Test Bank for Concepts for Nursing Practice 4th Edition by Jean Foret Giddens All Chapters 1-57 by ACADEMIAMILL

TEST BANK Concepts for Nursing Practice 4th Edition by Jean Foret Giddens | Chapters 1-57

Table of Contents Concept 1 Development Concept 2 Functional Ability Concept 3 Family Dynamics Concept 4 Culture Concept 5 Spirituality Concept 6 Adherence Concept 7 Self-Management

Concept 8 Fluid and Electrolytes Concept 9 Acid-Base Balance Concept 10 Thermoregulation Concept 11 Sleep Concept 12 Cellular Regulation Concept 13 Intracranial Regulation Concept 14 Hormonal Regulation Concept 15 Glucose Regulation Concept 16 Nutrition Concept 17 Elimination Concept 18 Perfusion Concept 19 Gas Exchange Concept 20 Reproduction

Concept 21 Sexuality Concept 22 Immunity Concept 23 Inflammation Concept 24 Infection Concept 25 Mobility Concept 26 Tissue Integrity Concept 27 Sensory Perception Concept 28 Pain Concept 29 Fatigue Concept 30 Stress and Coping Concept 31 Mood and Affect Concept 32 Anxiety Concept 33 Cognition Concept 34 Psychosis Concept 35 Addiction Concept 36 Interpersonal Violence Concept 37 Professional Identity Concept 38 Clinical Judgment Concept 39 Leadership Concept 40 Ethics Concept 41 Patient Education Concept 42 Health Promotion

Concept 43 Communication Concept 44 Collaboration Concept 45 Safety Concept 46 Technology and Informatics Concept 47 Evidence Concept 48 Health Care Quality Concept 49 Care Coordination Concept 50 Caregiving Concept 51 Palliative Care Concept 52 Health Disparities Concept 53 Population Health Concept 54 Health Care Organizations Concept 55 Health Care Economics Concept 56 Health Policy Concept 57 Health Care Law

Concept 01: Development Giddens: Concepts for Nursing Practice 4th Edition

MULTIPLE CHOICE

The nurse manager of a pediatric clinic could confirm that the new nurse

recognized the purpose of the HEADSS Adolescent Risk Profile when the new nurse responds that it is used to review for needs related to a.

anticipatory guidance.

low-risk adolescents.

physical development.

sexual development.

CORRECT ANSWER: A The HEADSS Adolescent Risk Profile is a psychosocial assessment screening tool which reviews home, education, activities, drugs, sex, and suicide for the purpose of identifying high-risk adolescents and the need for anticipatory guidance. It is used to identify high-risk, not low-risk, adolescents. Physical development is reviewed with anthropometric data. Sexual development is reviewed using physical examination.

OBJECTIVE: Maintenance

NCLEX Client Needs Category: Health Promotion and

The nurse preparing a teaching plan for a preschooler knows that,

according to Piaget, the expected stage of development for a preschooler is a.

concrete operational.

formal operational.

preoperational.

sensorimotor.

CORRECT ANSWER: C The expected stage of development for a preschooler (3–4 years old) is preoperational. Concrete operational describes the thinking of a school-age child (7– 11 years old). Formal operational describes the thinking of an individual after about 11 years of age. Sensorimotor describes the earliest pattern of thinking from birth to 2 years old.

OBJECTIVE:

NCLEX Client Needs Category: Health Promotion and

Maintenance

The school nurse talking with a high school class about the difference

between growth and development would best describe growth as a.

processes by which early cells specialize.

psychosocial and cognitive changes.

qualitative changes associated with aging.

quantitative changes in size or weight.

CORRECT ANSWER: D

Growth is a quantitative change in which an increase in cell number and size results in an increase in overall size or weight of the body or any of its parts. The processes by which early cells specialize are referred to as differentiation.

Psychosocial and cognitive changes are referred to as development. Qualitative changes associated with aging are referred to as maturation.

OBJECTIVE:

NCLEX Client Needs Category: Health Promotion and

Maintenance

The most appropriate response of the nurse when a mother asks what the

Denver II does is that it a.

can diagnose developmental disabilities.

identifies a need for physical therapy.

is a developmental screening tool.

provides a framework for health teaching.

CORRECT ANSWER: C The Denver II is the most commonly used measure of developmental status used by healthcare professionals; it is a screening tool. Screening tools do not provide a diagnosis. Diagnosis requires a thorough neurodevelopment history and physical examination. Developmental delay, which is suggested by screening, is a symptom, not a diagnosis. The need for any therapy would be identified with a comprehensive evaluation, not a screening tool. Some providers use the Denver II as a framework for teaching about expected development, but this is not the primary purpose of the tool.

OBJECTIVE:

NCLEX Client Needs Category: Health Promotion and

Maintenance

To plan early intervention and care for an infant with Down syndrome, the

nurse considers knowledge of other physical development exemplars such as a.

cerebral palsy.

failure to thrive.

fetal alcohol syndrome.

hydrocephaly.

CORRECT ANSWER: D Hydrocephaly is also a physical development exemplar. Cerebral palsy is an exemplar of adaptive developmental delay. Failure to thrive is an exemplar of social/emotional developmental delay. Fetal alcohol syndrome is an exemplar of cognitive developmental delay.

OBJECTIVE:

NCLEX Client Needs Category: Health Promotion and

Maintenance

To plan early intervention and care for a child with a developmental delay,

the nurse would consider knowledge of the concepts most significantly impacted by development, including a.

culture.

environment.

functional status.

nutrition. CORRECT ANSWER: C

Function is one of the concepts most significantly impacted by development. Others include sensory-perceptual, cognition, mobility, reproduction, and sexuality. Knowledge of these concepts can help the nurse anticipate areas that need to be addressed. Culture is a concept that is considered to significantly affect development; the difference is the concepts that affect development are those that represent major influencing factors (causes); hence determination of development would be the focus of preventive interventions. Environment is

considered to significantly affect development. Nutrition is considered to significantly affect development.

OBJECTIVE:

NCLEX Client Needs Category: Health Promotion and

Maintenance

A mother complains to the nurse at the pediatric clinic that her 4-year-old

child always talks to her toys and makes up stories. The mother wants her child to have a psychological evaluation. The nurse’s best initial response is to a.

refer the child to a psychologist immediately.

explain that playing make believe is normal at this age.

complete a developmental screening using a validated tool.

separate the child from the mother to get more information.

CORRECT ANSWER: B By the end of the fourth year, it is expected that a child will engage in fantasy, so this is normal at this age. A referral to a psychologist would be premature based only on the complaint of the mother. Completing a developmental screening would be very appropriate but not the initial response. The nurse would certainly want to get more information, but separating the child from the mother is not necessary at this time.

OBJECTIVE:

NCLEX Client Needs Category: Health Promotion and

Maintenance

A 17-year-old girl is hospitalized for appendicitis, and her mother asks the

nurse why she is so needy and acting like a child. The best response of the nurse is that in the hospital, adolescents a.

have separation anxiety.

rebel against rules.

regress because of stress.

want to know everything.

CORRECT ANSWER: C Regression to an earlier stage of development is a common response to stress. Separation anxiety is most common in infants and toddlers. Rebellion against hospital rules is usually not an issue if the adolescent understands the rules and would not create childlike behaviors. An adolescent may want to “know everything” with their logical thinking and deductive reasoning, but that would not explain why they would act like a child.

OBJECTIVE:

NCLEX Client Needs Category: Health Promotion and

Maintenance

Concept 02: Functional Ability Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

The nurse is reviewing a patient’s functional ability. Which patient best

demonstrates the definition of functional ability? a.

Considers self as a healthy individual; uses cane for stability

College educated; travels frequently; can balance a checkbook

Works out daily, reads well, cooks, and cleans house on the weekends

Healthy individual, volunteers at church, works part time, takes care of

family and house CORRECT ANSWER: D

Functional ability refers to the individual’s ability to perform the normal daily activities required to meet basic needs; fulfill usual roles in the family, workplace, and community; and maintain health and well-being. The other options are good; however, healthy individual, church volunteer, part time worker, and the patient who takes care of the family and house fully meets the criteria for functional ability.

OBJECTIVE:

NCLEX Client Needs Category: Physiological Integrity: Basic

Care and Comfort

The nurse is reviewing a patient’s functional performance. What

assessment parameters will be most important in this assessment? a.

Continence assessment, gait assessment, feeding assessment, dressing

assessment, transfer assessment b.

Height, weight, body mass index (BMI), vital signs assessment

Sleep assessment, energy assessment, memory assessment,

concentration assessment d.

Health and well-being, amount of community volunteer time, working

outside the home, and ability to care for family and house CORRECT ANSWER: A Functional impairment, disability, or handicap refers to varying degrees of an individual’s inability to perform the tasks required to complete normal life activities without assistance. Height, weight, BMI, and vital signs are part of a physical assessment. Sleep, energy, memory, and concentration are part of a depression screening. Healthy, volunteering, working, and caring for family and house are functional abilities, not performance.

OBJECTIVE:

NCLEX Client Needs Category: Physiological Integrity:

Reduction of Risk Potential

The nurse is reviewing a patient with a mobility dysfunction and wants to

gain insight into the patient’s functional ability. What question would be the most appropriate? a.

“Are you able to shop for yourself?”

“Do you use a cane, walker, or wheelchair to ambulate?”

“Do you know what today’s date is?”

“Were you sad or depressed more than once in the last 3 days?”

CORRECT ANSWER: B

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“Do you use a cane, walker, or wheelchair to ambulate?” will assist the nurse in determining the patient’s ability to perform self-care activities. A nutritional health risk assessment is not the functional assessment. Knowing the date is part of a mental status exam. Reviewing sadness is a question to ask in the depression screening.

OBJECTIVE:

NCLEX Client Needs Category: Physiological Integrity:

Physiological Adaptation

The nurse is developing an interdisciplinary plan of care using the Roper-

Logan-Tierney Model of Nursing for a patient who is currently unconscious. Which interventions would be most critical to developing a plan of care for this patient? a.

Eating and drinking, personal cleansing and dressing, working and playing

Toileting, transferring, dressing, and bathing activities

Sleeping, expressing sexuality, socializing with peers

Maintaining a safe environment, breathing, maintaining temperature

CORRECT ANSWER: D The most critical aspects of care for an unconscious patient are safe environment, breathing, and temperature. Eating and drinking are contraindicated in unconscious patients. Toileting, transferring, dressing, and bathing activities are BADLs. Sleeping, expressing sexuality, and socializing with peers are a part of the Roper-Logan-Tierney Model of Nursing; however, these are not the most critical for developing the plan of care in an unconscious patient.

OBJECTIVE:

NCLEX Client Needs Category: Physiological Integrity:

Physiological Adaptation

The home care nurse is trying to determine the necessary services for a

65-year-old patient who was admitted to the home care service after left knee replacement. Which tool is the best for the nurse to utilize? a.

Minimum Data Set (MDS)

Functional Status Scale (FSS)

24-Hour Functional Ability Questionnaire (24hFAQ)

The Edmonton Functional Assessment Tool

CORRECT ANSWER: C

The 24hFAQ reviews the postoperative patient in the home setting. The MDS is for nursing home patients. The FSS is for children. The Edmonton is for cancer patients.

OBJECTIVE:

NCLEX Client Needs Category: Health Promotion and

Maintenance

The nurse is reviewing a patient’s functional abilities and asks the patient,

“How would you rate your ability to prepare a balanced meal?” “How would you rate your ability to balance a checkbook?” “How would you rate your ability to keep track of your appointments?” Which tool would be indicated for the best results of this patient’s perception of their abilities? a.

Functional Activities Questionnaire (FAQ)

Mini Mental Status Exam (MMSE)

24hFAQ

Performance-based functional measurement CORRECT ANSWER: A

The FAQ is an example of a self-report tool which provides information about the patient’s perception of functional ability. The MMSE reviews cognitive impairment. The 24hFAQ is used to review functional ability in postoperative

patients. Performance-based tools involve actual observation of a standardized task, completion of which is judged by objective criteria.

OBJECTIVE: NCLEX Client Needs Category: Health Promotion and Maintenance

7.A

65-year-old female patient has been admitted to the medical/surgical unit.

The nurse is reviewing the patient’s risk for falls so that falls prevention can be implemented if necessary. Select all the risk factors that apply from this patient’s history and physical. (Select all that apply.) a.

Being a woman

Taking more than six medications

Having hypertension

Having cataracts

Muscle strength 3/5 bilaterally

Incontinence

CORRECT ANSWER: B, D, E, F Adverse effects of medications can contribute to falls. Cataracts impair vision, which is a risk factor for falls. Poor muscle strength is a risk factor for falls. Incontinence of urine or stool increases risk for falls. Men have a higher risk for falls. Hypertension itself does not contribute to falls. Taking medications to treat hypertension that may lead to hypotension and dizziness is a fall risk. Dizziness does contribute to falls.

OBJECTIVE:

NCLEX Client Needs Category: Physiological Integrity:

Reduction of Risk Potential

8. A 65-year-old female patient has been admitted to the medical/surgical unit. The nurse is assessing the patient’s risk for falls so that falls prevention can be implemented if necessary. Select all the risk factors that apply from this patient's history and physical. (Select all that apply.) e.

Being a woman

Taking more than six medications

Having hypertension

Having cataracts

Muscle strength 3/5 bilaterally

Incontinence

OBJECTIVE:

NCLEX Client Needs Category: Physiological Integrity:

Reduction of Risk Potential

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Concept 03: Family Dynamics Giddens: Concepts for Nursing Practice, 3rd Edition MULTIPLE CHOICE

The most appropriate initial nursing intervention when the nurse notes

dysfunctional interactions and lack of family support for a patient would be to a.

enforce hospital visiting policies.

monitor the dysfunctional interactions.

notify the primary care provider.

role model appropriate support.

CORRECT ANSWER: D Nurses can, at times, role model more appropriate interactions or provide suggestions for improving communication and interactions among family members. If the nurse determines that the number of visitors has a negative impact on the patient, hospital policy may be to limit visitors, but that would not be the initial action. Monitoring the dysfunctional interactions would not be an adequate response. The primary care provider should certainly be notified, but that would not be the initial response.

The nurse caring for a patient would identify a need for additional

interventions related to family dynamics when a.

extended family offers to help.

family members express concern.

the ill member demands attention.

memories are shared.

CORRECT ANSWER: C It is not uncommon for the ill family member to become demanding and indicate that they deserve special treatment and care, and the supportive family may need assistance in understanding the dynamics of the illness in order to continue to be supportive. Offers from extended family to help can be indicative of positive dynamics. Concern expressed by family members can be indicative of positive dynamics. Sharing of family memories can be indicative of positive dynamics.

Jane and Janet have an established long-term relationship and are

attending parenting classes in anticipation of finalizing adoption of baby Joan. Jane and Janet would be considered which type of family? a.

Cohabiting

Nuclear

Same-sex

Single parent

CORRECT ANSWER: C Jane and Janet would be considered a same-sex family. Cohabiting refers to a couple who live together with no legal bond. Nuclear refers to the traditional male and female core family with one or more children. Single parent refers to a family with one adult and one or more children.

Critical Thinking: The nurse identifies the family with a child graduating

from college as being in the family life cycle of a.

single young adult leaving home.

new couple joins their families through marriage or living together.

families with young children.

launching children and moving on.

CORRECT ANSWER: D The launching children and moving cycle occurs when the children become independent and establish their own home, as when they graduate and begin to establish their own lives, separate from the family of origin. Thesingle young adult leaving home cycle occurs when the “child” establishes their own home away from the family they grew up with. The new couple joins their families through marriage or living together cycle begins when a couple establishes a household separate from the family of origin. The families with young children cycle begins with the addition of a child to the family.

When reviewing the purposes of a family assessment, the nurse educator

would identify a need for further teaching if the student responded that family assessment is used to gain an understanding of the family a.

development.

function.

political views.

structure.

CORRECT ANSWER: C An understanding of the political views of family members is not a primary purpose of a family assessment. A family assessment provides the nurse with information and an understanding of family dynamics. This is important to nurses for the provision of quality health care. A family assessment provides an understanding of family development, function, and structure.

The nurse planning to assess the structure of a family would which

question? a.

“Who lives with you?”

“Who does the grocery shopping?”

“Who provides support in your family?”

“How old are the members of your family?”

CORRECT ANSWER: A The structure of the family includes who is in the family and what their relationship is. “Who does the shopping?” would provide information about family functioning. “Who provides support?” would provide information about family functioning. “How old are the members?” would provide information about family development.

Factors which would alert the nurse to negative/dysfunctional family

dynamics include a.

aging of family members.

chronic illness of a family member.

disability of a family member.

intimate partner violence.

CORRECT ANSWER: D Intimate partner violence is an exemplar of negative/dysfunctional family dynamics. Aging of family members is an exemplar of changes to family dynamics. Chronic illness of a family member is an exemplar of changes to family dynamics. Disability of a family member is an exemplar of changes to family dynamics.

REF: 24-25 OBJECTIVE: NCLEX® Client Needs Category: Psychosocial Integrity

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Concept 04: Culture Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

The nurse is caring for an older Chinese adult male who is grimacing and

appears restless after abdominal surgery. What is the nurse’s best action? a.

Ask the patient if he is anxious about his hospital stay.

Ask a translator to conduct a FACES pain scale assessment.

Ask the patient about pain and assess vital signs.

Ask the patient about any history of depression or anxiety.

CORRECT ANSWER: C In the Chinese culture, elderly Chinese people believe that they must be stoic about pain and there is a stigma about talking about any mental health problems.

The nurse should ask the patient about pain and also assess vital signs for physiological signs of pain, since the patient may not admit to any pain. Assuming the patient is depressed or anxious is not the best action when considering individual cultural differences and the risk of pain after major surgery. The registered nurse should never delegate assessment to any unlicensed member of the healthcare team such as a translator. The translator may assist with communication, but the nurse is responsible for the pain assessment.

REF: Page 30 OBJECTIVE: NCLEX® Client Needs Category: Psychosocial Integrity and Physiological Integrity: Basic Care and Comfort

Understanding cultural differences in health care is important because it

will help the nurse to understand the manner in which people decide on obtaining treatments and medical care. In independent cultures an individual will a.

put himself first.

consult family members for advice.

ask for a second opinion.

travel great distances to receive the best care.

CORRECT ANSWER: A In independent cultures, an individual will put himself first in the case of a lifethreatening illness, whereas even in dire circumstances, members of collectivist cultures may still consult other family members for the best course of action. In independent cultures, an individual will not consult with other family members, ask for a second opinion, or travel great distances to receive the best care.

REF: Page 30 Integrity

OBJECTIVE: NCLEX® Client Needs Category: Psychosocial

When teaching an Asian patient with newly diagnosed diabetes, the nurse

notes the patient nodding yes to everything that is being said. With a better understanding of cultural interdependence in self-concept, a nurse should immediately

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write everything down for the patient to refer to later.

prompt further to elicit additional questions or concerns.

call the recognized elder for this patient.

call the oldest male relative for help with decision making.

CORRECT ANSWER: B When a nurse provides nutritional education to a patient who is from a culture that values greater power distance, it might appear that the patient is willing to accept all that the nurse suggests, when further prompting would elicit additional questions or concerns. The patient from a collectivist culture will usually consult family members for a best course of action. It is not acceptable for nurses to take it upon themselves to call the recognized elder or oldest male relative for help with decision making. While writing everything down may be OK for some

cultures, with Asian patients it may be best to prompt further to elicit additional questions or concerns.

REF: Page 34

OBJECTIVE: NCLEX® Client Needs Category: Psychosocial

Integrity

Women who are given the job of caretaker for aging relatives are subject

to caregiver strain due to a.

feminine attributes.

unequal gender.

fixed gender roles.

female inequality.

CORRECT ANSWER: C In cultures with more fixed gender roles, women are usually given the role of caretaker for aging relatives and may suffer the stresses of caregiver strain. Feminine attributes refers to harmonious relationships, modesty, and taking care of others. Unequal gender refers to roles of males and females being unevenly distributed. Female inequality refers to female gender and roles being less than or unequal to male roles.

REF: Page 31

OBJECTIVE: NCLEX® Client Needs Category: Psychosocial

Integrity

A 60-year-old Italian immigrant presents for an annual physical. He is

counseled about diagnostic testing including laboratory testing, colonoscopy, influenza vaccination, and pneumococcal vaccination. His reply is “If it ain’t broke, don’t try to fix it.” When developing a plan of care, the nurse should consider which cultural orientation for this patient? a.

Short term

Long term

Leisurely term

Noncommittal

CORRECT ANSWER: A Short-term cultural orientation focuses on the present or past and emphasizes quick results. Long-term cultural orientation focuses the future and long-term rewards. Long-term-oriented cultures favor thrift, perseverance, and adopting to changing circumstances. Leisurely term and noncommittal are undefined in cultural orientation.

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REF: Page 31

OBJECTIVE: NCLEX® Client Needs Category: Psychosocial

Integrity

The emphasis on understanding cultural influence on health care is

important because of a.

disability entitlements.

HIPAA requirements.

increasing global diversity.

litigious society.

CORRECT ANSWER: C Culture is an essential aspect of health care because of increasing diversity. Disability entitlements refer to defined benefits for eligible mental or physically disabled beneficiaries in relation to housing, employment, and health care. HIPAA requirements refers to the HIPAA Privacy Rule, which protects the privacy of individually identifiable health information; the HIPAA Security Rule, which sets national standards for the security of electronic protected health information; and the confidentiality provisions of the Patient Safety Rule, which protect identifiable information being used to analyze patient safety events and improve patient safety. Litigious society refers to excessively ready to go to law or initiate a lawsuit.

REF: Page 32

OBJECTIVE: NCLEX® Client Needs Category: Health

Promotion and Maintenance

What interrelated constructs facilitate a nurse to become culturally

competent? a.

Cultural diversity, self-awareness, cultural skill, and cultural knowledge

Cultural desire, self-awareness, cultural knowledge, and cultural identity

Cultural desire, self-awareness, cultural knowledge, and cultural diversity

Cultural desire, self-awareness, cultural knowledge, and cultural skill

CORRECT ANSWER: D The process of cultural competence consists of four interrelated constructs: cultural desire, self-awareness, cultural knowledge, and cultural skill. Cultural diversity in the context of health care refers to achieving the highest level of health care for all people by addressing societal inequalities and historical and contemporary injustices. Cultural identity is the norms, values, beliefs, and behaviors of a culture learned through families and group members.

REF: Page 32 |Page 33 OBJECTIVE: NCLEX® Client Needs Category: Psychosocial Integrity

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Concept 05: Spirituality Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

The nurse is assessing a patient's spirituality and observes the patient

meditating before any treatments. What is the nurse’s best action? a.

Document that the patient is not religious

Offer the patient a copy of the bible to read

Arrange for quiet time for the patient as needed

Limit the time patient can meditate before procedures

CORRECT ANSWER: C The nurse can best promote the patient’s spirituality practices by arranging for the patient to be left alone when possible to meditate. Meditation is an exemplar of spirituality, not necessarily of the Christian faith. The bible is most often read by believers in the Christian faith. Meditation does not imply that the patient is not religious. Time for meditation should not be limited, whenever possible.

REF: Page 41 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Health Promotion and Maintenance

When conducting a spiritual assessment of a hospitalized patient, the

nurse should remain aware of which potential barrier to effective communication? a.

Clarifying the meaning of a patient’s statement

Multi-tasking while talking to the patient

Listening to patients’ complete statements

Discussing patient’s feelings while hospitalized

CORRECT ANSWER: B

Several barriers may result in the nurses’ inability to be totally present and communicate effectively with the patient. First, the nurse may be distracted by other things and may not pay attention to the patient. Multi-tasking while trying to listen to a patient may be a barrier to effective communication. Second, the nurses may miss the meaning of the patient’s message because of failure to clarify the meaning of a word, a phrase, or a facial expression. Third, the nurse may interject personal feelings and reactions into the patient’s situation rather than allow the patient to explore and discuss his own feelings and reactions. The last barrier occurs when the nurse is busy formulating a response while the patient is still talking. In this instance, the nurse never hears the patient’s message.

REF: Page 42 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Psychosocial Integrity

A patient uses rosary beads and attends mass once a week. This

expression of spirituality is best described with which term?

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Religiosity

Faith

Belief

Authenticity

CORRECT ANSWER: A There are a few similar and related terms to spirituality worth mentioning to provide distinction and clarification. Faith, as defined by Dyess, refers to an “evolving pattern of believing, that grounds and guides authentic living and gives meaning in the present moment of inter-relating.” Religiosity, another similar term, is an external expression (public or private), in the form of practicing a belief or faith, whereas spirituality is an internalized spiritual identity (or experiential). Specifically, religiosity is defined as “the adherence to religious dogma or creed, the expression of moral beliefs, and/or the participation in organized or individual worship, or sacred practices.”

REF: Page 43 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Psychosocial Integrity

When developing a plan of care, the nurse should consider which attribute

of the concept of spirituality? a.

Spirituality is not a well-known universal concept

Chronic versus acute illnesses affect spirituality

Convincing patients to pray is a priority intervention

Referrals may be needed to spiritual counselors

CORRECT ANSWER: D The attributes of the concept of spirituality in the context of nursing care are described below.

•

Spirituality is universal. All individuals, even those who profess no religious

belief, are driven to derive meaning and purpose from life. •

Illness impacts spirituality in a variety of ways. Some patients and families

will draw closer to God or however they conceive that higher Power to be in an effort to seek support, healing, and comfort. Others may blame and feel anger towards that Higher Power for any illness and misfortune that may have befallen a loved one or their entire family. Still others will be neutral in their spiritual reactions. •

There has to be willingness on the part of patient and/or family to share

and/or act on spiritual beliefs and practices. •

The nurse needs to be aware that specific spiritual beliefs and practices

are impacted by family and culture. •

The nurse needs to be willing to assess the concept of spirituality in

patients and families and based on this ongoing assessment to integrate the spiritual beliefs of patients and families into care. •

The nurse needs to be willing to refer the patient or family to a Spiritual

Expert i.e. a Minister, Priest, Rabbi, an Imam. •

Community based religious organizations can provide supportive care to

families and patients and nurses need to be aware of these resources.

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REF: Page 42 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Psychosocial Integrity

MULTIPLE RESPONSE

When completing the FICA tool for spiritual assessment, which questions

should the nurse ask the patient? (Select all that apply.) a.

What things do you believe in that give meaning to life?

Are you connected with a faith center in your community?

How has your illness affected your personal beliefs?

When was the last time you have been to church?

What can I do for you?

CORRECT ANSWER: A, B, C, E The FICA tool for spiritual assessment stands for Faith or beliefs, Importance and influence, Community, and Address. “When was the last time you have been to church?” is not a question included in the FICA assessment. The patient may attend community activities, besides church, that foster his/her spiritual wellbeing.

REF: Page 41

OBJECTIVE: NCLEX® Client Needs Category: Health

Promotion and Maintenance

Which are true statements about the definition of spirituality in nursing?

(Select all that apply.) a.

Patient’s quality of life, health, and sense of wholeness are affected by

spirituality

An exact definition was developed and adopted in the late 1980s

Encompasses principle, an experience, attitudes, and belief regarding God

Head knowledge affects spirituality more than heart knowledge

Mind, body, spirit, love, and caring are interconnected

CORRECT ANSWER: A, C, E The concept of Spirituality is an elusive concept to define. Authors that write about spirituality in nursing advocate the position that a patient’s quality of life, health, and sense of wholeness are affected by spirituality, yet still the profession of nursing struggles to define it. Why? There are a number of explanations for this. One explanation is that spirituality represents “heart” not “head” knowledge and “heart” knowledge is difficult to encapsulate into words. A second explanation is that spirituality is unique to each person so a precise definition is somewhat elusive. The definitions of spirituality encompass the following: a principle, an experience, attitudes and belief regarding God, a sense of God, the inner person. Most descriptions of spirituality include not only transcendence but also the connection of mind, body, and spirit, plus love, caring, and compassion and a relationship with the Divine.

REF: Page 39 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Health Promotion and Maintenance

The nurse recognizes that which life events can be spiritually life

changing? (Select all that apply.)

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Births

Weddings

Medical diagnoses

Career day to day job duties

Loss of independence

CORRECT ANSWER: A, B, C, E The meaning and significance of the event might only be experienced by one individual; others who might be participants in the event might be left virtually untouched and unchanged. These life changing spiritual events include just about any occurrence that has intense and personal relevance to those involved in the event. Examples of spiritually life changing events include births, deaths, weddings, divorces, illnesses, diagnoses, and loss of abilities, loss of independence, death and so many more. These events, having the power to change individuals and families, also have the power to draw people towards the transcendent – for many people that transcendent is known as God but this is not universal. Day to day activities are not the best examples of spiritually life changing events.

REF: Page 40 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Psychosocial Integrity

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Concept 6: Adherence Test Bank

MULTIPLE CHOICE

A patient has been newly diagnosed with hypertension. The nurse

assesses the need to develop a collaborative plan of care that includes a goal of adhering to the prescribed regimen. When the nurse is planning teaching for the patient, which is the most important initial learning goal? a.

The patient will select the type of learning materials they prefer.

The patient will verbalize an understanding of the importance of following

the regimen. c.

The patient will demonstrate coping skills needed to manage hypertension.

The patient will verbalize the side effects of treatment.

CORRECT ANSWER: A

Adults learn best when given information they can understand that is tailored to their learning styles and needs. Verbalizing an understanding is important; however, the nurse will first need to teach the patient.

REF: 50

OBJECTIVE: NCLEX® Client Needs Category: Health Promotion

and Maintenance

After the nurse implements a teaching plan for a newly diagnosed patient

with hypertension, the patient can explain the information but fails to take the medications as prescribed. The nurse's next action would be to a.

reeducate the patient, because learning did not occur because the

patient's behavior did not change. b.

assess the patient's perception and attitude towards the risks associated

with not taking their anti-hypertensives. c.

take full responsibility for helping the patient make dietary changes.

ask the provider to prescribe a different medication, because the patient

does not want to take this medication. CORRECT ANSWER: B Although the patient behavior has not changed, the patient's ability to explain the information indicates that learning has occurred. The nurse would need to ask what the patient’s perceptions are of taking the medications to determine if the patient understands the ramifications of not taking the medication. The patient may be in the contemplation or preparation state (see Health Belief Model). The nurse should reinforce the need for change and continue to provide information and assistance with planning for change.

REF: 52

OBJECTIVE: NCLEX® Client Needs Category: Health Promotion

and Maintenance

A diabetic patient presents to the diabetes clinic with A1c levels of 7.5%.

The nurse has met this patient for the first time. When applying principles of Theory of Planned Behavior (TPB), which teaching strategy by the nurse is most likely to be effective? a.

Provide information on the importance of blood glucose control in

maintenance of long-term health and evaluate how the patient has been following the prescribed regime. b.

Establish a rapport with the patient by complimenting them on what they

did

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correctly, and ask what strategies they have tried thus far. c.

Refer the patient to a certified diabetic educator, because the educator is

an expert on management of diabetes complications. d.

Have the patient explain what medications they are on and what diet they

should be following. CORRECT ANSWER: B Principles of a TPB indicate that the patient will need to establish a good rapport with the nurse in order to talk about nonadherence. If the patient finds it difficult to discuss their diabetes self-management and adherence with the nurse, the patient may not open up to the nurse. Although a referral to an educator is a

good idea, it would be better to use this resource as a follow-up for this visit. Having the patient verbalize medications and diet is not part of the TPB method.

REF: 52

OBJECTIVE: NCLEX® Client Needs Category: Health Promotion

and Maintenance

The nurse is assessing a newly diagnosed diabetic, and the patient's

readiness to learn about glucose monitoring. Before planning teaching activities, which approach would be most effective? a.

Assist the patient with long-term goals and plan teaching according to

these goals. b.

Provide the patient with all the latest research from the Internet on glucose

monitoring. c.

Refer the patient to the diabetic specialist who can assist the patient with

the glucometer. d.

Assist the patient in developing realistic short-term goals.

CORRECT ANSWER: D Concordance reflects development of an alliance with patients based on realistic expectations. Providing the patient with the research will not help with the practical skill of using the glucometer. Long-term goals are useful; however, the goals need to be immediate with a newly diagnosed patient learning a new skill. Referring the patient would be useful if the patient has not been able to grasp the concept after several attempts.

REF: 55

OBJECTIVE: NCLEX® Client Needs Category: Health Promotion

and Maintenance

The nurse is developing a care plan for a patient who has low motivation

and nonadherence with blood glucose monitoring. Which statement by the

patient would indicate to the nurse that the patient is not motivated and will most likely not comply? a.

"I do not like to test my sugar, but I do it because my wife nags me."

"I forget to check my sugar once in a while."

"I don't see or feel any different when I do keep my blood sugars under

control." d.

"I have no idea what the signs of low blood sugar are."

CORRECT ANSWER: C If patients do not perceive any benefit from changing their behavior, sustaining the change becomes very difficult. Having someone remind the patient is more likely to reinforce compliance. Forgetting to check glucose occasionally may indicate the patient needs memory cues or joggers. The patient who doesn't know the signs of low glucose will need further teaching.

REF: 52

OBJECTIVE: NCLEX® Client Needs Category: Health Promotion

and Maintenance

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The nurse is doing discharge teaching on a patient who has peripheral

vascular disease and has poor circulation to the feet. Which learning goal should the nurse include in the teaching plan? a.

The nurse will demonstrate the proper technique for trimming toenails.

The patient will understand the rationale for proper foot care after

instruction. c.

The nurse will instruct the patient on appropriate foot care before

discharge. d.

The patient will post reminder stickers on their calendar to check feet every

day and record scheduled appointments with podiatrist. CORRECT ANSWER: D To improve the patient adherence to treatment, it will be important to help them develop reminder strategies that fit into their lifestyle. Options A and C describe actions that the nurse will take, rather than behaviors that indicate that patient learning has occurred. Option B is too vague and nonspecific to measure whether learning has occurred.

REF: 55

OBJECTIVE: NCLEX® Client Needs Category: Health Promotion

and Maintenance

A patient with hypertension is prescribed a low-sodium diet. The patient's

teaching plan includes this goal: "The patient will select a 2-gram sodium diet from the hospital menu for the next 3 days." Which intervention would be most effective at increasing the patient's compliance with the diet? a.

Check the sodium content of the patient's menu choices over the next 3

days. b.

Ask the patient to identify which foods on the hospital menus are high in

sodium.

Have the patient list favorite foods that are high in sodium and foods that

could be substituted for these favorites. d.

Compare the patient's sodium intake over the next 3 days with the sodium

intake before the teaching was implemented. CORRECT ANSWER: C Including a patient's favorite foods will most likely increase compliance because the patient is not being deprived. Checking the sodium will be useful for teaching strategies but will not be the most effective means of increasing adherence.

REF: 55

OBJECTIVE: NCLEX® Client Needs Category: Health Promotion

and Maintenance

The nurse is evaluating the need to refer a patient with osteoarthritis for a

home care visit to be sure the patient can function in accomplishing daily activities independently. What is the nurse's first priority? a.

Determine if the patient has had home visits before and if the experience

was positive. b.

Check the patient's ability to bathe without any assistance the next day.

Have the patient demonstrate the learned skills at the end of the teaching

session. d.

Arrange a physical therapy visit before the patient is discharged from the

hospital. CORRECT ANSWER: A To begin the assessment of adherence, it is first important to clarify with the patient (a) their beliefs and perceptions about their health risk status, (b) their existing knowledge about cardiovascular disease risk reduction, (c) any prior experience with health care professionals, and (d) their degree of confidence with controlling the disease. The other actions allow evaluation of the patient's shortterm response to teaching.

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REF: 55

OBJECTIVE: NCLEX® Client Needs Category: Health Promotion

and Maintenance

When assessing a 22-year-old male patient, the nurse learns that he

smokes a pack of cigarettes daily. The patient tells the nurse, "I enjoy smoking and have no plans to quit." Which nursing diagnosis is most appropriate? a.

Health Seeking Behaviors related to cigarette use

Ineffective Health Maintenance related to tobacco use

Readiness for Enhanced Self-Health Management related to smoking

Deficient Knowledge related to long-term effects of cigarette smoking

CORRECT ANSWER: B The patient's statement indicates that he is not considering smoking cessation. Ineffective Health Maintenance is defined as the inability to identify, manage, and/or seek out help to maintain health.

REF: 51

OBJECTIVE: NCLEX® Client Needs Category: Health Promotion

and Maintenance

10.

A 73-year-old male patient is seen in the home setting for a routine

physical. The nurse notes which behavior as the most reassuring sign that the patient has been following the treatment plan for the diagnoses of hypertension, diabetes, and hyperlipidemia? a.

