary to human papillomavirus. The patient declines treatment and states, “I don’t want my parents to know I have been sexually active. If they find out about the cancer, they’ll know I have been having sex.” When planning a course of action, the nurse recognizes a conflict between the ethical principles of nonmaleficence and . 1. Autonomy 2. Veracity 3. Fidelity 4. Justice 22. When faced with a true ethical dilemma, the nurse plans implementation of a variety of strategies to resolve the issue. Which outcome does the nurse anticipate? 1. A satisfying solution will be found if the nurse logically applies more than one strategy for decision making. 2. If the nurse involves other members of the healthcare team in the decision-making process, a compromise will be reached that satisfies everyone. 3. The nurse will probably not find any course of action to be satisfactory, regardless of the strategy, model, or type of reasoning used. 4. A satisfactory decision can be reached that is comfortable for the nurse if the nurse applies a decision model to the dilemma. 23. The nurse provides care to a 12-year-old patient who is diagnosed with leukemia. The patient’s parents refuse to allow the patient to receive chemotherapy, saying they will not ruin what is left of his life with drugs that will make him feel sicker. Which solution represents an integrity-producing compromise? 1. Supporting the parents’ refusal to include chemotherapy as a patient treatment 2. Instructing the parents that the child will die without chemotherapy 3. Seeking a court order to ensure that chemotherapy is administered 4. Discussing administration of a chemotherapy agent that causes the fewest side effects 24. The patient is struggling with deciding whether or not to receive experimental treatment. To support the patient’s decision-making process, which action does the nurse take? 1. Offer recommended solutions. 2. Teach the patient how to apply logic to resolve the situation. 3. Advocate for the patient with the primary healthcare provider. 4. Ask the patient questions. 25. The nurse witnesses the patient’s signature on a consent form to participate in a physician’s research study. After the physician leaves the room, the patient tells the nurse, “I don’t really want to participate, but I’m afraid my doctor will be upset with me if I say no.” To advocate for the patient, which nursing action is most appropriate? 1. Tell the patient the physician will not be upset if she declines to participate.

2. Inform the physician about why the patient agreed to participate. 3. Explain the importance of the research study to the patient. 4. Ask the patient to tell the nurse whether or not any action should be taken. 26. The nurse applies the MORAL model to decision making. After recognizing a problem, which action does the nurse take next? 1. Define the main issues associated with the dilemma. 2. Consult a member of the organization’s ethics committee. 3. Outline available options for all involved parties. 4. View the situation using alternate ethical frameworks. 27. Through application of the MORAL model to decision making, the nurse who opposes abortion determines that caring for patients who undergo an abortion is still an ethical duty. Which outcome is the best indicator that the nurse effectively applied the MORAL model to the decision making process? 1. The patient is discharged without experiencing complications from the procedure. 2. The nurse believes quality care was delivered and feels satisfied with the decision. 3. The nurse manager commends the nurse for providing excellent patient care. 4. The patient thanks the nurse for being supportive during a difficult time. Multiple Response Identify one or more choices that best complete the statement or answer the question. 28. Whistleblowing includes reporting which kind of information? Select all that apply. 1. Fraudulent billing practices 2. Patient’s health status against the patient’s wishes 3. Unsafe work practices 4. A coworker who works under the influence of drugs 5. An incompetent surgeon 29. The nurse’s obligations in ethical situations include which actions? Select all that apply. 1. Advocating for the patient. 2. Engaging with institutional ethics committees. 3. Improving personal ethical decision making abilities. 4. Respecting patient confidentiality. 5. Functioning independently when ethical problems arise. 30. The nurse provides care for a patient who experienced a stroke leaving the left side of the body paralyzed. The patient states, “I can still bathe myself.” To ensure that the patient is properly cleaned, the nurse proceeds to bathe the patient. The nurse’s behavior illustrates violation of which ethical principles? Select all that apply. 1. Beneficence 2. Fidelity 3. Autonomy

4. Veracity 5. Nonmaleficence 31. Upon arrival to work, the staff nurse realizes the unit will not be adequately staffed. The charge nurse explains that one of the nurses called in sick at the last minute, leaving no time to find a replacement. The staff nurse is aware that working without adequate nursing staff increases the risk for undesirable patient outcomes. Which factors contribute to the staff nurse’s dilemma? Select all that apply. 1. The nurse’s multiple obligations and relationships 2. Value conflicts and lack of clarity within the profession 3. Autonomy versus escaping hard choices 4. Higher pay versus cost effectiveness 5. Caring versus the decreased time to spend with patients

Chapter 44. Ethics & Values Answer Section MULTIPLE CHOICE 1. ANS: 3 Chapter: Chapter 44 Ethics & Values Objective: Explain how developmental stages, values, ethical frameworks, professional guidelines, and ethical principles affect moral decisions. Page: 1176 (V1) Heading: What Factors Affect Moral Decisions? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Comprehension [Understanding] Concept: Ethics Difficulty: Easy Feedback 1 This is incorrect. Accepting gifts from patients is a breach of professional boundaries. Nurses cannot accept gifts from patients in the form of dinners, money, social contact, and so forth. 2 This is incorrect. Scolding the patient is inappropriate and may be perceived as incivility. Although declining the option to socialize reflects understanding about gifts and professional boundaries, it is not a therapeutic response and would not help build a trusting relationship. 3 This is correct. Socializing with patients and accepting gifts represent a breach of professional boundaries. Gifts from patients may take a variety of forms, including meals, money, and tangible items. The nurse should not enter into a relationship based on the patient’s attempt to compensate her for performing her role responsibilities. Politely and professionally declining the patient’s offer is the appropriate response. 4 This is incorrect. At any point in time, accepting gifts and socializing with patients is a breach of professional boundaries. The nurse must avoid inappropriate sexual or romantic relationships or other breaches of professional boundaries. PTS: 1 CON: Ethics 2. ANS: 3 Chapter: Chapter 44 Ethics & Values Objective: Identify the ethical issues and moral principles involved in a given ethical situation. Page: 1187 (V1) Heading: Ethical Decision Making Integrated Processes: Communication and Documentation

Client Need: Safe and Effective Care Environment Cognitive Level: Knowledge [Remembering] Concept: Ethics Difficulty: Easy Feedback 1 This is incorrect. Nursing ethics refers to ethical questions that arise out of nursing practice. 2 This is incorrect. Bioethics is a broad field that refers to the application of ethics to healthcare. 3 This is correct. An ethical dilemma occurs when a choice must be made between two or more equally undesirable actions, and there is no clearly right or wrong option. 4 This is incorrect. Moral distress occurs when someone is unable to carry out his or her moral decision. PTS: 1 CON: Ethics 3. ANS: 4 Chapter: Chapter 44 Ethics & Values Objective: Differentiate between morals, ethics, bioethics, and nursing ethics. Page: 1169 (V1) Heading: Ethics and Morals Integrated Processes: Culture and Spirituality Client Need: Safe and Effective Care Environment Cognitive Level: Comprehension [Understanding] Concept: Ethics Difficulty: Moderate Feedback 1 This is incorrect. There is no evidence to indicate the patient is confused. Unless otherwise indicated, the patient is presumed to be competent. The patient is aware of the risk and has given a valid refusal. The nurse should not assume that a patient is confused simply based on refusal to accept a prescribed treatment. 2 This is incorrect. A psychological evaluation is not needed simply because the patient refuses treatment that might result in his death. 3 This is incorrect. Family members cannot override the patient’s decision. The nurse should respect the patient’s decision. 4 This is correct. The nurse should follow the patient’s wishes and refrain from administering the blood transfusion. PTS: 1 CON: Ethics 4. ANS: 2 Chapter: Chapter 44 Ethics & Values Objective: Differentiate between morals, ethics, bioethics, and nursing ethics.

Page: 1169 (V1) Heading: Ethics and Morals Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Ethical agency or moral agency for nurses is the ability to base their practice on professional standards of ethical conduct and to participate in ethical decision making. Simply stated, it means that nurses have choices and are responsible for their actions. 2 This is correct. The nurse is experiencing an ethical dilemma based on the conflict between the ethical principles of beneficence and autonomy. 3 This is incorrect. The nurse does not perceive that others are acting immorally; thus, this is not moral outrage. 4 This is incorrect. This is not a situation of moral distress, in which the nurse would have made an acceptable moral decision, but was unable to implement it because of external constraints. PTS: 1 CON: Patient-Centered Care 5. ANS: 4 Chapter: Chapter 44 Ethics & Values Objective: Identify the ethical issues and moral principles involved in a given ethical situation. Page: 1176 (V1) Heading: What Factors Affect Moral Decisions? Integrated Processes: Caring Client Need: Safe and Effective Care Environment Cognitive Level: Comprehension [Understanding] Concept: Ethics Difficulty: Moderate Feedback 1 This is incorrect. Fidelity is the obligation to keep promises. 2 This is incorrect. Veracity means to tell the truth. 3 This is incorrect. Beneficence is the duty to do or promote good. 4 This is correct. Autonomy refers to a person’s right to choose and his or her ability to act on that choice. An autonomous person has control over the collection, use, and access of his personal information. This information should not be shared without the patient’s consent. PTS: 1 6. ANS: 2

CON: Ethics

Chapter: Chapter 44 Ethics & Values Objective: Compare and contrast four ethical frameworks: consequentialism (e.g., utilitarianism), deontology, an ethics of care, and feminist ethics. Page: 1176 (V1) Heading: What Factors Affect Moral Decisions? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Application [Applying] Concept: Ethics Difficulty: Easy Feedback 1 This is incorrect. An ethics-of-care nursing philosophy directs attention to the specific situations of individual patients viewed within the context of their life narrative. 2 This is correct. Utilitarianism, the most familiar consequentialist theory, asserts that the value of an action is determined by its usefulness. The principle of utility states that an act must result in the greatest good (positive benefit) for the greatest number of people. Any act can then become the ethical choice if it delivers “good” results. In healthcare, the principle of “first, do no harm” is consequentialist in nature. Triaging patients is an example of utilitarian reasoning. The practice of triage is used in a disaster when emergency workers sort patients to determine who will be treated first or who will receive the limited resources (e.g., oxygen or intravenous therapy). 3 This is incorrect. Deontology uses rules, principles, and standards to determine whether an action is right or wrong. The consequences of the act are not the major considerations. Deontology is in contrast to utilitarian theory, which centers on producing the greatest good for the greatest number of people. 4 This is incorrect. The categorical imperative states that one should act only if the action is based on a principle that is universal—or in other words, if you believe that everyone should act in the same way in a similar situation. PTS: 1 CON: Ethics 7. ANS: 3 Chapter: Chapter 44 Ethics & Values Objective: Discuss the role of the nurse as client advocate in ethical situations. Page: 1187 (V1) Heading: Ethical Decision Making Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Moderate

2 3

Feedback This is incorrect. The ICN Code of Ethics for Nurses serves as the standard for nurses worldwide. It stresses respect for human rights, including cultural rights, the right to life and choice, the right to dignity, and the right to be treated with respect. This is incorrect. Values clarification refers to the process of becoming conscious of and naming one’s values. This is correct. The nurse’s action illustrates patient advocacy. In nursing, advocacy includes asking clients whether they have an advance directive and educating them on their significance. This is incorrect. The Health Insurance Portability and Accountability Act (HIPAA) protects a patient’s medical information.

PTS: 1 CON: Patient-Centered Care 8. ANS: 2 Chapter: Chapter 44 Ethics & Values Objective: Apply the steps identified in the MORAL model to make ethical decisions. Page: 1187 (V1) Heading: Ethical Decision Making Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Knowledge [Remembering] Concept: Ethics Difficulty: Moderate Feedback 1 This is incorrect. MORAL is an acronym for the following steps: M, Massage the dilemma; O, Outline the options; R, Resolve the dilemma; A, Act by applying the chosen option; L, Look back and evaluate. Realizing the existence of information gaps is a part of Step 1 of the process. 2 This is correct. MORAL is an acronym for the following steps: M, Massage the dilemma; O, Outline the options; R, Resolve the dilemma; A, Act by applying the chosen option; L, Look back and evaluate. 3 This is incorrect. MORAL is an acronym for the following steps: M, Massage the dilemma; O, Outline the options; R, Resolve the dilemma; A, Act by applying the chosen option; L, Look back and evaluate. During step 2, a member of the ethics committee or the hospital chaplain might be asked to help the family and the doctor understand the opposing viewpoints. 4 This is incorrect. MORAL is an acronym for the following steps: M, Massage the dilemma; O, Outline the options; R, Resolve the dilemma; A, Act by applying the chosen option; L, Look back and evaluate. Recognizing the values and options of all major players is included in Step 1 of the process.