The patient has a list of glucose readings for the past 10 days.

The patient has a list of medications along with newly refilled meds.

The patient has a list of all foods and beverages for a 3-day period.

The patient verbalizes the side effects of all his medications.

CORRECT ANSWER: B Confirming how often a patient renews or refills his/her prescriptions is a measurement of the patient's persistence with continuation of the treatment. Having a list of glucose readings or verbalizing side effects does not necessarily mean that the patient is compliant unless the readings were all normal, which is not indicated. Listing foods may not indicate the patient is following the treatment plan.

REF: 55

OBJECTIVE: NCLEX® Client Nconeeeds Category: Health

Promotion and Maintenance

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Concept 07: Self-Management Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

The nurse is developing a plan of care for a newly diagnosed hypertensive

patient who is being discharged on medications and given the Dietary Approaches to Stop Hypertension (DASH) diet to follow. What statement by the patient signals to the nurse that the patient is motivated to learn?

"I am sure the medications will help to bring down my blood pressure."

"I can't wait to try the new recipes, and I'm hopeful I will lose weight."

"Do I really need to follow the diet and take medications?"

"I have my parents to blame for this. They both have high blood pressure."

CORRECT ANSWER: B A patient who is motivated will see what the benefits of following the teaching will do for them and will most likely be able to manage their own care. The patient who believes medications are the only solution may not be motivated to follow the prescribed diet. Blaming the parents for their condition does not show accountability or motivation for change.

REF: Page 55|Page 57 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity and Physiological Integrity: Physiological Adaptation

The nurse is assessing a patient's readiness to be discharged and ability to

manage care at home. What is the most appropriate question for the nurse to ask to determine the patient's learning needs before planning teaching activities? a.

"What are your hobbies and occupation?"

"What do you need to know before you go home from the hospital?"

"Do you have any cultural or religious beliefs that you would like

incorporated into your plan of care?" d.

"What were your grades and learning style when you were in school?"

CORRECT ANSWER: B Motivation and readiness to learn depend on what the patient values. The other questions are also important but do not address what information interests the patient most at present and will assist the patient in managing his own care.

REF: Page 55|Page 59

OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

The nurse planning care for a patient realizes that which acute medical

event requires self- management? a.

Prenatal care

Depression

Diabetes

Femur fracture

CORRECT ANSWER: D

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A femur fracture is considered an acute medical event. Pregnancy is an expected and normal life event/condition. Depression and diabetes are considered disease states.

REF: Page 57

OBJECTIVE: NCLEX® Client Needs Category: Health

Promotion and Maintenance

An 8-year-old child is newly diagnosed with asthma. Which nursing

intervention best promotes self-efficacy for the parents to help the child follow the prescribed treatments? a.

Ask parents to list all possible triggers for asthma

Requesting a spacer for the metered dose inhaler

Suggest the parents enforce a strict exercise regimen

Recommend replacing carpeting in the home with wood flooring

CORRECT ANSWER: B The most realistic and helpful interventions will promote self-management. A spacer is helpful for children learning to use inhaled medication. Listing all the triggers for asthma may be overwhelming. The parents should focus on the individual triggers for the child. Enforcing a strict exercise regimen is restrictive and will not promote self-management. Environmental changes must be feasible and cost-effective. Replacing carpeting is optimal but may not be affordable.

REF: Page 57|Page 58 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

When developing a plan of care to promote self-management, which

patient is least likely to be affected by depression? a.

55-year-old employed female

35-year-old Hispanic male

40 year old with 5th grade education

42 year old with private insurance

CORRECT ANSWER: D Individuals most affected by depression are midlife adults ages 45–64, women, minorities, individuals without a high school education, and individuals without health insurance.

Treatment for depression includes the use of medication and psychological therapy. Additionally, patients must learn to manage moods including suicidal thoughts, recognize triggers and relapse, and set goals for behavioral management of their disease.

REF: Page 59

OBJECTIVE: NCLEX® Client Needs Category: Health

Promotion and Maintenance

The nurse is assisting an older adult patient, diagnosed with type 2

diabetes, with self- injection of insulin. What is the most appropriate intervention for this patient at discharge? a.

Arrange daily home visits for injections

Request an insulin pen prescription

Recommend upper arm injection sites

Supply patient with 100 unit insulin syringes

CORRECT ANSWER: B

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An insulin pen will be the most effective method for injection for an older adult secondary to reduced eyesight and dexterity compared to using syringes. A 100 unit syringe has very small calibration marks and numbers, making it more difficult for older adults to see the appropriate doses. Daily home visits are not usually paid for by insurance. Most patients must learn to administer medications themselves. The upper arm subcutaneous site is too difficult for selfadministration and may not be feasible for an older adult.

REF: Page 59

OBJECTIVE: NCLEX® Client Needs Category: Health

Promotion and Maintenance

MULTIPLE RESPONSE

The nurse is developing a teaching plan for a patient diagnosed with

congestive heart failure. Which are the most appropriate teaching points to include that will assist in self-management of the disease? (Select all the apply.) a.

Side effects of medications

Activity restrictions

Daily weights

Increased sodium intake

Blood pressure monitoring

CORRECT ANSWER: A, B, C, E Congestive heart failure (CHF) is one of the most common complications of coronary artery disease in which the heart fails to pump efficiently enough to meet the metabolic demands of the body. Fluid overload is a common complication. As with most chronic conditions, patients with CHF benefit from education about their disease and self-managing diet, physical activity, weight,

and medication adherence. Fluid retention occurs with increased sodium intake; therefore sodium is usually restricted in a congestive heart failure diet.

REF: Page 59

OBJECTIVE: NCLEX® Client Needs Category: Health

Promotion and Maintenance

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Concept 8: Fluid and Electrolyte Balance Test Bank

MULTIPLE CHOICE

The nurse is admitting an older adult with decompensated congestive

heart failure. The nursing assessment reveals adventitious lung sounds, dyspnea, and orthopnea. The nurse should question which doctor's order? a.

Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr

Furosemide (Lasix) 20 mg PO now

Oxygen via face mask at 8 L/min

KCl 20 mEq PO two times per day

CORRECT ANSWER: A A patient with decompensated heart failure has extracellular fluid volume (ECV) excess. The IV of 0.9% NaCl is normal saline, which should be questioned because it would expand ECV and place an additional load on the failing heart. Diuretics such as furosemide are appropriate to decrease the ECV during heart failure. Increasing the potassium intake with KCl is appropriate, because

furosemide increases potassium excretion. Oxygen administration is appropriate in this situation of near pulmonary edema from ECV excess.

REF: 67

OBJECTIVE: NCLEX® Client Needs Category: Physiological

Integrity

The nurse assessed four patients at the beginning of the shift. Which

finding should the nurse report most urgently to the physician? a.

Swollen ankles in patient with compensated heart failure

Positive Chvostek's sign in patient with acute pancreatitis

Dry mucous membranes in patient taking a new diuretic

Constipation in patient who has advanced breast cancer

CORRECT ANSWER: B Positive Chvostek's sign indicates increased neuromuscular excitability, which can progress to dangerous laryngospasm or seizures and thus needs to be reported first. The other assessment findings are less urgent and need further assessment. Bilateral ankle edema is a sign of ECV excess, and follow-up is needed, but the situation is not immediately life-threatening. Dry mucous membranes in a patient taking a diuretic may be associated with ECV deficit; however, additional assessments of ECV deficit are required before reporting to the physician. Constipation has many causes, including hypercalcemia and opioid analgesics, and it needs action, but not as urgently as a positive Chvostek's sign.

REF: 68 Integrity

OBJECTIVE: NCLEX® Client Needs Category: Physiological

The nurse is assessing a patient before hanging an IV solution of 0.9%

NaCl with KCl in it. Which assessment finding should cause the nurse to hold the IV solution and contact the physician? a.

Weight gain of 2 pounds since last week

Dry mucous membranes and skin tenting

Urine output 8 mL/hr

Blood pressure 98/58

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CORRECT ANSWER: C Administering IV potassium to a patient who has oliguria is not safe, because potassium intake faster than potassium output can cause hyperkalemia with dangerous cardiac dysrhythmias. Dry mucous membranes, skin tenting, and blood pressure 98/58 are consistent with the need for IV 0.9% NaCl. Weight gain of 2 pounds in a week does not necessarily indicate fluid overload, because it can be from increased nutritional intake. Only an overnight weight gain indicates a fluid gain.

REF: 61 Integrity

OBJECTIVE: NCLEX® Client Needs Category: Physiological

At change-of-shift report, the nurse learns the medical diagnoses for four

patients. Which patient should the nurse assess most carefully for development of hyponatremia? a.

Vomiting all day and not replacing any fluid

Tumor that secretes excessive antidiuretic hormone (ADH)

Tumor that secretes excessive aldosterone

Tumor that destroyed the posterior pituitary gland

CORRECT ANSWER: B ADH causes renal reabsorption of water, which dilutes the body fluids. Excessive ADH thus causes hyponatremia. Excessive aldosterone causes ECV excess rather than hyponatremia. The posterior pituitary gland releases ADH; lack of ADH causes hypernatremia. Vomiting without fluid replacement causes ECV deficit and hypernatremia.

REF: 66

OBJECTIVE: NCLEX® Client Needs Category: Physiological

Integrity

The patient is receiving tube feedings due to a jaw surgery. What change

in assessment findings should prompt the nurse to request an order for serum sodium concentration? a.

Development of ankle or sacral edema

Increased skin tenting and dry mouth

Postural hypotension and tachycardia

Decreased level of consciousness

CORRECT ANSWER: D Tube feedings pose a risk for hypernatremia unless adequate water is administered between tube feedings. Hypernatremia causes the level of consciousness to decrease. The serum sodium concentration is a laboratory

measure for osmolality imbalances, not ECV imbalances. Edema is a sign of ECV excess, not hypernatremia. Skin tenting, dry mouth, postural hypotension, and tachycardia all can be signs of ECV deficit.

REF: 65

OBJECTIVE: NCLEX® Client Needs Category: Physiological

Integrity

The patient with which diagnosis should have the highest priority for

teaching regarding foods that are high in magnesium? a.

Severe hemorrhage

Diabetes insipidus

Oliguric renal disease

Adrenal insufficiency

CORRECT ANSWER: C

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When renal excretion is decreased, magnesium intake must be decreased also, to prevent hypermagnesemia. The other conditions are not likely to require adjustment of magnesium intake.

REF: 61

OBJECTIVE: NCLEX® Client Needs Category: Physiological

Integrity

The patient's laboratory report today indicates severe hypokalemia, and

the nurse has notified the physician. Nursing assessment indicates that heart rhythm is regular. What is the most important nursing intervention for this patient now? a.

Raise bed side rails due to potential decreased level of consciousness and

confusion. b.

Examine sacral area and patient's heels for skin breakdown due to

potential edema. c.

Establish seizure precautions due to potential muscle twitching, cramps,

and seizures. d.

Institute fall precautions due to potential postural hypotension and weak

leg muscles. CORRECT ANSWER: D Hypokalemia can cause postural hypotension and bilateral muscle weakness, especially in the lower extremities. Both of these increase the risk of falls. Hypokalemia does not cause edema, decreased level of consciousness, or seizures.

REF: 68

OBJECTIVE: NCLEX® Client Needs Category: Physiological

Integrity

MULTIPLE RESPONSE

The home health nurse has an acute immunodeficiency syndrome (AIDS)

patient who has chronic diarrhea. Which assessments should the nurse use to detect the fluid and electrolyte imbalances for which the patient has high risk? (Select all that apply.) a.

Bilateral ankle edema

Weaker leg muscles than usual

Postural blood pressure and heart rate

Positive Trousseau's sign

Flat neck veins when upright

Decreased patellar reflexes

CORRECT ANSWER: B, C, D Chronic diarrhea has high risk of causing ECV deficit, hypokalemia, hypocalcemia, and hypomagnesemia because it increases fecal excretion of sodium-containing fluid, potassium, calcium, and magnesium. Appropriate assessments include postural blood pressure and heart rate for ECV deficit; weaker leg muscles than usual for hypokalemia; and positive Trousseau's sign for hypocalcemia and hypomagnesemia. Bilateral ankle edema is a sign of ECV excess, which is not likely with chronic diarrhea. Flat neck veins when upright is a normal finding. Decreased patellar reflexes is associated with hypermagnesemia, which is not likely with chronic diarrhea.

REF: 67 Integrity

OBJECTIVE: NCLEX® Client Needs Category: Physiological

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The patient has recent bilateral, above-the-knee amputations and has

developed C. difficile diarrhea. What assessments should the nurse use to detect ECV deficit in this patient? (Select all that apply.) a.

Test for skin tenting.

Measure rate and character of pulse.

Measure postural blood pressure and heart rate.

Check Trousseau's sign.

Observe for flatness of neck veins when upright.

Observe for flatness of neck veins when supine.

CORRECT ANSWER: A, B, F ECV deficit is characterized by skin tenting; rapid, thready pulse; and flat neck veins when supine, which can be assessed in this patient. Although ECV deficit also causes postural blood pressure drop with tachycardia, this assessment is not appropriate for a patient with recent bilateral, above-the-knee amputations. Trousseau's sign is a test for increased neuromuscular excitability, which is not characteristic of ECV deficit. Flat neck veins when upright is a normal finding.

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Concept 09: Acid-Base Balance Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

The patient had diarrhea for 5 days and developed an acid-base

imbalance. Which statement would indicate that the nurse’s teaching about the acid-base imbalance has been effective? a.

“To prevent another problem, I should eat less sodium during diarrhea.”

“My blood became too acid because I lost some base in the diarrhea fluid.”

“Diarrhea removes fluid from the body, so I should drink more ice water.”

“I should try to slow my breathing so my acids and bases will be balanced.”

CORRECT ANSWER:

Diarrhea causes metabolic acidosis through loss of bicarbonate, which is a base. Eating less sodium during diarrhea increases the risk of ECV deficit. Although diarrhea does remove fluid from the body, it also removes sodium and bicarbonate which need to be replaced. Rapid deep respirations are the compensatory mechanism for metabolic acidosis and should be encouraged rather than stopped.

REF: Page 75

OBJECTIVE:

NCLEX® Client Needs Category:

Physiological Integrity

The patient has type B chronic obstructive pulmonary disease (COPD)

exacerbated by an acute upper respiratory infection. Which blood gas values should the nurse expect to see? a.

pH high, PaCO2 high, HCO - high

pH low, PaCO2 low, HCO - low

pH low, PaCO2 high, HCO - high

pH low, PaCO2 high, HCO - normal

CORRECT ANSWER:

Type B COPD is a chronic disease that causes impaired excretion of carbonic acid, thus causing respiratory acidosis, with PaCO2 high and pH low. This chronic disease exists long enough for some renal compensation to occur, manifested by high HCO -. Answers that include low or normal bicarbonate are not correct, because the renal compensation for respiratory acidosis involves excretion of more hydrogen ions than usual, with retention of bicarbonate in the blood. High pH occurs with alkalosis, not acidosis.

REF: Page 79

OBJECTIVE:

Physiological Integrity

NCLEX® Client Needs Category:

The patient has severe hyperthyroidism and will have surgery tomorrow.

What assessment is most important for the nurse to assess in order to detect development of the acid-base imbalance for which the patient has highest risk? a.

Urine output and color

Level of consciousness

Heart rate and blood pressure

Lung sounds in lung bases

CORRECT ANSWER:

Thyroid hormone increases metabolic rate, causing a patient with severe hyperthyroidism to have high risk of metabolic acidosis from increased production of metabolic acids. Metabolic acidosis decreases level of consciousness. Changes in urine output, urine color, and lung sounds are not signs of metabolic acidosis. Although metabolic acidosis often causes tachycardia, many other factors influence heart rate and blood pressure, including thyroid hormone.

REF: Page 83

OBJECTIVE:

NCLEX® Client Needs Category:

Physiological Integrity

The nurse is making a home visit to a child who has a chronic disease.

Which finding has the greatest implication for acid- base aspects of this patient’s care? a.

Urine output is very small today.

Whites of the eyes appear more yellow.

Skin around the mouth is very chapped.

Skin is sweaty under three blankets.

CORRECT ANSWER:

Oliguria decreases the excretion of metabolic acids and is a risk factor for metabolic acidosis. Jaundice requires follow-up but is not an acid-base problem. Perioral chapped skin needs intervention but is not an acid-base issue. With three blankets, diaphoresis is not unusual.

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REF: Page 79

OBJECTIVE:

NCLEX® Client Needs Category:

Physiological Integrity

The nurse has telephone messages from four patients who requested

information and assistance. Which one should the nurse refer to a social worker or community agency first? a.

“Is there a place that I can dispose of my unused morphine pills?”

“I want to lose at least 20 pounds without getting sick this time.”

“I think I have asthma because I cough when dogs are near.”

“I ran out of money and am cutting my insulin dose in half.”

CORRECT ANSWER:

Decreasing an insulin dose by half creates high risk of diabetic ketoacidosis, and this patient has the highest priority. The other patients have less priority due to lower risk situations with longer time course before development of an acid-base imbalance. The coughing when dogs are near is not a sign of a severe asthma episode that causes respiratory acidosis, although this patient does need attention after the insulin situation is handled. Disposing of morphine properly helps prevent respiratory acidosis from opioid overdose. Guidance regarding weight loss helps prevent starvation ketoacidosis.

REF: Page 83

OBJECTIVE:

NCLEX® Client Needs Category:

Physiological Integrity

MULTIPLE RESPONSE

The patient is hyperventilating from anxiety and abdominal pain. Which

assessment findings should the respiratory alkalosis? (Select all that apply.) a.

Skin pale and cold

Tingling of fingertips

Heart rate of 102

Numbness around mouth

Cramping in feet

CORRECT ANSWER:

B, D, E

Hyperventilation is a risk factor for respiratory alkalosis. Respiratory alkalosis can cause perioral and digital paresthesias and pedal spasms. Pallor, cold skin, and tachycardia are characteristic of activation of the sympathetic nervous system, not respiratory alkalosis.

REF: Page 81

OBJECTIVE:

NCLEX® Client Needs Category:

Physiological Integrity

Which statements said by patients indicate that the nurse’s teaching

regarding prevention of acid-base imbalances is successful? (Select all that apply.) a.

“Baking soda is an effective and inexpensive antacid.”

“I should take my insulin on time every day.”

“My aspirin is on a high shelf away from children.”

“I have reliable transportation to dialysis sessions.”

“Fasting is a great way to lose weight rapidly.”

CORRECT ANSWER:

B, C, D

Taking insulin as prescribed helps prevent diabetic ketoacidosis. Safeguarding aspirin from children prevents metabolic acidosis from increased acid intake. Regular dialysis reduces the risk of metabolic acidosis from decreased renal excretion of metabolic acid. Baking soda is sodium bicarbonate and should not be used as an antacid due to the risk of metabolic alkalosis. Fasting without carbohydrate intake is a risk factor for starvation ketoacidosis.

REF: Page 79

OBJECTIVE:

Physiological Integrity

NCLEX® Client Needs Category:

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Concept 10:Thermoregulation Test Bank

MULTIPLE CHOICE

The nursery nurse identifies a newborn at significant risk for hypothermic

alteration in thermoregulation because the patient is a.

large for gestational age.

low birth weight.

born at term.

well nourished.

CORRECT ANSWER: B Low birth weight and poorly nourished infants (particularly premature infants) and children are at greatest risk for hypothermia. A large for gestational age infant would not be malnourished. An infant born at term is not considered at significant risk. A well nourished infant is not at significant risk.

REF: 84

OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

A volunteer at the senior center asks the visiting nurse why the senior

citizens always seem to be complaining about temperatures. The nurse's best response is that older people have a diminished ability to regulate body temperature because of a.

active sweat glands.

increased circulation.

peripheral vasoconstriction.

slower metabolic rates.

CORRECT ANSWER: D Slower metabolic rates are one factor that reduces the ability of older adults to regulate temperature and be comfortable when there are any temperature changes. As the body ages, the sweat glands decrease in number and efficiency. Older adults have reduced circulation. The body conserves heat through peripheral vasoconstriction, and older adults have a decreased vasoconstrictive response, which impacts ability to respond to temperature changes.

REF: 84 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

The nurse admitting a patient to the emergency department on a very hot

summer day would suspect hyperthermia when the patient demonstrates a.

decreased respirations.

low pulse rate.

red, sweaty skin.

slow capillary refill.

CORRECT ANSWER: C With hyperthermia, vasodilatation occurs causing the skin to appear flushed and warm or hot to touch. There is an increased respiration rate with hyperthermia. The heart rate increases with hyperthermia. With hypothermia there is slow capillary refill.

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REF: 86 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

The priority nursing intervention for a patient suspected to be hypothermic

would be to a.

assess vital signs.

hydrate with intravenous (IV) fluids.

provide a warm blanket.

remove wet clothes.

CORRECT ANSWER: D The first thing to do with a patient suspected to be hypothermic is to remove wet clothes, because heat loss is five times greater when clothing is wet. Assessing vital signs is important, but the wet clothes should be removed first. Hydration is

very important with hyperthermia and the associated danger of dehydration, but there is not a similar risk with hypothermia. A warm blanket over wet clothes would not be an effective warming strategy.

REF: 84 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

Strategies to include in a community program for senior citizens related to

dealing with cold winter temperatures would include a.

avoiding hot beverages.

shopping at an indoor mall.

using a fan at low speed.

walking slowly in the park.

CORRECT ANSWER: B Shopping indoors where there is protection from the elements and temperature control is one strategy to avoid cold temperatures. Hot beverages can help an individual deal with cold weather. Avoiding breezes and air currents is recommended to conserve body temperature. Physical activity can increase body temperature, and if the senior is going to walk in the park, weather-appropriate (warm) clothing and a usual or brisk pace, not a slow pace, would be recommended.

REF: 84|88 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

During orientation to an emergency department, the nurse educator would

be concerned if the new nurse listed which of the following as a risk factor for impaired thermoregulation? a.

Impaired cognition

Occupational exposure

Physical agility

Temperature extremes

CORRECT ANSWER: C Physical agility is not a risk factor for impaired thermoregulation. The nurse educator would use this information to plan additional teaching to include medical conditions and gait disturbance as risk factors for hypothermia, because their bodies have a reduced ability to generate heat. Impaired cognition is a risk factor. Recreational or occupational exposure is a risk factor. Temperature extremes are risk factors for impaired thermoregulation.

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REF: 84-85 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

The most appropriate measure for a nurse to use in assessing core body

temperature when there are suspected problems with thermoregulation is a(n) a.

oral thermometer.

rectal thermometer.

temporal thermometer scan.

tympanic membrane sensor.

CORRECT ANSWER: B The most reliable means available for assessing core temperature is a rectal temperature, which is considered the standard of practice. An oral temperature is a common measure but not the most reliable. A temporal thermometer scan has some limitations and is not the standard. The tympanic membrane sensor could be used as a second source for temperature assessment.

REF: 87 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

The nurse planning care for a patient with hypothermia would consider

knowledge of similar exemplars including a.

heat exhaustion.

heat stroke.

infection.

prematurity.

CORRECT ANSWER: D Prematurity, frost bite, environmental exposure, and brain injury are considered exemplars of hypothermia. Heat exhaustion is an exemplar of hyperthermia. Heat stroke is an exemplar of hyperthermia. Infection is an exemplar of hyperthermia.

REF: 90

OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

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Concept 11: Sleep Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

A patient tells the nurse that he experiences daytime fatigue even after 7–8

hours of sleep each night. What is the best assessment question for the nurse to ask? a.

Have you tried getting 10 hours of sleep instead of 8 hours?

How long are you in the rapid eye movement (REM) stage?

Do you also have any recent lifestyle or behavior changes?

Do any of your close relatives have any sleep disorders?

CORRECT ANSWER: C The best question to elicit the most pertinent information is "Do you also have any recent lifestyle or behavior changes?" The patient is getting 7–9 hours/sleep each night, which is expected for the average adult. The patient will not be able to recall an unconscious state such as REM sleep. The patient may have close relatives with sleep disorders but this does not necessarily affect the patient’s own sleep habits.

REF: Page 98 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Basic Care and Comfort

The nurse is making rounds on the hospital unit and observes a patient

sleeping. The patient’s pulse and respiratory rates are slower than baseline. The nurse realizes the patient has most likely just entered which stage of non-rapid eye movement sleep? a.

Stage 1

Stage 2

Stage 3

Stage 4

CORRECT ANSWER: B In Stage 2 (N2), eye movement ceases; brain waves become even slower with the exception of an occasional burst or more rapid brain waves. Pulse rate and respirations slow and body temperature decreases as the individual moves toward deeper stages of sleep. Stage 3 (N3) and Stage 4 (N4) are the periods of deep sleep.

REF: Page 95 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Basic Care and Comfort

The nurse enters a patient’s room and the patient startles easily and

appears to jerk his arms and legs before awakening. Which stage of non-rapid eye movement sleep did the patient most likely awaken from? a.

Stage 1

Stage 2

Stage 3

Stage 4

CORRECT ANSWER: A

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In Stage 1 (N1 or Non-REM Stage 1), referred to as light sleep, the individual can be awakened easily. In this stage, brain waves slow and, on EEG, the slower wave pattern known as alpha waves appears. The individual at this point is likely to drift in and out of sleep and can be awakened easily. Sensations known as hypnagogic hallucinations can occur during this stage. A common sensation of this type is the feeling of falling. Uncontrolled muscle jerks sometimes occur at this stage along with sudden movements that can startle the individual and restore wakefulness.

REF: Page 95 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Basic Care and Comfort

The nurse must awaken a patient from Stage 4 non-rapid eye movement

sleep in order to prepare the patient for a procedure. The patient is disoriented. What is the nurse’s best action? a.

Notify the healthcare provider

Re-assess the patient’s orientation

Administer an anti-anxiety medication

Cancel the patient’s procedure

CORRECT ANSWER: B Stage 3 (N3) and Stage 4 (N4) are the periods of deep sleep. N3 is characterized by very slow brain waves called delta waves interspersed with smaller, faster waves. In Stage 4 (N4), the EEG shows almost exclusively delta waves. In this type of sleep it is difficult to awaken the individual and muscle activity is very limited or may be completely absent. A person awakened from Stage 3 or 4 of sleep could be disoriented for a brief period of time before regaining awareness.

REF: Page 95 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Basic Care and Comfort

A patient complains of not being able to fall asleep at night and asks the

nurse if there is a safe, non-prescription medication he can try. After consulting the healthcare provider, the nurse should recommend which naturally occurring hormone? a.

Melatonin

Cortisol

Leutinizing hormone

Estrogen

CORRECT ANSWER: A A rise in the hormone melatonin at the onset of sleep helps to promote and maintain sleep, and a drop in levels leads to eventual awakening. The immune system is enhanced as well during sleep as proteins associated with fighting illness are produced. The circadian rhythm, or the typical 24 hour (more or less) cycle through which the body passes, including both awake and sleep cycles, is responsible for regulating all of the physiologic processes in the body. An

adequate amount and quality of sleep, therefore, is essential to all of the regulatory mechanisms that take place in the body.

REF: Page 95|Page 100 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Basic Care and Comfort

A mother tells the nurse she is concerned because her 8 month old infant

sleeps all day and night and is only awake about 2–3 hours per day. What is the nurse’s best response?

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"This sleep pattern is very normal for an infant at this age."

"Adding an additional feeding will keep the child awake more"

"I recommend that you notify the child’s pediatrician."

"Be sure you are laying the child on his back to sleep at night."

CORRECT ANSWER: C By approximately 6 months of age, the infant should sleep through the night with at least one nap during the day. 2–3 hours of wakefulness per day is not an expected finding at age 8 months and should be reported to the pediatrician to determine the underlying cause. An additional feeding may be warranted;

however the pediatrician should be notified first. Lying on infant on the back to sleep is recommended to prevent sudden infant death syndrome; however the priority concern is the length of time the child is sleeping

REF: Page 95 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Basic Care and Comfort

The nurse is caring for a child with tonsillar enlargement. What is the

nurse’s priority concern? a.

Low oxygen saturation

Daytime fatigue

Increased temperature

Antibiotic administration

CORRECT ANSWER: A Tonsillar enlargement in children often leads to obstructive sleep apnea which can cause decreased oxygen saturation levels. Low oxygen is a priority concern which carries the highest safety risk to the child. Obstructive sleep apnea occurs in an estimated 1% to 3% of children, though the causative factors may differ with tonsillar enlargement being a significant component in children. Infection that leads to an increased temperature and requires antibiotic therapy is a concern, but the priority health concern is low oxygen levels. Obstructive sleep apnea can interfere with sleep patterns and lead to daytime fatigue, but the highest priority of care is low oxygen.

REF: Page 96 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

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Concept 12: Cellular Regulation Test Bank

MULTIPLE CHOICE

The nurse would incorporate which of the following into the plan of care as

a primary prevention strategy for reduction of the risk for cancer? a.

Yearly mammography for women aged 40 years and older

Using skin protection during sun exposure while at the beach

Colonoscopy at age 50 and every 10 years as follow-up

Yearly prostate specific antigen (PSA) and digital rectal exam for men

aged 50 and over CORRECT ANSWER: B Primary prevention of cancer involves avoidance to known causes of cancer, such as sun exposure. Secondary screening involves physical and diagnostic examination.

REF: 97

OBJECTIVE: NCLEX® Client Needs Category: Health Promotion

and Maintenance

While collecting a health history on a patient admitted for colon cancer,

which of the following questions would be a priority to ask this patient? a.

"Have you noticed any blood in your stool?"

"Have you been experiencing nausea?"

"Do you have back pain?"

"Have you noticed any swelling in your abdomen?"

CORRECT ANSWER: A Early colon cancer is often asymptomatic, with occult or frank blood in the stool being an assessment finding in a patient diagnosed with colon cancer. If pain is

present, it is usually lower abdominal cramping. Constipation and diarrhea are more frequent findings than nausea or ascites.

REF: 95

OBJECTIVE: NCLEX® Client Needs Category: Physiological

Integrity

While planning care for a patient experiencing fatigue due to

chemotherapy, which of the following is the most appropriate nursing intervention? a.

Prioritization and administration of nursing care throughout the day

Completing all nursing care in the morning so the patient can rest the

remainder of the day c.

Completing all nursing care in the evening when the patient is more rested

Limiting visitors, thus promoting the maximal amount of hours for sleep

CORRECT ANSWER: A Pacing activities throughout the day conserves energy, and nursing care should be paced as well. Fatigue is a common side effect of cancer and treatment; and while adequate sleep is important, an increase in the number of hours slept will not resolve the fatigue. Restriction of visitors does not promote healthy coping and can result in feelings of isolation.

REF: 100 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

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The nurse is caring for a patient who received a bone marrow transplant

10 days ago. The nurse would monitor for which of the following clinical manifestations that could indicate a potentially life-threatening situation? a.

Mucositis

Confusion

Depression

Mild temperature elevation

CORRECT ANSWER: D During the first 100 days after a bone marrow transplant, patients are at high risk for life- threatening infections. The earliest sign of infection in an immunosuppressed patient can be a mild fever. Mucositis, confusion, and depression are possible clinical manifestations but are representative of less lifethreatening complications.

REF: 98-99

OBJECTIVE: NCLEX® Client Needs Category: Physiological

Integrity

While the nurse is obtaining the health history of a 75-year-old female

patient, which of the following has the greatest implication for the development of cancer? a.

Being a 75-year-old woman

Family history of hypertension

Cigarette smoking as a teenager

Advancing age

CORRECT ANSWER: D According to the American Cancer Society, 2007, the most important risk factor for cancer development is advancing age.

REF: 93

OBJECTIVE: NCLEX® Client Needs Category: Physiological

Integrity

In caring for a patient following lobectomy for lung cancer, which of the

following should the nurse include in the plan of care? a.

Position the patient on the operative side only.

Avoid administering narcotic pain medications.

Keep the patient on strict bed rest.

Instruct the patient to cough and deep breathe.

CORRECT ANSWER: D Postoperative deep breathing and coughing is important to promote oxygenation and clearing of secretions. Pain medications will be given to lessen pain and allow for deep breathing and coughing. Strict bed rest is not instituted, because early ambulation will help lessen postoperative complications such as deep vein thrombosis. Prolonged lying on the operative side is avoided.

REF: 97-98

OBJECTIVE: NCLEX® Client Needs Category: Physiological

Integrity

A female patient complains of a “scab that just won’t heal” under her left

breast. During your conversation, she also mentions chronic fatigue, loss of appetite, and slight cough, attributed to allergies. What are the nurse’s next steps?

Continue to conduct a symptom analysis to better understand the patient’s

symptoms and concerns. b.

End the appointment and tell the patient to use skin protection during sun

exposure.

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Suggest further testing with a cancer specialist and provide the appropriate

literature. d.

Tell her to put a bandage on the scab and set a follow-up appointment in

one week. CORRECT ANSWER: A A comprehensive health history is vital to treating and caring for the patient. Often times, symptoms are vague. The nurse should conduct a symptom analysis to gather as much information as possible. Questions should address the duration of the symptoms and include the location, characteristics, aggravating and relief factors, and any treatments taken thus far.

REF: 95

OBJECTIVE: NCLEX® Client Needs Category: Health Promotion

and Maintenance

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Concept 13: Intracranial Regulation Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

The nurse is caring for a patient with increased intracranial pressure.

Which action is considered unsafe? a.

Aligning the neck with the body

Clustering many nursing activities

Elevating the head of the bed 30 degrees

Providing stool softeners or laxatives as ordered

CORRECT ANSWER: B It is important to minimize stress and activities that could increase intracranial pressure. Combining many nursing activities could increase oxygen demand and intracranial pressure. This would not be safe. Interventions which can promote venous outflow can help decrease intracranial pressure. The stress of constipation or bowel movements can increase intracranial pressure; stool softeners or laxatives can minimize this.

REF: Page 122 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

Which assessment finding would be the earliest and most sensitive

indicator that there is an alteration in intracranial regulation? a.

Change in level of consciousness

Inability to focus visually

Loss of primitive reflexes

Unequal pupil size

CORRECT ANSWER: A

A change in level of consciousness is the earliest and most sensitive indication of a change in intracranial processing. This is assessed with the Glasgow Coma Scale (GCS), which assesses eye opening and verbal and motor response. The inability to focus may indicate a change, but it is not one of the earliest indicators or a component of the GCS. Primitive reflexes refer to those reflexes found in a normal infant that disappear with maturation. These reflexes may reappear with frontal lobe dysfunction and may be tested for with a suspected brain injury, so it would be the reappearance of primitive reflexes. A change in pupil size or unequal pupils may indicate a change, but they are not one of the earliest indicators or a component of the GCS.

REF: Page 118 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

When caring for a patient after a head injury, the nurse would be most

concerned with assessment findings which included respiratory changes along with what other findings? a.

Hypertension and bradycardia

Hypertension and tachycardia

Hypotension and bradycardia

Hypotension and tachycardia

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CORRECT ANSWER: A Hypertension with widening pulse pressure, bradycardia, and respiratory changes are the ominous late signs of increased intracranial pressure and indications of impending herniation (Cushing's triad). It is bradycardia, not tachycardia, which is the component of this ominous triad. It is hypertension, not hypotension, which is the component of this ominous triad.

REF: Page 119 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

Components of the Glasgow Coma Scale (GCS) the nurse would use to

assess a patient after a head injury include which assessment? a.

Blood pressure

Cranial nerve function

Head circumference

Verbal responsiveness

CORRECT ANSWER: D Components of the GCS include eye opening, motor responsiveness, and verbal responsiveness. The nurse would want to assess the blood pressure, but this is not a component of the coma scale. Assessment of cranial nerve function is appropriate as alterations such as cranial nerve VI palsies may occur, but this is not part of the coma scale. Increases in head circumference are associated with alterations in intracranial pressure in infants, but this is not part of the coma scale.

REF: Page 118 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

The nurse should teach a patient that which is a primary prevention

strategy to reduce the occurrence of head injuries? a.

Blood pressure control

Smoking cessation

Maintaining a healthy weight

Violence prevention

CORRECT ANSWER: D Injury prevention measures such as wearing a seat belt, helmet use, firearm safety, and violence prevention programs reduce the risk of traumatic brain injuries. Blood pressure control and exercising can decrease the risk of vascular disease, impacting the cerebral arteries, rather than head injuries. Smoking cessation is one primary prevention strategy which can decrease the risk of vascular disease. Maintaining a healthy weight can decrease the risk of vascular disease.

REF: Page 120 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

The nurse preparing to care for a patient after a suspected stroke would

question which order? a.

Antihypertensive

Antipyretic

Osmotic diuretic

Sedative

CORRECT ANSWER: A

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Anti-hypertensive medications may be detrimental because the mean arterial pressure must be adequate to maintain cerebral blood flow and limit secondary injury. Fever can worsen the outcome after a stroke, and antipyretics can promote normothermia. Osmotic diuretics such as mannitol can decrease interstitial volume and decrease intracranial pressure. Short-acting sedatives can decrease intracranial pressure by reducing metabolic demand. Long-acting sedatives would be avoided to provide times for periodic neurologic assessments.

REF: Page 121 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

After shunt procedure, the nurse would monitor the patient's neurologic

status by using which test? a.

Electroencephalogram

Glasgow Coma Scale

National Institutes of Health Stroke Scale

Monro-Kellie doctrine

CORRECT ANSWER: B The GCS gives a standardized numeric score of the neurologic patient assessment. An electroencephalogram is used in diagnosing and localizing the area of seizure origin. This scale is an example of one type of specific tool for nurses to use when assessing a patient following stroke. The Monroe-Kellie doctrine is not an assessment or monitoring strategy; it describes the interrelationship of volume and compliance of the three cranial components, brain tissue, cerebral spinal fluid, and blood.

REF: Page 118 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

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Concept 14: Hormonal Regulation Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

A patient presents to the emergency room complaining of vomiting with

severe back and leg pain. The patient’s home medications include daily oral

corticosteroids. Vital signs reveal a low blood pressure and there are peaked T waves on the electrocardiogram. What is the nurse’s priority intervention? a.

Start an intravenous line

Collect urine specimen

Administer antiemetic

Administer narcotic analgesia

CORRECT ANSWER: A The patient is exhibiting signs of adrenal insufficiency (Addison’s disease) given the regular use of corticosteroids. Cortisone, hydrocortisone (Cortef), prednisone, and fludrocortisone (Florinef) are used for the treatment of adrenocorticoid deficiency. Treatment of Addisonian crisis includes administration of hydrocortisone, saline solution, and sugar (dextrose) to correct the insufficiency. The priority intervention is to start an intravenous line so that appropriate treatments may be administered. A urine specimen may be collected but is not the priority intervention. Since the patient is vomiting, administration of antiemetics or analgesia would be given through an intravenous line. The nurse should also assess for changes in the level of consciousness; so administration of analgesia may be contraindicated if any decrease in level of consciousness occurs.

REF: Page 130 |Page 132 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential

Which important teaching point should the nurse include in the plan of care

for a patient diagnosed with Cushing’s disease? a.

Daily weight using same scale

Wash hands frequently

Use exfoliating soaps when bathing

Avoid yearly influenza vaccine

CORRECT ANSWER: B Cushing’s syndrome is characterized by chronic excess glucocorticoid (cortisol) secretion from the adrenal cortex. This is caused by the hypothalamus, or the anterior pituitary gland, or the adrenal cortex. Cushing’s syndrome can also be caused by taking corticosteroids in the form of medication (such as prednisone) over time – referred to as exogenous Cushing syndrome. Regardless of the cause, excess secretion of cortisol has a systemic affect affecting immunity, metabolism, and fat distribution (truncal obesity), reduced muscle mass, loss of bone density, hypertension, fragility to microvasculature, as well as thinning of the skin. Washing hands is important because the patient’s immune system is suppressed due to the excess glucocorticoid level. Daily weights are not indicated. Exfoliating soaps may damage thin skin. The patient should receive vaccinations due to being immunocompromised.

REF: Page 131 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

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The nurse is caring for a patient diagnosed with syndrome of inappropriate

antidiuretic hormone (SIADH). What is the nurse’s best action? a.

Encourage increased fluid and water intake

Teach about risk for malignancies

Monitor for changes in level of consciousness

Assess labwork for potassium level changes

CORRECT ANSWER: C As the name suggests, SIADH is a condition in which antidiuretic hormone (ADH) is secreted despite normal or low plasma osmolarity, resulting in water retention and dilutional hyponatremia. In response to increased plasma volume, aldosterone secretion increases and further contributes to sodium loss. Hyponatremia frequently manifests with changes in level of consciousness from confusion to coma. A large number of clinical conditions can cause SIADH including malignancies, pulmonary disorders, injury to the brain, and certain pharmacologic agents. Malignancies often lead to SIADH versus SIADH causing malignant conditions. Water intoxication can lead to hyponatremia, therefore water intake is restricted. The most affected electrolyte from SIADH is sodium versus potassium.

REF: Page 132 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential

Following a parathyroidectomy, which electrolyte should the nurse most

closely monitor? a.

Potassium

Sodium

Magnesium

Calcium

CORRECT ANSWER: D Because the parathyroids are located on the thyroid gland, similar concerns for postoperative monitoring apply. Additionally, calcium levels are monitored to avoid hypocalcemic crisis.

REF: Page 130 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential

Radioactive iodine is indicated for the treatment of hyperthyroidism. The

nurse should include which teaching in this patient’s plan of care? a.

Isolation is required for 6–8 weeks

An additional dose may be needed

Thyroid replacement therapy is prescribed

An overnight hospital stay is required

CORRECT ANSWER: B Radioactive iodine (RAI) is indicated for the treatment of hyperthyroidism. It is given as an oral preparation, usually as a single dose on an outpatient basis. The radioactive iodine makes its way to the thyroid gland where it destroys some of the cells that produce thyroid hormone. The RAI is completely eliminated from the body after about 4 weeks. The extent of thyroid cell destruction is variable, thus the patient has ongoing monitoring of thyroid function. If thyroid production remains too high a second dose may be needed. The goal of this procedure is to destroy thyroid hormone producing cells; additional thyroid hormone is not prescribed.

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REF: Page 130 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

The nurse is caring for a patient who has undergone a thyroidectomy.

Which patient complaint is highest priority requiring further evaluation? a.

Pain at surgical site

Thirst

Hoarseness

Nausea

CORRECT ANSWER: C Thyroidectomy involves a surgical incision in the anterior neck. Hoarseness may be a sign of airway edema. A patent airway is always a priority of care for any post-operative patient. General anesthesia is used for this surgery requiring insertion of an artificial airway, therefore throat irritation and thirst is expected. Nausea may be a side effect from anesthesia. Pain is expected at the surgical site.

REF: Page 130 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential

Which statement made by a student nurse indicates the need for further

teaching about pituitary insufficiency? a.

“Synthetic human growth hormone may be prescribed for children who are

small for gestational age.” b.

“Testosterone supplements may be prescribed for women with

gonadotropin deficiency.” c.

“Estrogen is known to regulate the action of growth hormone in men and

women.” d.

“Chronic kidney disease treatment may include synthetic growth hormone

replacement.” CORRECT ANSWER: B Synthetic human growth hormone (HGH) is used for growth hormone deficiencies caused by pituitary insufficiency, as well as other conditions such as Turner’s syndrome, chronic kidney disease, and children small for gestation age. Testosterone is used as supplement for men with gonadotropin deficiency. Estrogen and progesterone supplements, also referred to as hormone replacement therapy (HRT), is indicated for women with gonadotropin deficiency and for the relief of post-menopausal symptoms. Estrogen is also known to regulate secretion and action of GH in men and women.

REF: Page 127 |Page 131 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

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Concept 15: Glucose Regulation Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

The nurse instructs a patient with type 1 diabetes mellitus to avoid which of

the following drugs while taking insulin? a.

Furosemide (Lasix)

Dicumarol (Bishydroxycoumarin)

Reserpine (Serpasil)

Cimetidine (Tagamet)

CORRECT ANSWER: A

Furosemide is a loop diuretic and can increase serum glucose levels; its use is contraindicated with insulin. Dicumarol, an anticoagulant; reserpine, an antihypertensive; and cimetidine, an H2 receptor antagonist, do not affect blood glucose levels.

REF: Page 135 |Page 141 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity

When a diabetic patient asks about maintaining adequate blood glucose

levels, which of the following statements by the nurse relates most directly to the necessity of maintaining blood glucose levels no lower than about 74 mg/dL? a.

“Glucose is the only type of fuel used by body cells to produce the energy

needed for physiologic activity.” b.

“The central nervous system cannot store glucose and needs a continuous

supply of glucose for fuel.” c.

“Without a minimum level of glucose circulating in the blood, erythrocytes

cannot produce ATP.” d.

“The presence of glucose in the blood counteracts the formation of lactic

acid and prevents acidosis.” CORRECT ANSWER: B The brain cannot synthesize or store significant amounts of glucose; thus a continuous supply from the body’s circulation is needed to meet the fuel demands of the central nervous system.

REF: Page 134

OBJECTIVE: NCLEX® Client Needs Category: Physiological

Integrity

The nurse associates which assessment finding in the diabetic patient with

decreasing renal function?

Ketone bodies in the urine during acidosis

Glucose in the urine during hyperglycemia

Protein in the urine during a random urinalysis

White blood cells in the urine during a random urinalysis

CORRECT ANSWER: C

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Urine should not contain protein. Proteinuria in a diabetic heralds the beginning of renal insufficiency or diabetic nephropathy with subsequent progression to end stage renal disease. Chronic elevated blood glucose levels can cause renal hypertension and excess kidney perfusion with leakage from the renal vasculature. This leaking allows protein to be filtered into the urine.

REF: Page 138 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity

What is the nurse’s best response about developing diabetes to the patient

whose father has type 1 diabetes mellitus? a.

“You have a greater susceptibility for development of the disease because

of your family history.” b.

“Your risk is the same as the general population, because there is no

genetic risk for development of type 1 diabetes.” c.

“Type 1 diabetes is inherited in an autosomal dominant pattern. Therefore

the risk for becoming diabetic is 50%.” d.

“Because you are a woman and your father is the parent with diabetes,

your risk is not increased for eventual development of the disease. However, your brothers will become diabetic.” CORRECT ANSWER: A Even though type 1 diabetes does not follow a specific genetic pattern of inheritance, those with one parent with type 1 diabetes are at an increased risk for development of the disease.

REF: Page 142 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity

The nurse recognizes which patient as having the greatest risk for

undiagnosed diabetes mellitus? a.

Young white man

Middle-aged African-American man

Young African-American woman

Middle-aged Native American woman

CORRECT ANSWER: D The highest incidence of diabetes in the United States occurs in Native Americans. With age, the incidence of diabetes increases in all races and ethnic groups.

REF: Page 137 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity

A diabetic patient is brought into the emergency department unresponsive.

The arterial pH is 7.28. Besides the blood pH, which clinical manifestation is seen in uncontrolled diabetes mellitus and ketoacidosis? a.

Decreased hunger sensation

Report of no urine output

Increased respiratory rate

Decreased thirst

CORRECT ANSWER: C

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Ketoacidosis decreases the pH of the blood, stimulating the respiratory control area of the brain to buffer the effects of the increasing acidosis. The rate and

depth of respirations are increased (Kussmaul's respirations) to excrete more acids by exhalation. Usually polydipsia (increased thirst), polyphagia (increased hunger), and polyuria (increased urine output) are seen with hyperglycemia and ketoacidosis.

REF: Page 135 |Page 137 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity

MULTIPLE RESPONSE

Which of the following would be included in the assessment of a patient

with diabetes mellitus who is experiencing a hypoglycemic reaction? (Select all that apply.) a.

Tremors

Nervousness

Extreme thirst

Flushed skin

Profuse perspiration

Constricted pupils

CORRECT ANSWER: A, B, E When hypoglycemia occurs, blood glucose levels fall, resulting in sympathetic nervous system responses such as tremors, nervousness, and profuse perspiration. Dilated pupils would also occur, not constricted pupils. Extreme thirst, flushed skin, and constricted pupils are consistent with hyperglycemia.

REF: Page 135 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity

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Concept 16: Nutrition Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

The home care nurse is assessing an older patient diagnosed with mild

cognitive impairment (MCI) in the home setting. Which information is of concern? a.

The patient's son uses a marked pillbox to set up the patient's medications

weekly. b.

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

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

at night. d.

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

CORRECT ANSWER: B A 10-pound weight loss in 1 month could indicate cancer or may be an indication of further progression of memory loss. Depression is also another common cause of weight loss. The use of a marked pillbox and planning by the family for 24-hour care are appropriate for this patient. It is not unusual that an older patient would have friends who have died.

REF: Page 151 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity

The nurse is assisting a 79-year-old patient with information about diet and

weight loss. The patient has a body mass index (BMI) of 31. How should the nurse instruct this patient? a.

“Your weight is within normal limits. Continue maintaining with current

lifestyle choices.” b.

“You are a little overweight. Cut down on calories and increase your

activity, and you should be fine.” c.

“You are morbidly obese, and we would like to schedule you an

appointment to speak with a bariatric specialist about surgery.” d.

“You are considered obese and will need to consult with your doctor about

a plan that includes exercises, not diet, to decrease weight.” CORRECT ANSWER: D This patient is at an increased risk for sarcopenia and should be instructed to increase activity that includes strength training to prevent muscle loss. Diet is not indicated. A BMI of 31 is considered obese; however, this patient does not qualify for surgical intervention until BMI reaches over 35.

REF: Page 151 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Basic Care and Comfort

The nurse is completing a nutritional assessment on a patient with

hypertension. What foods would be recommended for this patient? a.

Regular diet

Low sodium diet

Pureed diet

Low sugar diet

CORRECT ANSWER: B

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A low sodium diet will prevent water retention which could increase blood pressure. Patients with hypertension would not be on a regular diet due to sodium content. A pureed diet is indicated for stroke patients who may have impaired swallowing. A low sugar diet is indicated for patients with diabetes.

REF: Page 152 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Basic Care and Comfort

During a nutritional assessment, the nurse calculates that a female

patient's BMI is 27. The nurse would advise the patient to follow which of these recommendations? a.

This measurement indicates that the patient is overweight and should

follow a plan of diet and exercise to lose weight.

This measurement indicates that the patient is underweight and will need

to take measures to gain weight. c.

This measurement indicates that the patient is morbidly obese and may be

a candidate for bariatric surgery. d.

This measurement indicates that the patient is of normal weight and should

continue with current lifestyle. CORRECT ANSWER: A A BMI of 25 to 29.9 is in the overweight range. A BMI of <18.5 is in the underweight range. A BMI of 30 to 34.9 is obesity class I, a BMI of 35 to 39.9 is obesity class II, and a BMI of >40 is obesity class III (morbid obesity). A BMI of 19 to 24 is in the normal range.

REF: Page 151 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Basic Care and Comfort

During an interview, the nurse is discussing dietary habits with a patient.

Which tool would be the best choice to use as a quick screening tool to assess dietary intake? a.

Food diary

Calorie count

Comprehensive diet history

24-hour recall

CORRECT ANSWER: D A 24-hour recall is useful as a quick screening tool to assess dietary intake. A food diary provides detailed information, but it is not convenient and requires a follow-up visit. A calorie count requires several days to collect data and requires a trained dietician to analyze the results. A comprehensive diet history may

provide more accurate reflection of nutrient intake, but it is time consuming to acquire and requires a trained/skilled dietary interviewer.

REF: Page 149 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Basic Care and Comfort

During a physical examination, the nurse notes that the patient's skin is dry

and flaking, with patches of eczema. Which nutritional deficiency might be present? a.

Vitamin C

Vitamin B

Essential fatty acid

Protein

CORRECT ANSWER: C

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Dry and scaly skin is a manifestation of essential fatty acid deficiency. Vitamin C deficiency causes bleeding gums, arthralgia, and petechiae. Vitamin B deficiency is too large a category to consider. Specific categories of vitamin B deficiency have been identified, such as pyridoxine and thiamine. Protein deficiency causes decreased pigmentation and lackluster hair.

REF: Pages 147-148 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Basic Care and Comfort

During a physical examination, the nurse notes that the patient's skin is dry

and flaking. What additional data would the nurse expect to find to confirm the suspicion of a nutritional deficiency? a.

Hair loss and hair that is easily removed from the scalp

Inflammation of the tongue and fissured tongue

Inflammation of peripheral nerves and numbness and tingling in

extremities d.

Fissures and inflammation of the mouth

CORRECT ANSWER: A Hair loss (alopecia) and hair that is easily removed from the scalp (easy pluckability), like dry, flaking skin, is caused by essential fatty acid deficiency. Inflammation of the tongue (glossitis) and fissured tongue are manifestations of a niacin deficiency. Inflammation of peripheral nerves (neuropathy) and numbness and tingling in extremities (paresthesia) are manifestations of a thiamin deficiency. Fissures of the mouth (cheilosis) and inflammation of the mouth (stomatitis) are manifestations of a pyridoxine deficiency.

REF: Page 148 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Basic Care and Comfort

MULTIPLE RESPONSE

An African American is at an increased risk for which of the following?

(Select all that apply.) a.

Vitamin D deficiency

Type 1 diabetes

Celiac disease

Type 2 diabetes

Hypertension

Metabolic syndrome

CORRECT ANSWER: A, D, E, F Type 1 diabetes and celiac disease are more common in Northern European heritage.

REF: Page 148 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Basic Care and Comfort

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Concept 17: Elimination Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

A patient who was diagnosed with senile dementia has become incontinent

of urine. The patient’s daughter asks the nurse why this is happening. What is the nurse’s best response? a.

“The patient is angry about the dementia diagnosis.”

“The patient is losing sphincter control due to the dementia.”

“The patient forgets where the bathroom is located due to the dementia.”

“The patient wants to leave the hospital.”

CORRECT ANSWER: B Anger, wanting to leave the hospital, and forgetting where the bathroom is really have no bearing on the urinary incontinence. The patient is incontinent due to the mental ability to voluntarily control the sphincter. This is happening because of the dementia.

REF: Page 159

OBJECTIVE: NCLEX® Client Needs Category:

Psychosocial Integrity

The nurse is caring for a patient who has suffered a spinal cord injury and

is concerned about the patient's elimination status. What is the nurse’s best action? a.

Speak with the patient's family about food choices.

Establish a bowel and bladder program for the patient.

Speak with the patient about past elimination habits.

Establish a bedtime ritual for the patient.

CORRECT ANSWER: B Establishing a bowel and bladder program for the patient is a priority to be sure that adequate elimination is happening for the patient with a spinal cord injury. Speaking with the family to determine food choices is not the primary concern. Speaking with the patient to know past elimination habits does not apply, because the spinal cord injury changes elimination habits. Establishing a bedtime ritual does not apply to elimination.

REF: Page 162 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity

The process of digestion is important for every living organism for the

purpose of nourishment. Where does most digestion take place in the body? a.

Large intestine

Stomach

Small intestine

Pancreas

CORRECT ANSWER: C Most digestion takes place in the small intestine. The main function of the large intestine is water absorption. The pancreas contains digestive enzymes; the stomach secrets hydrochloric acid to assist with food breakdown.

REF: Page 157 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

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The nurse is listening for bowel sounds in a postoperative patient. The

bowel sounds are slow, as they are heard only every 3 to 4 minutes. The patient asks the nurse why this is happening. What is the nurse’s best response? a.

“Anesthesia during surgery and pain medication after surgery may slow

peristalsis in the bowel.” b.

“Some people have a slower bowel than others, and this is nothing to be

concerned about.” c.

“The foods you eat contribute to peristalsis, so you should eat more fiber in

your diet.” d.

“Bowel peristalsis is slow because you are not walking. Get more exercise

during the day.” CORRECT ANSWER: A Anesthesia and pain medication used in conjunction with the surgery are affecting the peristalsis of the bowel. Having a slower bowel, eating certain food, or lack of exercise will not have a direct effect on the bowel.

REF: Page 164 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity

What is a primary prevention tool used for colon cancer screening?

Abdominal x-rays

Blood, urea, and nitrogen (BUN) testing

Serum electrolytes

Occult blood testing

CORRECT ANSWER: D Occult blood testing will reveal unseen blood in the stool, and this may signal a potentially serious bowel problem like colon cancer. BUN is used to evaluate kidney function. Serum electrolytes and abdominal x-rays are not related to colon cancer screening.

REF: Page 162

OBJECTIVE: NCLEX® Client Needs Category: Health

Promotion and Maintenance

MULTIPLE RESPONSE

During an assessment, the patient states that his bowel movements cause

discomfort because the stool is hard and difficult to pass. As the nurse, you make which of the following suggestions to assist the patient with improving the quality of his bowel movement? (Select all that apply.) a.

Increase fiber intake.

Increase water consumption.

Decrease physical exercise.

Refrain from alcohol.

Refrain from smoking.

CORRECT ANSWER: A, B Increasing fiber assists in adding bulk to the stool. Increasing water assists in softening the stool and moving it through the large intestine. Decreasing exercise will have the opposite effect of slowing bowel movements. Refraining from alcohol and smoking have no direct effect on the quality of bowel movements.

REF: Page 162

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OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

When conducting a health history assessment, the nurse would want to

know what most important information about the patient's elimination status? (Select all that apply.) a.

Recent changes in elimination patterns

Changes in color, consistency, or odor of stool or urine

Time of day patient defecates

Discomfort or pain with elimination

List of medications taken by patient

Patient's preferences for toileting

CORRECT ANSWER: A, B, D, E Recent changes in elimination patterns, color, consistency, or odor are important for the nurse to know concerning elimination. Discomfort or pain during elimination is important for the nurse to know. A nurse should also know which medications the patient is on as this may affect elimination. Personal preferences are not the most important data the nurse needs to collect.

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Concept 18: Perfusion Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

The nurse is explaining to a student nurse about impaired central

perfusion. The nurse knows the student understands this problem when the student makes which statement? a.

“Central perfusion is monitored only by the physician.”

“Central perfusion involves the entire body.”

“Central perfusion is decreased with hypertension.”

“Central perfusion is toxic to the cardiac system.”

CORRECT ANSWER: B Central perfusion does involve the entire body as all organs are supplied with oxygen and vital nutrients. The physician does not control the body’s ability for perfusion. Central perfusion is not decreased with hypertension. Central perfusion is not toxic to the cardiac system.

REF: Page 167 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

A patient diagnosed with hypertension asks the nurse how this disease

could have happened to them. What is the nurse’s best response? a.

“Hypertension happens to everyone sooner or later. Don't be concerned

about it.” b.

“Hypertension can happen from eating a poor diet, so change what you are

eating.” c.

“Hypertension can happen from arterial changes that block the blood flow.”

“Hypertension happens when people do not exercise, so you should walk

every day.” CORRECT ANSWER: C Hardening of the arteries from atherosclerosis can cause hypertension in the patient. Hypertension does not happen to everyone. Changing the patient's diet

and exercising may be a positive life change, but these answers do not explain to the patient how the disease could have happened.

REF: Page 170 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

The patient asks the nurse to explain the function of the sinoatrial node in

the heart. What is the nurse’s best response? a.

“The sinoatrial node stimulates the heart to beat in a normal rhythm.”

“The sinoatrial node protects the heart from atherosclerotic changes.”

“The sinoatrial node provides the heart with oxygenated blood.”

“The sinoatrial node protects the heart from infection.”

CORRECT ANSWER: A The sinoatrial node is the natural pacemaker of the heart, and it assists the heart to beat in a normal rhythm. The sinoatrial node does not protect from atherosclerotic changes or infection, and it does not directly provide the heart with oxygenated blood.

REF: Page 167 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

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The patient is brought to the emergency department after a motor vehicle

accident. The patient is diagnosed with internal bleeding. What is the priority of care for this patient? a.

Mental alertness

Perfusion

Pain

Reaction to medications

CORRECT ANSWER: B Perfusion is the correct answer, because with internal bleeding, the nurse should monitor vital signs to be sure perfusion is happening. Mental alertness, pain, and medication reactions are important but not the primary concern.

REF: Page 167 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential

A patient's serum electrolytes are being monitored. The nurse notices that

the potassium level is low. What should the nurse monitor for in this patient? a.

Tissue ischemia

Brain malformations

Intestinal blockage

Cardiac dysrhythmia

CORRECT ANSWER: D Cardiac dysrhythmia is a possibility when serum potassium is high or low. Tissue ischemia, brain malformations, or intestinal blockage do not have a direct correlation to potassium irregularities.

REF: Page 173 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential

A nurse is explaining to a student nurse about perfusion. The nurse knows

the student understands the concept of perfusion when the student makes which statement? a.

“Perfusion is a normal function of the body, and I don't have to be

concerned about it.” b.

“Perfusion is monitored by the physician.”

“Perfusion is monitored by vital signs and capillary refill.”

“Perfusion varies as a person ages, so I would expect changes in the

body.” CORRECT ANSWER: C The best method to monitor perfusion is to monitor vital signs and capillary refill. This allows the nurse to know if perfusion is adequate to maintain vital organs. The nurse does have to be concerned about perfusion. Perfusion is not only monitored by the physician but the nurse too. Perfusion does not always change as the person ages.

REF: Page 171

OBJECTIVE: NCLEX® Client Needs Category: Health

Promotion and Maintenance

The nurse is conducting a patient assessment. The patient tells the nurse

that he has smoked two packs of cigarettes per day for 27 years. The nurse may find which data upon assessment? a.

Elevated blood pressure

Bounding pedal pulses

Night blindness

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Reflux disease

CORRECT ANSWER: A Smokers have a constriction of the blood vessels due to the tar and nicotine in cigarettes. This constriction may lead to hypertension. Bounding pulses, night blindness, and reflux disease do not have a direct link to smoking.

REF: Page 172 |Page 173 |Page 175 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

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Concept 19: Gas Exchange Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

The nurse is assigned a group of patients. Which patient finding would the

nurse identify as a factor leading to increased risk for impaired gas exchange?

Blood glucose of 350 mg/dL

Anticoagulant therapy for 10 days

Hemoglobin of 8.5 g/dL

Heart rate of 100 beats/min and blood pressure of 100/60

CORRECT ANSWER: C The hemoglobin is low (anemia), therefore the ability of the blood to carry oxygen is decreased. High blood glucose and/or anticoagulants do not alter the oxygen carrying capacity of the blood. A heart rate of 100 beats/min and blood pressure of 100/60 are not indicative of oxygen carrying capacity of the blood.

REF: Page 178 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential and Physiological Adaptation

The nurse is reviewing the patient's arterial blood gas results. The PaO2 is

96 mm Hg, pH is 7.20, PaCO2 is 55 mm Hg, and HCO3 is 25 mEq/L. What might the nurse expect to observe on assessment of this patient? a.

Disorientation and tremors

Tachycardia and decreased blood pressure

Increased anxiety and irritability

Hyperventilation and lethargy

CORRECT ANSWER: A The patient is experiencing respiratory acidosis ( pH and PaCO2) which may be manifested by disorientation, tremors, possible seizures, and decreased level of consciousness. Tachycardia and decreased blood pressure are not characteristic of a problem of respiratory acidosis. Increased anxiety and hyperventilation will cause respiratory alkalosis, which is manifested by an increase in pH and a decrease in PaCO2.

REF: Page 182 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential

The nurse would identify which patient condition as a problem of impaired

gas exchange secondary to a perfusion problem? a.

Peripheral arterial disease of the lower extremities

Chronic obstructive pulmonary disease (COPD)

Chronic asthma

Severe anemia secondary to chemotherapy

CORRECT ANSWER: A

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Perfusion relates to the ability of the blood to deliver oxygen to the cellular level and return the carbon dioxide to the lung for removal. COPD and asthma are examples of a ventilation problem. Severe anemia is an example of a transport problem of gas exchange.

REF: Page 179 |Page 180 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

The nurse is assessing a patient's differential white blood cell count. What

implications would this test have on evaluating the adequacy of a patient's gas exchange? a.

An elevation of the total white cell count indicates generalized

inflammation. b.

Eosinophil count will assist to identify the presence of a respiratory

infection. c.

White cell count will differentiate types of respiratory bacteria.

Level of neutrophils provides guidelines to monitor a chronic infection.

CORRECT ANSWER: A Elevation of total white cell count is indicative of inflammation that is often due to an infection. Upper respiratory infections are common problems in altering a patient's gas exchange. Eosinophil cells are increased in an allergic response. Neutrophils are more indicative of an acute inflammatory response. White cells do not assist to differentiate types of respiratory bacteria. Monocytes are an indicator of progress of a chronic infection.

REF: Page 182 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential 5.

The acid-base status of a patient is dependent on normal gas exchange.

Which patient would the nurse identify as having an increased risk for the development of respiratory acidosis? a.

Chronic lung disease with increased carbon dioxide retention

Acute anxiety, hyperventilation, and decreased carbon dioxide retention

Decreased cardiac output with increased serum lactic acid production

Gastric drainage with increased removal of gastric acid

CORRECT ANSWER: A Respiratory acidosis is caused by an increase in retention of carbon dioxide, regardless of the underlying disease. A decrease in carbon dioxide retention may lead to respiratory alkalosis. An increase in production of lactic acid leads to metabolic acidosis. Removal of an acid (gastric secretions) will lead to a metabolic alkalosis.

REF: Page 182 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

Which patient finding would the nurse identify as being a risk factor for

altered transport of oxygen? a.

Hemoglobin level of 8.0

Bronchoconstriction and mucus

Peripheral arterial disease

Decreased thoracic expansion

CORRECT ANSWER: A Altered transportation of oxygen refers to patients with insufficient red blood cells to transport the oxygen present. Bronchoconstriction and decreased thoracic expansion (spinal cord injury) would result in impairment of ventilation. Peripheral vascular disease would result in inadequate perfusion.

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REF: Page 180 |Page 182 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential

A 3-month-old infant is at increased risk for developing anemia. The nurse

would identify which principle contributing to this risk? a.

The infant is becoming more active.

There is an increase in intake of breast milk or formula.

The infant is unable to maintain an adequate iron intake.

A depletion of fetal hemoglobin occurs.

CORRECT ANSWER: D Fetal hemoglobin is present for about 5 months. The fetal hemoglobin begins deteriorating, and around 2 to 3 months the infant is at increased risk of developing an anemia due to decreasing levels of hemoglobin. Breast milk or formula is the primary food intake up to around 6 months. Often iron supplemented formula is offered, and/or an iron supplement is given if the infant is breastfed.

REF: Page 180 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

Which clinical management prevention concept would the nurse identify as

representative of secondary prevention? a.

Decreasing venous stasis and risk for pulmonary emboli

Implementation of strict hand washing routines

Maintaining current vaccination schedules

Prevention of pneumonia in patients with chronic lung disease

CORRECT ANSWER: D Prevention of and treatment of existing health problems to avoid further complications is an example of secondary prevention. Primary prevention includes infection control (hand washing), smoking cessation, immunizations, and prevention of postoperative complications.

REF: Pages 183-184 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

MULTIPLE RESPONSE

The nurse would identify which body systems as directly involved in the

process of normal gas exchange? (Select all that apply.) a.

Neurologic system

Endocrine system

Pulmonary system

Immune system

Cardiovascular system

Hepatic system

CORRECT ANSWER: A, C, E

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The neurologic system controls respiratory drive; the respiratory system controls delivery of oxygen to the lung capillaries; and the cardiac system is responsible for the perfusion of vital organs. These systems are primarily responsible for the adequacy of gas exchange in the body. The endocrine and hepatic systems are not directly involved with gas exchange. The immune system primarily protects the body against infection.

REF: Page 178 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

The nurse is assessing a patient for the adequacy of ventilation. What

assessment findings would indicate the patient has good ventilation? (Select all that apply.) a.

Respiratory rate is 24 breaths/min.

Oxygen saturation level is 98%.

The right side of the thorax expands slightly more than the left.

Trachea is just to the left of the sternal notch.

Nail beds are pink with good capillary refill.

There is presence of quiet, effortless breath sounds at lung base

bilaterally. CORRECT ANSWER: B, E, F Oxygen saturation level should be between 95 and 100%; nail beds should be pink with capillary refill of about 3 seconds; and breath sounds should be present at base of both lungs. Normal respiratory rate is between 12 and 20 breaths/min. The trachea should be in midline with the sternal notch. The thorax should expand equally on both sides.

REF: Page 178 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential

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Concept 20: Reproduction Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

A female college student is planning to become sexually active. She is

considering birth control options and desires a method in which ovulation will be prevented. To prevent ovulation while reaching 99% effectiveness in preventing pregnancy, which option should be given the strongest consideration? a.

Intrauterine device

Coitus interruptus

Natural family planning

Oral contraceptive pills

CORRECT ANSWER: D Oral contraceptive pills prevent ovulation and are 99% effective in preventing pregnancy when taken as directed. Intrauterine devices, coitus interruptus, and natural family planning will not prevent ovulation while reaching 99% effectiveness in preventing pregnancy, so they are not recommended for this college student.

REF: Page 201 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance and Physiological Integrity: Pharmacological and Parenteral Therapies

The nurse at the family planning clinic conducts a male history for infertility

evaluation. Which finding has the greatest implication for this patient’s care? a.

Practice of nightly masturbation

Primary anovulation

High testosterone levels

Impotence due to alcohol ingestion

CORRECT ANSWER: D Factors affecting male infertility include impotence due to alcohol. Nightly masturbation and high testosterone levels do not have the greatest implication on

male infertility in a patient with admitted alcohol issues. Primary anovulation refers to female infertility, so it is not a consideration for male infertility.

REF: Page 201 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

The emergency department nursing assessment of a pregnant female at

35 weeks gestation reveals back pain, blood pressure 150/92, and leaking of clear fluid from the vagina. Which complication of pregnancy does the nurse suspect? a.

Ectopic pregnancy

Spontaneous abortion

Premature rupture of membranes

Supine hypotension

CORRECT ANSWER: C

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Leaking of clear fluid from the vagina with back pain and elevated BP is associated with premature rupture of membranes, a complication of pregnancy. An ectopic pregnancy usually manifests as unilateral pain early in the pregnancy. Vaginal bleeding is a classic sign of miscarriage, or spontaneous abortion, not leaking of clear fluid. This patient’s blood pressure is elevated. Supine hypotension occurs when the woman is lying supine; then low blood pressure occurs due to the decrease in venous return from the gravid uterus placing pressure on the vena cava.

REF: Page 201 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential

The nurse is admitting a prenatal patient for diagnostic testing. While

eliciting the psychosocial history, the nurse learns the patient smokes a pack of cigarettes daily, drinks a cup of cappuccino with breakfast, has smoked marijuana in the remote past, and is a social drinker. Which action should the nurse first take? a.

Strongly advise immediate tobacco cessation

Elimination of all caffeinated beverages

Serum and urine testing for drug use and alcohol use

Referral to a 12-step program

CORRECT ANSWER: A There are numerous risk factors for women and men affecting reproductive health and pregnancy outcomes. These can be categorized into biophysical, psychosocial, sociodemographic, and environmental factors. Some of the risk factors for human reproduction fit into multiple categories. Psychosocial factors cover smoking, excessive caffeine, alcohol and drug abuse, psychologic status including impaired mental health, addictive lifestyles, spouse abuse, and

noncompliance with cultural norms. Drinking a cup of a caffeinated beverage a day is not associated with adverse fetal outcomes usually. Serum and urine testing for drug/alcohol use is not required for stated marijuana use in the remote past. Patient referral to a 12-step program is usually advisable for current alcohol and/or drug use.

REF: Page 204 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential

A female infertility patient is found to be hypoestrogenic at the

preconceptual clinic visit. She asks the nurse why she has never been able to get pregnant. Which response is best? a.

Circulating estrogen contributes to secondary sex characteristics.

Estrogen deficiency prevents the ovum from reaching the uterus and may

be a factor in infertility. c.

Hyperestrogen may be preventing the zona pellucida from forming an

ovum protective layer. d.

The corona radiata is preventing fertilization of the ovum.

CORRECT ANSWER: B

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The cilia in the tubes are stimulated by high estrogen levels, which propel the ovum toward the uterus. Without estrogen, the ovum won’t reach the uterus. The results of a series of events occurring in the ovary cause an expulsion of the oocyte from the ovarian follicle known as ovulation. The ovarian cycle is driven by multiple important hormones: (1) gonadotropic hormone, (2) follicle stimulating hormone (FSH), and (3) luteinizing hormone (LH). The cilia in the tubes are stimulated by high (4) estrogen levels, which propel the ovum toward the uterus. The zona pellucida (inner layer) and corona radiata (outer layer) form protective layers around the ovum. If an ovum is not fertilized within 24 hours of ovulation by a sperm, it is usually reabsorbed into a woman’s body. A patient who is hypoestrogenic would not have excess circulating estrogen. A patient with low estrogen would not be classified as hyperestrogenic. Without sufficient estrogen, there can be no fertilization of the ovum.

REF: Page 199 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

An obstetric multipara with triplets is placed on bed rest at 24 weeks’

gestation. Her perinatologist is managing intrauterine growth restriction with

serial ultrasounds. This prescribed treatment is an example of which type of care? a.