PTS: 1 CON: Ethics 9. ANS: 4 Chapter: Chapter 44 Ethics & Values Objective: Describe five major ethical principles that are used in reasoning about healthcare. Page: 1176 (V1) Heading: What Factors Affect Moral Decisions? Integrated Processes: Caring Client Need: Safe and Effective Care Environment Cognitive Level: Understanding [Comprehension] Concept: Ethics Difficulty: Easy Feedback 1 This is incorrect. Nonmaleficence is the twofold principle of doing no harm and preventing harm. 2 This is incorrect. Autonomy refers to a person’s right to choose and his ability to act on that choice. 3 This is incorrect. Beneficence is the duty to do or promote good. 4 This is correct. Fidelity is the obligation to keep promises. PTS: 1 CON: Ethics 10. ANS: 3 Chapter: Chapter 44 Ethics & Values Objective: Describe a systematic approach to resolving ethical dilemmas. Page: 1176 (V1) Heading: What Factors Affect Moral Decisions? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Synthesis [Creating] Concept: Ethics Difficulty: Moderate Feedback 1 This is incorrect. The social justice model focuses more on broad social issues involving the entire institution rather than on a single patient issue. 2 This is incorrect. The patient benefit model assists in decision making for the incompetent patient by using substituted judgment. 3 This is correct. The autonomy model is useful when the patient is competent to make personal decisions. This model emphasizes patient autonomy and choice as the highest values. 4 This is incorrect. Consequentialist theories focus on the rightness or wrongness of an action as opposed to an individual’s preferences. In consequentialist theories, the rightness or wrongness of an action depends on the consequences of the act rather than on the act itself. Utilitarianism is the most familiar

consequentialist theory, asserts that the value of an action is determined by its usefulness. PTS: 1 CON: Ethics 11. ANS: 3 Chapter: Chapter 44 Ethics & Values Objective: Explain how developmental stages, values, ethical frameworks, professional guidelines, and ethical principles affect moral decisions. Page: 1176 (V1) Heading: What Factors Affect Moral Decisions? Integrated Processes: Culture and Spirituality Client Need: Safe and Effective Care Environment Cognitive Level: Application [Applying] Concept: Ethics Difficulty: Easy Feedback 1 This is incorrect. Nonmaleficence is the twofold principle of doing no harm and preventing harm. 2 This is incorrect. Autonomy refers to a person’s right to choose and his ability to act on that choice. 3 This is correct. Paternalistic behavior occurs when the nurse thinks she knows what is best for a competent patient and coerces the patient to act as she wishes rather than to act as the patient originally desired. 4 This is incorrect. Beneficence is the duty to do or promote good. PTS: 1 CON: Ethics 12. ANS: 2 Chapter: Chapter 44 Ethics & Values Objective: Explain how developmental stages, values, ethical frameworks, professional guidelines, and ethical principles affect moral decisions. Page: 1176 (V1) Heading: What Factors Affect Moral Decisions? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Comprehension [Understanding] Concept: Legal Difficulty: Difficult Feedback 1 This is incorrect. Codes of ethics are open to public scrutiny. The ethical aspects of nursing work, just like the technical aspects, are subject to review by professional groups and licensure boards, which may use sanctions to punish code violations. Although nursing codes are not legally binding, they are often

used in legal cases involving nurses (e.g., malpractice) to identify deviations from professional standards of practice. This is correct. Nursing codes are not legally binding. However, they often exceed legal obligations. In most states, the state board of nursing uses the nursing code of ethics as the standard against which to evaluate a nurse’s ethical behavior. The board has the legal authority to censure or reprimand the nurse who does not practice within the boundaries of ethical practice. This is incorrect. Although nursing codes are not legally binding, they are often used in legal cases involving nurses (e.g., malpractice) to identify deviations from professional standards of practice. This is incorrect. While nursing codes are not legally binding, they often exceed legal obligations.

PTS: 1 CON: Legal 13. ANS: 2 Chapter: Chapter 44 Ethics & Values Objective: Apply the steps identified in the MORAL model to make ethical decisions. Page: 1187 (V1) Heading: Ethical Decision Making Integrated Processes: Culture and Spirituality Client Need: Safe and Effective Care Environment Cognitive Level: Knowledge [Remembering] Concept: Ethics Difficulty: Moderate Feedback 1 This is incorrect. In “Massaging the dilemma,” the team would already have identified and defined the issues in the dilemma, and considered the values and options of all the major players. 2 This is correct. At the “Outlining the options” step, someone should delineate all of the options to all parties, including those that are less realistic and conflicting. In that step, someone often asks a member of the ethics committee or the hospital chaplain to help the parties understand the opposing viewpoints. 3 This is incorrect. “Resolving the dilemma” is the step in which all the options are reviewed and basic ethical principles and frameworks are applied to arrive at a decision. 4 This is incorrect. “Looking back to evaluate” is done after a decision has been made and acted on. At that time, the entire process, including the consequences, are evaluated to determine how well they worked. PTS: 1 CON: Ethics 14. ANS: 3 Chapter: Chapter 44 Ethics & Values

Objective: Discuss what is meant by ethical agency. Page: 1169 (V1) Heading: Ethics and Morals Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Comprehension [Understanding] Concept: Ethics Difficulty: Moderate

1 2 3 4

Feedback This is incorrect. External constraints include nurses viewing nurse administrators more as a source of punishment than support. This is incorrect. External constraints include nurses viewing other staff nurses as being unsupportive on ethical issues. This is correct. Internal constraints include socializing nursing students to follow orders and not to question them. This is incorrect. Nurses’ views about primary care providers represent an external constraint. For example, nurses express fear that the provider would be angry, have them fired, retaliate, and make their job difficult.

PTS: 1 CON: Ethics 15. ANS: 4 Chapter: Chapter 44 Ethics & Values Objective: Differentiate between morals, ethics, bioethics, and nursing ethics. Page: 1169 (V1) Heading: Ethics and Morals Integrated Processes: Culture and Spirituality Client Need: Safe and Effective Care Environment Cognitive Level: Comprehension [Understanding] Concept: Ethics Difficulty: Moderate Nursing Processes: Implementation Feedback 1 This is incorrect. Ethics is a system of moral principles and standards that helps to decide conduct and actions, so although this applies to the situation, it is a more general guide and is not specific to this situation; there is a better answer choice. 2 This is incorrect. Morals are taught to us as children to guide behavior, such as learning that abortion is murder. However, this does not apply specifically to the nurse’s care for this patient. 3 This is incorrect. Bioethics refers to the application of ethical principles to healthcare, but is not exactly the term we should use in this case—the nurse can

provide high-quality care to someone who has a different set of morals from her own. This is correct. Nursing ethics are a specific subset of bioethics that apply only to nurses, and is the specific concept upon which the nurse’s behavior is based.

PTS: 1 CON: Ethics 16. ANS: 1 Chapter: Chapter 44 Ethics & Values Objective: Discuss what is meant by ethical agency. Page: 1169 (V1) Heading: Ethics and Morals Integrated Processes: Culture and Spirituality Client Need: Safe and Effective Care Environment Cognitive Level: Analysis [Analyzing] Concept: Ethics Difficulty: Moderate Nursing Processes: Implementation Feedback 1 This is correct. The nurse is demonstrating ethical agency (also referred to as moral agency) because the nurse perceives the difference between right and wrong, understands the abstract moral principle of right to die versus euthanasia, applies moral principles to decision making, decides and chooses freely that this action is not right for the nurse to perform, and acts according to choice. 2 This is incorrect. Morals reflect what the nurse was taught about right and wrong, but that is only one component of what this nurse is demonstrating. 3 This is incorrect. Bioethics is the application of ethics to healthcare, but this is only one component of what this nurse is demonstrating. 4 This is incorrect. Although the nurse is making a clinical decision, this is only one component of what this nurse is demonstrating. PTS: 1 CON: Ethics 17. ANS: 1 Chapter: Chapter 44 Ethics & Values Objective: Explain how developmental stages, values, ethical frameworks, professional guidelines, and ethical principles affect moral decisions. Page: 1176 (V1) Heading: What Factors Affect Moral Decisions? Integrated Processes: Culture and Spirituality Client Need: Safe and Effective Care Environment Cognitive Level: Comprehension [Understanding] Concept: Ethics Difficulty: Moderate

Nursing Processes: Planning Feedback 1 This is correct. Acting in accordance with an appropriate code of ethics and accepted standards of practice is reflective of the value of integrity. Integrity also includes honesty. 2 This is incorrect. Treating others fairly regardless of disability is reflective of the value of social justice. 3 This is incorrect. Ensuring equal access to quality healthcare is reflective of the value of social justice. 4 This is incorrect. Respecting the inherent worth and uniqueness of individuals and populations is reflective of the value of human dignity. PTS: 1 CON: Ethics 18. ANS: 3 Chapter: Chapter 44 Ethics & Values Objective: Differentiate personal values and morality from professional values. Page: 1169 (V1) Heading: Ethics and Morals Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Analysis [Analyzing] Concept: Ethics Difficulty: Difficult Nursing Processes: Evaluation Feedback 1 This is incorrect. Morals are something we learn that help us differentiate good from bad, right from wrong. 2 This is incorrect. Ethics refers to the study of a system of moral principles and standards; therefore, this coworker is not expressing ethics. 3 This is correct. A value is a belief about the worth of something. The nurse’s statement diminishes the knowledge and expertise of nurses who do not regularly exercise. Diminishing the value of an individual or population goes against nursing values of compassion and human dignity. 4 This is incorrect. A compromise is a solution in which parties with opposing positions all settle on a solution to a problem that is somewhere between what each party would ideally like to have. This nurse is simply stating a personal position about a topic. PTS: 1 CON: Ethics 19. ANS: 3 Chapter: Chapter 44 Ethics & Values Objective: Identify the ethical issues and moral principles involved in a given ethical situation.

Page: 1176 (V1) Heading: What Factors Affect Moral Decisions? Integrated Processes: Caring Client Need: Safe and Effective Healthcare Environment Cognitive Level: Analysis [Analyzing] Concept: Ethics Difficulty: Moderate Nursing Processes: Evaluation Feedback 1 This is incorrect. The scenario does not describe the nurse performing the procedure incorrectly, so there is no reason to think that the graduate did not provide good care. 2 This is incorrect. There is no indication the patient was harmed, so the nurse did not violate nonmaleficence. 3 This is correct. The graduate nurse was not honest with the patient, so the ethical principle of veracity was violated. 4 This is incorrect. There is no indication the new graduate shared any private, sensitive information about the patient with others; therefore, confidentiality was maintained. PTS: 1 CON: Ethics 20. ANS: 1 Chapter: Chapter 44 Ethics & Values Objective: Compare and contrast four ethical frameworks: consequentialism (e.g., utilitarianism), deontology, an ethics of care, and feminist ethics. Page: 1176 (V1) Heading: What Factors Affect Moral Decisions? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Analysis [Analyzing] Concept: Ethics Difficulty: Difficult Nursing Processes: Implementation Feedback 1 This is correct. Use of a risk-benefit analysis to determine every alternative action for its potential outcomes is utilitarianism. This nurse is using utilitarianism when balancing fairness to the staff with safety of the patients. 2 This is incorrect. Deontology is based on rules and principles using the language of rights and duties, or right and wrong, which does not apply to this manager’s approach. 3 This is incorrect. The categorical imperative states one should act only if the action is based on a principle that is universal, which does not apply to this

situation. This is incorrect. Feminist ethics is based on the belief that traditional ethical models provide a mostly masculine perspective and devalue women, which does not apply to this nurse manager’s problem.

PTS: 1 CON: Ethics 21. ANS: 1 Chapter: Chapter 44 Ethics & Values Objective: Describe five major ethical principles that are used in reasoning about healthcare. Page: 1187 (V1) Heading: Ethical Decision Making Integrated Processes: Culture and Spirituality Client Need: Safe and Effective Care Environment Cognitive Level: Analysis [Analyzing] Concept: Ethics Difficulty: Difficult Nursing Processes: Assessment Feedback 1 This is correct. Conflicting ethical principles include maintaining the confidentiality (one aspect of autonomy) of the patient’s health information versus the harm that will come to the patient if confidentiality is maintained (i.e., nonmaleficence). 2 This is incorrect. Veracity is the duty to tell the truth and is not a component of this scenario. The conflicting ethical principles include maintaining the confidentiality (one aspect of autonomy) of the patient’s health information versus the harm that will come to the patient if confidentiality is maintained (i.e., nonmaleficence). 3 This is incorrect. Fidelity relates to fulfilling one’s obligations and maintaining one’s commitments; this principle is not a source of conflict in this scenario. Ethical conflicts exist between maintaining the confidentiality (one aspect of autonomy) of the patient’s health information versus the harm that will come to the patient if confidentiality is maintained (i.e., nonmaleficence). 4 This is incorrect. Justice is the obligation to be fair. Justice is not in conflict in this scenario because fairness is not a primary concern. The conflicting ethical principles in this scenario include maintaining confidentiality (one aspect of autonomy) of the patient’s health information versus the harm that will come to the patient if confidentiality is maintained (i.e., nonmaleficence). PTS: 1 CON: Ethics 22. ANS: 3 Chapter: Chapter 44 Ethics & Values Objective: Describe a systematic approach to resolving ethical dilemmas.

Page: 1187 (V1) Heading: Ethical Decision Making Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Application [Applying] Concept: Ethics Difficulty: Difficult Nursing Processes: Planning Feedback 1 This is incorrect. True ethical dilemmas involve choosing between two equally undesirable actions, so the nurse will probably not be fully satisfied with any course of action, regardless of the strategy, number of strategies, model, or type of reasoning used. 2 This is incorrect. Because of the nature of a dilemma, even with the involvement of other team members it is unlikely the decision will be fully satisfying to any one participant. 3 This is correct. When resolving a true ethical dilemma, the choices include two equally undesirable actions. For this reason, the nurse will probably not be fully satisfied with any course of action, regardless of the strategy, model, or type of reasoning used. 4 This is incorrect. Ethical decision-making models will help the nurse carefully consider several perspectives, guide reasoning, and explain reasons for final action; however, true ethical dilemmas require deciding between the lesser of two evils, so any conclusion is likely to be unsatisfying in some ways. PTS: 1 CON: Ethics 23. ANS: 4 Chapter: Chapter 44 Ethics & Values Objective: Identify the ethical issues and moral principles involved in a given ethical situation. Page: 1187 (V1) Heading: Ethical Decision Making Integrated Processes: Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Easy Nursing Processes: Evaluation Feedback 1 This is incorrect. Allowing the child to avoid chemotherapy yields to the parents’ concerns but does not follow the concerns of the healthcare team to do no harm to the child. 2 This is incorrect. Frightening the parents into agreeing with the healthcare team

3 4

is coercion; a good compromise must be entered into freely. This is incorrect. A court order would forcibly settle the matter; a compromise cannot be obtained by force. This is correct. Administering the chemotherapy agent with the fewest side effects demonstrates a compromise because the child receives treatment, but the parents’ concerns about side effects are also considered.

PTS: 1 CON: Patient-Centered Care 24. ANS: 4 Chapter: Chapter 44 Ethics & Values Objective: Describe five major ethical principles that are used in reasoning about healthcare. Page: 1187 (V1) Heading: Ethical Decision Making Integrated Processes: Patient-Centered Care Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Caring Difficulty: Moderate Nursing Processes: Implementation Feedback 1 This is incorrect. The nurse’s role while the patient is making a decision is to support the patient, listen to his thoughts, ask questions to help the patient think things through, and provide unbiased information. The nurse should not lead the patient to what the nurse thinks is best but should allow the patient to make his own decision (autonomy). 2 This is incorrect. Although the nurse may help the patient think through the decision, the nurse would not teach the patient how to make a decision because this could bias the patient toward the nurse’s opinion (a subtle form of coercion). 3 This is incorrect. There is no need for the nurse to advocate for the patient until he makes a decision; this is not the nurse’s role at this time. 4 This is correct. While the patient is making a decision, the nurse’s role is to support the patient, listen to the patient’s perspectives, ask questions to help the patient through the process, and provide unbiased information. PTS: 1 CON: Caring 25. ANS: 2 Chapter: Chapter 44 Ethics & Values Objective: Discuss the role of the nurse as client advocate in ethical situations. Page: 1187 (V1) Heading: Ethical Decision Making Integrated Processes: Caring Client Need: Safe and Effective Healthcare Environment

Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Nursing Processes: Planning Feedback 1 This is incorrect. While the nurse can say the physician will not be upset, and it is likely to be true, this action will neither change how the patient feels nor provide an opportunity for the patient to change her mind. 2 This is correct. The nurse should inform the physician of the patient’s feelings and encourage the physician to talk with the patient to give her permission to change her mind. While the nurse can say the physician will not be upset, and it is likely to be true, it will not change how the patient feels nor provide her the opportunity to change her mind. Explaining the importance of the study would probably make the patient feel even more obligated to participate. The patient is likely to tell the nurse not to do anything, so the patient’s needs would still go unmet. 3 This is incorrect. Explaining the importance of the study would probably make the patient feel even more obligated to participate. 4 This is incorrect. The patient may advise the nurse to take no action, in which case the patient’s needs would still go unmet. PTS: 1 CON: Patient-Centered Care 26. ANS: 1 Chapter: Chapter 44 Ethics & Values Objective: Apply the steps identified in the MORAL model to make ethical decisions. Page: 1187 (V1) Heading: Ethical Decision Making Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Application [Applying] Concept: Ethics Difficulty: Moderate Nursing Processes: Implementation

2 3

Feedback This is correct. To apply the MORAL model, after a problem is identified, the first step to resolving the problem is “Massaging the dilemma,” which includes defining the issues in the dilemma. This is incorrect. Using the MORAL model, before “Outlining” all of the options to all parties, the key issues in the dilemma must be identified. This is incorrect. When applying the MORAL model, after recognizing a problem, the first step to resolving the problem is “Massaging the dilemma,”

which includes identifying the key issues. The fourth step in the MORAL model is “Outlining the available options.” This is incorrect. Viewing the situation from alternate ethical frameworks occurs during the final phase of the MORAL reasoning model: “Resolving the dilemma.”

PTS: 1 CON: Ethics 27. ANS: 2 Chapter: Chapter 44 Ethics & Values Objective: Discuss the concept of an integrity-producing compromise. Page: 1187 (V1) Heading: Ethical Decision Making Integrated Processes: Caring Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Ethics Difficulty: Difficult Nursing Processes: Evaluation Feedback 1 This is incorrect. The absence of complications may be reflective of good nursing care but is not a good criterion for evaluating an ethical decision process. 2 This is correct. Decisions that are in alignment with ethical standards should preserve personal integrity and inspire the individual to feel as though the right choice was made. The nurse’s personal belief that the correct action was taken and sense of satisfaction with the decision is the most important outcome when evaluating the decision making process. 3 This is incorrect. The nurse manager’s commendation does not necessarily indicate the decision making process was effective. 4 This is incorrect. The patient’s gratitude may be reflective of effective nursing care but does serve as an evaluation of the effectiveness of the ethical decision making process. PTS:

CON: Ethics

MULTIPLE RESPONSE 28. ANS: 1, 3, 4, 5 Chapter: Chapter 44 Ethics & Values Objective: Identify at least four factors that contribute to the frequency of nurses’ moral problems. Page: 1169 (V1) Heading: Ethics and Morals

Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Cognitive Level: Analysis [Analyzing] Concept: Ethics Difficulty: Moderate

Feedback This is correct. Whistleblowing is identifying incompetent, unethical, or illegal situations or actions of others in the workplace and reporting to someone who may be in a position to rectify the situation. Fraudulent billing practices are illegal and unethical. This is incorrect. Reporting a patient’s health status against the patient’s wishes is a breach of patient confidentiality. Whistleblowing is identifying incompetent, unethical, or illegal situations or actions of others in the workplace and reporting to someone who may be in a position to rectify the situation. This is correct. Whistleblowing is identifying incompetent, unethical, or illegal situations or actions of others in the workplace and reporting to someone who may be in a position to rectify the situation. Unsafe work practices are unethical and illegal. This is correct. Whistleblowing is identifying incompetent, unethical, or illegal situations or actions of others in the workplace and reporting to someone who may be in a position to rectify the situation. A coworker under the influence of drugs is a risk to patients, as well as acting in an illegal and unethical manner. This is correct. Whistleblowing is identifying incompetent, unethical, or illegal situations or actions of others in the workplace and reporting to someone who may be in a position to rectify the situation. Reporting a surgeon who demonstrates incompetent patient care is an example of whistleblowing.

PTS: 1 CON: Ethics 29. ANS: 1, 2, 3, 4 Chapter: Chapter 44 Ethics & Values Objective: Describe the nurse’s obligations in ethical decisions. Page: 1187 (V1) Heading: Ethical Decision Making Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Application [Applying] Concept: Ethics Difficulty: Moderate

Feedback This is correct. The nurse’s obligations in ethical situations include being a patient

2. 3. 4. 5.

advocate. This is correct. The nurse’s obligations in ethical situations include using and participating in institutional ethics committees. This is correct. The nurse’s obligations in ethical situations include improving ethical decision making. This is correct. Confidentiality is a basic patient right. The nurse’s role includes upholding that right. This is incorrect. The nurse should function as a team member when ethical problems arise.

PTS: 1 CON: Ethics 30. ANS: 1, 3, 5 Chapter: Chapter 44 Ethics & Values Objective: Describe five major ethical principles that are used in reasoning about healthcare. Page: 1176 (V1) Heading: What Factors Affect Moral Decisions? Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Ethics Difficulty: Moderate Nursing Processes: Evaluation

2. 3.

4. 5.

Feedback This is correct. Beneficence is doing good, and performing care for the patient rather than encouraging the patient to do as much for himself as possible is not doing the patient any good. To do good for this patient, the nurse should encourage the patient to perform as much of the bath as possible so he will regain his strength. This is incorrect. Fidelity is being loyal; this principle is not relevant to the scenario. This is correct. The nurse is limiting the patient’s autonomy by not encouraging the patient to do as much self-care as possible and not respecting the patient’s desire to try bathing by himself. This is incorrect. Veracity means the nurse should be honest; this principle is not relevant to the scenario. This is correct. Nonmaleficence is doing no harm and the nurse is harming this patient by encouraging dependence instead of autonomy.

PTS: 1 CON: Ethics 31. ANS: 1, 2, 5 Chapter: Chapter 44 Ethics & Values Objective: Identify at least four factors that contribute to the frequency of nurses’ moral problems. Page: 1169 (V1)

Heading: Ethics and Morals Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Analysis [Analyzing] Concept: Ethics Difficulty: Difficult Nursing Processes: Planning

Feedback This is correct. The staff nurse’s multiple obligations influence this dilemma because the nurse may want to refuse to work short staffed because of safety issues, but wants to provide care for patients, and does not want to be fired for refusing to work under these conditions. This is correct. The staff nurse’s dilemma is partially due to lack of clarity within the profession. Although the profession discusses the possibility of legal nurse-to-patient ratios, there is a lack of clarity about the best way to avoid short staffing. In addition, nurses are bound by a professional duty not to abandon patients. This is incorrect. Higher pay and cost-effectiveness are not relevant to autonomy; the nurse is not giving up her autonomy by escaping hard choices and letting the provider choose her course of action. This is incorrect. The understaffing situation was not caused by reduction in staff to save money. Instead, inadequate staffing was caused by a nurse who called in sick so close to the start of the shift that the charge nurse was unable to locate a replacement. This is correct. The staff nurse’s dilemma is also focused on the realization that there will be insufficient time to adequately care for patients.

PTS:

CON: Ethics

Chapter 45. Legal Accountability Multiple Choice Identify the choice that best completes the statement or answers the question. 1. A 15-year-old patient who is at 39 weeks gestation is transported by her mother to the emergency department (ED) of a private hospital. The patient reports she is in active labor. The patient’s mother states, “We don’t have any money or insurance, but this hospital is closer than the public hospital.” Which action does the ED nurse implement? 1. Arrange for an ambulance to transport the patient to the nearest public hospital. 2. Explain to the patient and her mother that the hospital only accepts patients who have health insurance. 3. Examine the patient to determine whether her condition is stable or whether she requires immediate medical attention. 4. Advise the patient’s mother to transport the patient to the nearest public hospital. 2. An alert, oriented, 87-year-old patient has just been diagnosed with cancer. According to the patient’s durable power of attorney, the patient’s son serves as the patient’s surrogate decision maker. The patient’s son tells the nurse he is refusing chemotherapy treatment on the patient’s behalf due to concerns about medication side effects and quality of life. Meanwhile, the patient states, “I want to receive chemotherapy.” Which action does the nurse take? 1. Assist the patient and her son with reaching a compromise. 2. Administer the patient’s chemotherapy treatment as ordered. 3. Advise the patient’s son to consult with the hospital legal department for guidance. 4. Ask the patient’s son to share more information about his decision to refuse the treatment. 3. The charge nurse lists the nurses’ patient assignments and the patients’ diagnoses on a whiteboard located at the nurse’s station. The charge nurse’s practice represents a violation of which federal regulation? 1. Americans with Disabilities Act (ADA) 2. Patient Self-Determination Act (PSDA) 3. Health Insurance Portability and Accountability Act (HIPAA) 4. Health Emergency Medical Treatment and Active Labor Act (EMTALA) 4. A 75-year-old patient is admitted to the emergency department (ED) for evaluation of confusion and memory loss. The initial patient assessment reveals bruises and scratches in various stages of healing on the patient’s arms, legs, and torso. Based on the assessment findings, the nurse suspects the patient may be a victim of physical abuse. Which legislation requires the nurse to notify a designated authority about the suspected abuse? 1. Good Samaritan laws 2. Mandatory reporting laws 3. Nurse practice act

4. Nursing standards of practice 5. Which aspect of patient care is guaranteed by the American Nurses Association (ANA) Code of Ethics for Nurses? 1. Helping a patient with billing claims 2. Assisting a patient who is leaving the hospital 3. Ensuring a clean and safe environment 4. Protecting the patient from misrepresentation 6. The charge nurse in a progressive care unit assigns the care of a patient receiving hemodialysis to a newly hired licensed practical nurse (LPN). The charge nurse does not ask whether or not the LPN is competent in caring for patients who are receiving hemodialysis. The LPN is in orientation and fails to inform the charge nurse that she does not have experience with patients who are undergoing hemodialysis treatments. Which term best describes the charge nurse’s actions? 1. Malpractice 2. Libel 3. Negligence 4. Abandonment 7. Under which circumstance is deferral of informed consent allowable? 1. The patient is confused and does not appear to understand the plan of treatment or the consent form. 2. The patient who is in cardiac arrest is transported to the emergency department without accompaniment by family members. 3. The surgeon requests that the patient be transferred to the surgical suite before the nurse has an opportunity to obtain the patient’s informed consent. 4. The patient is crying due to severe pain and is unable to verbalize understanding of the treatment plan. 8. A 4-year-old patient is transported to the emergency department by his mother. The patient presents with bruising on his chest and facial contusions. The patient’s mother reports that her boyfriend became angry and intentionally pushed the patient down the stairs. The patient appears to be experiencing significant pain. Which action does the nurse take first? 1. Notify the nursing supervisor of the suspected physical abuse. 2. Complete a physical assessment of the child. 3. Obtain an order for pain medication. 4. Notify Child Protective Services of the suspected abuse. 9. The nurse provides care to an alert, oriented adult patient who is recovering from abdominal surgery. During a period of frustration, the patient states, “I’m leaving the hospital. Remove my IV and surgical drains or I will do it myself.” In an effort to prevent the patient from removing the IV line and surgical drainage tubing, the nurse applies bilateral wrist restraints. Which terminology best describes the nurse’s actions? 1. Assault 2. Fraud