Antenatal diagnostics

Primary prevention

Secondary prevention

Collaborative intervention

CORRECT ANSWER: D An example of collaborative intervention relating to reproductive health would be managing fetal intrauterine growth restriction by serial ultrasounds. This type of diagnostic maternal/fetal monitoring is performed to determine the best time for delivery due to potential fetal nutritional, circulatory, or pulmonary compromise. A cesarean section (operative delivery) may be performed if maternal or fetal conditions indicate that delivery is necessary. Antenatal diagnostics refers to prior to pregnancy. An example of primary prevention is teaching a high school class about reproductive health. An example of secondary prevention is prenatal care in the second trimester of pregnancy to prevent problems for the developing fetus.

REF: Page 204 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

A female patient comes to the clinic after missing one menstrual period.

She lives in a house beneath electrical power lines which is located near an oil field. She drinks two caffeinated beverages a day, is a daily beer drinker, and has not stopped eating sweets. She takes a multivitamin and exercises daily. She denies drug use. Which finding in the history has the greatest implication for this patient’s plan of care? a.

Electrical power lines are a potential hazard to the woman and her fetus.

Living near an oil field may mean the water supply is polluted.

Alcohol exposure should be avoided during pregnancy due to

teratogenicity. d.

Eating sweets may cause gestational diabetes or miscarriage.

CORRECT ANSWER: C

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Stages of development include ovum, embryonic, and fetal. The beginning of the fourth week to the end of the eighth week comprise the embryonic period. Teratogenicity is a major concern because all external and internal structures are developing in the embryonic period. A pregnant woman should avoid exposure to all potential toxins during pregnancy, especially alcohol, tobacco, radiation, and infections during embryonic development. Living in a house beneath power lines is not the greatest implication in this patient’s plan of care as there are no definite risks to the developing fetus. Living near an oil field has no definite risks to the fetus. Eating sweets may contribute to maternal obesity, large for gestational age fetus, and maternal gestational diabetes but does not have the immediate implication of a daily beer drinker which can cause fetal alcohol syndrome.

REF: Page 200 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

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Concept 21: Sexuality Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

A 55-year-old male patient post–myocardial infarction (MI) asks the nurse

whether he will be healthy enough for sexual activity after discharge from the hospital. The patient has been prescribed anti-hypertensives and beta-blockers. During health teaching, the nurse understands that the three phases of the fourstage model of the human sexual response cycle that are of concern for this patient include which phases? a.

Excitement, plateau, and orgasmic

Plateau, orgasmic, and resolution

Excitement, orgasmic, and resolution

Arousal, excitement, and plateau

CORRECT ANSWER: A During these three phases, heart rate, blood pressure, and respirations increase steadily, increasing stress to the heart muscle. This would be the period of greatest concern for a patient who has recently experienced an MI. The plateau and orgasmic phases may be of physiologic concern to this patient, but during the resolution phase, vital signs return to normal, and muscles relax. Arousal is not a phase in the four-stage model of the human sexual response cycle, although some researchers feel this should be added.

REF: Page 208 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

In order to fully assess the patient and plan appropriate care including

health teaching regarding sexuality the nurse should realize that which patient is most at risk for sexual abuse? a.

A recently divorced 50-year-old woman

A Hispanic teenage girl

A 30-year-old African-American male

An individual with intellectual or

developmental disabilities CORRECT ANSWER: D As more of these individuals move into mainstream society, it is important that sexual health is promoted, including teaching regarding sexual norms. Otherwise these individuals are likely victims of unhealthy sexual practices or sexual abuse. In today’s society, the newly unpartnered are likely to begin dating and acquire one or more new sexual partners. This group is at significant risk for exposure to sexually transmitted infections and requires health teaching related to safer sexual practices. The Hispanic teenage girl is at increased risk for unintended teen pregnancy. Adolescent pregnancy puts an undue burden on the young woman during a crucial period of growth and development. Hispanic teens experience double the rate of pregnancy of Caucasian adolescents. Major health disparities continue to exist between African-Americans and

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their Caucasian counterparts—in particular a significantly increased risk for human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and other sexually transmitted diseases. REF: Page 211 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

A 37-year-old heterosexual African-American man has come for his annual

health screening. Which test must the nurse ensure is ordered for this patient? a.

Human papilloma virus (HPV)

Prostate-specific antigen (PSA)

HIV

Venereal disease research laboratory

(VDRL) CORRECT ANSWER: B PSA testing is recommended annually for men at increased risk for prostate cancer. This includes men with a family history or those of African-American descent. HPV testing would likely be ordered for patients with genital warts. This might not be necessary for this patient. Tests for HIV should be ordered for patients that belong to high-risk populations, including men who have sex with men, and all pregnant women. All sexually active men and women should have a VDRL and rapid plasma reagin performed. REF: Page 213 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity

The school nurse is developing a curriculum for a junior human sexuality

class. In order to provide the most up-to-date information, the nurse should be aware that which is the single most effective primary prevention strategy for preventing sexually transmitted infections (STIs)? a.

A vaccine to prevent HPV infection

HIV screening

Abstinence

The male condom

CORRECT ANSWER: C The single most effective (100%) way to prevent sexually transmitted infections is abstinence. When used correctly, the male condom is an effective method for preventing sexually transmitted infections as well as being a very highly effective contraceptive agent. A significant primary prevention strategy is the recent introduction of a vaccine used to prevent cervical cancer and genital warts caused by HPV. One of two FDA- approved vaccines should be routinely administered to 11- and 12-year-old girls and can be given up to the age of 26. HIV screening is recommended for all sexually active teens by the Centers for Disease Control and Prevention. Screening for existing infection is a secondary prevention strategy. By educating teens towards behavior change related to highrisk behaviors, nurses may be able to reduce the risk for contracting sexually transmitted infections.

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REF: Page 213 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

The nurse is caring for a 44-year-old married woman who is complaining of

painful intercourse and incontinence due to prolapse of reproductive organs. Clinical evaluation reveals that the patient has a cystocele. Which treatment option is most appropriate for this patient? a.

Pelvic floor training

Vaginal pessaries

Surgical correction

Lifestyle changes

CORRECT ANSWER: C Depending on the cause, a cystocele can be readily corrected by surgery. Pelvic muscle floor training (Kegel exercises) will most definitely help with symptoms of urinary incontinence. This alone is not adequate treatment for this patient. Vaginal pessaries are an excellent treatment modality for uterine prolapse. Lifestyle changes such as weight loss, avoiding constipation, and reducing highimpact exercise, such as running, will all help the patient with pelvic organ prolapse. Although these modalities will provide relief, they will not correct the cystocele without surgical intervention. REF: Page 215 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity

When assessing high-risk behaviors, which question specifically identifies

a blood-related risk for a sexually transmitted infection? a.

“Have you ever received donor semen,

eggs, or transplanted tissue?” b.

“Have you ever exchanged sex for drugs,

money, or shelter?” c.

“How do you protect yourself from HIV

and sexually transmitted infections?” d.

“Have you ever injected drugs using

shared equipment?” CORRECT ANSWER: A Receipt of any donated organ, tissue, semen, or eggs is considered a bloodrelated risk. Other blood-related risks include blood transfusion, sex with a person with hemophilia, or sharing equipment for tattoos and body piercing. The exchange of sex for money, drugs, or shelter is considered a drug use-related risk. Other drug use-related risks include having sex with a person who uses or shares, and having sex while stoned, high, or drunk so that you cannot remember the details. By using male condoms, female condoms, or other barriers, patient can protect themselves against sexual risk. Other high-risk behaviors in this category include: having sex against one’s will, failing to use protection, having sex with a partner who is bisexual or gay, having anal intercourse, and sexual activity with an increased number of partners. Sharing equipment to inject street drugs or steroids is a drug use-related risk.

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REF: Page 212 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

MULTIPLE RESPONSE

Which statements related to sexual dysfunction are correct? (Select all that

apply.) a.

Biological factors play a more significant

role than psychologic factors. b.

Sexual dysfunction is more prevalent

among men than women. c.

The best predictor of sexual health is

emotional well-being. d.

The patient with sexual dysfunction is at

risk for anxiety and depression. e.

Sexual dysfunction remains uncommon.

CORRECT ANSWER: C, D The best predictor of sexual health is emotional well-being rather than the impairment of the physical aspects of sexual arousal and function. Nurses must remain cognizant that sexual dysfunction, regardless of the cause, is likely to result in a number of negative consequences including anxiety, stress, and

depression. Although sexual arousal may be diminished by biological factors such as illness and hormone levels, psychologic factors such as anxiety, mood disorders, or stress play a more significant role in sexual health. Sexual dysfunction is more common in women, with 40 to 45% of women reporting symptoms as opposed to 20 to 30% of men. It appears that sexual dysfunction is very common among the general population, with rates varying from 20 to 50%.

REF: Page 214 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

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Concept 22: Immunity Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

The nurse is caring for a patient who is being discharged home after a

splenectomy. What information on immune function needs to be included in this patient’s discharge planning? a.

The mechanisms of the inflammatory response

Basic infection control techniques

The importance of wearing a face mask in public

Limiting contact with the general population

CORRECT ANSWER: B The spleen is one of the major organs of the immune system. Without the spleen, the patient is at higher risk for infection; so, the nurse must be sure that the patient understands basic principles of infection control. The patient with a splenectomy does not need to understand the mechanisms of inflammatory

response. The patient with a splenectomy does not need to wear a face mask in public as long as the patient understands and maintains the basic principles of infection control. The patient who has had a splenectomy does not need to limit contact with the general population as long as the patient understands and maintains the basic principles of infection control.

REF: Page 219 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

An 18-month-old female patient is diagnosed with her fifth ear infection in

the past 10 months. The physician notes that the child’s growth rate has decreased from the 60th percentile for height and weight to the 15th percentile over that same time period. The child has been treated for thrush consistently since the third ear infection. The nurse understands that the patient is at risk for which condition? a.

Primary immunodeficiency

Secondary immunodeficiency

Cancer

Autoimmunity

CORRECT ANSWER: A Primary immunodeficiency is a risk for patients with two or more of the listed problems. Secondary immunodeficiency is induced by illness or treatment. Cancer is caused by abnormal cells that will trigger an immune response. Autoimmune diseases are caused by hyperimmunity.

REF: Page 221 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

The nurse is caring for a postoperative patient who had an open

appendectomy. The nurse understands that this patient should have some erythema and edema at the incision site 12 to 24 hours post operation dependent on which condition? a.

His immune system is functioning properly.

He is properly vaccinated.

He has an infection.

The suppressor T-cells in his body are activated.

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CORRECT ANSWER: A Tissue integrity is closely associated with immunity. Openings in the integumentary system allow for the entrance of pathogens. If the immune response is functioning optimally, the body responds to the insult to the tissue by protecting the area from invasion of microorganisms and pathogens with inflammation. Routine vaccinations have no bearing on the body’s response to intentional tissue impairment. The redness and swelling at the incision site in the first 12 to 24 hours is part of optimal immune functioning. A patient with erythema and edema that persist or worsen should be evaluated for infection. Suppressor T-cells help to control the immune response in the body.

REF: Page 225 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

While caring for a patient preparing for a kidney transplant, the nurse

knows that the patient understands teaching on immunosuppression when she makes which statement? a.

“My body will treat the new kidney like my original kidney.”

“I will have to make sure that I avoid being around people.”

“The medications that I take will help prevent my body from attacking my

new kidney.” d.

“My body will only have a problem with my new kidney if the donor is not

directly related to me.” CORRECT ANSWER: C Immunosuppressant therapy is initiated to inhibit optimal immune response. This is necessary in the case of transplantation, because the normal immune response would cause the body to recognize the new tissue as foreign and attack it. The body will identify the new kidney as foreign and will not treat it as the original kidney. While patients with transplants must be careful about exposure to others, especially those who are or might be ill, and practice adequate and consistent infection control techniques, they don’t have to avoid people or social interaction. The new kidney brings foreign cells regardless of relationship between donor and recipient.

REF: Page 222 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

The nurse is caring for a patient who was started on intravenous antibiotic

therapy earlier in the shift. As the second dose is being infused, the patient

reports feeling dizzy and having difficulty breathing and talking. The nurse notes that the patient’s respirations are 26 breaths/min with a weak pulse of 112 beats/min. The nurse suspects that the patient is experiencing which condition? a.

Suppressed immune response

Hyperimmune response

Allergic reaction

Anaphylactic reaction

CORRECT ANSWER: D

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The patient is exhibiting signs and symptoms of an anaphylactic reaction to the medication. These signs and symptoms during administration of a medication do not correspond to a suppressed immune response but a type of hyperimmune response. While the patient is experiencing a hyperimmune response, the signs and symptoms allow for a more specific response. While the patient is

experiencing an allergic reaction, the signs and symptoms presented in the scenario allow for a more specific response.

REF: Page 221 |Page 225 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

The nurse is preparing to administer medications to a patient with

rheumatoid arthritis (RA). The nurse should explain which goal of treatment to the patient? a.

Eradicate the disease

Enhance immune response

Control inflammation

Manage pain

CORRECT ANSWER: C Medications for RA are intended to control the inflammation that results from the body’s hyperimmune response. Autoimmune diseases like RA are chronic and currently have no curative treatments. Autoimmune diseases like RA are caused by hyperimmune response. The immune system needs to be suppressed, not enhanced. While the medications used for RA might help with pain management, the goal of medication intervention is to manage the inflammation.

REF: Page 223 |Page 224 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

MULTIPLE RESPONSE

The parents of a newborn question the nurse about the need for

vaccinations: “Why does our baby need all those shots? He’s so small, and they have to cause him pain.” The nurse can explain to the parents that which of the following are true about vaccinations? (Select all that apply.) a.

Are only required for infants

Are part of primary prevention for system disorders

Prevent the child from getting childhood diseases

Help protect individuals and communities

Are risk free

Are recommended by the Centers for Disease Control and Prevention

(CDC) CORRECT ANSWER: B, D, F Immunizations are considered part of primary prevention, help protect individuals from contracting specific diseases and from spreading them to the community at large, and are recommended by the CDC. Immunizations are recommended for people at various ages from infants to older adults. Vaccination does not guarantee that the recipient won’t get the disease, but it decreases the potential to contract the illness. No medication is risk free.

REF: Page 224 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

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Concept 23: Inflammation Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

A nurse is instructing her patient with ulcerative colitis regarding the need

to avoid enteric coated medications. The nurse knows that the patient understands the reason for this teaching when he states which of the following? a.

“The coating on these medications is irritating to my intestines.”

“I need a more immediate response from my medications than can be

obtained from enteric coated medications.” c.

“Enteric coated medications are absorbed lower in the digestive tract and

can be irritating to my intestines or inadequately absorbed by my inflamed tissue.” d.

“I don’t need to use these medications because they cause diarrhea, and I

have had enough trouble with diarrhea and rectal bleeding over the past weeks.” CORRECT ANSWER: C Enteric coatings on medications are designed to prevent breakdown and absorption of the medication until lower in the digestive tract, usually to prevent stomach irritation or to reach a certain point in the digestive tract for optimal absorption. For the patient with ulcerative colitis, the intestinal lining is inflamed or susceptible to inflammation and can have impaired absorption; therefore, enteric coated medications should be avoided. The coating is not irritating, but the medication can be. The response time of the medication is not a concern in

this instance. Enteric coated medicines do not cause diarrhea simply because they are enteric coated.

REF: Page 238 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

A patient is diagnosed with a sprain to her right ankle after a fall. The

patient asks the nurse about using ice on her injured ankle. What is the nurse’s best response? a.

“Use ice only when the ankle hurts.”

“Ice should be applied for 15 to 20 minutes every 2 to 3 hours over the

next 1 to 2 days.” c.

“Wrap an ice pack around the injured ankle for the next 24 to 48 hours.”

“Ice is not recommended for use on the sprain because it would inhibit the

inflammatory response.” CORRECT ANSWER: B Ice is used on areas of injury during the first 24 to 48 hours after the injury occurs to prevent damage to surrounding tissues from excessive inflammation. Ice should be used for a maximum of 20 minutes at a time every 2 to 3 hours. Ice must be used according to a schedule for it to be effective and not be overused. Using ice more often or for longer periods of time can cause additional tissue damage. Ice is recommended to inhibit the inflammatory process from damaging surrounding tissue.

REF: Page 235 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

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A patient is being treated with an antibiotic for an infected orthopedic

injury. What explanation should the nurse give to the patient about this medication? a.

“Antibiotics will decrease the pain at the site.”

“An antibiotic helps to kill the infection causing the inflammation.”

“An antibiotic inhibits cyclooxygenase, an enzyme in the body.”

“Antibiotics will reduce the patient’s fever.”

CORRECT ANSWER: B Antimicrobials treat the underlying cause of the infection which leads to inflammation. Analgesics and nonsteroidal antiinflammatory drugs (NSAIDs) help to treat pain. NSAIDs and other antipyretics are cyclooxygenase inhibitors. Antipyretics help to reduce fever.

REF: Page 236 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

On admission to the clinic, the nurse notes a moderate amount of serous

exudate leaking from the patient’s wound. The nurse realizes what information about this fluid? a.

Contains the materials used by the body in the initial inflammatory

response. b.

Indicates that the patient has an infection at the site of the wound.

Is destroying healthy tissue.

Results from ineffective cleansing of the wound area.

CORRECT ANSWER: A Exudate is fluid moved from the vascular spaces to the area around a wound. It contains the proteins, fluid, and white blood cells (WBCs) needed to contain possible pathogens at the site of injury. Exudate appears as part of all inflammatory responses and does not mean an infection is present. Exudate is part of normal inflammatory responses which contain self- monitoring mechanisms to help prevent damage to healthy tissue. Exudate appears at wound sites regardless of cleaning done to the area of injury.

REF: Page 234 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

The nurse reviews the patient’s complete blood count (CBC) results and

notes that the neutrophil levels are elevated, but monocytes are still within normal limits. This indicates what type of inflammatory response? a.

Chronic

Resolved

Early stage acute

Late stage acute

CORRECT ANSWER: C

Elevated neutrophils and monocytes within normal limits are findings indicative of early inflammatory response. Neutrophils increase in just a few hours, while it takes the body days to increase the monocyte levels. Chronic inflammation results in varying elevations in WBCs dependent on multiple issues. Elevated neutrophils are not indicative of resolved inflammation. Elevations in monocytes occur later in the inflammatory response.

REF: Page 232

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OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential

A patient comes to the clinic with a complaint of painful, itchy feet. On

interview, the patient tells the nurse that he is a college student living in a dormitory apartment that he shares with five other students. What teaching should the nurse provide for this patient? a.

“Don’t eat with the other students.”

“Avoid sharing razors and other personal items.”

“Have a complete blood count (CBC) checked monthly.”

“Disinfect showers and bathroom floors weekly after use.”

CORRECT ANSWER: B Avoidance of sharing personal items like razors and hairbrushes can decrease the spread of pathogens that cause inflammation and infection. Not eating with the others in his college apartment won’t relieve or prevent the spread of infection. A CBC monthly will not treat or prevent inflammation. Showers should be disinfected before and after each use.

REF: Page 234 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

MULTIPLE RESPONSE

The nurse assesses the patient and notes all of the following. Select all of

the findings that indicate the systemic manifestations of inflammation. a.

Oral temperature 38.6° C/101.5° F

Thick, green nasal discharge

Patient complaint of pain at 6 on a 0 to 10 scale on palpation of frontal and

maxillary sinuses d.

WBC 20 cells/McL 109/L

Patient reports, “I’m tired all the time. I haven’t felt like myself in days.”

CORRECT ANSWER: A, D, E Systemic manifestations of inflammatory response include elevated temperature, leukocytosis, and malaise and fatigue. Purulent exudates and pain are both considered local manifestations of inflammation.

REF: Page 234 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential

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Concept 24: Infection Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

The nurse is working on a plan of care with her patient which includes

turning and positioning and adequate nutrition to help the patient maintain intact skin integrity. The nurse helps the patient to realize that this breaks the chain of infection by eliminating which element? a.

Host

Mode of transmission

Portal of entry

Reservoir

CORRECT ANSWER: C Broken or impaired skin creates a portal of entry for pathogens. By maintaining intact tissue, the patient and the nurse have broken the chain of infection by eliminating a portal of entry. Host is incorrect because you are not eliminating the person or organism. Intact tissue does not eliminate the mode of transmission. Skin can still be used to transfer pathogens regardless of it being intact or broken. Intact skin does not eliminate the location for pathogens to live and grow.

REF: Page 243 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

While reviewing the complete blood count (CBC) of a patient on her unit,

the nurse notes elevated basophil and eosinophil readings. The nurse realizes that this is most indicative of which type of infection? a.

Bacterial

Fungal

Parasitic

Viral

CORRECT ANSWER: C Parasitic infections are frequently indicated on a CBC by elevated basophil and eosinophil levels. Bacterial infections do not lead to elevated basophil and eosinophil levels but elevated B and T lymphocytes, neutrophils, and monocytes. Fungal infections do not lead to elevated basophil and eosinophil levels. Viral infections create elevations in B and T lymphocytes, neutrophils, and monocytes.

REF: Page 246 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential

Which set of assessment data is consistent for a patient with severe

infection that could lead to system failure? a.

Blood pressure (BP) 92/52, pulse (P) 56 beats/min, respiratory rate (RR)

10 breaths/min, urine output 1200 mL in past 24 hours b.

BP 90/48, P 112 beats/min, RR 26 breaths/min, urine output 240 mL in

past 24 hours c.

BP 112/64, P 98 beats/min, RR 18 breaths/min, urine output 2400 mL in

past 24

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hours d.

BP 152/90, P 52 beats/min, RR 12 breaths/min, urine output 4800 mL in

past 24 hours CORRECT ANSWER: B The patient with severe infection presents with low BP and compensating elevations in pulse to move lower volumes of blood more rapidly and respiration to increase access to oxygen. Urine output decreases to counteract the decreased circulating blood volume and hypotension. These vital signs are all too low: Blood pressure (BP) 92/52, pulse (P) 56 beats/min, respiratory rate (RR) 10 breaths/min, urine output 1200 mL in past 24 hours. The patient with severe infection does have a low BP, but the pulse and respiratory rate increase to compensate. This data is all within normal limits: BP 112/64, P 98 beats/min, RR 18 breaths/min, urine output 2400 mL in past 24 hours. This set of data reflects an elevated BP with a decrease in pulse and respiratory rates along with normal urine output: BP 152/90, P 52 beats/min, RR 12 breaths/min, urine output 4800 mL in past 24 hours. None of these is a typical response to severe infection.

REF: Page 241 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

A nurse is teaching a group of business people about disease

transmission. He knows that he needs to reeducate when one of the participants states which of the following? a.

“When traveling outside of the country, I need to be sure that I receive

appropriate vaccinations.” b.

“Food and water supplies in foreign countries can contain microorganisms

to which my body is not accustomed and has no resistance.”

“If I don’t feel sick, then I don’t have to worry about transmitted diseases.”

“I need to be sure to have good hygiene practices when traveling in

crowded planes and trains.” CORRECT ANSWER: C People can transmit pathogens even if they don’t currently feel ill. Some carriers never experience the full symptoms of a pathogen. Travelers may need different vaccinations when traveling to countries outside their own because of variations in prevalent microorganisms. Food and water supplies in foreign countries can contain microorganisms that will affect a body unaccustomed to their presence. Adequate hygiene is essential when in crowded, public spaces like planes and other forms of public transportation.

REF: Page 245 |Page 246 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

In order to provide the best intervention for a patient, the nurse is often

responsible for obtaining a sample of exudate for culture. What information will this provide? a.

Whether a patient has an infection.

Where an infection is located.

What cells are being utilized by the body to attack an infection.

What specific type of pathogen is causing an infection.

CORRECT ANSWER: D

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People can transmit pathogens even if they don’t currently feel ill. Some carriers never experience the full symptoms of a pathogen. A CBC will identify that the patient has an infection. Inspection and radiography will help identify where an infection is located. The CBC with differential will identify the white blood cells being used by the body to fight an infection. The culture will grow the microorganisms in the sample for identification of the specific type of pathogen.

REF: Page 246 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential

MULTIPLE RESPONSE

The nurse is caring for a patient with a diagnosed case of Clostridium

difficile. The nurse expects to implement which of the following interventions? (Select all that apply.) a.

Administration of protease inhibitors

Use of personal protective equipment

Patient teaching on methods to inhibit transmission

Preventing visitors from entering the room

Administration of intravenous fluids

Strict monitoring of intake and output

CORRECT ANSWER: B, C, E, F Protease inhibitors are used for treatment of viral infections, not bacterial infections. The nurse wants to protect visitors from exposure to the bacteria and protect the patient from secondary infection while immunocompromised, but the patient will need the support of family and close friends. Contact isolation precautions must be strictly followed along with the use of personal protective equipment and teaching on methods to inhibit transmission to help break the chain of infection. Intravenous fluids and strict intake and output monitoring will be important for the patient suffering the effects of Clostridium difficile, because it causes diarrhea with fluid loss.

REF: Page 246 |Page 247 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Basic Care and Comfort and Physiological Adaptation

Individuals of low socioeconomic status are at an increased risk for

infection because of which of the following? (Select all that apply.) a.

Uninsured or underinsured status

Easy access to health screenings

High cost of medications

Inadequate nutrition

Mostly female gender

CORRECT ANSWER: A, C, D Individuals of low socioeconomic status tend to be part of the underinsured or uninsured population. Lack of insurance decreases accessibility to health care in general and health screening services specifically. High costs of medication and nutritious food also make this population at higher risk for infection. Gender has

not been shown to be an increased risk factor for infection in the lower socioeconomic population.

REF: Page 243

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OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Basic Care and Comfort and Psychosocial Integrity

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Concept 25: Mobility Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

A patient who has been in the hospital for several weeks is about to be

discharged. The patient is weak from the hospitalization and asks the nurse to explain why this is happening. What is the nurse’s best response? a.

“Your iron level is low. This is known as anemia.”

“Your immobility in the hospital is known as deconditioning.”

“Your poor appetite is known as malnutrition.”

“Your medications have caused drug induced weakness.”

CORRECT ANSWER: B When a person is ill and immobile the body becomes weak. This is known as deconditioning. Anemia, malnutrition, and medications may have an adverse effect on the body, but this is not known as deconditioning which is the most likely cause in this patient’s situation.

REF: Page 252 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

An older patient is talking with the nurse about hip fractures. The patient

would like to know the best approach to strengthen the bones. What is the nurse’s best response? a.

“Walk at least 5 miles every day for exercise.”

“Wear proper fitting shoes to prevent tripping.”

“Talk with your physician about a calcium supplement.”

“Stand up slowly so you don’t feel faint.”

CORRECT ANSWER: C Calcium strengthens the bones. A calcium supplement will help strengthen bones as they may be affected by aging, illness, or trauma. Walking several miles will help strengthen the bones, but the patient should consult with the healthcare

provider before any exercise regimen is implemented for the older adult. Wearing proper shoes and standing slowly to prevent dizziness is important but they will not prevent fractures.

REF: Page 253 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity

Mobility for the patient changes throughout the life span. What is the term

that best describes this process? a.

Aging and illness

Illness and disease

Health and wellness

Growth and development

CORRECT ANSWER: D Growth and development happens from infancy to death. Muscular changes are always happening, and these changes affect the individual and his or her performance in life. Aging, illness, health, and wellness do have an effect on a person, but they don’t always affect mobility.

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REF: Page 253 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity

The nurse is talking to the unlicensed assistive personnel about moving a

patient in bed. The nurse knows the unlicensed assistive personnel understands the concept of mobility and proper moving techniques when making which statement? a.

“Patients must have a trapeze over the bed to move properly.”

“Patients should move themselves in bed to prevent immobility.”

“Patients should always have a two-person assist to move in bed.”

“Patients must be moved correctly in bed to prevent shearing.”

CORRECT ANSWER: D Patients must be moved properly in bed to prevent shearing of the skin. Having a trapeze over the bed is only functional if the patient can assist in the moving process. A two-person assist is good, but the patient still needs to be moved properly. A patient may move himself or herself if he or she is able; but shearing may still occur.

REF: Page 254 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity

The nurse and a student nurse are discussing the effects of bed immobility

on patients. The nurse knows that the student nurse understands the concept of mobility when making which statement? a.

“Patients with impaired bed mobility have an increased risk for pressure

ulcers.” b.

“Patients with impaired bed mobility like to have extra visitors.”

“Patients with impaired bed mobility need to have a mechanical soft diet.”

“Patients with impaired bed mobility are prone to constipation.”

CORRECT ANSWER: A Patients who cannot move themselves in bed are more susceptible to pressure ulcers because they cannot relieve the pressure they feel. Extra visitors or diet consistency do not have any bearing on mobility. Constipation should not be a by-product of immobility if a bowel regimen is instituted.

REF: Page 254 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

What percentage of hip fractures is the result of falls?

50%

b. 80% c.

90%

d. 100% CORRECT ANSWER: C About 90% of falls end with a hip fracture.

REF: Page 255 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

The lack of weight bearing leads to what effects on the skeletal system?

Demineralization, calcium loss

Thickened bones

Increased range of motion

Increased calcium deposition in the bones

CORRECT ANSWER: A

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Weight bearing helps to strengthen the bone. Lack of weight bearing means that the bone is losing minerals and calcium that strengthen it. Thickened bones will not occur with the lack of weight bearing. Range of motion may be decreased with a lack of weight bearing movements.

REF: Page 257 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity

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Concept 26: Tissue Integrity Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

An older patient has developed age spots and is concerned about skin

cancer. How would the nurse instruct the patient to perform skin checks to assess for signs of skin cancer? a.

“Limit the time you spend in the sun.”

“Monitor for signs of infection.”

“Monitor spots for color change.”

“Use skin creams to prevent drying.”

CORRECT ANSWER: C The ABCD method (check for asymmetry, border irregularity, color variation, and diameter) should be used to assess lesions for signs associated with cancer. Color change could be a sign of cancer and needs to be looked at by a dermatologist. Limiting time spent in the sun is a preventative measure but will not assist the patient in checking the skin or detecting skin cancer. Infection is usually not found in skin cancer. Skin creams have not been shown to prevent cancer nor would they assist in detecting skin cancer.

REF: Page 266 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

A patient is to receive phototherapy for the treatment of psoriasis. What is

the nursing priority for this patient? a.

Obtaining a complete blood count (CBC)

Protection from excessive heat

Protection from excessive ultraviolet (UV) exposure

Instructing the patient to take their multivitamin prior to treatment

CORRECT ANSWER: C Protection from excessive UV exposure is important to prevent tissue damage. Protection from heat is not the most important priority for this patient. There is no need for vitamins or a CBC for patients with psoriasis.

REF: Page 267

OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment Safety: Safety and Infection Control

A patient was given a patch test to determine what allergen was

responsible for their atopic dermatitis. The provider prescribes a steroid cream. What important instructions should the nurse give to the patient? a.

Apply the cream generously to affected areas.

Apply a thin coat to affected areas, especially the face.

Apply a thin coat to affected areas; avoid the face and groin.

Apply an antihistamine along with applying a thin coat of steroid to affected

areas. CORRECT ANSWER: C The patient should avoid the face and groin area as these areas are sensitive and may become irritated or excoriated. An antihistamine cream would also excoriate the area if the pruritus is cause by an allergen. There may be a need to administer oral steroid if the rash is generalized.

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REF: Pages 266-267

OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

A patient in the outpatient setting was diagnosed with atopic dermatitis.

What interventions will the plan of care focus primarily on? a.

Decreasing pain

Decreasing pruritus

Preventing infection

Promoting drying of lesions

CORRECT ANSWER: B Pruritus is the major manifestation of atopic dermatitis and causes the greatest morbidity. The urge to scratch may be mild and self-limiting, or it may be intense, leading to severely excoriated lesions, infection, and scarring.

REF: Page 267 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

To help decrease the threat of a melanoma in a blonde-haired, fair-skinned

patient at risk, the nurse would advise the patient to do which of the following? a.

Apply sunscreen 1 hour prior to exposure.

Drink plenty of water to prevent hot skin.

Use vitamins to help prevent sunburn by replacing lost nutrients.

Apply sunscreen 30 minutes prior to exposure.

CORRECT ANSWER: D Wearing sunglasses and sunscreen are recommended by the National Cancer Institute. Drinking water will help with heat exhaustion but will not prevent melanoma. Green tea, fish oil, soy products, and vitamin E are thought to be

helpful in minimizing the risk of developing melanoma; however, vitamins do not prevent burn.

REF: Page 266 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

A nurse is educating a 21-year-old lifeguard about the risk of skin cancer

and the need to wear sunscreen. Which statement by the patient indicates that the need for further teaching? a.

“I wear a hat and sit under the umbrella when not in the water.”

“I don’t bother with sunscreen on overcast days.”

“I use a sunscreen with the highest SPF number.”

“I wear a UV shirt and limit exposure to the sun by covering up.”

CORRECT ANSWER: B The sun’s rays are as damaging to skin on cloudy, hazy days as on sunny days. The other options will all prevent skin cancer.

REF: Page 266 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

A patient has cellulitis on the right forearm. The nurse would anticipate

orders to administer medications to eradicate which organism? a.

Candida albicans

Group A beta-hemolytic streptococci

Staphylococcus aureus

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E. Coli

CORRECT ANSWER: C Staphylococcus aureus is the usual cause of cellulitis, although other pathogens may be responsible. A small abrasion or lesion can provide a portal for opportunistic or pathogenic infectious organisms to infect deeper tissues.

REF: Page 268 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

A nurse is conducting community education classes on skin cancer. One

participant says to the nurse: “I read that most melanomas occur on the face and arms in fair-skinned women. Is this true?” The nurse’s most helpful response would be which of the following? a.

“That is not correct. Melanoma is more commonly found on the torso or the

lower legs of women.” b.

“That is correct, because the face and arms are exposed more often to the

sun.” c.

“That is not correct. Melanoma occurs on the top of the head in men but is

rare in women.” d.

“That is incorrect. Melanoma is most commonly seen in dark-skinned

individuals.”

CORRECT ANSWER: A Melanoma is more commonly found on the torso or the lower legs in women. Melanoma can occur anywhere and is not associated with direct exposure. For example, an individual can have melanoma under the skin and on the soles of the feet. Dark-skinned individuals are less likely to get melanoma.

REF: Page 264 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

The nurse is instructing the nursing assistant to prevent pressure ulcers in

a frail older patient. Which action indicates the nursing assistant has understood the nurse’s teaching? a.

Bathing and drying the skin vigorously to stimulate circulation

Keeping the head of the bed elevated 30 degrees

Limiting intake of fluid and offer frequent snacks

Turning the patient at least every 2 hours

CORRECT ANSWER: D The patient should be turned at least every 2 hours as permanent damage can occur in 2 hours or less. If skin assessment reveals a stage I ulcer while on a 2hour turning schedule, the patient must be turned more frequently. Limiting fluids will prevent healing; however, offering snacks is indicated to increase healing particularly if they are protein based, because protein plays a role in healing. Use of doughnuts, elevated heads of beds, and overstimulation of skin may all stimulate, if not actually encourage, dermal decline.

REF: Page 164 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

10.

A patient asks the nurse what the purpose of the Wood’s light is. Which

response by the nurse is accurate? a.

“We will put an anesthetic on your skin to prevent pain.”

“The lamp can help detect skin cancers.”

“Some patients feel a pressure-like sensation.”

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“It is used to identify the presence of infectious organisms and proteins

associated with specific skin conditions.” CORRECT ANSWER: D The Wood’s light examination is the use of a black light and darkened room to assist with physical examination of the skin. The examination does not cause discomfort.

REF: Page 265 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

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Concept 27: Sensory Perception Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

A 75-year-old woman walks into the emergency department with

complaints of “not feeling well.” Her blood pressure is 145/95, pulse 85 beats/min, respirations 24 breaths/min, and blood sugar 300. Upon inspection, the nurse notices that the woman has an open wound on the bottom of her foot, but the patient states she is not aware of this. How should the nurse interpret these findings? a.

Normal in the older adult

A need for the patient to be evaluated for cognitive impairment

A side effect of anti-hypertensive medication

Pathologic impairment of sensory responses

CORRECT ANSWER: D This degree of sensory impairment at this age is not expected. Lack of sensation does not imply lack of knowledge, but rather decreased ability to perceive the stimuli. Anti- hypertensive medication does not typically cause decreased skin sensation. This is more common in antineoplastic drugs. Most likely the patient has diabetes, which is causing decreased sensation. Not feeling well is secondary to a change in blood sugar as a result of the wound response.