3. False imprisonment 4. Quasi-intentional tort 10. The nurse is assigned to provide care to an older adult patient who is experiencing confusion. After completing the patient’s physical assessment, the nurse forgets to raise the siderails on the patient’s bed. Later in the day, the patient falls out of bed and sustains a hip fracture. The nurse is most likely to be sued on which grounds? 1. Malpractice 2. Battery 3. Assault 4. Negligence 11. A nurse who administers the wrong medication to a patient does not notify anyone of the error. Instead, the nurse documents administration of the correct medication. Ultimately, the error is discovered and the nurse is reported to the state board of nursing. Which action does the state board of nursing take against the nurse in this situation? 1. Disciplinary action against the nurse’s license to practice 2. Criminal misdemeanor charges against the nurse 3. Medical malpractice lawsuit against the nurse 4. Termination of the nurse’s employment 12. The nurse provides care to a patient who is diagnosed with a sexually transmitted infection (STI). The nurse explains to the patient that the STI diagnosis must be reported to the local Health department based on which regulation? 1. Americans with Disabilities Act (ADA) 2. Safe Harbor laws 3. Good Samaritan Law 4. Mandatory reporting 13. The night shift nurse is assigned to care for a patient who is confused and who frequently attempts to climb out of bed. During one of the patient’s attempts to get up, the nurse pushes the patient back onto the bed. The nurse then shows the patient a set of limb restraints and states, “If you keep trying to get up, I will tie you to the bed and leave you there until tomorrow morning.” The nurse’s actions are best described as: 1. Assault and battery 2. Libel and slander 3. False imprisonment 4. Medical malpractice 14. The unit manager stops the staff nurse in the hallway to discuss concerns about the staff nurse’s delivery of unsafe patient care. The unit manager’s comments are based on false information reported by a disgruntled patient. The conversation is overheard by other members of the healthcare team. Which term describes the unit manager’s behavior? 1. Assault 2. Battery

3. Slander 4. Libel 15. The nurse enters a patient’s room with a portable computer station to assess the patient. The nurse does not log out while assisting a patient to the bathroom. A visitor reads the patient’s health record and begins to question the nurse about the patient information. This is an example of: 1. Quasi-intentional torts 2. Breach of confidentiality 3. Vicarious liability 4. Character defamation 16. The nursing student asks the nurse preceptor to explain the purpose of accurate documentation in the electronic health record (EHR). Which response does the nurse choose? 1. “Charting communicates to members of the healthcare team the patient’s care and responses during my shift.” 2. “Charting allows me to share with the healthcare team my opinions of what happened with the patient.” 3. “Charting helps the other nurses understand the patient care provided during my shift.” 4. “Charting is required to comply with practice guidelines and institutional policies.” 17. The staff nurse asks the clinical nurse leader to explain the main purpose of an incident report. Which response does the clinical nurse leader choose? 1. “Incident reports are used by nurse managers to discipline nursing staff for making errors.” 2. “If an error in care occurs, an incident report must be kept in the patient’s medical record in case of a lawsuit.” 3. “To promote open communication, a copy of the incident report should be provided to the patient.” 4. “The risk management team uses incident reports to prevent the incident from recurring.” 18. Effective delegation is a vital part of the nurse’s responsibilities. Which factor is most important for the nurse to consider when correctly delegating a nursing task? 1. The delegatee’s level of experience 2. The job description of the delegatee 3. The patient’s opinion of the delegatee 4. The delegatee’s sense of confidence 19. Which issue is directly addressed by Safe Harbor laws? 1. Guarantee of peer review 2. Prevention of workplace violence 3. Exemption from mandatory overtime 4. Assurance of safe staffing

Multiple Response Identify one or more choices that best complete the statement or answer the question. 20. Which nursing action constitutes invasion of privacy? Select all that apply. 1. Searching the patient’s belongings without permission 2. Reviewing the patient’s plan of care with nursing team members in the hospital cafeteria 3. Discussing an unconscious patient’s treatment plan with the patient’s power of attorney 4. Photographing a patient’s leg wound without patient consent 5. Concealing information that should have been disclosed 21. The patient asks the nurse, “Will you please help me understand advance directives?” Which information does the nurse include in the response? Select all that apply. 1. “Advance directives establish the patient’s choices about healthcare treatment if the patient should become unable to communicate.” 2. “Legal requirements for advance directives are the same in every state.” 3. “A patient may change the advance directive by telling the attending physician or by making changes in writing.” 4. “Advance directives help to make sure the patient receives as much or as little care as he wishes.” 5. “Examples of advance directives include living wills and durable power of attorney for healthcare.” 22. The nurse educator teaches a cohort of nursing students about intentional and unintentional torts. Which information does the nurse educator include in the discussion? Select all that apply. 1. Negligence is an example of an intentional tort. 2. Battery is an example of an intentional tort. 3. Intentional torts include invasion of privacy. 4. Malpractice is a type of unintentional tort. 5. False imprisonment is an example of an unintentional tort. 23. A patient files a court complaint related to care that was delivered during a recent hospital admission. In an effort to prevent a trial hearing, the hospital’s legal team attempts to resolve the patient dispute. Which processes represent methods of alternative dispute resolution? Select all that apply. 1. Deposition 2. Mediation 3. Litigation 4. Arbitration 5. Negotiation

24. The nursing student creates a presentation about the impact of the American Nurses Association (ANA) Code of Ethics on nursing practice. Which information does the nursing student include in the presentation? Select all that apply. 1. The ANA Code of Ethics is a collection of federal and state laws. 2. The ANA Code of Ethics guarantees the patient’s right to dignity. 3. Violation of a standard in the ANA Code of Ethics is considered to be a criminal offense. 4. The patient’s privacy is guaranteed by the ANA Code of Ethics. 5. Violation of the ANA Code of Ethics may result in disciplinary action by the state board of nursing. 25. The nurse provides care to an adult patient who is admitted to a walk-in clinic for a follow-up visit. As a result of providing care to the patient over the course of several weeks, the nurse has developed a strong rapport with the patient. Which nursing actions represent a boundary violation? Select all that apply. 1. Expressing a personal attraction toward the patient 2. Accepting a grocery store gift card from the patient 3. Agreeing to meet the patient for coffee after the patient is fully healed 4. Sharing details about the nurse’s personal problems with the patient 5. Denying the patient’s parents access the patient’s medical record 26. In a malpractice lawsuit, which elements must be established by a plaintiff in order to win and recover damage? Select all that apply. 1. Duty 2. Breach of duty 3. Intent to harm 4. Injury 5. Causation

Chapter 45. Legal Accountability Answer Section MULTIPLE CHOICE 1. ANS: 3 Chapter: Chapter 45 Legal Accountability Objective: Identify four basic sources of law. Page: 1196 (V1) Heading: What Laws and Regulations Guide Nursing Practice? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Application [Applying] Concept: Legal Difficulty: Moderate Feedback 1 This is incorrect. In accordance with the Emergency Medical Treatment and Active Labor Act (EMTALA), healthcare facilities must provide emergency medical treatment to patients (including those in labor) who seek healthcare in the ED. The medical facility must provide medical screening to determine whether an emergency exists and to stabilize the patient before facilitating transfer another healthcare facility. 2 This is incorrect. The Emergency Medical Treatment and Active Labor Act (EMTALA) requires healthcare facilities to provide emergency medical treatment to patients (including those in labor) who seek healthcare in the ED, regardless of their ability to pay, legal status, or citizenship status. 3 This is correct. According to the Emergency Medical Treatment and Active Labor Act (EMTALA) healthcare facilities are required to provide emergency medical treatment to patients (including those in labor) who seek healthcare in the ED, regardless of their ability to pay, legal status, or citizenship status. The initial intervention involves provision of medical screening to determine whether an emergency exists and to stabilize the patient before transferring the patient to another healthcare facility. 4 This is incorrect. As per the Emergency Medical Treatment and Active Labor Act (EMTALA), healthcare facilities must provide emergency medical treatment to patients (including those in labor) who seek healthcare in the ED, regardless of their ability to pay, legal status, or citizenship status. PTS: 1 CON: Legal 2. ANS: 2 Chapter: Chapter 45 Legal Accountability

Objective: Discuss the effects of the Patient Self-Determination Act (PSDA) on healthcare practices. Page: 1196 (V1) Heading: What Laws and Regulations Guide Nursing Practice? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Application [Applying] Concept: Legal Difficulty: Easy Feedback 1 This is incorrect. The patient is not required to compromise with regard to her healthcare treatment choices. 2 This is correct. The patient is alert and oriented, and can make her own healthcare decisions. The patient’s son only has the authority to make healthcare decisions if the patient becomes incompetent and is unable to process information to make decisions. 3 This is incorrect. Legal intervention is not indicated. The patient is within her rights to personally choose to consent to or refuse treatment. The patient’s son does not have the authority to supersede the patient’s choice. 4 This is incorrect. Additional information from the patient’s son may be a component of therapeutic communication, but no further information from the patient’s son is necessary in order to administer care to the patient. PTS: 1 CON: Legal 3. ANS: 3 Chapter: Chapter 45 Legal Accountability Objective: Relate the impact of the Health Insurance Portability and Accountability Act (HIPAA) to patient rights and protections. Page: 1196 (V1) Heading: What Laws and Regulations Guide Nursing Practice? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Comprehension [Understanding] Concept: Legal Difficulty: Moderate Feedback 1 This is incorrect. ADA provides protection against discrimination of individuals with disabilities. Failure to protect the confidentiality of patient information represents a violation of HIPAA. 2 This is incorrect. PSDA recognizes the client’s right to make decisions regarding his own healthcare. The healthcare provider must inform the patient about available medical or surgical treatment options and benefits, risks, and

alternatives. The charge nurse’s failure to maintain the confidentiality of patient information represents a violation of HIPAA. This is correct. HIPAA mandates comprehensive protection for the privacy of protected health information (confidentiality of patient records). Writing the nurses’ assignments with the corresponding patients and their diagnoses in a location where others may view it is a violation of HIPAA. Assignments should be kept in the nurses’ conference room or a location that is not accessible to patients, their family members, or visitors. This is incorrect. EMTALA requires healthcare facilities to provide emergency medical treatment to patients (including those in labor) who seek healthcare in the emergency department (ED), regardless of their ability to pay, legal status, or citizenship status. The nurse who fails to protect the confidentiality of patient information is in violation of HIPAA.

PTS: 1 CON: Legal 4. ANS: 2 Chapter: Chapter 45 Legal Accountability Objective: Apply state mandatory reporting laws to patient care situations. Page: 1196 (V1) Heading: What Laws and Regulations Guide Nursing Practice? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Application [Applying] Concept: Legal Difficulty: Moderate Feedback 1 This is incorrect. Good Samaritan laws are designed to protect from liability those who provide emergency care to someone who is in need of medical services. 2 This is correct. In accordance with mandatory reporting laws, healthcare workers are required to report communicable diseases, as well as physical, sexual, or emotional abuse or neglect of vulnerable individuals (e.g., children, older adults, the mentally ill). The intent is to protect people who cannot protect themselves and to protect society against the spread of communicable diseases. Mandatory reporting laws vary from state to state. The nurse should be familiar with applicable laws in the state in which the nurse practices. 3 This is incorrect. Nurse practice acts (NPAs) are statutory laws passed by each state’s legislative body that define the practice of nursing. Nurse practice acts are designed to regulate nursing practice to protect the health, safety, and welfare of the general public; define the scope of nursing practice; and approve programs providing prelicensure nursing education to students. 4 This is incorrect. Nursing standards of practice establish the minimum level of

competency for nurses. Nurses are expected to follow the standards that apply to their specialty areas. PTS: 1 CON: Legal 5. ANS: 4 Chapter: Chapter 45 Legal Accountability Objective: Identify four basic sources of law. Page: 1196 (V1) Heading: What Laws and Regulations Guide Nursing Practice? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Analysis [Analyzing] Concept: Ethics Difficulty: Difficult Feedback 1 This is incorrect. The Patient Care Partnership (PCP), which replaced the American Hospital Association’s Patient Bill of Rights, advises patients of several aspects of care that should be expected during a period of hospitalization. In accordance with the PCP, hospitalized patients are advised that their expectations should include help with billing claims. 2 This is incorrect. The Patient Care Partnership (PCP), which replaced the American Hospital Association’s Patient Bill of Rights, advises patients of several aspects of care that should be expected during a period of hospitalization. In accordance with the PCP, hospitalized patients are advised that their expectations should include receiving help when leaving the hospital. 3 This is incorrect. The Patient Care Partnership (PCP), which replaced the American Hospital Association’s Patient Bill of Rights, advises patients of several aspects of care that should be expected during a period of hospitalization. In accordance with the PCP, hospitalized patients are advised that their expectations should include a safe, clean environment. 4 This is correct. The ANA Code of Ethics for Nurses guarantees the patient the right to dignity, privacy, and safety. According the ANA Code, the nurse will protect the client from misinformation and misrepresentation. PTS: 1 CON: Ethics 6. ANS: 3 Chapter: Chapter 45 Legal Accountability Objective: Discuss basic principles of criminal law that affect nursing practice. Page: 1204 (V1) Heading: What Is Criminal Law? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment

Cognitive Level: Application [Applying] Concept: Legal Difficulty: Moderate Feedback 1 This is incorrect. Malpractice is one source of legal liability. It means that a professional person has failed to act in a reasonable and prudent manner. If someone is harmed, the professional may be held liable. 2 This is incorrect. Libel is the written or published form of defamation of character. 3 This is correct. Negligence is the failure to use ordinary or reasonable care or the failure to act in a reasonable and prudent (careful) manner. It is negligent to assign a nurse to care for a patient without verifying the nurse has training, experience, and clinical competence in caring for such patients. 4 This is incorrect. Abandonment occurs if the nurse fails to provide care to a patient for whom the nurse has accepted responsibility. Nurses are legally responsible for the assignments they you accept. If the assignment becomes overwhelming and unmanageable, the nurse is required to immediately contact the charge nurse or nursing supervisor for assistance. PTS: 1 CON: Legal 7. ANS: 2 Chapter: Chapter 45 Legal Accountability Objective: Discuss common causes of malpractice litigation. Page: 1211 (V1) Heading: How Can You Minimize Your Malpractice Risks? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Analysis [Analyzing] Concept: Legal Difficulty: Moderate Feedback 1 This is incorrect. Informed consent is the necessary authorization by the patient for any and all types of care and must be written and signed by the patient or the person legally responsible for the patient for hospital admission and for invasive or specialized treatments or diagnostic procedures. 2 This is correct. Informed consent is the client’s permission to receive any and all types of care with full knowledge of the risks, benefits, costs, and alternatives. For hospital admission and for invasive or specialized treatments or diagnostic procedures, the consent must be written and signed by the client or his legal guardian. The law provides for implied or assumed consent in emergency situations; therefore, written consent is not necessary in an emergency if experts would agree that there was an immediate threat to the client’s life or health.

3 4

This is incorrect. The patient’s assigned physician, and not the nurse, is responsible obtaining the patient’s informed consent. This is incorrect. Severe pain is not an acceptable reason for failing to obtain informed consent.

PTS: 1 CON: Legal 8. ANS: 2 Chapter: Chapter 45 Legal Accountability Objective: Discuss common causes of malpractice litigation. Page: 1211 (V1) Heading: How Can You Minimize Your Malpractice Risks? Integrated Processes: Communication and Documentation Client Need: Physiological Integrity Cognitive Level: Analysis [Analyzing] Concept: Legal Difficulty: Moderate Feedback 1 This is incorrect. The nurse should notify the nursing supervisor about the need to contact an outside agency (Child Protective Services) to report suspected physical abuse. However, the nurse’s initial primary responsibility is evaluation of the patient’s physical condition and extent of his injuries. 2 This is correct. Although the nurse must report suspected physical abuse to designated authorities (Child Protective Services), the primary responsibility of the nurse in this situation is evaluation of the patient’s physical condition and extent of his injuries. 3 This is incorrect. Pain medication should not be administered prior to completion of a thorough physical assessment. 4 This is incorrect. Although the nurse must report to designated authorities (Child Protective Services) suspected physical abuse, the primary responsibility of the nurse in this situation is to evaluate the patient’s physical condition and extent of his injuries for appropriate medical treatment to be provided. PTS: 1 CON: Legal 9. ANS: 3 Chapter: Chapter 45 Legal Accountability Objective: Compare and contrast intentional and unintentional torts. Page: 1205 (V1) Heading: What Is Civil Law? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Application [Applying] Concept: Legal

Difficulty: Moderate Feedback 1 This is incorrect. An assault occurs when a nurse intentionally places a patient in immediate fear of personal violence or offensive contact. An assault must include words expressing an intention to cause harm and some type of action. For example, a nurse has committed an assault if she says to the patient “I will slap you” and raises her hand as if to slap the patient. The combination of the words and action causes the patient to believe the threat will be carried out. 2 This is incorrect. Fraud is the false representation of significant facts by words or by conduct. It is intentionally misleading or deceiving another person to act (or not act) for the personal gain of the one committing the fraud. Methods of committing fraud include making false statements, falsifying documentation, or concealing information that should have been disclosed. 3 This is correct. False imprisonment involves an intentional or willful detention of a patient without consent or authority to do so. Restraining a patient without consent is another form of civil false imprisonment. Competent patients have a right to leave an institution, even if it is harmful to their health. Whenever possible, have the person sign a form stating that he is aware that he is leaving against medical advice. 4 This is incorrect. Quasi-intentional torts involve actions that injure a person’s reputation. The overall concept for these torts is defamation of character. All four of the essential elements of defamation of character must be present. PTS: 1 CON: Legal 10. ANS: 1 Chapter: Chapter 45 Legal Accountability Objective: Discuss common causes of malpractice litigation. Page: 1205 (V1) Heading: What Is Civil Law? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Analysis [Analyzing] Concept: Legal Difficulty: Difficult Feedback 1 This is correct. Malpractice, which is one source of legal liability, means that a professional person has failed to act in a reasonable and prudent manner. If someone is harmed, the professional may be held liable. To win and recover damages (money) in a malpractice lawsuit, the plaintiff must prove four elements: duty, breach of duty, causation, and damages. 2 This is incorrect. A battery is committed when (1) an offensive or harmful physical contact is made to the client without his consent, or (2) there is

unauthorized touching of a person’s body by another person. This is incorrect. An assault occurs when a nurse intentionally places a patient in immediate fear of personal violence or offensive contact. An assault must include words expressing an intention to cause harm and some type of action. For example, a nurse has committed an assault if she says to the patient “I will slap you” and raises her hand as if to slap the patient. The combination of the words and action causes the patient to believe the threat will be carried out. This is incorrect. Negligence is the failure to use ordinary or reasonable care or the failure to act in a reasonable and prudent (careful) manner. While the nurse’s actions were negligent, this is not the best response. The nurse is most likely to be sued for malpractice as the plaintiff’s legal team will likely be successful in proving the four required elements that must be present in order to establish malpractice: duty, breach of duty, causation, and damages.

PTS: 1 CON: Legal 11. ANS: 1 Chapter: Chapter 45 Legal Accountability Objective: Explain disciplinary actions for unacceptable nursing decisions or actions. Page: 1196 (V1) Heading: What Laws and Regulations Guide Nursing Practice? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Application [Applying] Concept: Legal Difficulty: Moderate Feedback 1 This is correct. The state board of nursing is empowered to initiate disciplinary action against the nurse’s license for professional misconduct. 2 This is incorrect. The board does not bring criminal charges or sentence the nurse to jail; that is the prerogative of the state prosecutor and judge. 3 This is incorrect. A medical malpractice lawsuit is filed by an individual who has been harmed or by the individual’s designated legal representatives. 4 This is incorrect. While the nurse may be subject to termination of employment, the institution would be responsible for making this decision. PTS: 1 CON: Legal 12. ANS: 4 Chapter: Chapter 45 Legal Accountability Objective: Apply state mandatory reporting laws to patient care situations. Page: 1196 (V1) Heading: What Laws and Regulations Guide Nursing Practice? Integrated Processes: Communication and Documentation

Client Need: Safe and Effective Care Environment Cognitive Level: Knowledge [Remembering] Concept: Legal Difficulty: Moderate Feedback 1 This is incorrect. The ADA protects those with disabilities from discrimination. 2 This is incorrect. Safe harbor laws, found in the nurse practice act or other state laws, provide for exceptions to certain laws. They protect you from being suspended, terminated, disciplined, or discriminated against for refusing to do (or not do) something you believe would be harmful to a client. 3 This is incorrect. The Good Samaritan Law is designed to protect from liability those people who assist in an emergency situation outside of the workplace. 4 This is correct. Mandatory reporting is state law that requires health practitioners to report STIs to reduce the incidences of more people being infected/reinfected. PTS: 1 CON: Legal 13. ANS: 1 Chapter: Chapter 45 Legal Accountability Objective: Discuss common causes of malpractice litigation. Page: 1205 (V1) Heading: What Is Civil Law? Integrated Processes: Communication and Documentation Client Needs: Safe and Effective Care Environment Cognitive Level: Comprehension [Understanding] Concept: Legal Difficulty: Moderate Feedback 1 This is correct. Assault involves intentionally placing a patient in immediate fear of personal violence or offensive contact. An assault must include words expressing an intention to cause harm and some type of action. Assault occurred when the nurse showed the patient a set of restraints while threatening to tie up the patient until morning. Battery involves touching the patient without his permission or in a way that is forceful. Pushing the patient onto the bed is considered battery. 2 This is incorrect. Libel is the written or published form of defamation of character. Slander is the spoken or verbal form of defamation of character. 3 This is incorrect. False imprisonment is the restraint of a person without proper legal authorization. While use of restraints was threatened, the patient was not restrained. 4 This is incorrect. Medical malpractice refers to a lawsuit brought against a healthcare provider for damages (e.g., money) when there has been death of,

injury to, or other loss to the person being treated. PTS: 1 CON: Legal 14. ANS: 3 Chapter: Chapter 45 Legal Accountability Objective: Discuss basic principles of criminal law that affect nursing practice. Page: 1205 (V1) Heading: What Is Civil Law? Integrated Processes: Communication and Documentation Client Needs: Safe and Effective Care Environment Cognitive Level: Application [Applying] Concept: Legal Difficulty: Moderate Feedback 1 This is incorrect. An assault occurs when a nurse intentionally places a patient in immediate fear of personal violence or offensive contact. An assault must include words expressing an intention to cause harm and some type of action. For example, a nurse has committed an assault if she says to the patient “I will slap you” and raises her hand as if to slap the patient. The combination of the words and action causes the patient to believe the threat will be carried out. 2 This is incorrect. A battery is committed when (1) an offensive or harmful physical contact is made to the client without his consent, or (2) there is unauthorized touching of a person’s body by another person. 3 This is correct. Slander is the spoken or verbal form of defamation of character. To establish slander, the comments regarding the person have to be false, communicated or overheard by a third party, and defame the nurse’s character. 4 This is incorrect. Libel is the written or published form of defamation of character. PTS: 1 CON: Legal 15. ANS: 2 Chapter: Chapter 45 Legal Accountability Objective: Discuss common causes of malpractice litigation. Page: 1211 (V1) Heading: How Can You Minimize Your Malpractice Risks? Integrated Processes: Communication and Documentation Client Needs: Safe and Effective Care Environment Cognitive Level: Application [Applying] Concept: Legal Difficulty: Moderate Feedback 1 This is incorrect. Quasi-intentional torts involve actions that injure a person’s

reputation. The overall concept for these torts is defamation of character. There is no evidence of quasi-intentional torts in the described scenario. This is correct. Even though it was an inadvertent act in this situation, failure to maintain patient confidentiality and privacy are applicable to patient records. By not closing the patient’s electronic medical record, the nurse made it available to someone not directly involved with the patient’s care. Family and friends do not have the right to have access to the patient’s chart by virtue of their relationship to the patient. This is incorrect. Vicarious liability states the nurse is legally accountable for personal actions or inactions. This is a common legal principle that should guide the nurse’s behavior. This is incorrect. Defamation of character is central to quasi-intentional torts, which involve actions that injure a person’s reputation. Based on the scenario, there is no evidence that defamation of character occurred.