REF: Page 273 |Page 274 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

The nurse requests that a mother give permission for a hearing test in a

newborn infant. The mother questions the importance of such a test. The nurse correctly responds with which of the following statements? a.

“This will help us to identify your baby’s risk for ear infections the first year

of life.”

“Hearing is important so your baby hears and responds to your voice,

which makes you feel like a mother.” c.

“Socialization skills include the need to hear in order to interpret the

emotional aspect of the words that are spoken to your child.” d.

“Imitation of sounds is the first step in language development, and it is

important to identify alterations early.” CORRECT ANSWER: D Newborn screening of hearing does not identify risk of infection but only of sensory responses. The baby’s response to the mother is important to bonding, but this not the most important reason to evaluate hearing. Likewise, socialization and tone recognition are functions of hearing, but the most significant reason to test hearing is to identify losses and provide compensatory ways to encourage language development.

REF: Page 274 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

An adult male patient is complaining of decreased appetite. He states he

just finished taking his antibiotics for an episode of pneumonia. What is the nurse’s best response? a.

“Your wife should increase the spices in your food, as the pneumonia

changes your

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sense of smell.” b.

“Notify your doctor immediately, because this is a concerning reaction to

the medication.” c.

“You need to take an appetite stimulant, as your body will need good

nutrition to recover from the infection.” d.

“You should see an improvement in the next week or so. Call if this

continues.” CORRECT ANSWER: D Many medications cause a change in sense of taste, including antibiotics. This is temporary and does not require interventions. Pneumonia affects the lower respiratory tract, and is less likely to cause change in smell. The short-term effects of the antibiotic should not necessitate major concern regarding diet intake, including stimulants.

REF: Page 276 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

An 80-year-old patient is being discharged after he was diagnosed with

diabetes mellitus and retinopathy. His daughter has been part of the discharge instruction process. Understanding of the instructions is evident when the daughter says which of the following? a.

“I will make sure that Dad always wears warm socks.”

“Dad needs to wear his glasses so he can delay the onset of macular

degeneration.”

“I will ask the home health aide to carefully inspect Dad’s feet every day

when she helps him bathe.” d.

“We will give him only warm foods, so that he doesn’t burn his mouth.”

CORRECT ANSWER: C Diabetes increases risk of peripheral neuropathy, and it is hard to inspect one’s own feet. Though socks that fit well are important, warmth is not the main issue. Glasses do not affect the onset of eye disorders, including macular degeneration. The sensory deficit regarding perception of heat and cold is usually associated with the distal extremities.

REF: Page 277 |Page 278 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

The patient who had a hip replacement yesterday has a visual acuity of

20/200 after correction. What is the nurse’s best action to provide recreational activities during the rehabilitation phase? a.

Place the television to the left or right of patient’s visual field.

Encourage the patient to learn braille.

Suggest use of talking books.

Provide headphones for listening to music.

CORRECT ANSWER: C Talking books would provide a quick, short-term means of entertainment. Braille might be recommended as a long-term solution to visual deficits. The placement of the television is not helpful with low acuity, unless the patient has macular degeneration. Headphones may be nice, but the patient has a visual deficit and no indication that hearing is a problem.

REF: Page 277 OBJECTIVE: NCLEX® Client Needs Category: Psychosocial Integrity

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The nurse is examining the eyes of a newborn infant. If the nurse notes the

absence of the red reflex, what is the next best action? a.

Notify the physician.

Document the finding in the records.

Recheck the reflex after several hours.

Monitor the eye movements and pupil reactions closely.

CORRECT ANSWER: A The absence of the red reflex suggests the presence of congenital cataracts, which is an abnormal finding. It will not change in several hours, nor do the eye movements and pupil reaction provide significant changes in this situation.

REF: Page 277 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity

The nurse is providing health teaching to a group of mothers of school-

aged children. Which statement by a mother indicates the need for additional instruction? a.

“I will take my child to the audiologist because he doesn’t seem to hear me

except when I look directly at him.” b.

“Both of my children have the same eye medication, which is a real bonus,

because I only need to buy one bottle.” c.

“Making my child wear ear plugs when she goes to a rock concert may

save her hearing!” d.

“I see now why when my child has a cold, he complains about everything

tasting blah!” CORRECT ANSWER: B Each person should always have their own eye medication to prevent infection transfer between them. The child who only hears with direct visional contacts may be lip-reading and have a hearing loss. Exposure to loud noises is known to cause hearing loss. Sense of taste and smell can be altered by upper respiratory infections.

REF: Page 274 |Page 275 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

During the examination of the ear, a dark yellow substance is noted in the

ear canal. The tympanic membrane is not visible. The patient’s wife complains that he never hears what she says lately. These findings would suggest that the nurse prepare the patient for which procedure? a.

Tympanoplasty

Irrigation of the ear

Pure tone test

Otoscopic exam by a specialist

CORRECT ANSWER: B The symptoms are consistent with blockage of the ear canal with cerumen, which then needs to be removed by irrigation, so that further examination of the ear drum and hearing can be accomplished. A tympanoplasty is only warranted if there has been a perforation, which is unknown at the present.

REF: Page 278 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity

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Concept 28: Pain Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

A 62-year-old male has fallen while trimming tree branches sustaining

tissue injury. He describes his condition as an aching, throbbing back. This is characteristic of what type of pain?

Neuropathic pain

Nociceptive pain

Chronic pain

Mixed pain syndrome

CORRECT ANSWER: B Nociceptive pain refers to the normal functioning of physiological systems that leads to the perception of noxious stimuli (tissue injury) as being painful. Patients describe this type of pain as aching, cramping, or throbbing. Neuropathic pain is pathologic and results from abnormal processing of sensory input by the nervous system as a result of damage to the brain, spinal cord, or peripheral nerves. Patients describe this type of pain as burning, sharp, and shooting. Chronic pain is constant and unrelenting such as pain associated with cancer. Mixed pain syndrome is not easily recognized, is unique with multiple underlying and poorly understood mechanisms like fibromyalgia and low back pain.

REF: Page 283 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

A 19-year-old male has sustained a transection of C-7 in a motor vehicle

crash rendering him a quadriplegic. He describes his pain as burning, sharp, and shooting. What type of pain is this patient describing? a.

Neuropathic pain

Ghost pain

Mixed pain syndrome

Nociceptive pain

CORRECT ANSWER: A Neuropathic pain results from the abnormal processing of sensory input by the nervous system as a result of damage to the brain, spinal cord, or peripheral

nerves. Simply put, neuropathic pain is pathologic. Examples of neuropathic pain include postherpetic neuralgia, diabetic neuropathy, phantom pain, and post stroke pain syndrome. Patients with neuropathic pain use very distinctive words to describe their pain, such as “burning,” “sharp,” and “shooting.” Ghost pain is pain associated with loss of a limb or digit. Mixed pain syndrome is not easily recognized, is unique with multiple underlying and poorly understood mechanisms like fibromyalgia and low back pain. Nociceptive pain refers to the normal functioning of physiological systems that leads to the perception of noxious stimuli (tissue injury) as being painful. Patients describe this type of pain as aching, cramping, or throbbing. Neuropathic pain is pathologic and results from abnormal processing of sensory input by the nervous system as a result of damage to the brain, spinal cord, or peripheral nerves. Patients describe this type of pain as burning, sharp, and shooting.

REF: Page 285

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OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

Controlling pain is important to promoting wellness. Unrelieved pain has

been associated with complication?

Prolonged stress response and a cascade of harmful effects system-wide

Large tidal volumes and decreased lung capacity

Decreased tumor growth and longevity

Decreased carbohydrate, protein, and fat destruction

CORRECT ANSWER: A Pain triggers a number of physiologic stress responses in the human body. Unrelieved pain can prolong the stress response and produce a cascade of harmful effects in all body systems. The stress response causes the endocrine system to release excessive amounts of hormones, such as cortisol, catecholamines, and glucagon. Insulin and testosterone levels decrease. Increased endocrine activity in turn initiates a number of metabolic processes, in particular, accelerated carbohydrate, protein, and fat destruction, which can result in weight loss, tachycardia, increased respiratory rate, shock, and even death. The immune system is also affected by pain as demonstrated by research showing a link between unrelieved pain and a higher incidence of nosocomial infections and increased tumor growth. Large tidal volumes are not associated with pain while decreased lung capacity is associated with unrelieved pain. Decreased tumor growth and longevity are not associated with unrelieved pain. Decreased carbohydrate, protein, and fat are not associated with pain or stress response.

REF: Page 285 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4.

An elderly Chinese woman is interested in biologically based therapies to

relieve osteoarthritis (OA) pain. You are preparing a plan of care for her OA. Options most conducive to her expressed wishes may include which actions or activities? a.

Pilates, breathing exercises, and aloe vera

Guided imagery, relaxation breathing, and meditation

Herbs, vitamins, and tai chi

Alternating ice and heat to relieve pain and inflammation

CORRECT ANSWER: C Nonpharmacologic strategies encompass a wide variety of nondrug treatments that may contribute to comfort and pain relief. These include the body-based (physical) modalities, such as massage, acupuncture, and application of heat and cold, and the mind-body methods, such as guided imagery, relaxation breathing, and meditation. There are also biologically based therapies which involve the use of herbs and vitamins, and energy therapies such as reiki and tai chi. Pilates, breathing exercises, aloe vera, guided imagery, relaxation breathing, meditation, and alternating ice and heat are multimodal therapies for pain management. They are not exclusively biologically based, which involves the use of herbs and vitamins.

REF: Page 289 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

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A 70-year-old retired nurse is interested in nondrug, mind-body therapies,

self-management, and alternative strategies to deal with joint discomfort from rheumatoid arthritis. What options should you consider in her plan of care considering her expressed wishes? a.

Stationary exercise bicycle, free weights, and spinning class

Mind-body therapies such as music therapy, distraction techniques,

meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy c.

Chamomile tea and IcyHot gel

Acupuncture and attending church services

CORRECT ANSWER: B Mind-body therapies are designed to enhance the mind’s capacity to affect bodily function and symptoms and include music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy, among many others. Stationary exercise bicycle, free weights, and spinning are not mind-body therapies. They are classified as exercise therapies. Chamomile tea and IcyHot gel are not mid-body therapies per se. They are classified as herbal and topical thermal treatments. Acupuncture is an ancient Chinese complementary therapy, while attending church services is a religious prayer mind-body therapy capable of enhancing the mind’s capacity to affect bodily function and symptoms.

REF: Page 289 OBJECTIVE: NCLEX® Client Needs Category: Psychosocial Integrity

A 30-year-old male is admitted to the hospital with acute pancreatitis. He is

in acute pain described as a 10/10, which is localized to the abdomen,

periumbilical area, and some radiation to his back. The abdomen is grossly distended so it is difficult to assess. He is restless and agitated, with elevated pulse and blood pressure. An appropriate pain management plan of care may include which medication(s)? a.

IV Dilaudid q 4 hours prn, hydrocodone 5/500 PO q 6 hours prn, and

acetaminophen b.

Norco 5/500 q 4 hours PO and Benadryl 25 mg PO q 6 hours

Phenergan 25 mg IM q 6 hours

Tylenol 325 mg q 6 hours

CORRECT ANSWER: A A variety of routes of administration are used to deliver analgesics. A principle of pain management is to use the oral route of administration whenever feasible. All of the first-line analgesics used to manage pain are available in short-acting and long-acting formulations. For patients who have continuous pain, a long-acting analgesic, such as modified-release oral morphine, oxycodone, or hydromorphone, or transdermal fentanyl, is used to treat the persistent baseline pain. A fast-onset, short-acting analgesic (usually the same drug as the longacting) is used to treat breakthrough pain if it occurs. When the oral route is not possible, such as in patients who cannot swallow or are NPO or nauseated, other routes of administration are used, including intravenous (IV), subcutaneous, transdermal, and rectal. Norco, Benadryl, Phenergan, and Tylenol are not appropriate solo choices for acute pancreatitis with pain reported as 10/10.

REF: Page 289 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

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An 80-year-old male patient is in the intensive care unit has suffered a

fractured femur. You are making rounds and notice he is somnolent, with no response to verbal or physical stimulation. He has been on round the clock opioid doses q 4 hours. What is the nurse’s first action? a.

Call the rapid response team to care for the patient immediately.

Discontinue the opioids on the medication administration record.

Assess the patient’s blood pressure and pain level.

Start a second intravenous line with a large bore catheter.

CORRECT ANSWER: B After establishing unresponsiveness, the next action is to call a Rapid Response. The patient is not able to subjectively describe pain if unresponsive. Another IV line may be needed, but first the nurse should call for help. The opioids should be discontinued on the MAR; however the priority action is to call for help.

REF: Page 289 |Page 291 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

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Concept 29: Fatigue Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

Based on the significant effects of chronic idiopathic fatigue, what is the

nurse’s priority assessment? a.

Cholesterol level and lipid profile

Creatinine and BUN levels

Memory loss testing

Mental health evaluation

CORRECT ANSWER: D Fatigue does not cause death or organ failure, but mortality from suicide was higher than the general population in patients with chronic idiopathic fatigue. Therefore a mental health evaluation is a priority assessment. Cholesterol and lipid levels are indicative of heart disease. Creatinine and BUN levels are indicators of kidney function. Memory loss is not a significant effect of chronic fatigue.

REF: Page 293 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential

The nurse is assessing for fatigue in a patient diagnosed with multiple

sclerosis. Which self -reporting tool is best for the nurse to utilize? a.

Multidimensional Assessment of Fatigue (MAF)

Fatigue Severity Scale (FSS)

Brief Fatigue Inventory (BFI)

Multidimensional Fatigue Inventory (MFI)

CORRECT ANSWER: B The FSS was developed for patients with multiple sclerosis and lupus. The MAF was designed for arthritis patients and is also used in cancer patients and those with chronic pulmonary disease. The BFI is used for cancer patients. The MFI is used with various patient populations, including cancer, chronic fatigue syndrome, and COPD.

REF: Page 296 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential

A patient presents to the clinic complaining of nausea, vomiting, and

fatigue. Lab results reveal elevated BUN and creatinine levels. Which acute condition is this patient at most risk for developing? a.

Influenza

Mononucleosis

Acute renal failure

Pneumonia

CORRECT ANSWER: C

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The patient’s symptoms are most congruent with dehydration. Hypovolemia, due to dehydration, can lead to decreased perfusion to the kidneys resulting in acute renal failure. Influenza symptoms include headache, fever, body aches, and

fatigue. Mononucleosis can manifest as severe fatigue. Pneumonia presents with cough, respiratory distress, and decreases in oxygen saturation.

REF: Page 298 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

The nurse is caring for a patient diagnosed with amyotrophic lateral

sclerosis. The nurse should assess for which priority problem? a.

Fatigue

Bradypnea

Hypertension

Fall risk

CORRECT ANSWER: B Amyotrophic lateral sclerosis is a chronic condition that causes fatigue; however specific respiratory muscle fatigue leading to braypnea is the priority safety risk. Respiratory muscle fatigue can lead to bradypnea, decreased ventilation, and eventually cessation of breathing which is the condition of highest importance with this illness. Hypertension is not a high priority problem specifically related to ALS. While the patient is a fall risk due to overall skeletal muscle fatigue, respiratory depression is the priority safety risk.

REF: Page 296 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential

A patient with chronic kidney disease is most likely to complain of which

symptom? a.

Fatigue

Thirst

Constipation

Excess bleeding

CORRECT ANSWER: A Erythropoietin is produced by the kidneys. A patient with chronic kidney disease produces less erythropoietin, resulting in anemia and fatigue as a common symptom. Thirst, or polydipsia, is a common sign of hyperglycemia and diabetes which can lead to chronic kidney disease. Constipation is not a common symptom of chronic kidney disease. Excessive bleeding can result from a decrease in platelets and clotting factors that are produced by the liver, not the kidneys.

REF: Page 295 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential

A patient has been recently diagnosed with chronic fatigue syndrome and

asks the nurse about the cause of this illness. What is the nurse’s best response? a.

“The provider will be able to tell you when the lab results are back.”

“An exact cause may not be determined, but a treatment plan will be

discussed.” c.

“Stress is the main cause; a referral to a counselor may be helpful.”

“This is considered a psychiatric illness requiring behavioral medicine.”

CORRECT ANSWER: B

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Chronic fatigue syndrome is considered an illness with an unknown etiology. There are no specific lab results that reveal chronic fatigue syndrome. Stress and mental illnesses may be contributing factors, but are not classified as exact causes of chronic fatigue syndrome.

REF: Page 295 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential

The nurse palpates swollen nodes in a patient’s neck who presented to the

clinic with complaints of fatigue lasting at least 2 weeks. What is the nurse’s best action? a.

Advise patient this finding is normal.

Review patient’s thyroid labwork.

Perform deep tendon reflexes.

Notify the healthcare provider.

CORRECT ANSWER: D The nurse should notify the healthcare provider for further evaluation. Palpation is indicated to assess for the presence of lymphadenopathy, thyroid nodules or goiter. These findings could implicate the need to test further for cancer, thyroid disease or infection. These conditions should be ruled out by the healthcare provider. Thyroid nodules or changes in size indicate the need for further assessment of the thyroid. Deep tendon reflexes are part of a neuro-muscular examination and are not directly related to cervical node enlargement.

REF: Page 296 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential

MULTIPLE RESPONSE

The nurse is assessing a patient for risk factors of chronic fatigue

syndrome. Which factors should the nurse identify as placing the patient at risk for chronic fatigue syndrome? (Select all that apply.) a.

Feeling tired upon awakening

Chronic migraines

Tenderness under the jaw

5 episodes tonsillitis/past year

Swollen, painful knees

CORRECT ANSWER: A, C, D, E The individual has severe chronic fatigue for 6 or more consecutive months that is not due to ongoing exertion or other medical conditions associated with fatigue (these other conditions need to be ruled out by a doctor after diagnostic tests have been conducted). The fatigue significantly interferes with daily activities and work. The individual concurrently has four or more of the following eight symptoms: •

Post exertion malaise lasting more than 24 hours

•

Unrefreshing sleep

•

Significant impairment of short-term memory or concentration

•

Muscle pain

•

Multi-joint pain without swelling or redness

•

Headaches of a new type, pattern, or severity

•

Tender cervical or axillary lymph nodes

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•

Frequent or recurring sore throat

REF: Page 295 |Page 296 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential

The occupational health nurse is making rounds in a factory. Which

employees need further education about energy conservation strategies? a.

Workers reaching up to high shelf often to obtain cleaning supplies

Workers bending over to lift boxes onto conveyer belt

Workers who have delegated out parts of their activities

Workers standing for long periods

Workers standing at desks at waist level

CORRECT ANSWER: A, B, D The employee health nurse should provide teaching to employees about energy conservation strategies to protect workers from job-related injuries. These strategies include: placing frequently used items within reach; using proper body mechanics (not bending over and straining the back); and standing for long

periods of time. Delegating parts of activities is an appropriate energy conserving strategy. When standing is necessary, it is important that desks or tables are at waist level of the employee to prevent excess reaching or straining.

REF: Page 296 | Page 297 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential

The nurse recognizes that which patients are at highest risk for physiologic

fatigue? (Select all that apply.) a.

Parents of a newborn

Adolesent with anorexia

25-year-old pregnant female

Grandmother who takes mile walks

Businessman who consumes six cups coffee/day

CORRECT ANSWER: A, B, C, E Physiologic causes of fatigue include: protein calorie malnutrition, excessive physical activity, sleep deprivation, excessive caffeine or alcohol use, and pregnancy. Parents of a newborn are likely experiencing sleep deprivation. A patient with anorexia is likely not consuming adequate amounts of protein. Consumption of six cups of coffee/day is considered excessive. A

mile walk is an appropriate exercise for an older adult and not considered

excessive physical activity.

REF: Page 296 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential

Which are treatment related causes of fatigue? (Select all that apply.)

Blood transfusion

Chemotherapy

Radiation therapy

Surgery

Side effects of medications

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CORRECT ANSWER: B, C, D, E Cancer treatments, such as chemotherapy and radiation, commonly cause fatigue. A risk of any surgery is blood loss, which can possibly lead to fatigue if the hemoglobin and hematocrit drop significantly. Fatigue is a side effect of many medications. A blood transfusion is more likely to lead to increased energy versus fatigue as the hematocrit and hemoglobin levels would be expected to rise with the transfusion.

REF: Page 297 | Page 298 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential

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Chapter 30: Stress and Coping

MULTIPLE CHOICE

The nurse knows that one theory explaining the variation in response to

stress among individuals is called: a.

stress appraisal.

sense of coherence.

allostasis.

homeostasis.

CORRECT ANSWER: B Sense of coherence (SOC) is a characteristic of personality that references one’s perception of the world as comprehensible, meaningful, and manageable. Stress appraisal is the automatic, often unconscious assessment of a demand or stressor. Allostasis is an alternative term for the stress response. Homeostasis is the tendency of the body to seek and maintain a condition of balance or equilibrium.

DIF: Understanding

REF: pp. 730-732

OBJECTIVE: 32.1

TOP: Assessment MSC: NCLEX Client Needs Category: Psychosocial Integrity NOT: Concepts: Stress

The nurse is caring for a patient with a new diagnosis of diabetes type 2.

Which of the following statements indicates a negative coping response? a.

“I will look up information on the Internet about diabetes.”

“I will join a support group.”

“I will only focus on learning to manage my medication first.”

“I will make changes slowly so I can adapt to each change.”

CORRECT ANSWER: C

When the patient puts limits on learning by stating he/she will only learn about medication, he/she is using avoidance strategies to alleviate stress. Using strategies such as information gathering (seeking information about diabetes) is positive. Joining support groups and making changes slowly to adapt is also taking direct action by moving forward.

DIF: Understanding

REF: p. 733

OBJECTIVE: 32.1

TOP: Assessment MSC: NCLEX Client Needs Category: Psychosocial Integrity NOT: Concepts: Coping

The nurse is caring for a patient who is undergoing a major cardiac

procedure. The patient tells you her heart is racing and she feels nauseated. You know this is part of hormone response known as: a.

sense of coherence.

stress appraisal.

fight or flight.

sympathoadrenal response.

CORRECT ANSWER: C

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In the “fight or flight” response, the corticotropin-releasing hormone (CRH) released by the hypothalamus stimulates the pituitary to release adrenocorticotropic hormone (ACTH). These hormones increase the heart rate, resulting in increased cardiac output, and the motility of the digestive tract is decreased, slowing digestive processes that could result in abdominal distress. Sense of coherence (SOC) is a characteristic of personality that references one’s perception of the world as comprehensible, meaningful, and manageable. Stress appraisal is the automatic, often unconscious, assessment of a demand or stressor. The sympathoadrenal response is a consequence of hypothalamic activation in sympathetic stimulation, which triggers epinephrine and norepinephrine release from the adrenal medulla.

DIF: Applying

REF: p. 730 | pp. 732-733

OBJECTIVE: 32.2

TOP: Assessment MSC: NCLEX Client Needs Category: Psychosocial Integrity NOT: Concepts: Coping

The nurse is measuring her patient’s blood glucose levels after an acute

myocardial infarction (MI). She knows the rationale for doing this is: a.

damaged muscle tissue releases glucose.

corticosteroids increase glucose.

myocardial infarctions are often seen in diabetics.

all patients should have their blood glucose checked.

CORRECT ANSWER: B The endocrine system responds to stress on the body such as what happens during an acute MI. Corticosteroids are important in the stress response because they increase serum glucose levels and inhibit the inflammatory response.

Although MIs can be seen in diabetics, there is nothing to indicate this patient is diabetic. All patients do not routinely have their blood glucose checked regularly.

DIF: Applying

REF: p. 734

OBJECTIVE: 32.2

TOP:

Implementation MSC: NCLEX Client Needs Category: Psychosocial Integrity NOT: Concepts: Coping

The nurse is teaching her patient about the difference between mild

anxiety and moderate anxiety. Which statement by the patient indicates a need for further education? a.

“Mild anxiety can help me remember things.”

“Moderate anxiety will narrow my focus.”

“Mild anxiety will help me be creative.”

“Moderate anxiety will increase my perception.”

CORRECT ANSWER: D Moderate anxiety narrows a person’s focus, dulls perception, and may challenge a person to pay attention or use appropriate problem-solving skills. Mild anxiety can be motivational, foster creativity, and actually increase a person’s ability to think clearly.

DIF: Analyzing

REF: p. 735

OBJECTIVE: 32.2

TOP:

Implementation MSC: NCLEX Client Needs Category: Psychosocial Integrity

NOT: Concepts:

Stress and Coping

The nurse is providing discharge instructions for a patient with multiple

sclerosis (an autoimmune disease). Which discharge instruction is aimed at preventing a future exacerbation? a.

Engage in some form of exercise as tolerated.

Avoid highly stressful situations.

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Check your skin regularly for pressure sores.

Eat a diet with lots of fiber.

CORRECT ANSWER: B High stress levels are known to exacerbate multiple sclerosis and other autoimmune diseases. Exercise helps keep muscles loose and helps with balance, and assessing skin for pressure sores and eating a diet with high fiber prevents complications from multiple sclerosis.

DIF: Analyzing

REF: p. 735

OBJECTIVE: 32.3

TOP:

Implementation MSC: NCLEX Client Needs Category: Psychosocial Integrity

NOT: Concepts:

Stress and Coping

The nurse is assessing level of stress in a patient from another culture.

Which question is the most appropriate in helping the nurse understand the impact of the patient’s belief system? a.

“Do you engage in prayer to help you during times of stress?”

“Do you go to church or other form of organized worship?”

“Do you have certain beliefs that are helpful during times of stress?”

“Do you want spiritual counseling while you are here?”

CORRECT ANSWER: C The nurse needs to obtain a knowledge base of the patient’s culture as well as identify health beliefs and cultural values from the patient’s worldview. Asking the patient specific questions about prayer or church or spiritual counseling is inappropriate until the nurse first understands what the patient’s own beliefs and practices are. DIF: Analyzing

REF: pp. 736-737

OBJECTIVE: 32.4

TOP:

Assessment MSC: NCLEX Client Needs Category: Psychosocial Integrity

NOT: Concepts:

Stress and Coping

The nurse is performing a physical assessment of patient who is

undergoing a bone marrow biopsy. What finding by the nurse indicates the patient is experiencing stress? a.

Blood pressure of 120/84

Temperature of 37.5° C

Heart rate of 110 beats/min

Respiratory rate of 10 breaths/min

CORRECT ANSWER: C The release of hormones increase the heart rate, resulting in increased cardiac output and elevated blood pressure. A reading of 120/84 is a normal blood pressure, and temperature is elevated is indicative of an infection. The respiratory rate increases in stress not decreases.

DIF: Analyzing

REF: p. 733

OBJECTIVE: 32.4

MSC: NCLEX Client Needs Category: Psychosocial Integrity Stress and Coping

TOP: Assessment NOT: Concepts:

The nurse is assessing the patient’s use of coping skills in response to

stressful situations. Which of the following questions is the most useful? a.

“Have you been evaluated for stress?”

“Do you have someone you can go to for help when you are stressed?”

“How have you managed stressful situations in the past?”

“Does stress cause you to experience muscle tension or headaches?”

CORRECT ANSWER: C

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The use of open-ended questions assists in obtaining accurate information regarding the patient’s stressors and coping skills. Questions that elicit yes/no answers will not allow the patient to provide as much information. Asking the patient about headaches and tension is asking about physical symptoms, not coping skills.

DIF: Applying Assessment

REF: pp. 736-737

OBJECTIVE: 32.4

TOP:

MSC: NCLEX Client Needs Category: Psychosocial Integrity

NOT: Concepts:

Stress and Coping

10.

The nurse is caring for a patient on a medical-surgical inpatient unit. The

patient tells the nurse he is very sad and is considering suicide. What is the first thing the nurse should do? a.

Notify the health care provider.

Make a referral to psychiatric services.

Implement one-on-one observations.

Document in the electronic medical record.

CORRECT ANSWER: C Verbalization of suicidal ideation or a suicide plan must be taken seriously. In the case of a hospitalized patient, one-on-one observation should be implemented to ensure patient safety. Once the patient is under observation, the health care provider is notified to put in the referral; nurses generally do not put in the referral. Documentation is always done after the patient’s safety is ensured.

DIF: Analyzing

REF: p. 738

OBJECTIVE: 32.4

TOP:

Implementation MSC: NCLEX Client Needs Category: Psychosocial Integrity

NOT: Concepts:

Stress and Coping

11.

The nurse knows an appropriate goal for the nursing diagnosis of

Ineffective coping would be: a.

The patient will report an ability to remember discharge instructions.

The patient’s family will understand how to access respite care services.

The patient will discuss possible coping strategies during weekly

counseling sessions. d.

The patient will attend an online support group weekly.

CORRECT ANSWER: C An appropriate goal for Ineffective coping would be to discuss coping strategies. Remembering discharge instructions is an appropriate goal for Anxiety. Understanding how to access respite care services is an appropriate goal for Caregiver role strain, and attending a support group is an appropriate goal for Readiness for enhanced coping.

DIF: Applying

REF: p. 738

OBJECTIVE: 32.6

MSC: NCLEX Client Needs Category: Psychosocial Integrity

TOP: Diagnosis NOT: Concepts:

Stress and Coping

12.

The nurse knows an appropriate goal for Stress overload is:

The patient will attend a weekly support group.

The patient will discuss possible coping strategies during weekly office

visits. c.

The patient will discuss strategies for coping with relationship violence

within 24 hours. d.

The patient’s family will use respite care once a week for the next month.

CORRECT ANSWER: C

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Strategies for coping with relationship violence within 24 hours (short timeframe) is an appropriate goal for Stress overload. Attending a weekly support group is an appropriate goal for Readiness for enhanced coping. An appropriate goal for Ineffective coping would be to discuss possible coping strategies during weekly visits. Using respite care once a week for the next month is an appropriate goal for Caregiver role strain.

DIF: Applying

REF: p. 738

OBJECTIVE: 32.6

MSC: NCLEX Client Needs Category: Psychosocial Integrity

TOP: Diagnosis NOT: Concepts:

Stress and Coping

13.

The nurse knows that an appropriate goal for Readiness for enhanced

coping would be: a.

The patient will report an ability to focus on discharge instructions.

The patient will attend a coping skills class on a weekly basis.

The patient will discuss possible coping strategies during weekly office

visits. d.

The patient will discuss strategies for coping with relationship violence

within 24 hours. CORRECT ANSWER: C The patient will discuss possible coping strategies during weekly office visits is an appropriate goal for Readiness for enhanced coping. The patient will report an ability to focus on discharge instructions is an appropriate goal for Anxiety. An appropriate goal for Ineffective coping would be to discuss possible coping strategies during weekly visits. Strategies for coping with relationship violence within 24 hours (short timeframe) is an appropriate goal for Stress overload.

DIF: Applying

REF: p. 738

OBJECTIVE: 32.6

MSC: NCLEX Client Needs Category: Psychosocial Integrity

TOP: Diagnosis NOT: Concepts:

Stress and Coping

14.

The nurse knows that when coordination between multiple health care

disciplines is needed, the following role is used: a.

Pastoral care

Case manager

Social worker

Dietitian

CORRECT ANSWER: B If coordination of care between multiple health care disciplines is needed, a case manager is used. Pastoral care plays a significant role in addressing stress and anxiety issues when the patient has a preferred religion or strong faith background. A social worker identifies appropriate services and resources. A dietician can provide education regarding dietary needs and food choices.

DIF: Understanding

REF: p. 739

OBJECTIVE: 32.6 TOP:

Implementation MSC: NCLEX Client Needs Category: Psychosocial Integrity

NOT: Concepts:

Stress and Coping

15.

The nurse is providing education to a patient around anger management

strategies. Which statement indicates a need for further education by the patient? a.

“Exercise can help me deal with the anger.”

“I can use humor.”

“I can punch things.”

“I can take a time out.”

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CORRECT ANSWER: C Strategies should focus on non-violent methods. Some anger management interventions include expressing feelings in a calm, non-confrontational manner; exercising; identifying potential solutions; taking a time out; forgiving; diffusing the situation with humor; owning one’s feelings; and breathing deeply.

DIF: Understanding

REF: p. 741

OBJECTIVE: 32.7 TOP:

Implementation MSC: NCLEX Client Needs Category: Psychosocial Integrity

NOT: Concepts:

Stress and Coping

16.

The nurse is educating the patient about alternative therapies. Which

statement by the patient indicates a need for more information? a.

Alternative therapies can include relaxation techniques.

Alternative therapies are used in conjunction with medical therapies.

Alternative therapies can be used when patients are experiencing stress.

Some alternative therapists require certification.

CORRECT ANSWER: B

Alternative therapies are used in place of medical treatment. These types of interventions are useful when patients are experiencing physiologic and psychological responses to stress. Some complementary and alternative therapies such as therapeutic touch, Reiki, biofeedback, and massage therapy require additional certification and training, whereas muscle relaxation and guided imagery do not.

DIF: Understanding

REF: p. 741

OBJECTIVE: 32.7 TOP:

Implementation MSC: NCLEX Client Needs Category: Psychosocial Integrity

NOT: Concepts:

Stress and Coping

17.

The nurse is educating the patient on the use of relaxing therapy. Which

statement by the patient indicates a need for further education? a.

“I should relax my muscles from head to toe.”

“I visual the relaxed muscle.”

“I should do this three times a week.”

“I focus on muscles that are tense.”

CORRECT ANSWER: C This technique should be done daily. Typically, relaxation progresses from head to toe. With practice, the patient visualizes an image of the relaxed muscles and will be able to relax muscles from the mental image. Progressive relaxation is implemented by having patients focus on muscles that are tensed and then intentionally relax those muscle groups.

DIF: Applying

REF: pp. 741-742

OBJECTIVE: 32.7

TOP:

Implementation MSC: NCLEX Client Needs Category: Psychosocial Integrity Stress and Coping

NOT: Concepts:

18.

The nurse is seeing a patient during a follow-up visit after discharge in

which the patient had a nursing diagnosis of Ineffective coping. Which statement by the patient would be a cause for concern? a.

“I am sleeping better most nights.”

“I feel less anxious.”

“I do not need to do the relaxation exercises anymore.”

“I am continuing my exercises every day.”

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CORRECT ANSWER: C Patients should continue using the stress-reduction techniques to maintain a feeling of well- being. Once stress decreases, patients typically report feeling better, sleeping more soundly, and feeling less anxious. Continuing their positive activities such as exercising is good.

DIF: Applying

REF: p. 743

OBJECTIVE: 32.8

TOP:

Implementation MSC: NCLEX Client Needs Category: Psychosocial Integrity Stress and Coping

NOT: Concepts:

MULTIPLE RESPONSE

The nurse knows that when patients are experiencing stress, the following

change can be seen in their signs and symptoms: (Select all that apply.) a.

Increase in heart rate

Increase in gastric motility

Pupil dilation

Decrease in blood pressure

Increase in respiratory rate

CORRECT ANSWER: A, C, E The physiologic response to stress, whether physical or psychological, is activation of the autonomic nervous system, resulting in an increase in heart rate, blood pressure, and respirations along with pupil dilation and a decrease in gastric motility and blood flow to the skin.

DIF: Applying

REF: p. 730

OBJECTIVE: 32.1

MSC: NCLEX Client Needs Category: Psychosocial Integrity

TOP: Assessment NOT: Concepts:

Stress

The nurse knows that the body’s response to the release of hormones in

the “fight or flight” response is which of the following? (Select all that apply.) a.

Decreased respiratory rate

Slowing of the digestive process

Glucose being mobilized from the liver

Pupils dilating

Smooth muscles in the bronchi constricting

CORRECT ANSWER: B, C, D The release of hormones increases the heart rate, resulting in increased cardiac output and elevated blood pressure. There is an increase in the flow of blood to

muscles at the expense of the digestive and other systems not immediately needed in the fight-or-flight response. Smooth muscles in the bronchi relax and dilate the bronchi and smaller airways, and the respiratory rate increases, allowing for an enhanced flow of welloxygenated blood to muscles and other organs. The motility of the digestive tract is decreased, slowing digestive processes, but glucose and fatty acids are mobilized from the liver and other stores to support increased mental activities (alertness) and skeletal muscle function. Pupillary dilation produces a larger visual field.

DIF: Understanding

REF: pp. 733-734

OBJECTIVE: 32.2

TOP: Assessment MSC: NCLEX Client Needs Category: Psychosocial Integrity NOT: Concepts: Stress

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The nurse knows that certain personality factors have been shown to

buffer the impact of stress. These factors are: (Select all that apply.) a.

resilience.

sense of coherence.

gender.

hardiness.

coping style.