PTS: 1 CON: Legal 16. ANS: 1 Chapter: Chapter 45 Legal Accountability Objective: Identify strategies to minimize liability in nursing practice. Page: 1211 (V1) Heading: How Can You Minimize Your Malpractice Risks? Integrated Processes: Communication and Documentation Client Needs: Safe and Effective Care Environment Cognitive Level: Application [Applying] Concept: Communication Difficulty: Moderate Feedback 1 This is correct. Accurate charting is needed to clearly communicate the patient’s care and responses to other members of the healthcare team, not just the other nurses. This statement reflects the nurse’s understanding of this principle. 2 This is incorrect. The nurse’s opinions are not to be placed in a chart because they are not factual. 3 This is incorrect. While accurate charting does help nurses understand the nature of the patient care that is provided during various shifts, the need for communication extends to non-nursing team members, as well. Accurate documentation is needed to clearly communicate the patient’s care and responses to all members of the interdisciplinary healthcare team. 4 This is incorrect. While charting is important to comply with standards of practice and institutional policy, compliance is not the main purpose for ensuring accurate charting. PTS:

CON: Communication

17. ANS: 4 Chapter: Chapter 45 Legal Accountability Objective: Identify strategies to minimize liability in nursing practice. Page: 1211 (V1) Heading: How Can You Minimize Your Malpractice Risks? Integrated Processes: Communication and Documentation Client Needs: Safe and Effective Care Environment Cognitive Level: Analysis [Analyzing] Concept: Communication Difficulty: Moderate Feedback 1 This is incorrect. Although incident reports have been used to discipline nurses, this is not the current trend and is not their purpose. 2 This is incorrect. Incident reports are not a part of the patient’s medical record. 3 This is incorrect. Incident reports should not be shared with the patient. 4 This is correct. The main function of an incident report is to prevent the incident from happening again. The report allows the nurse manager and risk management to evaluate the context in which the incident occurred and to identify appropriate strategies to prevent a recurrence. PTS: 1 CON: Communication 18. ANS: 1 Chapter: Chapter 45 Legal Accountability Objective: Identify strategies to minimize liability in nursing practice. Page: 1211 (V1) Heading: How Can You Minimize Your Malpractice Risks? Integrated Processes: Communication and Documentation Client Needs: Safe and Effective Care Environment Cognitive Level: Application [Applying] Concept: Professionalism Difficulty: Moderate Feedback 1 This is correct. Effective delegation requires the nurse to consider the education level and experience of the person being delegated a task. This enables the nurse to accurately align the patient’s care needs with the patient assignments. Once the nurse knows the delegatee’s educational level and experience, patient care assignments can be given with consideration to patient requests. The delegatee’s job description can provide insight into his scope of responsibilities, but even if a task is within the delegatee’s scope of practice, the nurse must base delegation on the delegatee’s skill level and experience. 2 This is incorrect. While the delegatee’s job description can provide insight into his scope of responsibilities, the delegate must possess the necessary skill level

to safely complete the task. This is incorrect. The patient’s opinion and preferences should be taken into consideration. However, this is not the most important factor to consider when delegating a task. As a priority, safe delegation requires the nurse to consider the educational level and experience of the person being delegated a task. This is incorrect. The delegatee’s level of confidence may or may not be reflective of the individual’s actual skill level. The priority considerations include the delegatee’s education level and experience.

PTS: 1 CON: Professionalism 19. ANS: 1 Chapter: Chapter 45 Legal Accountability Objective: Identify seven rights of nurses within the healthcare workplace. Page: 1211 (V1) Heading: How Can You Minimize Your Malpractice Risks? Integrated Processes: Communication and Documentation Client Needs: Safe and Effective Care Environment Cognitive Level: Comprehension [Understanding] Concept: Professionalism Difficulty: Difficult Feedback 1 This is correct. Safe Harbor laws provide for exceptions to certain laws. They protect nurses from being suspended, terminated, disciplined, or discriminated against for refusing to do (or not do) something they believe would be harmful to a client. Under these laws, the nurse has a right to ask for peer review of either the situation or directives they believe would violate the nursing practice act. The nurse must follow the guidelines required under the safe harbor provisions. 2 This is incorrect. The Nurses’ Bill of Rights provides a framework for employers to understand what nurses need for a safe work environment and to support nurses as they address a variety of issues, including workplace violence. 3 This is incorrect. The Nurses’ Bill of Rights provides a framework for employers to understand what nurses need for a safe work environment and to support nurses as they address a variety of issues, including mandatory overtime. 4 This is incorrect. The Nurses’ Bill of Rights provides a framework for employers to understand what nurses need for a safe work environment and to support nurses as they address a variety of issues, including unsafe staffing. PTS:

MULTIPLE RESPONSE

CON: Professionalism

20. ANS: 1, 2, 4 Chapter: Chapter 45 Legal Accountability Objective: Discuss basic principles of criminal law that affect nursing practice. Page: 1205 (V1) Heading: What Is Civil Law? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Analysis [Analyzing] Concept: Legal Difficulty: Easy

1. 2. 3.

Feedback This is correct. Searching patients’ private items without permission is invasion of privacy. This is correct. Invasion of privacy includes discussing patient matters in a public setting. This is incorrect. A durable power of attorney is a document empowering a person selected by the patient to make healthcare decisions in the event that the patient is unable to do so. It is permissible to discuss pertinent issues related to the welfare of the patient with the person holding the power of attorney. This is correct. Invasion of privacy violates a person’s right to be free from unwanted interference in her private affairs. Photographing patients without their permission is an example of invasion of privacy. This is incorrect. Concealing information that should have been disclosed constitutes fraud.

PTS: 1 CON: Legal 21. ANS: 1, 3, 4, 5 Chapter: Chapter 45 Legal Accountability Objective: Discuss the effects of the Patient Self-Determination Act (PSDA) on healthcare practices. Page: 1196 (V1) Heading: What Laws and Regulations Guide Nursing Practice? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Application [Applying] Concept: Legal Difficulty: Moderate

Feedback This is correct. Advance directives establish the patient’s wishes regarding future

4. 5.

healthcare should he become unable to give instructions. This is incorrect. As a legal document, the requirements for living wills may vary from state to state. However, language common in living wills gives the person the opportunity to specify treatment in numerous areas. This is correct. A person may change or revoke an advance directive at any time. Changes and written revocation should be signed and dated and shared with the patient’s physician. Even without an official written change, orally expressed direction to the physician generally has priority over any statement made in an advance directive as long as the patient is able to decide for himself and can communicate his wishes. This is correct. A patient may specify actions in a living will to ensure the patient’s plan of care includes as much or as little care as the patient wishes to receive. This is correct. There are two types of legal written advance directives: the living will and the durable power of attorney for healthcare.

PTS: 1 CON: Legal 22. ANS: 2, 3, 4 Chapter: Chapter 45 Legal Accountability Objective: Compare and contrast intentional and unintentional torts. Page: 1204 (V1) Heading: What Is Criminal Law? Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment Cognitive Level: Analysis [Analyzing] Concept: Legal Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is incorrect. Negligence is an example of an unintentional tort. This is correct. Battery is among the most commonly encountered intentional torts in nursing. This is correct. Invasion of privacy is an intentional tort. This is correct. Malpractice is a type of unintentional tort. This is incorrect. False imprisonment is an example of an intentional tort.

PTS: 1 CON: Legal 23. ANS: 2, 4, 5 Chapter: Chapter 45 Legal Accountability Objective: Describe the phases of the litigation process in a nursing malpractice case. Page: 1209 (V1) Heading: Litigation in Civil Claims Integrated Processes: Communication and Documentation

Client Need: Safe and Effective Care Environment Cognitive Level: Knowledge [Remembering] Concept: Legal Difficulty: Moderate

3. 4.

Feedback This is incorrect. During litigation, the discovery phase is the point at which both parties gather facts and evidence about the case that can be used at trial. Processes through which attorneys may obtain discovery include depositions. During a deposition, one or more attorneys orally question parties to the lawsuit under oath, as though they were testifying in court. This is correct. Lawyers and involved parties usually try to resolve disputes before going to trial. The three most common methods of alternative dispute resolution include mediation, arbitration, and negotiation. This is incorrect. Litigation is the formal process wherein the legal issues, rights, and duties between the parties are heard and decided (adjudicated). This is correct. Usually, in an effort to avoid a trial, lawyers and involved parties try to resolve disputes. The three most common methods of alternative dispute resolution include arbitration, mediation, and negotiation. This is correct. In an attempt to resolve disputes before going to trial, lawyers and involved parties usually try to use a method of alternative dispute resolution. The three most common methods of alternative dispute resolution include negotiation, mediation, and arbitration.

PTS: 1 CON: Legal 24. ANS: 2, 4, 5 Chapter: Chapter 45 Legal Accountability Objective: Identify strategies to minimize liability in nursing practice. Page: 1196 (V1) Heading: What Laws and Regulations Guide Nursing Practice? Integrated Processes: Communication and Documentation Client Needs: Safe and Effective Care Environment Cognitive Level: Comprehension [Understanding] Concept: Ethics Difficulty: Moderate

Feedback This is incorrect. The ANA Code of Ethics is not a law but, rather, standards of professional responsibilities of the nurse using behavior that is ethical and expected by or acceptable to the profession. This is correct. The ANA code guarantees the patient the right to dignity, privacy, and safety.

3. 4. 5.

This is incorrect. The Code of Ethics is not a law, and therefore you would not be charged with criminal offenses for violating the code’s provisions. This is correct. The ANA code guarantees the patient the right to privacy, dignity, and safety. This is correct. A nurse who violates a provision of the Code of Ethics may have to defend her action to the state board of nursing.

PTS: 1 CON: Ethics 25. ANS: 1, 2, 3, 4 Chapter: Chapter 45 Legal Accountability Objective: Identify strategies to minimize liability in nursing practice Page: 1211 (V1) Heading: How Can You Minimize Your Malpractice Risks? Integrated Processes: Communication and Documentation Client Needs: Safe and Effective Care Environment Cognitive Level: Application [Applying] Concept: Ethics Difficulty: Easy

1. 2. 3. 4. 5.

Feedback This is correct. Communication that is sexual in nature or reveals personal attraction between client and nurse represents a boundary violation. This is correct. Violations of professional boundaries may be physical, sexual, emotional, or financial in nature. Do not accept gifts from clients. This is correct. Off-duty visits with a patient are a potential violation of professional boundaries. This is correct. Discussing personal problems or intimate details with the patient represents a boundary violation. This is incorrect. The nurse must always maintain patient confidentiality unless directed by law to do otherwise (e.g., when a patient is threatening to harm someone). Family members and significant others do not have an automatic right to information about the patient. For example, parents do not have an automatic right to see the medical records of their adult child or minor child who is married or emancipated.

PTS: 1 CON: Ethics 26. ANS: 1, 2, 4, 5 Chapter: Chapter 45 Legal Accountability Objective: Compare and contrast intentional and unintentional torts. Page: 1205 (V1) Heading: What Is Civil Law? Integrated Processes: Communication and Documentation

Client Needs: Safe and Effective Care Environment Cognitive Level: Comprehension [Understanding] Concept: Legal Difficulty: Moderate

1. 2. 3.

4. 5.

Feedback This is correct. To win a malpractice lawsuit, duty, breach of duty, causation, and injury must be proven. This is correct. To win a malpractice lawsuit, the plaintiff must establish four elements: duty, breach of duty, causation, and damages. This is incorrect. To win and recover damages in a malpractice lawsuit, it is not necessary for the plaintiff to prove the healthcare provider intended to cause harm. Four elements must be proven by the plaintiff in order to win a malpractice lawsuit: duty, breach of duty, causation, and damages. This is correct. To win and recover damages in a malpractice lawsuit, the plaintiff must prove four elements: duty, breach of duty, causation, and damages. This is correct. For the plaintiff to win a malpractice lawsuit and recover damages, four elements must be proven: duty, breach of duty, causation, and damages.

PTS:

CON: Legal

Chapter 46. Holistic Healing Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The concept of holism focuses on which of the following? 1. Relationship between nurse and patient 2. Practice of spiritualism 3. Relationships among all living things 4. Totality of the body 2. A patient is receiving healthcare focused on his illness and counteracting his symptoms. What type of healthcare is he receiving? 1. Holistic 2. Integrative 3. Complementary 4. Allopathic 3. A client has a diagnosis of chronic pain. The physician has prescribed tramadol hydrochloride (Ultram) for the pain. The patient also receives therapeutic touch (TT) from a practitioner three times a week. In this situation, TT is considered to be which of the following? 1. A complementary modality 2. An alternative modality 3. A placebo response 4. Holistic healthcare 4. A client tells the nurse that he is having difficulty sleeping. He says, “I don’t want to use sleeping pills, but I’m thinking about getting some melatonin.” Which of the following statements is the priority teaching point that the nurse should include in a response to the client? 1. “Melatonin is an effective treatment for certain sleep disorders.” 2. “Melatonin appears to be a relatively safe sleep aid for most people.” 3. “You may experience some side effects, such as elevated blood pressure.” 4. “Before taking melatonin, you should consult your primary care provider.” 5. A woman is receiving physical therapy after surgery to repair a hip fracture. She tells the therapist before therapy begins that she expects therapy to be very painful. She rates her pain as 1 on a scale of 1 to 10 before therapy. Three minutes into the treatment session, the patient complains of excruciating pain rated as 10 and says she cannot tolerate exercise any longer. The therapist is concerned about the amount of pain because severe pain is not expected during that form of exercise. The therapist considers the patient could be experiencing: 1. Phantom limb pain 2. Ineffective pain medication 3. A nocebo effect 4. A complication from the surgery

6. A client wishes to avoid taking blood pressure medications. He is watching his diet and exercising. In addition, a complementary and alternative modalities (CAM) therapist has recommended an alternative therapy that will allow him to learn voluntary control over his blood pressure. What type of therapy is the therapist probably recommending? 1. Homeopathy 2. Naturopathy 3. Biofeedback 4. Hypnosis 7. The health and well-being of a holistic nurse in relation to helping patients constitute an important part of the healing process. A method that would be helpful to nurses in fostering their own health and the health of their patients is: 1. Role modeling healthy behaviors 2. Avoiding discussions on personal behaviors 3. Working and acting in isolation 4. Setting goals for the patient 8. Herbal products are very popular worldwide for the prevention and treatment of illness. As a nurse you should: 1. Advise patients to purchase herbal products from the least expensive source. 2. Inform patients that research conclusively states that herbs are safe. 3. Learn about herbal therapies and include them in questions when taking a patient’s history. 4. Disregard patients’ use of herbal products, as their use will not impact traditional medicine. 9. The nurse is caring for a patient who had radiation therapy after removal of a tumor. The patient, without consulting his primary provider, added nutritional therapy and the use of acupuncture. The treatments chosen by the patient are examples of what type of treatments? 1. Alternative modalities 2. Complementary modalities 3. Integrative healthcare 4. Conventional biomedical therapies 10. The nurse is caring for a patient with severe, chronic headaches. According to a recent medical work-up, there “is no definitive physiological reason for these headaches.” The nurse counsels the patient about alternative therapies for headaches, knowing that: 1. Homeopathic medications eliminate migraine and other chronic headaches. 2. Acupuncture is more effective than medication in relieving chronic headaches. 3. Western medicine has no alternative treatment for severe, chronic headaches. 4. There is no palliative care for chronic headaches without physiological basis.

11. The nurse is caring for a patient, who recently emigrated from India. The patient states the reason for the visit is for a well-patient visit. While taking the patient’s history, the nurse ascertains that the patient is using ayurvedic herbal remedies. Which statement below assists the nurse to determine whether the patient understands the pros and cons of these herbal remedies? 1. “I can continue to order these herbal remedies from the shop in India where I have always purchased them.” 2. “I can order these herbal remedies from any Internet source selling them.” 3. “I should order these herbal remedies over the Internet from an FDA-approved site.” 4. “I have had no problems from taking these herbal remedies, so I can continue their use.” 12. A patient has been taking herbal remedies to decrease blood pressure. The patient is convinced that this has reduced his blood pressure and he refuses to take a prescribed antihypertensive medication. The nurse checks his blood pressure reading during an office visit, with the following results: left arm: 130/94, 140/86, and 160/90 mm Hg. With this information, what is the nurse’s best response to the patient’s refusal to take antihypertensive medications? 1. “I see that you are correct; your blood pressure readings do not indicate hypertension.” 2. “Your blood pressure is elevated, so you will need to take a prescribed antihypertensive.” 3. “Your blood pressure is within normal limits, and does not need anything for it.” 4. “Your blood pressure is elevated. It is important to discuss this with your doctor.” 13. The nurse in a women’s health clinic, educates patients about the benefits of probiotic therapy. Today, the nurse is working with a patient complaining of recurrent vaginal yeast infections. The patient’s laboratory tests confirm Candida albicans. Which statement helps the nurse to determine that the patient needs more teaching regarding probiotic therapy? 1. “If I eat yogurt, I will not get any more yeast infections.” 2. “I can eat yogurt, and it will reduce my yeast infections.” 3. “Eating yogurt once a day will help to balance my natural body flora.” 4. “I can take probiotics once I read their labels to ensure the bacteria are live.” 14. The nurse understands that complementary and alternative modalities (CAM) therapies are popular with many patients. What is the most important thing for the nurse to know regarding safe use of CAM therapies? CAM therapies: 1. Must be sensitive to the patient’s culture 2. Need to be tested to establish their effectiveness 3. Should be determined by the patient 4. Chosen by the patient can bypass testing

15. The health clinic nurse is interviewing a new patient. The nurse asks questions about the patient’s self-care and about his healthcare providers. Which statement is likely to yield the most information from the patient regarding the use of complementary and alternative modalities (CAM)? 1. “Many people go to a medical provider and other healers, as well. Please tell me about the practitioners and healers you use.” 2. “Some people go to both medical and nonmedical providers for healthcare. Do you use both?” 3. “Many people only go to a medical physician. Tell me about the practitioners you see for healthcare.” 4. “Some people go to different types of CAM healers. You don’t use CAM, do you?” Multiple Response Identify one or more choices that best complete the statement or answer the question. 16. Which of the following beliefs is an essential component of holistic healthcare? Select all that apply. 1. Illness occurs when there is a shift in an individual’s balance. 2. Regardless of the type of care received, ultimately all healing is self-healing. 3. More healthcare resources should be focused on alternative healers. 4. Illness can create an opportunity for personal and spiritual growth. 5. Disease is usually caused by one specific biological factor. 17. Which of the following complementary and alternative modalities may be considered alternative medical systems? Select all that apply. 1. Homeopathy 2. Prayer 3. Ayurveda 4. Aromatherapy 5. Chiropractic 18. Mind–body interventions target the patient’s mood and reaction to stress. Identify the following mind–body interventions that have become a part of conventional healthcare. 1. Humor 2. Biofeedback 3. Yoga 4. Music therapy 5. Massage

19. An elderly client with a history of chronic obstructive pulmonary disease (COPD) is having difficulty sleeping and does not wish to see a medical practitioner. Which of the following strategies should the nurse discourage the client from using or urge him to see a physician before beginning the therapy? The client has not used any of these therapies in the past. Select all that apply. 1. Aromatherapy 2. T’ai chi 3. Yoga 4. Melatonin 5. Music therapy 20. Massage is one of the oldest forms of healing. It involves the manipulation of muscles and other soft tissues. Although it is relaxing, it is not advisable for everyone. In which of the following scenarios would a massage be contraindicated? Select all that apply. 1. A patient with a history of phlebitis 2. A patient with chronic back pain 3. A preterm infant with a nasogastric (NG) tube 4. A patient with deep vein thrombosis (DVT) 5. A low birth weight infant with physiological jaundice 21. A client undergoing chemotherapy becomes very anxious and stressed just before every 3-week treatment. Which of the following would be an appropriate therapy for this person to learn? 1. Yoga 2. Meditation 3. Reflexology 4. Music therapy 5. Imagery 22. Herbs are used in a number of ways in complementary and alternative modalities (CAM). Why might a patient choose to use CAM for healing? Select all that apply. 1. Aromatherapy 2. Health maintenance 3. Health promotion 4. Infection prevention 5. Avoidance of treatment side effects 23. The nurse understands that there are potential risks with herb use, just as there are risks with standard Western medications. These risks with herb use include which of the following? Select all that apply. 1. Interaction with other medications 2. Standardization of herbal preparations 3. Variations in active ingredients 4. Lack of a formulary 5. Reduced chance of toxicity

Chapter 46. Holistic Healing Answer Section MULTIPLE CHOICE 1. ANS: 3 Chapter: Chapter 46 Holistic Healing Objective: Explain holism and holistic care. Page: 1220 (V1) Heading: About the Key Concepts > Holism Integrated Processes: Culture and Spirituality Client Need: Health Promotion and Maintenance Cognitive Level: Knowledge [Remembering] Concept: Health Promotion Difficulty: Easy Feedback 1 This is incorrect. The relationship between the nurse and patient is just one aspect of holism. 2 This is incorrect. Spirituality is the vital process of discovering meaning, purpose, fulfillment and value in life. 3 This is correct. The concept of holism focuses on the relationships among all living things. 4 This is incorrect. The concept of holism includes more than the sum of the body parts. In addition to the body it includes spirituality, emotions, culture, relationships and the geopolitical environment-all affecting and being affected by each other. PTS: 1 CON: Health Promotion 2. ANS: 4 Chapter: Chapter 46 Holistic Healing Objective: Compare and contrast complementary, alternative, integrative, and allopathic healthcare. Page: 1220 (V1) Heading: What Is Holistic Healthcare? Integrated Processes: Culture and Spirituality Client Need: Health Promotion and Maintenance Cognitive Level: Knowledge [Remembering] Concept: Health Promotion Difficulty: Easy Feedback 1 This is incorrect. Holistic healthcare uses the concept of holism to focus on the relationships among all living things.

2 3 4

This is incorrect. Integrative healthcare encompasses all traditional and alternative health practices used by a patient. This is incorrect. Complementary healthcare is alternative care used in conjunction with traditional medical care. This is correct. Allopathic care is conventional medical care focused on counteracting symptoms.

PTS: 1 CON: Health Promotion 3. ANS: 1 Chapter: Chapter 46 Holistic Healing Objective: Compare and contrast complementary, alternative, integrative, and allopathic healthcare. Page: 1235 (V1) Heading: Manipulative and Body-Based Therapies > Energy Therapies > Biofield Therapies > Therapeutic Touch Integrated Processes: Culture and Spirituality Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate Feedback 1 This is correct. A complementary modality is one that is used alongside traditional medical care. The patient receives prescription medication from a physician and also receives TT. 2 This is incorrect. An alternative modality is one that is used instead of traditional medical care. 3 This is incorrect. A placebo response is the client’s expectation that a treatment will be effective. 4 This is incorrect. Holistic healthcare uses the concept of holism to focus on the relationships among all living things. PTS: 1 CON: Health Promotion 4. ANS: 4 Chapter: Chapter 46 Holistic Healing Objective: Discuss the most commonly used CAM therapies. Page: 1234 (V1) Heading: Other Nonherbal Biologically Based Products > Melatonin Integrated Processes: Teaching and Learning Client Need: Physiological Integrity Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Difficult

1 2 3 4

Feedback This is incorrect. Melatonin can be effective for certain sleep disorders, but it is not the most important teaching point. This is incorrect. Although melatonin appears to be relatively safe for most people; this statement is not the priority. This is incorrect. Melatonin can have some side effects, but the most important teaching point is to instruct the client to consult their primary care provider. This is correct. It most important to consult the primary care provider because melatonin is known to interact with other medications, including prescription medications. Therefore, this is the priority teaching point.

PTS: 1 CON: Patient-Centered Care 5. ANS: 3 Chapter: Chapter 46 Holistic Healing Objective: Explain how the placebo response relates to holistic care. Page: 1221 (V1) Heading: The Placebo Response Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is incorrect. Phantom limb pain is sometimes experienced after an amputation but has nothing to do with surgery to repair a hip fracture. 2 This is incorrect. There is no evidence that the patient is taking pain medication. Her pain was self-reported as being a “1” on the pain scale of 1 to 10 before therapy. 3 This is correct. The nocebo effect is a demonstration of the power of the mind to create bodily distress. The patient was expecting the treatment to be very painful, and this tends to increase the treatment discomfort. 4 This is incorrect. There is no evidence that she is experiencing a complication from surgery. PTS: 1 CON: Patient-Centered Care 6. ANS: 3 Chapter: Chapter 46 Holistic Healing Objective: Discuss the most commonly used CAM therapies Page: 1223 (V1) Heading: What Healing Modalities Are Commonly Used? > Biofeedback Integrated Processes: Nursing Process Client Need: Safe and Effective Care

Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Homeopathy is based on an understanding of how the body heals itself and an acceptance that all symptoms represent the body’s attempt to restore itself to health. 2 This is incorrect. Naturopathy is the belief that nature and each living being have the innate ability to establish, maintain, and restore health. 3 This is correct. Biofeedback is a technique by which people learn voluntary control over typically involuntary activities. 4 This is incorrect. Hypnosis is a trancelike state characterized by relaxed brain waves, hypersuggestibility, and heightened imagination. Hypnosis has been used to promote relaxation, weight loss, and smoking cessation and to suppress various symptoms. PTS: 1 CON: Patient-Centered Care 7. ANS: 1 Chapter: Chapter 46 Holistic Healing Objective: Identify ways to integrate CAM into nursing care. Page: 1123 (V1) Heading: Holistic Concepts > Role Modeling Integrated Processes: Teaching and Learning Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate

2 3 4

Feedback This is correct. A holistic nurse role models healthy behaviors for her patients. Practically speaking, a holistic nurse understands that unless her own health is balanced, it is difficult to sustain the energy necessary to be a constructive presence and an effective practitioner. This is incorrect. Avoiding discussions on personal behaviors is not a method that would be helpful to nurses to foster their own care. This is incorrect. Working in isolation does not allow one to gain the perspectives and insights of others in a commonly shared experience. This is incorrect. Setting goals for the patient is not a method that would be helpful to nurses in fostering their own health.

PTS: 1 8. ANS: 3

CON: Health Promotion

Chapter: Chapter 46 Holistic Healing Objective: Discuss the trends in use of complementary and alternative modalities (CAM). Page: 1223 (V1) Heading: What Healing Modalities Are Commonly Used? > Biologically Based Therapies Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate Feedback 1 This is incorrect. Advise patients to purchase herbs from a reliable source and seek advice from credentialed practitioners when incorporating herbs into their care. 2 This is incorrect. Although herbs are popular, they are not risk free. There is a lack of a formulary, as well as a lack of standardization. Herbs can interact with other medications and some herbal supplements can be toxic. 3 This is correct. Because herbal products are readily available and widely used, the nurse should learn about herbal products and include them in questions when taking a patient's history. The National Center for Complementary and Alternative Medicine (NCCAM) offers extensive material on herbal products for professionals and consumers. 4 This is incorrect. Questions regarding the use of herbs and dietary supplements should be included in the nursing assessment. Many herbs are known to interact with other medications and to adversely affect some disease processes and interfere with lab results. PTS: 1 CON: Health Promotion 9. ANS: 2 Chapter: Chapter 46 Holistic Healing Objective: Compare and contrast complementary, alternative, integrative, and allopathic healthcare. Page: 1220 (V1) Heading: What Is Holistic Healthcare? > Complementary Modality Integrated Processes: Culture and Spirituality Client Need: Safe and Effective Care Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. Alternative modalities are used instead of conventional medical therapies. 2 This is correct. Complementary modalities (i.e., nutritional therapy and

3 4

acupuncture) are used in conjunction with traditional medical care (the radiation treatments). This is incorrect. Integrative modalities are therapies that are proved to be effective and safe when combined with or integrated into conventional therapies. This is incorrect. Conventional biomedical therapies include radiation therapy.