CORRECT ANSWER: A, B, D Personality factors such as resilience, hardiness, and sense of coherence can buffer the impact of stress, reducing the negative consequences. Gender is not a personality factor. Coping style refers to a pattern of measures taken to relieve stress but is not a personality factor.

DIF: Understanding

REF: p. 734

OBJECTIVE: 32.2

TOP: Assessment MSC: NCLEX Client Needs Category: Psychosocial Integrity NOT: Concepts: Stress and Coping

The nurse knows that childhood stress related to the school experience

centers on: (Select all that apply.) a.

goal achievement.

family dissolution.

life changes.

test anxiety.

competition.

CORRECT ANSWER: A, D, E Childhood stress related to the school experience centers on competition, goal achievement, and test anxiety. Family dissolution and life changes are not related to the school experience.

DIF: Understanding

REF: p. 736

OBJECTIVE: 32.3

TOP: Assessment MSC: NCLEX Client Needs Category: Psychosocial Integrity NOT: Concepts: Stress

The nurse knows that the coping strategies that are more frequently seen

in older adults are: (Select all that apply.) a.

anger.

withdrawal.

information gathering.

avoidance.

problem focused.

CORRECT ANSWER: A, B Cognitive changes may affect an older adult’s ability to cope. Anger or withdrawal as coping strategies may be used more frequently than in the past.

DIF: Applying

REF: p. 736

OBJECTIVE: 32.3

MSC: NCLEX Client Needs Category: Psychosocial Integrity

TOP: Assessment NOT: Concepts:

Stress and Coping

The nurse manager of a busy oncology unit is concerned about

compassion fatigue among her nursing staff. Which of the following signs and symptoms would alter her to this problem? (Select all that apply.) a.

Nurses become very emotionally upset without an apparent cause.

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Nurses start to avoid caring for certain patients.

Nurses start to call in sick more often.

Nurses begin working more overtime.

Nurses have difficulty showing empathy for patients.

CORRECT ANSWER: A, B, C, E Compassion fatigue occurs when deeply caring and empathetic nurses become overwhelmed by the constant needs of patients and families. Symptoms include mood swings, avoidance ofworking with some patients, frequent sick days, irritability, reduced memory, poor concentration, and a decreased ability to show empathy.

DIF: Applying

REF: p. 744

OBJECTIVE: 32.8

MSC: NCLEX Client Needs Category: Psychosocial Integrity

TOP: Assessment NOT: Concepts:

Stress and Coping

The nurse manager of the unit is implementing a program to assist the

nursing staff in managing compassion fatigue. Which intervention will be the most successful? (Select all thatapply.) a.

Support group that nurses can participate in that meets on the unit

Exercise completion to encourage nurse to exercise and log their time

Organized break times so nurses can get off the unit for breaks and

lunches d.

Quiet area on the unit where the nurses can go during break

Promotion of work-life balance

CORRECT ANSWER: A, B, C, D, E To care most effectively for others, nurses must first take time to care for themselves. Many ofthe stress reduction interventions incorporated into patient care plans can be effective in addressing the stressors faced by nurses. Exercise, balanced nutrition, and mindfulness therapy have been shown to help health care professionals in coping with the demands of patient care.

Interventions designed specifically to prevent nurse burnout and address compassion fatigue include mentoring programs, quiet areas on a nursing unit for relaxation, availability of pastoral care, the sharing of feelings with trusted colleagues, and promotion of work-life balance.

DIF: Applying

REF: p. 744

OBJECTIVE: 32.8

MSC: NCLEX Client Needs Category: Psychosocial Integrity

TOP: Assessment NOT: Concepts:

Stress and Coping

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Concept 31. Mood and Affect Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE 1.

A nurse in an acute care mental health facility is caring for a client who has

depression. After 3 days of treatment, the nurse notices that the client suddenly seems cheerful and relaxed and there are no longer signs of depressive state. Which of the following interventions is appropriateto include in the plan of care? a.

Encourage family to take the client out of the facility for short periods of

time b.

Reward the client for her change in behavior

Monitor the client’s whereabouts at all times

Ask the client why her behavior has changed

ANS. D *Clients who have depression and exhibit a sudden change in behavior are at a risk and suicide precautions should be included in the plan of care. Antidepressant medications generally take 1 to 3 weeks before improvement is seen. A cheerful mood with no signs of depressive state 3 days after treatment begins might indicate that the client has made a decision to commit suicide.

A nurse is reviewing the medical record of a client who has schizophrenia

and is receiving olanzapine. Which of the following findings should the nurse identify as an adverse effect ofolanzapine? a.

Weight gain of 3 lbs in 2 weeks

Delusions of grandeur

Heart rate 60/min

Oral candidiasis ANS. A

*Weight gain is a common adverse effect of olanzapine

A nurse is teaching a client who has a new prescription for lithium to treat

bipolar disorder. The nurse should instruct the client to ensure an adequate intake of which of the following dietary elements? a.

Sodium.

Potassium

Vitamin K

Vitamin C ANS. A

Lithium is a salt. If Sodium level falls, the client will retain lithium and have an increasedrisk for lithium toxicity

A nurse is caring for a client following a suicide attempt. The client has a

history of depression,substance abuse and anorexia nervosa. Which of the following actions is the nurse’s priority? a.

Reviewing the client’s toxicology laboratory report

Making a contract with the client for eating behavior

Initiating suicide precautions

Administering the Hamilton Depression Scale

ANS. C *Client safety is the nurse’s priority. Therefore, the first action the nurse should take forthis client is to initiate suicide precautions.

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A nurse is caring for a client 3 days after admission for treatment of

depression. The client leaves her current activity, approaches the nurse and states, “There’s no reason to go on living.I just want to end it all.” Which of the following actions should the nurse take? a.

Ask the client if she has a plan to commit suicide

Recognize the attempt at manipulation and escort the client back to her

activity c.

Assist the client to her room and allow her to rest before resuming activity

Notify the client’s family and request a visitor to stay with the client until

thoughts of suicideare gone. ANS. A *The nurse should take seriously all statements regarding suicide. Asking the client if shehas a suicide plan is a specific question that the nurse should include when assessing a client who has possible suicide ideation.

A nurse is discussing postpartum depression with a newly licensed nurse.

Which of thefollowing statements indicates an understanding of this disorder? a.

“Postpartum depression usually begins 48 hours after childbirth.”

“It’s common for clients who have postpartum depression to exhibit

psychotic behavior.” c.

“The most common manifestation of postpartum depression is harming the

infant.” d.

“Postpartum depression is most often seen in women who have a history

of depression.” ANS. B *Psychotic behavior is a common finding in clients who have postpartum psychosis.

A nurse in an acute care mental health facility is preparing to administer

morning medicationfor a client who has been taking lithium for 2 weeks and has a current lithium level of 1.0 mEq/L. Which of the following actions should the nurse take? a.

Prepare for gastric lavage due to an extremely elevated lithium level

Administer the morning dose of lithium

Check the client’s medication record to assess whether the client has been

refusing her lithium d.

Hold the medication and assess for early manifestations of toxicity ANS. B

*The nurse should administer the lithium dose since a lithium level of 1.0 meq/L is withinthe expected initial therapeutic range of 0.8-1.3 mEq/L. At a therapeutic level the client might demonstrate adverse effects of lithium, such as a fine had tremor, thirst, and mild nausea and the nurse should note if any of these manifestations are present. The nurse should continue to monitor for adverse effects and signs of toxicity, which usually occur atlevels of 1.5 mEq/L or higher.

A nurse is caring for a client who has been hospitalized for the treatment of

bipolar disorder and will be discharged with a prescription for lithium. The nurse’s discharge teaching should include information cautioning against which of the following factors that may cause lithium toxicity? a.

Experiencing diarrhea

Exercising moderately

Increasing sodium intake

Drinking green tea

ANS. A

*Lithium is used to treat the manic stage of bipolar disorder. Toxicity occurs when the levelof lithium in the blood becomes too high. A low sodium levels, or factors which result in a low sodium level, (such as dehydration, diarrhea, sweating, excess exercise in hot weather,diuretic use, a low sodium diet) increases the lithium level because the kidney processes sodium and lithium in the same way. If sodium levels fall, the body conserves the lithium, causing lithium levels to rise. This study source was downloaded by 100000822308352 from CourseHero.com on 08-14-2021 03:28:16 GMT -05:00

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A nurse who works in a psychiatric unit is caring for a client who has

bipolar disorder. Theclient comes to the nurse’s station at 0300 demanding that the nurse call the provider immediately. Which of the following responses by the nurse is appropriate? a.

“You are being unreasonable and I will not call your doctor at this hour.”

“Go back to your room and I’ll try to get in touch with your doctor.”

“I can’t call a doctor in the middle of the night unless it’s an emergency.”

“You must be very upset about something.”

ANS. D This therapeutic response allows the nurse to show empathy for the client’s feelings. The response is also open-ended, which allows for further communication and encourages theclient to clarify the situation.

10.

A nurse on a crisis hotline is speaking to a client who says, “I just took an

entire bottle of

amitriptyline.” Which of the following responses should the nurse take? a.

“I’m glad you called, and I want to send an ambulance to help you.”

“You must have been feeling pretty depressed to do that.”

“Do you know how many pills were in the bottle?”

“Were you trying to kill yourself by taking an overdose?” ANS. A

*Amitriptyline, a tricyclic antidepressant, is used to treat depression. This therapeutic statement shows the nurse’s concern for the client’s safety and responds to the client’spriority need. Maslow’s hierarchy of needs states that the client’s physical and safety needs come first. Therefore, the client needs to be evaluated immediately.

11.

A nurse is caring for a client who is in a manic phase of bipolar disorder.

The client is runningaround the unit trying to organize competitive games with the clients. Which of the followingis an appropriate intervention? a.

Recommend a game of table tennis with another client

Suggest the client exercise on a stationary bike

Take the client outside for a walk

Praise the client’s efforts to engage in social interaction ANS. C

*Clients who are experiencing mania are at a risk for physical exhaustion; therefore, the nurse should redirect the client to a different activity that will decrease stimulation and slow the client’s physical activity expenditure.

12.

A nurse is providing discharge teaching to a client who has bipolar disorder

and will be discharged with a prescription for lithium. The nurse should teach the client that which of the following factors puts her at risk for lithium toxicity? a.

The client runs 4 miles outside every afternoon

The client drinks 2 liters of fluid daily

The client eats 2 to 3 gm of sodium-containing foods daily

The client eats foods high in tyramine ANS. A

*Strenuous exercise in outdoor heat, which can lead to dehydration, puts the client at riskfor lithium toxicity. Mild to moderate exercise will not lead to lithium toxicity, but if the client engages in strenuous exercise during hot weather, she should take care to replace any water and sodium that have been lost through profuse sweating. This also applies to other factors that can cause the client to become dehydrated, such as having diarrhea or taking diuretics.

13.

A nurse in an acute mental health unit is admitting a client who has bipolar

disorder. Which ofthe following findings support the admitting the diagnosis of acute mania? This study source was downloaded by 100000822308352 from CourseHero.com on 08-14-2021 03:28:16 GMT -05:00

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The client’s spouse reports that the client has recently gained weight

The client is dressed in all black

The client responds to questions with disorganized speech

The client reports that voices are telling her to write a novel

ANS. C *Clients who are experiencing acute mania exhibit disorganized speech such as flight ofideas.

14.

A nurse asks a client who is suicidal to make a safety contract, but the

client declines. Which ofthe following actions should the nurse identify as the priority? a.

Lock the doors to the unit and secure windows so they cannot be opened

Provide the client with plastic eating utensils for meals

Remove any objects from the client’s environment that could be used for

self-harm d.

Assign a staff member to stay with the client at all times

ANS D. *The greatest risk to this client is self-injury during unsupervised time; therefore, the nurseshould identify the priority action is to assign a staff member to stay with the client at all times. The staff member can monitor all of the client’s behaviors and actions and prevent the client from harming herself.

15.

A nurse is caring for a client who has major depressive disorder and

attempted suicide. The client tells the nurse, “I should have died because I am totally worthless.” Which of thefollowing responses should the nurse make? a.

“You have a great deal to live for.”

“It’s not unusual for depressed people to feel this way.

“Why do you feel you are worthless?”

“You’ve been feeling that your life has no meaning.”

ANS. D *This open-ended statement uses the communication tool of empathy and addresses the client’s feeling of worthlessness. This therapeutic response communicates to the client that the nurse was listening, and it will encourage the client to talk further about personalfeelings.

16.

A nurse is reviewing medications for a newly admitted client who has

bipolar disorder and is experiencing mania. Which of the following client prescriptions should the nurse realize isexpected to reduce the client’s mania?

Fluvastatin

Carbamazepine

Lorazepam

Propranolol

ANS. B *Carbamazepine, an anti-seizure medication and a mood stabilizer, is prescribed to treatand prevent mania in clients who have bipolar disorder.

17.

A nurse is caring for a client who has bipolar disorder and has been taking

lithium for 1 year.Before administering the medication, the nurse should check to see that which of the following tests have been completed? a.

Thyroid hormone assay

Liver function tests

Erythrocyte sedimentation rate

Brain natriuretic peptide ANS. A

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*Thyroid testing is important because long-term use of lithium may lead to thyroiddysfunction.

18.

A nurse is collecting data from an adolescent. Which of the following

should the nurse identifyas the greatest risk for suicide? a.

Availability of firearms

Family conflict

Homosexuality

Active psychiatric disorder

ANS. D *An active psychiatric disorder represents the greatest risk for suicide. An activepsychiatric disorder is present in 90% of those who complete suicide.

19.

A nurse is caring for a client who has bipolar disorder and a new

prescription for valproate.Which of the following instructions should the nurse give the client about the use of this medication? a.

Thyroid function tests should be performed every 6 months

A pretreatment electroencephalogram (EEG) will be done

Liver function tests must be monitored

High serum sodium levels can cause toxic levels of valproate

ANS. C *Pancreatic, hepatic dysfunction and thrombocytopenia are serious adverse effectsoccasionally associated with valproate. Liver function tests should be monitored periodically to check for hepatic failure

20.

A nurse in an emergency department is caring for an adolescent following

a suicide attempt. After reviewing the client’s history, the nurse should determine that which of the following is the priority risk for suicide completion? a.

Active psychiatric disorder

Previous suicide attempt

Loss of a parent

History of substance abuse ANS. B

*A prior suicide attempt is found in as many as half of the adolescents who attemptsuicide.

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Concept 32: Anxiety Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

A patient complains of insomnia during his stay in the hospital. Which

nursing diagnosis would be a top priority for this patient? a.

Anxiety related to hospitalization

Ineffective Coping related to hospitalization

Denial related to hospitalization

High Risk for Insomnia related to hospitalization

CORRECT ANSWER: A The information about the patient indicates that anxiety is an appropriate nursing diagnosis. The patient’s data do not support Defensive Coping, Ineffective Denial, or Risk-Prone Health Behavior as problems for this patient.

REF: Page 327 OBJECTIVE: NCLEX® Client Needs Category: Psychosocial Integrity

A female patient is anxious after receiving the news that she needs a

breast biopsy to rule out breast cancer. The nurse is assisting with a breast biopsy. Which relaxation technique will be best to use at this time? a.

Massage

Meditation

Guided imagery

Relaxation breathing

CORRECT ANSWER: D

Relaxation breathing is the easiest of the relaxation techniques to use. It will be difficult for the nurse to provide massage while assisting with the biopsy. Meditation and guided imagery require more time to practice and learn.

REF: Page 332 OBJECTIVE: NCLEX® Client Needs Category: Psychosocial Integrity

The nurse is teaching a hospitalized patient to use mindfulness to reduce

anxiety. Which statement by the nurse is appropriate? a.

“How do you feel about what happened to you as a child?”

“How do you feel about what is going on right now?”

“Remember a time when you were calm.”

“Tap your hands until the feeling goes away.”

CORRECT ANSWER: B Mindfulness trains the mind to think in the here and now, and emphasizes attentiveness to all sensations and feelings related to these experiences. Recalling and remembering being calm or previous experiences is not included in mindfulness training. Eye movement desensitization and reprocessing (EMDR) includes expression of feelings and memories while focusing on other stimuli such as sounds, hand taps, and/or eye movements.

REF: Page 332 OBJECTIVE: NCLEX® Client Needs Category: Psychosocial Integrity

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The nurse is assessing the social support of a patient who is recently

divorced and has moved from their hometown to the city due to change in jobs. Which response related to social support would be most therapeutic? a.

Encourage the patient to begin dating again, perhaps with members of her

church. b.

Discuss how divorce support groups could increase coping and social

support. c.

Note that being so particular about potential friends reduces social contact.

Discuss using the Internet as a way to find supportive others with similar

values. CORRECT ANSWER: B High-quality social support enhances mental and physical health and acts as a significant buffer against distress. Low-quality support relationships are known to affect a person’s coping effectiveness negatively. Resuming dating soon after a divorce could place additional stress on the patient rather than helping them cope with existing stressors. Developing relationships on the Internet probably would not substitute fully for direct contact with other humans and could expose the patient to predators misrepresenting themselves to take advantage of vulnerable persons.

REF: Page 332 OBJECTIVE: NCLEX® Client Needs Category: Psychosocial Integrity

A patient reports that he is overwhelmed with anxiety. Which question

would be most important to use in assessing the patient during your first meeting? a.

“What kinds of things do you do to reduce or cope with your stress?”

“Tell me about your family history—do any relatives have problems with

stress?” c.

“Tell me about exercise—how far do you typically run when you go

jogging?” d.

“Stress can interfere with sleep. How much did you sleep last night?”

CORRECT ANSWER: A The most important data to collect during an initial assessment is that which reflects how stress is affecting the patient and how he is coping with stress at present. This data would indicate whether his distress is placing him in danger (e.g., by elevating his blood pressure dangerously or via maladaptive responses such as drinking) and would help you understand how he copes and how well his coping strategies and resources are serving him. Therefore, of the choices presented, the highest priority would be to determine what he is doing to cope at present, preferably via an open-ended or broad-opening inquiry. Family history, the extent of his use of exercise, and how much sleep he is getting are all helpful but seek data that is less of a priority. Also, the manner in which such data is sought here is likely to provide only brief responses (e.g., how much sleep he got on one particular night is probably less important than how much he is sleeping in general).

REF: Page 333 OBJECTIVE: NCLEX® Client Needs Category: Psychosocial Integrity

A patient is newly diagnosed with anxiety and placed on a selective

serotonin reuptake inhibitors (SSRIs). The nurse is developing the plan of care for this patient. How long will it take for this medication to become effective? a.

The medication will become effective immediately.

The medication may take up to 12 weeks to become effective.

The medication may take up to 6 weeks to become effective.

The medication may take up to 4 weeks to become effective.

CORRECT ANSWER: B Efficacy may take at least 8 to 12 weeks. The other options are not realistic.

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REF: Page 332 OBJECTIVE: NCLEX® Client Needs Category: Psychosocial Integrity

MULTIPLE RESPONSE

The nurse knows that which of the following medical conditions are most

commonly associated with anxiety? (Select all that apply.) a.

Cancer

Pancreatitis

Hypothyroidism

Dysrhythmias

Encephalitis

Hyperthyroidism

CORRECT ANSWER: A, C, D, E, F Cancer, COPD, dysrhythmias, encephalitis, hypothyroidism, and hyperthyroidism are all associated with anxiety. Pancreatitis is not listed as a condition most commonly associated with anxiety.

REF: Page 330 OBJECTIVE: NCLEX® Client Needs Category: Psychosocial Integrity

The nurse wishes to use guided imagery to help an anxious patient relax.

Which comment would be appropriate to include in the guided imagery script? (Select all that apply.) a.

“Imagine others treating you the way they should, the way you want to be

treated…” b.

“With each breath, you are feeling calmer, more relaxed, almost as if you

are floating…” c.

“You are alone on a beach; the sun is warm; and you hear only the sound

of the surf…” d.

“You have taken control; nothing can hurt you now; everything is going

your way…” e.

“You have grown calm; your mind is still; there is nothing to disturb your

well- being…” f.

“You will feel better as work calms down, as your boss becomes more

understanding…” CORRECT ANSWER: B, C, E

The intent of guided imagery for managing stress is to lead the patient to envision images that are calming and health enhancing. Statements that involve the patient calming progressively with breathing, feeling increasingly relaxed, being in a calm and pleasant location, being away from stressors, and having a peaceful and calm mind are therapeutic and should be included in the script. However, words that raise stressful images or memories or that involve unrealistic expectations or elements beyond the patient’s control (e.g., that others will treat the patient as he desires, that everything is going the patient’s way, that bosses are understanding) interfere with relaxation and/or do not promote effective coping. These attempts are not health promoting and should not be included in the script.

REF: Page 332 OBJECTIVE: NCLEX® Client Needs Category: Psychosocial Integrity

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Concept 33: Cognition Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

A nurse working in a pediatric clinic recognizes that which child is most at

risk for cognitive impairment? a.

An infant who is being fed reconstituted powdered formula

A toddler living in an older home that is being remodeled

A preschooler who attends a play group 3 days a week

A school-age child who rides a school bus 5 days a week

CORRECT ANSWER: B Older homes frequently have lead-based paint; paint chips generated by remodeling put toddlers, who often put foreign objects in their mouths, at risk for exposure to lead which is a known toxic substance that can affect cognitive function. Powdered formulas, attendance at play groups, or riding on a school bus are not known to impair cognitive development.

REF: Page 341 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

The nurse is reviewing new medication orders for several patients in a

long-term care facility. Which patient does the nurse recognize as being at the highest risk for having cognitive impairment related to prescribed medications? a.

The patient prescribed an antibiotic for a urinary tract infection.

The patient prescribed a cholinesterase inhibitor for early Alzheimer’s

disease. c.

The patient prescribed a beta-blocker for hypertension.

The patient prescribed a bisphosphonate for osteoporosis.

CORRECT ANSWER: C

Anti-hypertensives such as the beta-blockers can cause adverse changes in cognition. While an infection can affect cognition, antibiotics do not generally cause cognitive changes. The cholinesterase inhibitors are prescribed to slow the progression in cognitive decline for patients diagnosed with Alzheimer’s disease. Bisphosphonates are used for osteoporosis and are not generally a risk for altered cognition.

REF: Page 341 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity

The nurse is developing a care plan for a patient newly admitted to a unit

that cares for patients with cognitive impairment. What is an important component of care for the patients on this unit? a.

Allow food selections from a menu with several choices.

Schedule frequent field trips off the unit for cognitive stimulation.

Plan for attendance at activities with several other patients on the unit.

Plan for a structured daily routine of events and caregivers.

CORRECT ANSWER: D Patients with a cognitive impairment benefit from a predictable routine and consistent caregivers. Trips off of the unit may confuse the patient and disrupt their normal routine. Offering too many selections causes confusion and can lead to agitation. Being in large groups for activities can overstimulate the patient and lead to agitation and fear.

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REF: Page 344 OBJECTIVE: NCLEX® Client Needs Category: Psychosocial Integrity

A patient who is dehydrated has been experiencing confusion. The

daughter is concerned about taking the patient home in a confused state. What statement by the nurse is correct? a.

“Don’t worry; the patient should be fine once they are in a familiar

environment.” b.

“I can make a referral for a home health aide to assist with the patient.”

“Once the dehydration is corrected, the patient’s confusion should

improve.” d.

“I can show you how to care for the patient once you return home.”

CORRECT ANSWER: C The confusion caused by an underlying medical condition is a temporary condition that can be corrected once the underlying condition is treated, in this case once the patient is rehydrated. It is not necessary to teach home care or make a referral to home health because it is not expected that the patient will be confused at discharge. Telling the daughter that there is nothing to worry about diminishes her concern and may decrease her trust in the nurse.

REF: Page 344 |Page 345 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity

An older adult who is cognitively impaired is admitted to the hospital with

pneumonia. Which sign or symptom would the nurse expect to be exhibited by the patient? a.

Severe headache

Flank pain

Increased confusion

Decreased blood glucose

CORRECT ANSWER: C Increased confusion is a symptom that occurs in cognitively impaired patients who experience an infection. Severe headache occurs with migraines, meningitis, and other conditions. Flank pain occurs with pyelonephritis. Blood glucose typically increases with an infection.

REF: Page 344 |Page 345 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity

The nurse is sitting with the family of a patient who has just received the

diagnosis of dementia. The family asks for information on what treatment will be needed to cure the condition. What is the nurse’s best response? a.

“Hormone therapy will reverse the condition.”

“Vitamin C and zinc will reverse the condition.”

“There is no treatment that reverses dementia.”

“Dementia can be reversed with diet, exercise, and medications.”

CORRECT ANSWER: C Currently there is no proven treatment that has been shown to reverse dementia, although some treatments can slow the progression of the illness. Hormone therapy, vitamin therapy, diet, and exercise are all important for overall health but do not reverse the progression of dementia.

REF: Page 344 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity

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A cognitively impaired patient newly admitted to the hospital is

experiencing signs of sundown syndrome. Which intervention is best for the nurse to implement? a.

Leave a night light on in the room at all times.

Leave the television on at night with the volume up.

Restrain the patient to maintain safety during the confusion.

Administer a sleeping medication to help the patient sleep.

CORRECT ANSWER: A Having a night light on for the patient can help orient them to their surroundings. Having the flickering light and sound from a television will not help a confused patient remain calm or oriented. Restraining a patient will increase their agitation and actually increase their risk of injury if they try to get out of bed. Sleeping medications often increase confusion in cognitively impaired patients.

REF: Page 346 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

An 82-year-old patient who is in the hospital awakens from sleep and is

disoriented to where she is at the present time. The nurse reorients the patient to her surroundings and helps the patient return to sleep. What data does the nurse consider as a probable cause of the patient’s confusion? a.

Pain medication received earlier in the night

The death of the patient’s spouse 2 years ago

The patient’s history of diabetes

The age of the patient

CORRECT ANSWER: A Medications such as narcotics, hypertensives, sleeping meds, and others can cause disorientation and symptoms of delirium. The death of a spouse is more likely to cause depression than disorientation. A history of diabetes alone does not cause disorientation. Normal aging alone does not cause disorientation, although it is a risk factor.

REF: Page 344 |Page 345 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity

MULTIPLE RESPONSE

The nurse is teaching primary prevention of cognitive impairment at a

community health fair. Which topics would be included in the presentation? (Select all that apply.) a.

Do not use substances such as cannabis and alcohol.

Wear helmets when riding bicycles and motorcycles.

Complete a Mini Mental Status Exam (MMSE) yearly.

Correct acid-base imbalances related to underlying disease processes.

Wear a seat belt whenever riding in a motorized vehicle.

Complete a Confusion Assessment Method (CAM) scale yearly.

CORRECT ANSWER: A, B, E

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Primary prevention attempts to prevent injury. Not using chemical substances, wearing a helmet, and wearing a seat belt are all measures to prevent injury to the brain, which protects cognitive function. An MMSE and CAM are secondary prevention, or screening tools performed once symptoms are present. Correcting acid-base imbalances from underlying disease processes is a tertiary prevention level, aimed at minimizing complications for disease already present.

REF: Page 340 |Page 341

OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

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Concept 34: Psychosis Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

A client previously diagnosed as psychotic expresses to the nurse that he

is seeing spiders climbing up the walls in his room and he is concerned that they will get into his bed. What is the nurse’s best response? a.

Ignore his remarks and remain silent when providing care.

Express doubt that there are spiders on the wall.

Ask the client if he also sees spiders in the day room.

Tell the client there are no spiders and he should stop worrying about it.

CORRECT ANSWER: B The client is experiencing visual hallucinations. Appropriate care for this client would not include reinforcing his hallucinations, being dismissive of him, or ignoring him. Expressing reasonable doubt is the correct answer.

REF: Page 354 OBJECTIVE: NCLEX® Client Needs Category: Psychosocial Integrity

A client with schizophrenia has relapsed and has been identified as being

in stage four of relapse. The nurse expects to observe which behavior that most consistent with this stage of relapse? a.

Expressing feelings of anxiety

Expressing feelings of being overwhelmed

Bizarre behaviors and speech

Presence of hallucinations

CORRECT ANSWER: D Schizophrenic clients who relapse go through five stages. Correctly identifying which stage the relapsing client is in is important so that interventions can be specific to the behavior. Expressing feelings of anxiety would be part of stage two, expressing feelings of being overwhelmed would be part of stage one, and bizarre behaviors and speech would be part of stage three. Presence of hallucinations is consistent with stage four, psychotic disorganization.

REF: Page 354 OBJECTIVE: NCLEX® Client Needs Category: Psychosocial Integrity

The nurse is planning discharge teaching for a patient taking clozapine.

Which information is essential to include in the teaching plan? a.

Caution about sunlight exposure

Reminder to call the clinic if fever, sore throat, or malaise develops

Instructions regarding dietary restrictions

A chart to record patient weight

CORRECT ANSWER: B Fever, sore throat, and malaise are symptoms of agranulocytosis, a serious side effect of taking clozapine. Weekly blood counts are necessary to monitor for the condition. Sunlight exposure is a risk for persons taking chlorpromazine hydrochloride (Thorazine). There are no dietary restrictions for persons taking clozapine. While weight gain may occur when taking antipsychotic medication, daily monitoring is not required.

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REF: Page 353 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

Which side effect is highest priority for the nurse to assess for when

diphenhydramine is administered to a patient also taking antipsychotic medication? a.

Increased pychosis

Cognitive impairment

Respiratory depression

Impaired memory

CORRECT ANSWER: C Diphenhydramine is an anticholinergic medication that may induce drowsiness or even respiratory depression taken along with anti-psychotic medication. Respiratory depression and airway are always highest priorities of care. While increased psychosis may occur, respiratory depression is highest priority. Cognitive impairment and impaired memory are not well known effects of diphyenhydramine.

REF: Page 353

OBJECTIVE: NCLEX® Client Needs Category: Pharmacological and Parenteral Therapies

MULTIPLE RESPONSE

A 23-year-old male veteran of the war in Iraq is admitted with a diagnosis

of posttraumatic stress disorder (PTSD) following his arrest for destroying his girlfriend’s apartment. This is not his first angry outburst resulting in destruction of property. Which interventions by the nurse will be most helpful to this patient? (Select all that apply.) a.

Allow opportunities for him to express his anger.

Provide patient and family teaching regarding PTSD.

Tell the patient that hurting himself will solve nothing.

Report him to the authorities.

Exhibit a nonjudgmental attitude.

Reassure him that everything will be all right.

CORRECT ANSWER: A, B, E Allowing appropriate opportunities for him to express his anger will help him learn how to control his emotions or express them in a socially acceptable manner. Providing education to the patient and family will help them learn why he behaves the way he does and how to prevent or redirect his anger. Options C, D, and F are nontherapeutic in that they undermine the nurse-patient relationship. Being nonjudgmental in interactions with patients is a basic tenet of developing a therapeutic relationship.

REF: Page 354 |Page 355 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Basic Care and Comfort

In discussing disease prevention with a 15-year-old boy and his mother,

the nurse identifies which of the following as risk factors for psychosis? (Select all that apply.) a.

Father diagnosed with paranoid schizophrenia

Rural residence

Recent immigration from Ecuador

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Occasional cannabis use

January birth date

Physical abuse by the father

CORRECT ANSWER: A, C, E, F Genetic predisposition has been identified as a risk factor for development of schizophrenia. Immigration, winter birth, and family difficulties such as abuse have also been identified as risk factors. Urban residence, not rural, and chronic cannabis use, not occasional, have also been identified.

REF: Page 351 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

Clients who are psychotic because of underlying psychiatric illness are

treated with antipsychotic medications. Typical antipsychotic medications can improve positive symptoms in clients with schizophrenia. Positive symptoms include which of the following? (Select all that apply.) a.

Hallucinations

Disorganized speech and behavior

Anhedonia

Delusions

Agitation

CORRECT ANSWER: A, D, E Positive symptoms of schizophrenia include the distortion or exaggeration of normal behavior, such as when the client experiences hallucinations, delusions, or agitation. Negative symptoms are those that cause a loss of normal function, such as when the client exhibits disorganized speech and behavior and anhedonia.

REF: Page 352 OBJECTIVE: NCLEX® Client Needs Category: Psychosocial Integrity

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Concept 35: Addiction Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

The nurse is assessing a patient using the CAGE Questionnaire. The

patient answers yes to all of the questions. The nurse suspects alcoholism and feels the patient is in denial when the patient makes which statement? a.

“I go to meetings once a day and still drink.”

“My family and friends have been avoiding me lately.”

“I don’t have a problem with alcohol. I can quit anytime I want to.”

“I know it will be hard to quit, but I am willing to try.”

CORRECT ANSWER: C The patient may need help admitting that there is a problem. The CAGE is designed to objectively assist in assessing problems related to alcohol use. A patient who states they are going to meetings is admitting they have a problem even if they still drink. Admitting that quitting is difficult is acceptance that there is a problem. Reality is setting in for a patient who can see that family and friends are avoiding them.

REF: Page 360 OBJECTIVE: NCLEX® Client Needs Category: Psychosocial Integrity

A patient who was admitted 24 hours ago has become increasingly irritable

and now says there are bugs on his bed. Which condition should the nurse suspect? a.

Alcohol-induced psychosis

Delirium tremens (DTs)

Neurologic injury related to a fall

Posttraumatic stress reaction

CORRECT ANSWER: B

During the 6 to 96 hours after last alcohol use, patients may experience DTs, as evidenced by disorientation, nightmares, abdominal pain, nausea, and diaphoresis, as well as elevated temperature, pulse rate, and blood pressure measurement and visual and auditory hallucinations.

REF: Page 361 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

To prevent Wernicke’s encephalopathy from heavy alcohol use, the nurse

anticipates an order for which medications? a.

Benzodiazepine

Thiamine and B complex

Vitamins C and D3

Klonopin

CORRECT ANSWER: B The B vitamins will prevent or reverse Wernicke’s if given early enough. Benzodiazepines are often used to prevent and treat DTs and to decrease respiratory depression and hypertension. Vitamins C and D3 are not related to alcohol withdrawal. Klonopin is administered for hypertension and anxiety related to withdrawal.

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REF: Page 361 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

The nurse is caring for a patient who is experiencing alcohol withdrawal.

What is the highest priority for this patient? a.

Describe how the alcohol is causing the withdrawal effects.

Leave the patient by him/herself so as not to cause agitation.

Promote a safe, calm, and comfortable environment.

Refer the patient to an alcohol-abuse counselor.

CORRECT ANSWER: C The main priority is the patient’s safety due to risk of harm from seizures, DTs, and anxiety. The nurse could provide referrals or discuss the relationship of alcohol to physical problems after the withdrawal period is over. Do not leave the patient alone, as many patients will need reassurance that they will survive the ordeal of withdrawal.

REF: Page 361 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

The nurse assesses the outcomes of a motivational interview on a patient

with a dual diagnosis of alcoholism with delirium tremens (DTs) and determines that the communication was nontherapeutic. What is the nurse’s next priority?

Encourage the patient to think of ways to change environmental triggers to

abuse substances. b.

Ask the patient what methods they think would work and encourage

participating in self-help groups. c.

Notify provider to obtain order for oxazepam and vitamin B infusion.

Notify provider to obtain order for CT scan and psychologic consult.

CORRECT ANSWER: C The patient will need to be treated for the psychosis prior to conducting the motivational interview, because the patient can become violent and nonreceptive to the interventions. Oxazepam and vitamin B are the two therapies that work for DTs.

REF: Page 361 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

A 45-year-old man is brought to the emergency department presenting

with a respiratory rate of 6 breaths/min, and cardiac dysrhythmias. What is the most appropriate question the nurse should ask the patient’s friend? a.

“Does he take amphetamines or uppers?”

“Has he ever used LSD?”

“Have you two been out of the country in the last 2 days?”

“Is he using any opioids such as heroin?”

CORRECT ANSWER: D

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The clinical manifestations of an opioid overdose include seizures, shock, respiratory depression, dysrhythmias, and altered level of consciousness. An opioid overdose is a medical emergency. Amphetamine overdose is ruled out because it causes hypertension and central nervous system disturbances such as paranoia, panic, and delusions. LSD overdose would also manifest with hypertension and tachypnea along with hallucinations and possible loss of contact with reality. Travel outside the country is unrelated.

REF: Page 364 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

During history-taking, a patient tells the nurse that he is addicted to

alprazolam and that he takes six 1 mg tablets a day. He quit cold turkey yesterday and now presents with extreme agitation, increased heart rate, and panic. The nurse suspects which disorder? a.

Stress reaction

Delerium tremens

Overdose

Relapse

CORRECT ANSWER: A

Stress reaction is a withdrawal symptom that can occur when detoxing too quickly. DTs are usually associated with alcohol withdrawal. Overdose of alprazolam would present with extreme drowsiness, confusion, muscle weakness, and loss of balance or coordination. The effects of alprazolam are dizziness, drowsiness, dry mouth, and lightheadedness.

REF: Page 359 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

MULTIPLE RESPONSE

Strategies that a nurse could use in a motivational interview to increase the

chances of change include which of the following? (Select all that apply.) a.

Educating the patient on the physical damage the substance is causing

Encouraging the patient to think of ways to change environmental triggers

to abuse substances c.

Asking the patient how they think substance abuse affects their family life

Explaining to the patient that substance abuse affects everyone in the

family and give examples e.

Asking the patient what methods they think would work and encouraging

participating in self-help groups CORRECT ANSWER: B, C, E Empowering the patient by helping them see what effect the abuse has on their life is a key component of motivation. Educating the patient is too much like lecturing and may cause resistance. Explaining how the family responds to the problem may elicit guilt and resistance.

REF: Page 362 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

The nurse recognizes a potential health threat to an alcoholic patient who

is using the drug disulfiram when the nurse reads in the health record that the patient is also taking which of the following? (Select all that apply.) a.

Blood thinners

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Diphenhydramine

Alcohol

Penicillin

Mouthwash

CORRECT ANSWER: A, C, E Disulfiram increases the effect of anticoagulants such as warfarin (Coumadin). Ingesting alcohol may cause headache, nausea, vomiting, tachycardia, chest pain, or dizziness. Mouthwash can have alcohol as one of the main ingredients and should be checked prior to using.

REF: Page 363

OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

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Concept 36: Interpersonal Violence Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

A nurse is caring for a patient in the emergency department who has been

a victim of intimate partner violence. What is most important for the nurse to include in the plan of care? a.

Medication to calm the perpetrator of the violence

A list of community resources

A referral for self-defense training

A referral to the victim’s religious advisor

CORRECT ANSWER: B Providing education that will address immediate safety needs for the patient is a priority action for the nurse. The nurse is not creating a plan for the perpetrator, nor is it the responsibility of the victim to receive medication for another person. Self-defense training does not meet the immediate safety concern for the patient and may aggravate the perpetrator further. Accessing support from a religious advisor is good for ongoing support, but it does not address the immediate need for safety information.

REF: Page 371 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

The nurse working at a women’s health clinic is seeing a teenage female

patient who has come in for a refill on her birth control medication and with a complaint of abdominal pain. When the nurse enters the room, the patient is sitting in the chair with her head down, rocking back and forth, does not make eye contact, and answers questions with no expression on her face. What assessment question would be important for the nurse to ask the patient? a.

“What brings you to the clinic today?”

“What can we do to help you today?”

“Do you feel safe in your current relationship?”

“Have you changed your diet lately?”

CORRECT ANSWER: C This patient is exhibiting signs of being abused. It is important to ask about the safety of the patient. General questions about her visit do not give an opportunity for the patient to discuss her safety needs. While a diet change can cause stomach problems, this assessment would be addressed once safety is addressed.

REF: Page 371 OBJECTIVE: NCLEX® Client Needs Category: Psychosocial Integrity

The nurse is seeing a patient who has been in the clinic eight times in the

past 6 months for injuries from an abusive partner. The patient states, “I don’t see any way to get away from my partner, and I can’t keep going on like this.” What assessment question is most important for the nurse to ask? a.

“Do you have any family in the area that can help?”

“Have you thought about hurting yourself or someone else?”

“Have you thought about moving to a different city?”

“Have you discussed this with anyone else?”

CORRECT ANSWER: B

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Depression and an increased risk of suicide are common outcomes from individuals experiencing interpersonal violence. It is critical that the nurse specifically assess for the risk of harm to the patient or to others during assessment. Asking if family or friends are available for support is good, but it is more important to assess for the safety concern of suicide or harm to others. It is not helpful to ask if a person who has stated that they don’t see a way out has thought of leaving—their comment indicates that they can’t see any solution. This situation is a high risk for suicide, or even homicide against the perpetrator.

REF: Page 371 OBJECTIVE: NCLEX® Client Needs Category: Psychosocial Integrity

The nurse is reviewing case files for children at risk for injury resulting in

brain injury. Which child is at most risk for experiencing this type of violence? a.

A Caucasian, 6-month-old infant living with a single mother

An African-American, 24-month-old child living with her grandmother

A Mexican, 3-year-old child living in an inner city apartment

A Japanese, 8-year-old child living in a home with three generations of

family CORRECT ANSWER: A The highest incidence of traumatic brain injury occurs in Caucasian children aged birth to 1 year, and the abuse occurs most often from women.

REF: Page 371 |Page 372 OBJECTIVE: NCLEX® Client Needs Category: Psychosocial Integrity

Critical Thinking: A crisis intervention nurse is training emergency

department staff on treatment needs of persons in abusive relationships. What is a common difficulty staff encounter when caring for this population? a.

There is not a good legal pathway to help persons in abusive relationships.

The abused person may return to the abusive home setting.

Hospital policies do not identify the legal care needed for abused persons.

Because length of care is short in the emergency department, there is little

staff can do for patients who have been abused. CORRECT ANSWER: B Abused persons return to abusive settings because they feel they have no other options or they fear reprisal from the abusive partner. There are policies in all health care facilities that describe the legal needs and the legal process that needs to be followed when caring for abused patients. Even in short-stay care settings there are interventions that can be helpful to a patient who has experienced abuse.

REF: Page 373 OBJECTIVE: NCLEX® Client Needs Category: Psychosocial Integrity

The nurse is counseling women at a crisis shelter about risk factors for

increased intimate partner violence. What event is most likely to trigger an increase in abusive behaviors? a.

Moving to a new community

Starting a new job

Becoming pregnant

The death of a grandfather

CORRECT ANSWER: C

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Abuse is not likely to decrease, and can often increase when a woman becomes pregnant. Moving, starting a new job, and a death in the family are all stressors, but they are not identified as factors that specifically increase violence more than pregnancy.

REF: Page 373 OBJECTIVE: NCLEX® Client Needs Category: Psychosocial Integrity

MULTIPLE RESPONSE

The nurse is admitting a child with a history of abuse. The nurse

understands that the child may exhibit what behaviors that are consequences of being in an abusive environment? (Select all that apply.) a.

Reliving abuse incidents

Sleep disturbance

Overeating

Acting out behaviors

Intermittent fever

CORRECT ANSWER: A, B, D

Posttraumatic stress disorder symptoms, depression symptoms, and aggression are all outcomes that children who are exposed to abuse experience. Overeating may be associated with some stressors, but it is not specifically indicative of abuse. Fever is not associated with abuse. REF: Page 372 |Page 373 OBJECTIVE: NCLEX® Client Needs Category: Psychosocial Integrity

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Concept 37: Professional Identity Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

The scope of professional nursing practice is determined by the rules

promulgated by which organization? a.

American Nurses’ Association (ANA)

Institute of Medicine (IOM)

State Board of Nursing

State Nursing Association

CORRECT ANSWER: C

Professional nursing practice is regulated by each state’s Board of Nursing. The ANA is the professional organization of registered nursing in the United States and may influence, but it does not regulate. The IOM collaborated with the Robert Wood Johnson Foundation to improve the fractured health care system in the United States, and it makes recommendations, not rules. The state nursing associations are state organizations of the ANA and may collaborate with the public and boards of nursing to promote nursing rules which improve health care.

REF: Page 382 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

A new registered nurse asks the registered nurse (RN) preceptor what

could be done to become more professional. What is the preceptor’s best response? a.

“Attend nursing educational meetings.”

“Listen to other nurses.”

“Read the agency newsletter.”

“Pass the licensing exam.”

CORRECT ANSWER: A Knowledge and commitment are essential components of professionalism. Attending nursing educational meetings can promote collaborative learning with peers and maintenance of competence in an ever-changing health care environment. Listening can promote professionalism, and communication is certainly a component of professionalism; however, there is also a social sense to listening, and without the educational/learning component, this is not the best answer. An agency newsletter could include information about professional opportunities, but it is not the best answer. The new nurse would have already passed the licensing exam, the legal requirement to be considered a nurse.

REF: Page 385 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

The qualities of leadership, clinical expertise and judgment, mentorship,

and lifelong learning would best describe which type of nurse? a.

Administrator

Certified nurse specialist

Practitioner

Professional

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CORRECT ANSWER: D The qualities listed are those of a professional nurse. The other options are all nurses who may have these qualities, but the focus of their title includes qualities not essential for the professional nurse. The administrator would have management qualities; the clinical nurse specialist would have specialty area knowledge; and the practitioner would meet legal requirements as a health care provider.

REF: Page 377 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

The American Nurses’ Association (ANA) outlines expectations of the

nursing profession in which type of documentation? a.

Gallup poll

Goldman report

Social Policy Statement

Social identity theory

CORRECT ANSWER: C The ANA’s Nursing’s Social Policy Statement outlines expectations of nurses. The national Gallup poll has found nursing to be one of the most trusted professions for their honesty and ethical standards almost every year, but it does not outline expectations. Emma Goldman was a radical anarchist nurse who advocated and cared for indigent women in New York. She demonstrated the expectations of a professional nurse. Social identity theory posits that social identity is derived from group membership and that most people work to attain a positive social identity, and it not specific to nursing.

REF: Page 382 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

What nursing recommendations are published in the Institute of Medicine

(IOM’s) report The future of nursing: Leading change, advancing health? a.

Teach, advocate, assess, and nurture.

Should have a graduate degree to practice.

Diagnose and recommend treatments.

Must have continuing education.

CORRECT ANSWER: A Professional nurses teach, advocate, assess, and nurture. The IOM recommends that 80% of nurses have a minimum baccalaureate degree (not graduate degree) by 2020. Physicians diagnose and recommend treatments, and nurses provide the majority of these treatments. Lifelong learning is recommended, and some, not all, states require continuing education.

REF: Page 379 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

Nursing demonstrates dedication to improving public health through which

avenue? a.

Changing health care standards

Legal regulations

Scope of practice

Technology

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CORRECT ANSWER: C Through the scope of practice, specialized knowledge, and code of ethics, the discipline of nursing has demonstrated its dedication to improving public health. The changing health care environment is one of the challenges to nursing, not an indicator of dedication. Legal regulations are generally promulgated by legislators rather than nurses to protect the public. A highly technological environment is considered a challenge to nursing rather than an indicator of dedication.

REF: Page 379 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

MULTIPLE RESPONSE

Components of a professional identity in nursing include which attributes?

(Select all that apply.) a.

Accountability

Advocacy

Autonomy

Competence

Culture

CORRECT ANSWER: A, B, C, D The scope of professional identity in nursing includes: autonomy, knowledge, competence, professionalism, accountability, advocacy, collaborative practice, and commitment. Cultural sensitivity is important to professional nursing; however, culture is an inherent quality of nurses and patients, not a component of the professional identity.

REF: Page 379 |Page 380

OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

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Concept 38: Clinical Judgment Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

A student nurse is studying clinical judgment theories and is working with

Tanner’s Model of Clinical Judgment. How can the student nurse best generalize this model? a.

A reflective process where the nurse notices, interprets, responds, and

reflects in action b.

One conceptual mechanism for critiquing ideas and establishing goal-

oriented care c.

Researching best practice literature to create care pathways for certain

populations d.

Assessing, diagnosing, implementing, and evaluating the nursing care

plans CORRECT ANSWER: A Looking across theories and definitions of clinical judgment, they all have in common the ability to reflect on data and choose actions. Reflection also considers evaluating the result of the actions to determine whether they were

effective. Although critiquing ideas and establishing goal-oriented care could be considered part of a generalized statement of critical thinking, this is not broad enough without the reflection and evaluation. Clinical judgment would most likely be used to create care paths derived from the evidence; however, this is not the cornerstone of the Tanner Model. Clinical judgment is used when engaging in the nursing process, but this is too narrow in focus to capture the essence of critical thinking definitions and theories. Critical thinking is not synonymous with the nursing process.

REF: Page 389 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

The nurse is implementing a plan of care for a patient newly diagnosed

with type 2 diabetes mellitus. The plan includes educating the patient about diet choices. The patient states that they enjoy exercising and understand the need to diet; however, they can’t see living without chocolate on a daily basis. Using the principles of responding in the Model of Clinical Judgment, how would the nurse proceed with the teaching? a.

The nurse explains to the patient that chocolate has a high glycemic index.

The nurse then focuses on foods that have low glycemic indexes and provides a list for the patient to choose from. b.

The nurse explains that the patient may eat whatever they would like as

long as the patient’s glucose reading and A1c remain stable. c.

The nurse derives a new nursing diagnosis of Knowledge Deficit and

readjusts the plan of care to include additional sessions with the registered dietician.

The nurse examines the patient’s daily glucose log and incorporates the

snack into the time of day that has the lowest readings. The nurse then follows up and evaluates the response in 1 week. CORRECT ANSWER: D

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Responding entails adjusting the plan of care to the particular patient issue through one or more nursing interventions. In this case, the nurse is working with the patient’s wishes, knowing that the patient will most likely cheat. The patient will be allowed to “cheat.” The plan will be evaluated to be sure the snack does not elevate the glucose excessively and be readjusted if warranted. While it is true that most chocolate has a high glycemic index, providing a list of foods that do not include the one thing the patient enjoys will most likely lead to nonadherence to the diet. Advising the patient that they can have whatever they want to eat may lead to further dietary indiscretions and cause side effects such

as obesity or high glucose readings. Knowledge Deficit is an inaccurate diagnosis for this patient as evidenced by the patient stating they understand the need to exercise and the need to diet.

REF: Page 389 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

A new graduate nurse is working with an experienced nurse to chart

assessment findings. The new nurse notes that the physical therapist wrote on the chart that the patient is lazy and did not want to participate in assigned therapies this AM. The experienced nurse asks the new nurse what may be going on here. What is the best explanation for this statement? a.

Data on the chart can sometimes be documented in a biased manner.

Data on the chart changes as the patient’s condition changes.

Data on the chart is usually accurate and can be verified from the patient.

Reading the chart is not a wise use of time as this can be time consuming

and tedious. CORRECT ANSWER: A It is important that the nurse records only what is assessed, without adding judgments or interpretations to the record. Data do indeed change (and need to be charted) as the patient’s condition changes, but this would not be the best answer to this question. Assessment data may at times be difficult to obtain, but that would not occur often enough to warrant a warning about the difficulty in charting it. Also, obtaining data is clearly a different activity from charting it. Charting can be time consuming and tedious, but this is not the most complete answer to this question.

REF: Page 391

OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

A home care nurse receives a physician order for a medication that the

patient does not want to take because the patient has a history of side effects from this medication. The nurse carefully listens to the patient, considers it in light of the patient’s condition, questions its appropriateness, and examines alternative treatments. What is the nurse’s best action? a.

Call the physician, explain rationale, and suggest a different medication.

Consult an experienced nurse on whether there are other similar

treatments. c.

Hold the drug until the physician returns to the unit and can be questioned.

Question other staff as to the physician’s acceptance of nursing input.

CORRECT ANSWER: A

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Determining how best to proceed on behalf of a patient’s best health care outcomes may require clinical judgment. At the committed level of critical thinking, the nurse chooses an action after all possibilities have been examined. A home care nurse who is using good clinical judgment techniques should have confidence in their decision and may not have another nurse available as this is an autonomous setting. Holding the drug might jeopardize the patient’s health, so this is not the best solution. The nurse working at this level of critical thinking makes choices based on careful examination of situations and alternatives; whether or not the physician is open to nursing input is not relevant.

REF: Page 388 |Page 393 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

A patient has been admitted for a skin graft following third degree burns to

the bilateral calves. The plan of care involves 3 days inpatient and 6 months outpatient treatment, to include home care and dressing changes. When should the nurse initiate the educational plan? a.

After the operation and the patient is awake

On admission, along with the initial assessment

The day before the patient is to be discharged

When narcotics are no longer needed routinely

CORRECT ANSWER: B Initial discharge planning begins upon admission. After the operation has been completed is too late to begin the discharge planning process. The day before discharge is too late for the nurse to gather all pertinent information and begin teaching and coordinating resources. After a complicated operation, the patient may well be discharged on narcotic analgesics. Waiting for the patient to not

need them anymore might mean the patient gets discharged without teaching being done.

REF: Page 387 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

A nurse has designed an individualized nursing care plan for a patient, but

the patient is not meeting goals. Further assessment reveals that the patient is not following through on many items. Which action by the nurse would be best for determining the cause of the problem? a.

Assess whether the actions were too hard for the patient.

Determine whether the patient agrees with the care plan.

Question the patient’s reasons for not following through.

Reevaluate data to ensure the diagnoses are sound.

CORRECT ANSWER: B Having patient and/or family provide input to the care plan is vital in order to gain support for the plan of action. The actions may have been too difficult for the patient, but this is a very narrow item to focus on. The nurse might want to find out the rationale for the patient not following through, but instead of directly questioning the patient, which can sound accusatory, it would be best to offer some possible motives. Reevaluation should be an ongoing process, but the more likely cause of the patient’s failure to follow through is that the patient did not participate in making the plan of care.

REF: Page 393 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

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A new nurse appears to be second-guessing herself and is constantly

calling on the other nurses to double-check their plan of care or rehearse what they will say to the doctor before she call on the patient’s behalf. This seems to be annoying some of the nurse’s coworkers. What is the nurse manager’s best response? a.

Explain to coworkers that this is a characteristic of critical thinking and is

important for the new nurse to improve reasoning skills. b.

Agree with the staff and have someone follow and work more closely with

a preceptor. c.

Have a talk with the nurse and suggest asking fewer questions.

Tell the staff that all new nurses go through this phase, and ignore their

behavior. CORRECT ANSWER: A Reflection-on-action is critical for development of knowledge and improvement in reasoning. It is where learning from practice is incorporated into experience. Inquisitiveness is a characteristic of critical thinking and reflects a desire to learn even when the knowledge may not appear readily useful. The manager should promote this. Suggesting the nurse work more closely with a preceptor implies that the manager thinks the nurse needs to learn more and increase confidence.

In reality, this nurse is demonstrating a characteristic of critical thinking. Suggesting that the nurse ask fewer questions would hamper the development of the nurse as a critical thinker. All new nurses do go through a phase of asking more questions at one time, but dismissing the nurse’s behavior with this explanation is simplistic and will discourage critical thinking. REF: Page 393 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

A nurse has committed a serious medication error and has reported the

error to the hospital’s adverse medication error hotline as well as to the unit manager. The manager is a firm believer in developing critical thinking skills. From this standpoint, what action by the manager would best nurture this ability in the nurse who made the error? a.

Have the nurse present an in-service related to the cause of the error.

Instruct the nurse to write a paper on how to avoid this type of error.

Let the nurse work with more experienced nurses when giving

medications. d.

Send the nurse to refresher courses on medication administration.

CORRECT ANSWER: A

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Nurturing critical thinking skills is done in part by turning errors into learning opportunities. If the nurse presents an in-service on the cause and prevention of the type of error committed, not only will the nurse learn something but many others nurses on the unit will learn from it to. This is the best example of developing critical thinking skills. This option would allow the nurse to learn from the mistake, which is a method of developing critical thinking skills, but the paper would benefit only the nurse, so this option is not the best choice. Letting the nurse work with more experienced nurses might be a good option in a very limited setting, for example, if the nurse is relatively new and the manager discovers a deficiency in the nurse’s orientation or training on giving medications in that system.

Otherwise, this option would not really be beneficial. Sending the nurse to refresher courses might be a solution, but it is directed at the nurse’s learning, not critical thinking. The nurse might feel resentful at having to attend such classes, but even if they were helpful, only this one nurse is learning. Going to generic classes also does not address the specific reason this error occurred, and thus might be irrelevant. Critical thinking and learning can be enhanced by a presentation to the staff on the causes of the error.

REF: Page 387 |Page 393 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

MULTIPLE RESPONSE

A nurse is caring for a patient in a long-term care facility who has not been

sleeping well. She notes that the patient is new to the facility, has been refusing therapy, and is also not eating well. The nurse interprets this to mean that the patient has been having trouble adjusting. The nurse decides to meet with the patient’s care team. The team decides to assess the patient’s willingness to participate in group recreational activities, The patient agrees to participate. After 1 week, the nurse reevaluates the plan of care and notes that the patient has been sleeping much better. Which of the following terms best describe processes used in the nurse’s plan? (Select all that apply.) a.

Clinical judgment

Evidence-based practice

The nursing process

Collaborative care planning

Positive reward process

CORRECT ANSWER: A, C, D Clinical judgment is a reflective process by which the nurse notices, interprets, responds, and reflects in action. The nursing process is a process by which the nurse assesses, diagnoses, implements, and evaluates the nursing care plan. Consulting and gaining input from the healthcare team is collaborative care planning. Evidence-based practice refers to using interventions found in research studies. The positive reward process is not a term used in care planning.

REF: Page 393 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

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Concept 39: Leadership Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

The nursing unit director exhibits the definition of leadership in which of the

following responses? a.

The nurse manager refers the concern to the director of the department.

The nurse manager corrects the concern with the patient directly and does

not communicate her actions to the staff. c.

The nurse manager meets with the staff to discuss the concern and

identify solutions. d.

The nurse manager tells the staff that they need to correct the situation by

tomorrow and leaves the meeting. CORRECT ANSWER: C Leadership is defined as an interactive process that provides needed guidance and direction which is present in the correct answer. The other choices do not involve an interactive process with staff to resolve the concern.

REF: Page 396 |Page 397 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

The nurse who is certified as a Critical Care Registered Nurse (CCRN™)

represents the unit on the organizational performance improvement team. This is an example of which type of leadership? a.

Formal

Unit

Organizational

Informal

CORRECT ANSWER: D Informal leaders are recognized as leaders because of their capabilities and actions. Formal leaders are recognized because of the position they hold such as director or manager. Unit leadership refers to the leader of the particular unit. Organizational leadership refers to any leader within the organization.

REF: Page 397 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

The hospital must reduce the number of readmissions from 11% to 8% in

the next year. Which of the following best represents the transformational leadership style in accomplishing this goal? a.

The director communicates the goal of reducing readmissions to the

hospital operations team and tells them to submit their action plan by the end of the week. b.

The organization charters three work teams to identify solutions for the top

three causes for readmissions. These teams are given full authority to implement their solution. c.

The director of quality develops a vision statement and action plan to

achieve the goal. The director works directly with the involved departments to implement the action plan.

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The CEO communicates the goal to the organizational directors and

managers and states that they are entrusted to solve the problem. CORRECT ANSWER: C Transformational leaders communicate a vision and motivate employees to accomplish the goal. The director who communicates the goal of reducing readmissions to the hospital operations team and tells them to submit their action plan by the end of the week leaves the solution to achieve the goal to the followers to develop without motivating them. The solution that is left to the work teams to resolve is not an example of transformational leadership. The CEO entrusts the managers and directors to solve the problem without giving them a vision or engaging in the solution with them.

REF: Page 397 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

The new director of case management assessed the need to improve the

organization's patient satisfaction with the discharge process. Which statement below illustrates the vision that would lead the team to this goal? a.

“The department will deliver reliable, collaborative, and compassionate

discharge planning services to all patients.” b.

“The department will hold weekly meetings every Tuesday at 11:00 AM.”

“There will be implementation of a new uniform policy so staff can be

readily identified.” d.

“Staff are encouraged to complain about difficult patients, families, and

physicians.” CORRECT ANSWER: A A vision is a statement about the long-term desired state for the department. The other choices describe specific actions, not a long-term vision statement.

REF: Page 397 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

The clinical nurse leader needs to identify the staff who must go home due

to low census. Which answer below describes a democratic style of decision making? a.

The clinical nurse leader identifies the staff person with the most vacation

and asks them to go home. b.

The clinical nurse leader tells the last person to show up for their shift to go

home. c.

The clinical nurse leader decides not to send anyone home because it is

too difficult to decide who should lose hours. d.

The clinical nurse leader asks the group if any of them would like the

opportunity to go home and selects staff who volunteer. CORRECT ANSWER: D Democratic leaders use a participatory style of decision making. In the other choices, the clinical nurse leader makes the decision independent of the staff.

REF: Page 397 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

According to situational and contingency theory, which statement is true?

The theory challenges the concept that one leadership style is always best.

The theory supports employee feelings, morale, and feedback during the

change process.

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Motivation through inspiration and recognition is the focus for transforming

employee behavior. d.

A leader is someone who possesses great intelligence and decision-

making authority. CORRECT ANSWER: A Situational and contingency theory challenges the assumption that there is “one best way” to lead. “The theory supports employee feelings, morale, and feedback during the change process” describes behavioral leadership. “Motivation through inspiration and recognition is the focus for transforming employee behavior” describes transformational leadership. “A leader is someone who possesses great intelligence and decision-making authority” describes Great Man or Trait theory.

REF: Page 399 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

To be an effective nursing leader today requires effective collaboration,

which is modeled by which answer below? a.

The nursing manager of the observation unit was certain the psychology

department would assist the unit with a motivational plan, so she did not request their assistance.

The nursing manager of the observation unit worked with the psychology

department and physical therapy to develop a motivational plan for patients on the unit. c.

The nursing director of behavioral health services followed the

administrative directive to reduce services and refused to provide services for patients on other units. d.

Frustrated by the trend of patients unwilling to work with therapy, the unit

manager recommended that these patients be placed on another unit. CORRECT ANSWER: B The nursing manager works collaboratively with other departments to solve the patient care issue. In the other choices, the unit manager does not involve collaboration to resolve the patient concern.

REF: Page 400 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

MULTIPLE RESPONSE

What are the main features of complex adaptive systems that are relevant

to nursing leadership? (Select all that apply.) a.

Focused on creating organizational change and looking at the whole

versus individual parts. b.

Defined by efforts of leadership to mandate organizational change.

Autocratic in nature with a top-down structure for change.

Dependent on employees knowing what change is necessary and acting

independently. e.

Non-linear and dynamic in nature, versus a static process.

CORRECT ANSWER: A, E

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Complexity science posits that interactions of the parts within a system are more important than the individual parts. Complexity science, however, recognizes that organizational processes are often non-linear and unpredictable. Through the dynamic interplay of negative and positive feedback an organization is able to make changes to keep abreast of the environmental context. The autocratic topdown decision-making and mandates do not create a sustainable change. Being dependent on employees knowing what change is necessary and acting independently lacks interaction of leadership to stimulate change and adaptation among employees.

REF: Page 399 |Page 400 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

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Concept 40: Ethics Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

A patient suffered a brain injury from a motor vehicle accident and has no

brain activity. The patient has a living will which states no heroic measures. The family requests that no additional heroic measures be instituted for their son. The nurse respects this decision in keeping with which principle? a.

Accountability

Autonomy

Nonmaleficence

Veracity

CORRECT ANSWER: B Patients and families must be treated in a way that respects their autonomy and their ability to express their wishes and make informed choices about their treatment. Accountability is inherent in the nurse's ethical obligation to uphold the highest standards of practice and care, assume full personal and professional responsibility for every action, and commit to maintaining quality in the skill and knowledge base of the profession. Nonmaleficence is a principle that implies a duty not to inflict harm. In ethical terms, nonmaleficence means to abstain from injuring others and to help others further their own well-being by removing harm and eliminating threats. Veracity means telling the truth as a moral and ethical requirement.

REF: Page 407 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

A male patient suffered a brain injury from a motor vehicle accident and

has no brain activity. The spouse has come up to see the patient every day for the past 2 months. She asks the nurse, “Do you think when he moves his hands he is responding to my voice?” The nurse feels bad because she believes the movements are involuntary, and the prognosis is grim for this patient. She states,

“He can hear you, and it appears he did respond to your voice.” The nurse is violating which principle of ethics? a.

Autonomy

Veracity

Utilitarianism

Deontology

CORRECT ANSWER: B Veracity is the principle of telling the truth in a given situation. Autonomy is the principle of respect for the individual person; this concept states that humans have incalculable worth or moral dignity. Utilitarianism is an approach that is rooted in the assumption that an action or practice is right if it leads to the greatest possible balance of good consequences or to the least possible balance of bad consequences. Giving the spouse false reassurance is not a good consequence. Deontologic theory claims that a decision is right only if it conforms to an overriding moral duty and wrong only if it violates that moral duty. Persons are to be treated as ends in themselves and never as means to the ends of others.

REF: Page 407 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

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The nurse is faced with an ethical issue. When assessing the ethical issue,

which action should the nurse perform first? a.

Ask, “What is the issue?”

Identify all possible alternatives.

Select the best option from a list of alternatives.

Justify the choice of action or inaction.

CORRECT ANSWER: A The first step in the situational assessment procedure is to find out the technical and scientific facts and assess the human dimension of the situation—the feelings, emotions, attitudes, and opinions. Trying to understand the full picture of a situation is time consuming and requires examination from many different perspectives, but it is worth the time and effort that is required to understand an issue fully before moving forward in the assessment procedure. Identifying alternatives is the second step in the situation assessment procedure. A set of alternatives cannot be established until an assessment has been completed. Selecting the best option is actually the third step in the situation assessment procedure. Options cannot be selected until an assessment has been done to define the issue. Justifying the action or inaction is the final step in the situational assessment procedure. No justification can be made until the assessment and action phases have been completed.

REF: Page 409 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

A nursing student is conducting a survey of fellow nursing students. Which

ethical concept is the student following when calculating the risk-to-benefit ratio and concluding that no harmful effects were associated with a survey? a.

Beneficence

Human dignity

Justice

Human rights

CORRECT ANSWER: A Beneficence is a term that is defined as promoting goodness, kindness, and charity. In ethical terms, beneficence means to provide benefit to others by promoting their good. Human dignity is the inherent worth and uniqueness of a person. Justice involves upholding moral and legal principles. Human rights are the basic rights of each individual.

REF: Page 407 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

A nurse on the unit makes an error in the calculation of the dose of

medication for a critically ill patient. The patient suffered no ill consequences from the administration. The nurse decides not to report the error or file an incident report. The nurse is violating which principle of ethics? a.

Fidelity

Individuality

Justice

Values clarification

CORRECT ANSWER: A

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Fidelity is the principle that requires us to act in ways that are loyal. In the role of a nurse, such action includes keeping your promises, doing what is expected of you, performing your duties, and being trustworthy. Individuality is something that distinguishes one person or thing from others. Injustice is when a person is denied a right or entitlement. Values clarification is a tool that allows the nurse to examine personal values in terms of ethical situations.

REF: Page 407 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

An unconscious patient is treated in the emergency department for head

trauma. The patient is unconscious and on life support for 2 weeks prior to making a full recovery. The initial actions of the medical team are based on which ethical principle? a.

Utilitarianism

Deontology

Autonomy

Veracity

CORRECT ANSWER: B

Deontology is an approach that is rooted in the assumption that humans are rational and act out of principles that are consistent and objective and that compel them to do what is right. Deontologic theory claims that a decision is right only if it conforms to an overriding moral duty and wrong only if it violates that moral duty. Utilitarianism is an approach that is rooted in the assumption that an action or practice is right if it leads to the greatest possible balance of good consequences or to the least possible balance of bad consequences. An attempt is made to determine which actions will lead to the greatest ratio of benefit to harm for all persons involved in the dilemma. Autonomy is the principle of respect for the individual person. People are free to form their own judgments and perform whatever actions they choose. Veracity is defined as telling the truth in personal communication as a moral and ethical requirement.

REF: Page 408 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

MULTIPLE RESPONSE

A drug-addicted nurse switches a patient's morphine injection with normal

saline so that the nurse can use the morphine. The nurse is violating which principles of ethics? (Select all that apply.) a.

Autonomy

Utilitarianism

Beneficence

Dilemmas

Veracity

CORRECT ANSWER: A, B, C, E

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Beneficence is providing benefit to others by promoting their welfare. In general terms, to be beneficent is to promote goodness, kindness, and charity. By taking the patient’s pain medication and substituting saline, the nurse did harm, not good, for the patient. Autonomy is the principle of respect for the individual person; the nurse does not respect someone upon whom the nurse is inflicting harm. Utilitarianism is the principle that assumes that an action is right if it leads to the greatest possible balance of good consequences or to the least possible balance of bad consequences. Because the patient’s pain medication was taken away, the consequences were all bad. Dilemmas are not included as a principle of ethics. Veracity involves truth-telling.

REF: Page 407 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

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Concept 41: Patient Education Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

What is the most appropriate resource to include when planning to provide

patient education related to a goal in the psychomotor domain? a.

Diagnosis-related support groups

Internet resources

Manikin practice sessions

Self-directed learning modules

CORRECT ANSWER: C A teaching goal in the psychomotor domain should be matched with teaching strategies in the psychomotor domain, such as demonstration, practice sessions with a manikin, and return demonstrations. Diagnosis-related support groups would be most effective with goals in the affective domain. Internet resources would be most effective for goals in the cognitive domain. Self-directed learning modules would be most effective for goals in the cognitive domain.

REF: Page 415 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

The nurse educator would identify a need for further teaching when the

student lists which example as a type of learning? a.

Affective

Cognitive

Psychomotor

Self-directed

CORRECT ANSWER: D

Self-directed is one approach to learning but is not considered a type or domain of learning. Self-directed would be a cognitive way of learning. Affective (feelings/attitude), cognitive (knowledge), and psychomotor (skills/performance) are the main domains of learning.

REF: Page 415 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

When describing patient education approaches, the nurse educator would

explain that informal teaching is an approach that involves which quality? a.

Addresses group needs

Follows formalized plans

Has standardized content

Often occurs one-to-one

CORRECT ANSWER: D

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Informal teaching is individualized one-on-one teaching which represents the majority of patient education done by nurses that occurs when an intervention is explained or a question is answered. Group needs are often the focus of formal patient education courses or classes. Informal teaching does not necessarily follow a specific formalized plan. It may be planned with specific content, but it is individualized responses to patient needs. Formal teaching involves the use of a curriculum/course plan with standardized content.

REF: Page 419 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

Barriers to patient education the nurse considers in implementing a

teaching plan include which factor? a.

Family resources

High school education

Hunger and pain

Need perceived by patient

CORRECT ANSWER: C A patient who is hungry or in pain has limited ability to concentrate or learn. Family resources would be considered in developing a plan of care and could be an asset or a barrier to patient education. The patient's educational level would be considered in planning teaching strategies but would not be a barrier to education. A need perceived by a patient would provide motivation for learning and would not be a barrier.

REF: Page 416 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

Strategies to include in a teaching plan for an adult who has repeatedly not

followed the written discharge instructions would include which information source? a.

Individualized handout

Instructional videos

Internet resources

Self-help books

CORRECT ANSWER: B An instructional video would provide a visual/auditory approach for discharge instructions. Repeatedly not following written instructions is a clue that the patient may not be able to read or understand the information. While assessing the literacy level of an adult patient can be challenging, the information that they have not been able to follow previous written instructions would suggest that the nurse use an alternate strategy that does not require a high degree of literacy. An individualized handout would be written, very similar to previous instructions, and would not address a concern about literacy. Internet resources generally require an individual to be able to read, and although videos are available through the Internet, this is not the best response. Self-help books would be appropriate for an individual who reads. There is a question about whether this patient is literate, so these would not be the best choice.

REF: Page 419 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

When planning to evaluate a patient's satisfaction with a teaching activity,

what is the most

appropriate strategy? a.

Include a survey instrument.

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Observe for level of skill mastery.

Present information more than one time.

Provide for a return demonstration.

CORRECT ANSWER: A A survey or questionnaires can be used to measure affective behavior change as well as patient satisfaction with the teaching experience. Observing for level of skill mastery would evaluate achievement of a psychomotor goal rather than satisfaction with the experience. Repeating information more than one time or in more than one way may be appropriate strategies to include in the teaching plan but would provide no evaluation data. Providing for a return demonstration would help in evaluating achievement of a psychomotor goal, not satisfaction with the activity.

REF: Page 417 OBJECTIVE: NCLEX® Client Needs Category: Psychosocial Integrity

Interrelated concepts to the professional nursing role a nurse manager

would consider when addressing concerns about the quality of patient education include which factor? a.

Adherence

Developmental level

Motivation

Technology

CORRECT ANSWER: D The interrelated concepts to the professional role of a nurse include health promotion, leadership, technology/informatics, quality, collaboration, and communication. Adherence, culture, developmental level, family dynamics, and motivation are considered interrelated concepts to patient attributes and preference.

REF: Page 417 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

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Concept 42: Health Promotion Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

Which tertiary prevention measure should be included in the health

promotion plan of care for a patient newly diagnosed with diabetes? a.