PTS: 1 CON: Patient-Centered Care 10. ANS: 2 Chapter: Chapter 46 Holistic Healing Objective: Discuss the most commonly used CAM therapies. Page: 1223 (V1) Heading: What Healing Modalities Are Commonly Used? > Acupuncture Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate Feedback 1 This is incorrect. Homeopathic medicine is person specific and not disease/symptom specific—that is, it cannot be said that it affects headaches in a specific way. 2 This is correct. Acupuncture has been shown to more effectively relieve chronic headaches than medications. 3 This is incorrect. Western medicine does have other alternative treatments for severe and chronic headache management (e.g., biofeedback, botulinum toxin). 4 This is incorrect. There is palliative care for chronic headaches to manage the process rather than affecting a “cure.” PTS: 1 CON: Health Promotion 11. ANS: 3 Chapter: Chapter 46 Holistic Healing Objective: Discuss the trends in use of complementary and alternative modalities (CAM). Page: 1224 (V1) Heading: Ayurveda > Ayurvedic Remedies Contain Herbs, Metals, Minerals, Spices, and Other Materials Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate Feedback 1 This is incorrect. Some ayurvedic herbal remedies have been found to contain

harmful levels of lead, mercury, and/or arsenic. Therefore, users of herbal remedies should be advised to only order products approved by ConsumerLab.com and the United States Pharmacopeia. This is incorrect. Users of herbal remedies should only order from a U.S. Food and Drug Administration (FDA)-approved site since there is little sound scientific research supporting the effectiveness and safety of these remedies. This is correct. Ayurvedic herbal remedies are frequently combined with metals that can be harmful to the patient. Purchasing them from an unregulated shop or Web site increases the chances of there being higher levels of toxic metals in the herbal mixtures. Therefore, the patient should purchase these herbal remedies only from an FDA-approved Web site. This is incorrect. Since the patient believes there is no problem with taking these unregulated remedies, the nurse must educate him about the potential issues with use. Users of ayurvedic medicine may be at risk for heavy metal toxicity.

PTS: 1 CON: Health Promotion 12. ANS: 4 Chapter: Chapter 46 Holistic Healing Objective: Discuss the most commonly used CAM therapies. Page: 1230 (V1) Heading: Biologically Based Therapies > Herbal Products > What Risks Are Associated With Herb Use? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. The nurse cannot tell the patient he is correct and does not have hypertension because his vital signs do not support that. 2 This is incorrect. The nurse is not the person to determine potential therapies for the patient. 3 This is incorrect. The patient’s blood pressure is not within normal limits. 4 This is correct. The nurse identifies that these blood pressure readings are elevated and correctly suggests a discussion with the patient’s physician. PTS: 1 CON: Patient-Centered Care 13. ANS: 1 Chapter: Chapter 46 Holistic Healing Objective: Discuss the most commonly used CAM therapies. Page: 1233 (V1) Heading: Nonherbal Dietary Supplements > Probiotics

Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate Feedback 1 This is correct. Eating yogurt does not eliminate yeast infections permanently or completely take away the potential for them to occur. The statement that probiotics will prevent future infections is false, so the patient requires teaching on this point. 2 This is incorrect. Eating a probiotic, such as yogurt, can reduce vaginal yeast infections. 3 This is incorrect. Eating yogurt or taking a probiotic supplement on a regular basis can help support healthy body flora. 4 This is incorrect. Probiotics are most helpful when the bacteria are live and of a sufficient number to re-establish healthy amounts of flora. PTS: 1 CON: Health Promotion 14. ANS: 2 Chapter: Chapter 46 Holistic Healing Objective: Discuss the importance of a holistic nursing assessment. Page: 1239 (V1) Heading: Practical Knowledge: Knowing How > Assessment Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Application [Applying] Concept: Evidenced-Based Practice Difficulty: Moderate Feedback 1 This is incorrect. Although sensitivity to the patient’s culture should be taken into consideration, it is not the most important thing to consider. 2 This is correct. Patients may use CAM therapies even if there is no accurate evidence on which to base their effectiveness. Therefore, the nurse needs to look at empirical research to guide the nurse, patient, and healthcare provider in using these therapies. 3 This is incorrect. Patients need protection against dangerous practices, therefore allowing patients to determine on their own which CAM’s to use is not appropriate. 4 This is incorrect. People tend to assume that CAMs are harmless and risk free but many products can interact with medications and some practices of CAM can be contraindicated based on a person’s medical condition. Therefore, in order to be safe and effective, CAM therapies need to be researched and tested

before applying their use. PTS: 1 CON: Evidence-Based Practice 15. ANS: 1 Chapter: Chapter 46 Holistic Healing Objective: Discuss the importance of a holistic nursing assessment. Page: 1220 (V1) Heading: What Is Holistic Healthcare? > Integrative Healthcare Integrated Processes: Culture and Spirituality Client Need: Safe and Effective Care Cognitive Level: Application [Applying] Concept: Communication Difficulty: Moderate Feedback 1 This is correct. For therapeutic questioning, the nurse should use open-ended questions to yield the most information. 2 This is incorrect. The question ending in “Do you use both?” is a yes/no question that will likely elicit very little information. 3 This is incorrect. Although the option ending with “Tell me about the practitioners you see for healthcare,” seems open-ended, the negative use of “only” (“only go to a medical physician”) implies that there is only one acceptable answer, thus decreasing the information the patient may share. 4 This is incorrect. “You don’t use CAM, do you?” is a negative, closed-ended question. It suggests that the patient should answer “No” and almost certainly will elicit a one-word answer. PTS:

CON: Communication

MULTIPLE RESPONSE 16. ANS: 1, 2, 4 Chapter: Chapter 46 Holistic Healing Objective: Recognize the beliefs that form the basis of holistic care. Page: 1220 (V1) Heading: What Is Holistic Healthcare? Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Moderate Feedback

1. 2. 3.

4. 5.

This is correct. Illness occurs when there is a shift in an individual’s balance in any dimension or with the environment. This is correct. All healing is self -healing. The patient’s expectation that the treatment will be effective is part of self-healing. This is incorrect. Although holistic healthcare includes the use of alternative modalities, it does not emphasize the use of healthcare resources (money, time, etc.) for alternative healers. This is correct. Illness is an opportunity for growth and has meaning within the context of the life experience. This is incorrect. Disease is the result of multiple contributing factors rather than one cause.

PTS: 1 CON: Patient-Centered Care 17. ANS: 1, 3, 5 Chapter: Chapter 46 Holistic Healing Objective: Compare and contrast complementary, alternative, integrative, and allopathic healthcare. Page: 1220 (V1) Heading: What Is Holistic Healthcare? Integrated Processes: Culture and Spirituality Client Need: Safe and Effective Care Cognitive Level: Knowledge [Remembering] Concept: Patient-Centered Care Difficulty: Moderate

2. 3. 4. 5.

Feedback This is correct. Homeopathy is a complete system of medical theory and practice. It is based on an understanding of how the body heals itself and an acceptance that all symptoms represent the body’s attempt to restore itself to health. This is incorrect. Prayer is a mind–body intervention. This is correct. Ayurveda is a healing system derived from ancient India. This is incorrect. Aromatherapy is a biologically based therapy. This is correct. Chiropractic is an alternative medical system in that it takes a different approach than standard medicine in treating health problems. Manipulation of body structures, especially the spinal column, realigns the vertebrae to allow nerve impulses to flow without interruption, thereby improving health.

PTS: 1 CON: Patient-Centered Care 18. ANS: 1, 2, 3, 4 Chapter: Chapter 46 Holistic Healing Objective: Discuss the trends in use of complementary and alternative modalities. Page: 1226 (V1)

Heading: Mind–Body Interventions Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Comprehension [Understanding] Concept: Health Promotion Difficulty: Moderate

3. 4.

Feedback This is correct. Laughter releases endorphins and improves depressive symptoms. Reading, telling jokes, viewing funny movies, and simply appreciating the humor of situations all help release tension and increase coping abilities. This is correct. Biofeedback is a technique by which some people can learn voluntary control over involuntary activities, such as heart rate. It is classified as a mind–body therapy. This is correct. Though many people practice yoga as exercise, it is designed to integrate body, mind, and spirit. This is correct. Music therapy is an evidenced mind–body intervention that can activate the relaxation response. It can be designed to promote wellness, release emotions, manage stress, relieve pain, improve communication, and promote physical rehabilitation. This is incorrect. Massage is classified as a manipulative and body-based therapy.

PTS: 1 CON: Health Promotion 19. ANS: 3, 4 Chapter: Chapter 46 Holistic Healing Objective: Identify ways to integrate CAM into nursing care Page: 1241 (V1) Heading: Using CAM safely and effectively Integrated Processes: Nursing Process Client Need: Physiological Integrity Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

1. 2. 3.

Feedback This is incorrect. Aromatherapy is known to be safe and effective for promoting sleep and does not require a physician visit before starting therapy. This is incorrect. Tai chi is safe for older adults and may be effective for sleep. This is correct. Yoga is physically rigorous, so it has the potential to be harmful for older adults, who may have a variety of chronic conditions. A physician should be consulted before beginning yoga. This is correct. Melatonin is effective for certain sleep disorders, but it does interact

with several prescription drugs. Therefore, the client should not take melatonin without consulting a physician. This is incorrect. Music can activate the relaxation response. This, in turn, promotes deep breathing, lowers heart rate and blood pressure, reduces muscle tension, reduces stress, promotes better sleep, and relieves physical pain. It is relatively risk free and does not require the patient to see a physician before beginning therapy.

PTS: 1 CON: Patient-Centered Care 20. ANS: 1, 4 Chapter: Chapter 46 Holistic Healing Objective: Discuss the importance of a holistic nursing assessment. Page: 1235 (V1) Heading: Manipulative and Body-Based Methods > Massage Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Difficult

1. 2. 3. 4. 5.

Feedback This is correct. Massage is contraindicated in patients with a history of phlebitis due to the risk of clot formation and the possibility of causing an embolus. This is incorrect. Massage can be effective for pain management if performed by a trained massage therapist. This is incorrect. Massage can facilitate weight gain in preterm infants and decrease postnatal complications. This is correct. Massage is contraindicated in patients with vascular disorders, such as DVT, because of the risk of dislodging a clot and causing an embolus. This is incorrect. Low-birth-weight infants who receive massage therapy gain more weight each day and spend less time in the hospital.

PTS: 1 CON: Patient-Centered Care 21. ANS: 2, 4, 5 Chapter: Chapter 46 Holistic Healing Objective: Identify ways to integrate CAM into nursing care. Page: 1226 (V1) Heading: Mind–Body Interventions Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate

1. 2. 3.

Feedback This is incorrect. Yoga can be physically rigorous, so this would not be a good choice for a patient receiving chemotherapy. This is correct. Meditation uses practices that help to quiet the mind and induce relaxation. It is a process that anyone can use to calm themselves. This is incorrect. Reflexology is a massage technique that applies pressure to the feet to unblock a terminal nerve to improve function along that nerve pathway. This needs to be performed by a trained professional and is not indicated to reduce anxiety. This is correct. Music therapy can be designed to promote wellness, release emotions, and manage stress. It can promote the relaxation response which, in turn, can promote deep breathing and reduce muscle tension and stress. This is correct. Imagery is also known as visualization and has been successfully used to reduce stress and anxiety.

PTS: 1 CON: Patient-Centered Care 22. ANS: 1, 2, 3, 4 Chapter: Chapter 46 Holistic Healing Objective: Discuss the most commonly used CAM therapies. Page: 1230 (V1) Heading: Biologically Based Therapies > Herbal Products Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Analysis [Analyzing] Concept: Health Promotion Difficulty: Difficult

2. 3. 4. 5.

Feedback This is correct. Aromatherapy is used for stress reduction, mood regulation, sleep enhancement, immune support, first aid, enhanced energy, reduction of pain, and accelerated wound recovery. This is correct. The use of herbs for stress reduction, mood regulation, sleep enhancement, immune support, and enhanced energy assist with maintaining health. This is correct. Aloe vera is thought to have antioxidant and anti-inflammatory properties that can assist with promoting health. This is correct. Herbal remedies have long been used to prevent or fight infection. Topical applications may help heal wounds, burns, and skin infections. This is incorrect. As with pharmacological therapies, herbal remedies are not risk free and sometimes do have complications (e.g., allergic response) as well as side effects.

PTS: 1 CON: Health Promotion 23. ANS: 1, 3, 4 Chapter: Chapter 46 Holistic Healing Objective: Discuss the most commonly used CAM therapies. Page: 1230 (V1) Heading: Biologically Based Therapies > Herbal Products > What Risks Are Associated With Herb Use? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Cognitive Level: Analysis [Analyzing] Concept: Health Promotion Difficulty: Moderate

1. 2. 3.

4. 5.

Feedback This is correct. Many herbs are known to interact with medications and adversely affect some disease processes and lab values. This is incorrect. Herbs and dietary supplements are not as regulated or standardized as Western medications are. This is correct. Herbal products may contain different amounts of the active ingredient, or they may even contain harmful contaminants. In addition, herbs may chance in response to soil and weather conditions. This is correct. Herbal products lack a formulary in the United States. This is incorrect. In addition to interacting with other drugs, herbs have the potential for toxicity.

PTS:

CON: Health Promotion