Avoiding carcinogens

Foot screening techniques

Glaucoma screening

Seat belt use

CORRECT ANSWER: B Foot screening is considered a tertiary prevention measure, one that minimizes the problems with foot ulcers, an effect of diabetic disease and disability. Avoiding carcinogens is considered primary prevention—those strategies aimed at optimizing health and disease prevention in general and not linked to a single disease entity. Glaucoma screening is considered secondary screening— measures designed to identify individuals in an early state of a disease process so that prompt treatment can be started. Seat belt use is considered primary prevention—those strategies aimed at optimizing health and disease prevention in general and not linked to a single disease entity.

REF: Page 422 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance and Physiological Integrity: Reduction of Risk Potential

When teaching a patient with a family history of hypertension about health

promotion, the nurse describes blood pressure screening as which type of prevention? a.

Illness

Primary

Secondary

Tertiary

CORRECT ANSWER: C

Blood pressure screening is considered secondary prevention. It is a measure designed to identify individuals in an early state of a disease process so that prompt treatment can be started. Illness prevention is considered primary prevention. Primary prevention measures are those strategies aimed at optimizing health and disease prevention in general and not linked to a single disease entity. Tertiary prevention measures are those that minimize the effects of disease and disability.

REF: Pages 422-423 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance and Physiological Integrity: Reduction of Risk Potential

The primary health care nurse would recommend screening based on

known risk factors, because of which action? a.

Eliminate the possibility of developing a condition.

Identify appropriate treatment guidelines.

Initiate treatment of a condition or disease.

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Make a substantial difference in morbidity and mortality.

CORRECT ANSWER: D

Screenings are typically indicated and recommended if the effort makes a substantial difference in morbidity and/or mortality of conditions, and they are safe, cost effective, and accurate. Ideally a screening measure will accurately differentiate individuals who have a condition from those who do not have a condition 100% of the time; however, there may be a false-negative result, or the patient may develop a condition after the screening was conducted. A screening does not specify treatment guidelines; the screen provides results, and the health care provider identifies the treatment. The goal of screening is to identify individuals in an early state of a disease so that prompt treatment can be initiated. The screening results are used for this purpose.

REF: Page 422 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential

At the well-child clinic, how does the nurse correctly teach a mother about

health promotion activities and describe immunizations? a.

Unique for children

Primary prevention

Secondary prevention

Tertiary prevention

CORRECT ANSWER: B Immunizations/vaccinations are considered primary prevention measures, those strategies aimed at optimizing health and disease prevention in general. Immunizations/vaccinations are primary prevention measures for individuals across the life span, not just children. Secondary prevention measures are those designed to identify individuals in an early state of a disease process so that prompt treatment can be started. Tertiary prevention measures are those that minimize the effects of disease and disability.

REF: Page 423 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance and Physiological Integrity: Reduction of Risk Potential

The nurse in a newly opened community health clinic is developing a

program for the individuals considered at greatest risk for poor health outcomes. How should the nurse consider this group? a.

Global community

Sedentary society

Unmotivated population

Vulnerable population

CORRECT ANSWER: D Vulnerable populations refer to groups of individuals who are at greatest risk for poor health outcomes. The entire world is the global community. Sedentary refers to the lifestyles of people worldwide who have epidemic rates of obesity and many other related chronic diseases. Unmotivated population refers to the individuals who have not demonstrated interest in changing.

REF: Page 425 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential

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When there is evidence that supports a screening for an individual patient

but not for the general population, the nurse would expect the United States Preventive Services Task Force Grading to be what? a.

No recommendation for or against

Recommends

Recommends against

Strongly recommends

CORRECT ANSWER: A The United States Preventive Services Task Force Grading is an example of how evidence is used to make guidelines and determine priority. When there is evidence that supports a screening for an individual patient but not for the general population, there is no recommendation for or against screening the general population. Recommends is the grading when there is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. Recommends against is the grading when there is moderate or high certainty that the intervention has no net benefit or that the harms outweigh the benefits. Strongly recommends is the grading when there is high certainty that the net benefit is substantial.

REF: Page 423 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential

MULTIPLE RESPONSE

Interrelated concepts to professional nursing a nurse manager would

consider when addressing concerns about the quality of health promotion include which concepts? (Select all that apply.) a.

Culture

Development

Evidence

Nutrition

Health policy

CORRECT ANSWER: C, E The interrelated concepts to professional nursing include evidence, health care economics, health policy, and patient education. Culture is a patient attribute concept. Development is a patient attribute concept. Nutrition is a health and illness concept.

REF: Page 425 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

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Concept 43: Communication Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

A patient states, “I had a bad nightmare. When I woke up, I felt emotionally

drained, as though I hadn't rested well.” Which response by the nurse would be an example of interpersonal therapeutic communication? a.

“It sounds as though you were uncomfortable with the content of your

dream.” b.

“I understand what you're saying. Bad dreams leave me feeling tired, too.”

“So, all in all, you feel as though you had a rather poor night's sleep?”

“Can you give me an example of what you mean by a 'bad nightmare'?”

CORRECT ANSWER: D The technique of clarification is therapeutic and helps the nurse examine meaning. The distracters focus on patient feelings but fail to clarify the meaning of the patient's comment.

REF: Page 435 OBJECTIVE: NCLEX® Client Needs Category: Psychosocial Integrity

The nurse is admitting a patient to the medical/surgical unit. Which

communication technique would be considered appropriate for this interaction? a.

“I've also had traumatic life experiences. Maybe it would help if I told you

about them.” b.

“Why do you think you had so much difficulty adjusting to this change in

your life?” c.

“You will feel better after getting accustomed to how this unit operates.”

“I'd like to sit with you for a while to help you get comfortable talking to me.”

CORRECT ANSWER: D Because the patient is newly admitted to the unit, allowing the patient to become comfortable with the setting a technique that can assist in establishing the nursepatient relationship. It helps build trust and convey that the nurse cares about the patient. The nurse should not reveal their life experiences as this is not therapeutic. Asking why the patient is having difficulty may provide insight; however, this would be best saved for an established relationship with the patient. Assuring the patient that they will feel better may not be true depending on the reason for the admission.

REF: Page 435 OBJECTIVE: NCLEX® Client Needs Category: Psychosocial Integrity

The nurse is seeking clarification of a statement that was made by a

patient. What is the best way for the nurse to seek clarification? a.

“What are the common elements here?”

“Tell me again about your experiences.”

“Am I correct in understanding that…”

“Tell me everything from the beginning.”

CORRECT ANSWER: C Clarification ensures that both the nurse and patient share mutual understanding of the communication. The distracters encourage comparison rather than clarification and present implied questions that suggest the nurse was not listening.

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REF: Page 435

OBJECTIVE: NCLEX® Client Needs Category:

Psychosocial Integrity

A nurse is conducting a therapeutic session with a patient in the inpatient

psychiatric facility. Which remark by the nurse would be an appropriate way to begin an interview session? a.

“How shall we start today?”

“Shall we talk about losing your privileges yesterday?”

“Let's get started discussing your marital relationship.”

“What happened when your family visited yesterday?”

CORRECT ANSWER: A

The interview is patient centered; thus, the patient chooses issues. The nurse assists the patient by using communication skills and actively listening to provide opportunities for the patient to reach goals. In the distracters, the nurse selects the topic.

REF: Page 435

OBJECTIVE: NCLEX® Client Needs Category:

Psychosocial Integrity

The nurse and the patient are conversing face to face. What

communication technique is being demonstrated? a.

Linguistic

Paralinguistic

Explicit

Metacommunication

CORRECT ANSWER: A Conversing face to face, reading newspapers and books, and even texting are all common forms of linguistic communication. Paralinguistics include less recognizable but important means of transmitting messages such as the use of gestures, eye contact, and facial expressions. Explicit communication is not a therapeutic communication technique. Metacommunication factors that affect how messages are received and interpreted would include internal personal states (such as disturbances in mood), environmental stimuli related to the setting of the communication, and contextual variables (such as the relationship between the people in the communication episode).

REF: Page 431 |Page 432 OBJECTIVE: NCLEX® Client Needs Category: Psychosocial Integrity

MULTIPLE RESPONSE

The nurse is working with a patient diagnosed with posttraumatic stress

disorder related to childhood sexual abuse. The patient is crying and states, “I should be over this by now; this happened years ago.” Which response(s) by the nurse will facilitate communication? (Select all that apply.) a.

“Why do you think you are so upset?”

“I can see that this situation really bothers you.”

“The abuse you endured is very painful for you.”

“Crying is a way of expressing the hurt you’re experiencing.”

“Let’s talk about something else, since this subject is upsetting you.”

CORRECT ANSWER: B, C, D

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Reflecting and giving information are therapeutic techniques. “Why” questions often imply criticism or seem intrusive or judgmental. They are difficult to answer. Changing the subject is a barrier to communication.

REF: Page 435 OBJECTIVE: NCLEX® Client Needs Category: Psychosocial Integrity

OTHER

A patient is admitted to the intensive care unit for congestive heart failure.

Using the situation–background–assessment–recommendation (SBAR) format, put the following statements in the order in which the nurse should report changes to the health care team.

Our patient was admitted 2 days ago with heart failure and has been

receiving furosemide (Lasix) for diuresis, but his urine output has been low. b.

I think that our patient needs to be evaluated immediately and may need

intubation and mechanical ventilation. c.

This is the nurse on the surgical unit. I am calling about our patient in room

3. After assessing him, I am very concerned about his shortness of breath. d.

Today, our patient has crackles audible throughout the posterior chest and

his O2 saturation is 89%. His condition is very unstable.

CORRECT ANSWER: C, A, D, B The order of the nurse’s statements follows the SBAR format. The nurse explains the situation by identifying herself, then gives the immediate background of the patient. She then assesses the patient and gives her recommendation.

REF: Page 433 OBJECTIVE: NCLEX® Client Needs Category: Physiological Adaptation: Reduction of Risk Potential

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Concept 44: Collaboration Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

A newly licensed nurse is assigned to an experienced nurse for training on

a medical unit of a hospital. What type of nurse-to-nurse collaboration does this assignment demonstrate? a.

Interprofessional

Shared governance

Interorganizational

Mentoring

CORRECT ANSWER: D Mentoring is a collaborative partnership between a novice nurse and an expert nurse to help transition a nurse through career development, personal growth, and socialization into the profession. Interprofessional collaboration is working with several disciplines. Shared governance is a type of management for nursing. Interorganizational collaboration often includes teams from inside and outside an organization to meet a common goal.

REF: Page 438 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

The nurse is presenting an in-service on the importance of collaborative

communication. The nurse includes which critical event identified by the Joint Commission as an outcome of poor communication among health care team members? a.

The occurrence of a patient event resulting in death or serious injury

Decreased ability to document expenses of care provided

Longer time to begin surgical cases

Increased time to discharge patients to outpatient care

CORRECT ANSWER: A The Joint Commission has identified that poor communication is the primary factor in the occurrence of sentinel events, or events resulting in unintended death or serious injury to patients. Lack of documentation, longer time to begin surgery, and increased delays in discharge all contribute to the management of health care, but do not result in critical patient outcomes.

REF: Page 442 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

Which patient scenario describes the best example of professional

collaboration? a.

The nurse, physician, and physical therapist have all visited separately

with

the patient.

The nurse, physical therapist, and physician have all developed separate

care plans for the patient. c.

The nurse mentions to the physical therapist that the patient may benefit

from a muscle strengthening evaluation. d.

The nurse and physician discuss the patient's muscle weakness and

initiate a referral for physical therapy. CORRECT ANSWER: D Professional collaboration includes team management and referral to needed providers to meet patient needs. Each discipline retains responsibility for their own scope of practice but recognizes the expertise of other providers. Working separately does not develop a comprehensive plan of care. Casual mentioning of patient needs does not follow professional communication channels and frequently delays needed interventions.

REF: Page 442 |Page 443 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

Which statement correctly describes the nurses' role in collaboration?

State boards of nursing mandate that collaboration can only occur in

hospitals. b.

Collaboration should occur only with physicians.

Collaboration occurs only between nurses with the same level of

education. d.

Collaboration may occur in health-related research.

CORRECT ANSWER: D Nurses collaborate with many different persons, including patients, managers, educators, and researchers. Collaboration does not occur only with physicians or

nurses of equivalent educational background, but with anyone who is working towards meeting patient goals. Collaboration occurs in any health care setting as well as community and home settings.

REF: Page 442 |Page 443 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

A nurse manager has recently overheard several negative comments

made by nurses on the unit about other nurses on the unit. The manager recognizes that the nurses are exhibiting what type of behavior that is detrimental to collaboration? a.

Vertical violence

Lateral violence

Descending violence

Personal violence

CORRECT ANSWER: B Lateral violence undermines collaboration and occurs nurse-to-nurse. Vertical or descending violence implies one participant has a higher status than another. Personal violence falls in a legal category, and while it will hinder collaboration, it is not specific to coworkers.

REF: Page 441

OBJECTIVE: NCLEX® Client Needs Category:

Psychosocial Integrity

The nurse and physician are explaining that home care that will be needed

by a patient after discharge. The patient's spouse states angrily that it will not be possible to provide the care recommended. What is the best response by the nurse? a.

“Let me review what is needed again.”

“It is important that you do what the physician has prescribed.”

“What concerns do you have about the prescribed care?”

“I can come back after you talk with your spouse about the care.”

CORRECT ANSWER: C The patient needs to be the focus of developing care plans, and communication is an important part of collaboration with the patient to discover barriers for the patient to follow recommendations. It is important to either provide solutions to the barriers or present other options. Reviewing the care again does not demonstrate willingness to have the patient be part of the team. Insisting that the patient do what is prescribed is autocratic and does not recognize the role the patient has in their care. Leaving the patient and spouse with the situation unresolved fosters distrust and more anger.

REF: Page 441 OBJECTIVE: NCLEX® Client Needs Category: Psychosocial Integrity

The nurse is caring for a patient with a progressive, degenerative muscle

illness. The patient states that she would like to remain in her home with her daughter as long as possible. What action should the nurse take? a.

Teach the patient muscle strengthening and stretching exercises.

Tell the patient to make plans to move to an assisted-living facility.

Discuss resources to help the patient and make appropriate referrals.

Ask the patient to come in for daily

physical therapy. CORRECT ANSWER: C To honor the patient's request to stay at home the nurse should make appropriate referrals for needed evaluation and assistance. Most nurses will not have the expertise to teach appropriate exercises for degenerative illness. Asking the patient to move to an assisted-living facility does not account for the patient's request. The patient has not been assessed for the need of daily therapy, and it is not likely that a patient with a degenerative illness will be able to make daily appointments for treatment as the illness progresses.

REF: Page 440 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity

A patient has been admitted to an acute care hospital unit. The nurse

explains the hospital philosophy that the patient be an active part of planning their care. The patient verbalizes understanding of this request when they make which statement? a.

“I will have to do whatever the physician says I need to do.”

“Once a plan is developed, it cannot be changed.”

“My insurance will not pay if I don't do what you want me to do.”

“We can work together to adjust my plan as we need to.”

CORRECT ANSWER: D

Treatment plans need to be developed, evaluated, and adapted as needed based on the patient status and willingness to complete the prescribed care. Stating that the patient has to do whatever the care provider prescribes does not include the principle of collaboration. Care plans can be altered based on patient status. Insurance providers do not determine a patient's ability to complete prescribed care, although they do reimburse for standard care given.

REF: Page 440 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

The management of a community hospital is trying to encourage a more

collaborative environment among staff members. Which concept is most important for management to develop first? a.

Post educational posters about how well collaboration is being performed

Highlight that no single profession can meet the needs of all patients

Provide meetings for each department on how their role affects patients

Begin implementing evaluations of collaborative skills on annual

performance

reviews CORRECT ANSWER: B Recognizing that collaboration needs all professions to provide patient-centered care is an important first step to implementing a different philosophy in the hospital. Posting an evaluation of performance before education will not encourage participation. Collaboration requires an understanding of more than

your own discipline. It is unfair to evaluate staff on a requirement that they have not been introduced to.

REF: Page 440 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

MULTIPLE RESPONSE

Which activities are appropriate for the nurse to collaborate with a patient?

(Select all that apply.) a.

Prescribing a new medication dose

Health promotion activities

End-of-life comfort decisions

Interpreting laboratory results

Lifestyle changes to improve health

CORRECT ANSWER: B, C, E Nurses should include patients and their families when exploring health promotion activities, end-of-life decisions, lifestyle changes, and treatment options. Prescribed medication doses are initiated by educated professionals, although the patient gives feedback on the effectiveness of medications. Patients are not trained to interpret lab results, but patients rely on health professionals to explain results to them.

REF: Page 440 |Page 441 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

Concept 45: Safety Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

A sentinel event refers to which situation?

An event that could have harmed a patient, but serious harm didn't occur

because of chance. b.

An event that harms a patient as a result of underlying disease or

condition. c.

An event that harms a patient by omission or commission, not an

underlying disease or condition. d.

An event that signals the need for immediate investigation and response.

CORRECT ANSWER:

A sentinel event is an unexpected occurrence involving death or serious physical or psychologic injury or the risk thereof called sentinel, because they signal the need for immediate investigation and response. A near-miss refers to an error or commission or omission that could have harmed the patient, but serious harm did not occur as a result of chance. Harm that relates to an underlying disease or condition provides the rationale for the close monitoring and supervision provided in a health care setting. An adverse event is one that results in unintended harm because of the commission or omission of an act.

REF: Page 446 OBJECTIVE:

NCLEX® Client Needs Category: Safe and Effective Care

Environment: Safety and Infection Control

The nurse is caring for a patient experiencing an allergic reaction to a bee

sting who has an order for diphenhydramine (BenaDRYL). The only medication in the patient's medication bin is labeled BenaZEPRIL. The nurse contacts the pharmacy for the correct medication to avoid what type of error? a.

Communication

Diagnostic

Preventive

Treatment

CORRECT ANSWER:

The nurse avoided a treatment error, giving the wrong medication. Benazepril is an ace inhibitor used to treat blood pressure. According to Leape, treatment errors occur in the performance of an operation, procedure, or test; in administering a treatment; in the dose or method of administering a drug; or in avoidable delay in treatment or in responding to an abnormal test. Communication errors refer to those that occur from a failure to communicate. Diagnostic errors are the result of a delay in diagnosis, failure to employ indicated tests, use of outmoded tests, or failure to act on results of monitoring or testing. Preventive errors occur when there is inadequate monitoring or failure to provide prophylactic treatment or follow-up of treatment.

REF: Page 446

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OBJECTIVE:

NCLEX® Client Needs Category: Safe and Effective Care

Environment: Safety and Infection Control and Physiological Integrity: Pharmacological and Parenteral Therapies

The strategy to avoid medication errors endorsed by the Institute for Safe

Medication Practices (ISMP) to differentiate products with look-alike names is referred to as which term? a.

Automatic alerts

Bar coding

Computer order entry

Tallman lettering

CORRECT ANSWER:

Tallman lettering is a term coined by ISMP to describe the practice of using unique letter characteristics of similar drug names known to have been confused with one another. Tallman lettering is used to differentiate products with look-alike names such as BenaDRYL (antihistamine) and BenaZEPRIL (ace inhibitor). The other options are examples of safety- enhancing technologies strategies designed to minimize drug errors, but they are not directed at look-alike medications. Automatic alerts are computer-generated alarms that can be programmed to occur with such things as allergies and incompatible medications. Bar coding is used with medication administration systems that can be programmed to match patient identification bracelets with documentation. Computer order entry systems are designed to include components of a standard medication order. REF: Page 446 |Page 447

OBJECTIVE:

NCLEX® Client Needs Category: Safe and Effective Care

Environment: Safety and Infection Control and Physiological Integrity: Pharmacological and Parenteral Therapies

Prior to drug administration the nurse reviews the seven rights, which

include right patient, right medication, right time, right dose, right education, right documentation, and what other right? a.

Room

Route

Physician

Manufacturer

CORRECT ANSWER:

The right route (e.g., oral or intramuscular) is an essential component to verify prior to the administration of any drug. The patient does not need to be in a specific location. There may be a number of physicians caring for a patient who prescribe medications for any given patient. A similar drug may be made by a number of different companies, and checking the manufacturer is not considered one of the seven rights. However, the nurse will want to be aware of a difference, because different companies prepare the same medication in different ways with different inactive ingredients, which can affect patient response.

REF: Page 451 OBJECTIVE:

NCLEX® Client Needs Category: Safe and Effective Care

Environment: Safety and Infection Control and Physiological Integrity: Pharmacological and Parenteral Therapies

Which is an essential element of a standard order set to verify a

medication order?

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Volume only

Number of tablets

Metric dose/strength

Hour of administration

CORRECT ANSWER:

The ISMP recommendations for standardized medication order sets include such elements as the drug name (generic followed by brand when appropriate), metric dose/strength, frequency and duration, route, and indication. Although a prescription may include volume or number of tablets, the essential component is dose or strength, because the volume or number of tablets may vary by manufacturer. The exact hour of administration can be based on factors such as the frequency, agency protocols, and patient preferences.

REF: Page 446 OBJECTIVE:

NCLEX® Client Needs Category: Safe and Effective Care

Environment: Safety and Infection Control and Physiological Integrity: Pharmacological and Parenteral Therapies

To promote safety, the nurse manager sensitive to point of care (sharp

end) and systems level (blunt end) exemplars works closely with staff to address which point of care exemplar? a.

Care coordination

Documentation

Electronic records

Fall prevention

CORRECT ANSWER:

The most common safety issues at the sharp end include prevention of decubitus ulcers, medication administration, fall prevention, invasive procedures, diagnostic workup, recognition of/action on adverse events, and communication. These are the most common issues the staff nurse providing direct patient care encounters. Each of the other options are classified as systems level exemplars.

REF: Page 450 OBJECTIVE:

NCLEX® Client Needs Category: Safe and Effective Care

Environment: Management of Care

Aspects of safety culture that contribute to a culture of safety in a health

care organization include which component? a.

Communication

Fear of punishment

Malpractice implications

Team nursing

CORRECT ANSWER:

Aspects that contribute to a culture of safety include leadership, teamwork, an evidence base, communication, learning, a just culture, and patient-centered care. Fear of professional or personal punishment and concern about

malpractice implications are considered barriers to a culture of safety. No model of nursing care has been related to a culture of safety.

REF: Page 450 OBJECTIVE:

NCLEX® Client Needs Category: Safe and Effective Care

Environment: Management of Care

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A staff nurse reports a medication error due to failure to administer a

medication at the scheduled time. What is the charge nurse’s best response? a.

“We’ll conduct a root cause analysis.”

“That means you’ll have to do continuing education.”

“Why did you let that happen?”

“You’ll need to tell the patient and family.”

CORRECT ANSWER:

In a just culture the nurse is accountable for their actions and practice, but people are not punished for flawed systems. Through a strategy such as root cause analysis the reasons for errors in medication administration can be identified and strategies developed to minimize future occurrences. Requiring continued education may be an appropriate recommendation but not until data is collected about the event. Telling the patient is part of transparency and the sharing and

disclosure among stakeholders, but it is generally the role of risk management staff, not the staff nurse.

REF: Page 447 OBJECTIVE:

NCLEX® Client Needs Category: Safe and Effective Care

Environment: Management of Care

To promote a safety culture, the nurse manager preparing the staff

schedule considers the anticipated census in planning the number and experience of staff on any given shift. Which is the human factor primarily addressed with this consideration? a.

Available supplies

Interdisciplinary communication

Interruptions in work

Workload fluctuations

CORRECT ANSWER:

Including an adequate number of staff members with experience caring for anticipated patients is a strategy to manage the workload and potential fluctuations. A safety culture requires organizational leadership (e.g., the nurse manager) that gives attention to human factors such as managing workload fluctuations. This strategy also applies principles of crew resource management in that it addresses workload distribution. Lack of supplies can create a challenge for safe care but could not be addressed with the schedule. Concerns with communication and coordination across disciplines, including power gradients, and excessive professional courtesy can create hazards but would not be the best answer. Strategies to minimize interruptions in work are essential but would not be the best answer in this situation.

REF: Page 448

OBJECTIVE:

NCLEX® Client Needs Category: Safe and Effective Care

Environment: Management of Care

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Concept 46: Technology and Informatics Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

The staff nurse who uses informatics in promoting quality patient care is

most likely to access data in which domain? a.

Certified clinical information systems (CIS)

Clinical health care informatics

Public health/population informatics

Translational bioinformatics

CORRECT ANSWER: B Clinical health care informatics and the subset, nursing informatics, provides for the development of direct approaches to patients and their families which can be used by the staff nurse to promote quality patient care. Certified CIS refers to the tools for achieving quality outcomes, including electronic health records, clinical data repositories, decision support programs, and handheld devices—not the data. Public health/population informatics is the domain which relates information, computer science, and technology to public health science to improve the health of populations; this domain would provide data for the nurse working with communities. Translational bioinformatics refers to the research science domain where biomedical and genomic data are combined; it‘s a new term that describes the domain of where bioinformatics meets clinical medicine, generally for health care research rather than direct patient care.

REF: Page 453 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

When discussing the purposes of health care informatics with a nurse

during orientation, the nurse educator would be concerned if the nurse orientee stated that which is one purpose of informatics? a.

Develop a cognitive science.

Improve disease tracking.

Improve the health provider‘s work flow.

Increase administrative efficiencies.

CORRECT ANSWER: A Cognitive science is one of the theories that play a role in the implementation of informatics. Its development is not a purpose, and the nurse educator would use

this incorrect response of the orientee to plan additional teaching about the purposes of health care informatics. Purposes of information health technology include to improve health provider work flow, improve health care quality, prevent medical errors, reduce health care costs, increase administrative efficiencies, decrease paperwork, and improve disease tracking.

REF: Page 456 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

To design and implement a decubitus ulcer risk management protocol in

the electronic health record, the informatics nurse would first perform which action? a.

Build the screens in the electronic health record.

Determine evidence supporting decubitus ulcer risk management.

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Develop the training program for staff.

Select the appropriate standardized language.

CORRECT ANSWER: B

Collecting the evidence related to the issue is the first step in addressing a problem (remember the nursing process, the foundation of nursing practice). Based on the evidence, an assessment tool or tools and data needed from a patient perspective would be identified. The screens in the electronic record would be based on the workflow surrounding the patient assessment. A training program could not be developed until the protocol is adopted. The appropriate standardized language is selected based on what needs to be documented and what has been approved for use by the agency (e.g., ANA recognized terminologies).

REF: Page 456 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

The application of information processing that deals with the storage,

retrieval sharing, and use of health care data, information, and knowledge for communication and decision making is the definition of which area? a.

Computer science

Health informatics

Health information technology

Nursing informatics

CORRECT ANSWER: C This is the definition of health information technology. Computer science is a branch of engineering that studies computation and computer technology, hardware, software, and the theoretical foundations of information and computation techniques. Health informatics is a discipline in which health data are stored, analyzed, and disseminated through the application of information and communication technology. Nursing informatics is a specialty that integrates

nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing practice.

REF: Page 458 |Page 459 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

The nurse manager of a medical/surgical unit wants to increase the use of

health care technology on the unit and is working with an ANA-certified informatics nurse to reduce which barriers to health information exchange? a.

Basic informatics knowledge and skills

Offering the best set of tools

Privacy and security policies

Unit-specific terminology

CORRECT ANSWER: D

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Unit-specific terminology would be a barrier to sharing health information because there could be confusion about terms. Standardized terminology within the electronic health record is critical for communicating care to the interprofessional team and exchanging health information. Competency in informatics including basic informatics knowledge and skills could facilitate the use of informatics; lack of competency could be a barrier. Offering the best set of tools could promote the ease of data entry and access. Privacy and security policies reduce legal and ethical concerns about sharing data, thus reducing barriers to health information exchange.

REF: Page 453 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

Florence Nightingale, the first nurse informatician, sought hospital data for

comparison purposes to compete which goal? a.

Allow faster and accurate diagnosis.

Better coordinate care.

Improve the efficiency of care.

Show people how their money was spent.

CORRECT ANSWER: D “They would show the subscribers how their money was being spent, what amount of good was really being done with it, or whether the money was not doing mischief rather than good” (Florence Nightingale, 1863). Although health

information and informatics could fulfill the other purposes, none of these were the focus of Florence Nightingale‘s published purposes of her requests for hospital information.

REF: Page 458 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

Which are exemplars of the health informatics concept?

Clinical research informatics

Hardware and software

Privacy and security

Standard terminology

CORRECT ANSWER: A Exemplars of the health informatics concept include clinical health care informatics, clinical research informatics, public/population health informatics, and translational bioinformatics. Hardware and software, privacy and security, and standardized information systems and terminology are considered attributes related to the concept, not exemplars.

REF: Page 459 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

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Concept 47: Evidence Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

One of the first nurse researchers to document evidence-based practice

for nursing was Florence Nightingale. What did Nightingale incorporate into her practice that made her practice different from her colleagues? a.

Nightingale gathered scientific data.

Nightingale calculated statistics to report her findings.

Nightingale communicated her findings to powerful others.

Nightingale based her nursing practice on her findings.

CORRECT ANSWER: D Florence Nightingale had tried to develop the role of researcher by using evidence from her practice and implementing these findings. Evidence-based

practice (EBP) includes conducting quality studies, synthesizing the study findings into the best research evidence available, and using that research evidence effectively in practice. Although gathering scientific data, calculating statistics to report findings, and communicating findings to powerful others are all important components of conducting research, Nightingale's action that most appropriately reflects the current nursing research priority is that she based her nursing practice on her findings.

REF: Page 465 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

The nurse administrator is doing a study that entails gathering data about

new employees over a 10-year period. Which research method would be the best one to use for this type of study? a.

Quantitative longitude cohort

Qualitative longitudinal

Qualitative interview

Qualitative case study

CORRECT ANSWER: A Quantitative research has been defined as being "focused on the testing of a hypothesis through objective observation and validation". The types of studies that make up this category include randomized controlled studies, cohort studies, longitudinal studies, case-controlled studies, and case reports. The other options are examples of quantitative, not qualitative, studies.

REF: Page 465|Page 466 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

The nurse in the outpatient setting would like to conduct a research study

that compares patients who take tramadol (Ultracet) to patients who take oxycodone hydrochloride and acetaminophen (Percocet) for managing back pain. Which quantitative research method should yield the best results? a.

Longitude study

Controlled study

Systematic reviews/meta-analysis

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Survey study

CORRECT ANSWER: B A controlled study is a type of quantitative research that seeks to control and examine the variables to determine effectiveness. In this case, the variables would be those that were administered tramadol (Ultracet) and those that were administered hydrochloride and acetaminophen (Percocet) for managing back pain. Correlational research methods help determine association between or among variables. A longitudinal study examines variables over a designated course of time. A systematic reviews/meta-analysis is a type of literature review and not a research method. A survey study is a type of qualitative research method.

REF: Page 466 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

The nurse in the psychiatric unit is involved in a research study for a

depression medication. In the study, patients are randomly assigned to one depression medication and the other group is receiving no medication to treat the depression. What method of research are the patients involved with? a.

Descriptive

Correlational

Quasi-experimental

Experimental

CORRECT ANSWER: D Experimental tests an intervention and includes both a control group and random assignment. This research study tests an intervention and includes both a control group and random assignment. Descriptive defines the magnitude of a concept and its characteristics. Correlational determines association between or among variables. Quasiexperimental tests an intervention and lacks either a control group or random assignment.

REF: Page 466 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

MULTIPLE RESPONSE

How does the Iowa model transcend mere nursing care? (Select all that

apply.) a.

It includes formalized internal feedback loops.

Its triggers can have their origins practically anywhere.

It generates change in practice solely through research.

It implies a layer of policy development.

It addresses multiple disciplines' impacts on quality.

CORRECT ANSWER: A, B, D, E

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The triggers addressed within the Iowa model process can be problem focused and evolve from risk management data, process improvement data,

benchmarking data, financial data, and clinical problems. The triggers can also be knowledge focused, such as new research findings, change in a national agency's or an organization's standards and guidelines, expanded philosophy of care, or questions from the institutional standards committee. Because the Iowa model is often implemented at a fairly high level of nursing or hospital administration, it scrutinizes the input of nursing and other disciplines in its process. Its output is applied as widely as possible throughout the organization, and it can affect policy within a multihospital system and even across systems. The success of EBP is determined by all involved, including health care agencies, administrators, nurses, physicians, and other health care professionals.

REF: Page 465 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

Which statements are true about the Iowa model of EBP? (Select all that

apply.) a.

It addresses utilization of research findings at an individual level.

It prioritizes pressing items of interest related to quality of care.

Individual nurses enact an Iowa decision tree when they examine risk

management data. d.

It identifies triggers capable of posing hazard or benefit.

It reiterates that innovators embrace change far earlier than laggards.

CORRECT ANSWER: B, D The Iowa model of EBP provides direction for the development of EBP in a clinical agency. This EBP model was initially developed in 1994 and revised in 2001. In a health care agency, there are triggers that initiate the need for change, and the focus should always be to make changes based on best evidence.

These triggers can be problem focused and evolve from risk management data, process improvement data, benchmarking data, financial data, and clinical problems. The triggers can also be knowledge focused, such as new research findings, change in a national agency's or an organization's standards and guidelines, expanded philosophy of care, or questions from an institutional standards committee.

REF: Page 465 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

The nurse is conducting a review of the literature for pain management

techniques. Which of the following would the nurse consider when conducting research that yields solid EBP? (Select all that apply.) a.

Search the literature to uncover evidence to answer the question.

Evaluate the outcome.

Use the nursing process to evaluate evidence.

Evaluate the evidence found.

Develop an answerable question.

Develop a question that has not been answered.

Apply the evidence to the practice situation.

CORRECT ANSWER: A, B, D, E, G To facilitate the use of evidence, steps have been developed to systematically approach a question of patient care. The steps are outlined as follows: •

Develop an answerable question

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•

Search the literature to uncover evidence to answer the question

•

Evaluate the evidence found

•

Apply the evidence to the practice situation

•

Evaluate the outcome

•

The nursing process is a method of problem solving and can be used to

develop a plan of care. Formulating a question that has not been answered in the research would be considered primary research. Therefore, there is no evidence in which to draw from.

REF: Page 465 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

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Concept 48: Health Care Quality Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

Which statement is true regarding the patient’s perception of his or her

care? a.

Patent perception is just as important as the outcome of care.

Patient perception is insignificant compared to the outcome of care.

Patient satisfaction has no relation to quality of care.

Patient satisfaction is insignificant compared to the outcome of care.

CORRECT ANSWER: A

The patient’s perception of his or her care is just as important as the outcome of the care. If the patient perceives the care as meeting the aspects of quality, then patient satisfaction increases.

REF: Page 472 OBJECTIVE: NCLEX® Client Needs Category: Psychosocial Integrity

Two nurses are discussing health care quality. They agree which event

contributes to increased health care quality? a.

Magnet status hospitals

Fewer adverse events

Collaboration of multiple health care agencies

Increased patient education

CORRECT ANSWER: C Multiple health care agencies are able to collaborate and provide better outcomes for health care personnel and patients. Magnet status hospitals may be good, but the status does not always mean a quality outcome. Fewer adverse events and increased patient education are good, but they may be the result of other variables and not just quality of care rendered.

REF: Page 476 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

A student nurse is talking with his instructor. The student asks how quality

of care is evaluated. What is the best response by the instructor? a.

"Quality of care is evaluated by the patient getting well."

"Quality of care is evaluated on the basis of process and outcomes."

"Quality of care is evaluated by the physician’s assessment."

"Quality of care is evaluated by the patient’s satisfaction."

CORRECT ANSWER: B Quality of care is evaluated by process and outcomes. If the outcomes are achieved, then the care has achieved what is was designed to do. The patient getting well may be an action of the body doing what it is supposed to do and not quality of care; the same can be said of the physician’s assessment. The patient’s satisfaction is subjective according to his or her perceptions and not the quality of care.

REF: Page 472 OBJECTIVE: NCLEX® Client Needs Category: Psychosocial Integrity

What are two major foci of The Joint Commission (TJC) in the delivery of

health care? a.

Cost containment; safety

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Safety; quality

Quality; assessment

Assessment; evaluation

CORRECT ANSWER: B

The focus of TJC is quality and safety for patient care. TJC does not address cost containment, assessment of care, or evaluation of care.

REF: Page 475 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

A student nurse and clinical instructor are discussing quality in health care.

The instructor knows the student understands when the student makes which statement? a.

"Quality is apparent in all health care."

"Quality is an outcome of health care."

"Quality is seen and unseen in health care."

"Quality is achieved by collaboration in health care."

CORRECT ANSWER: C Quality in health care is tangible and intangible. Quality in health care is not apparent in all health care, as many areas of health care are lacking. Quality of care does not always affect the outcome of care; the patient may recover no matter what care is given. Quality is not always achieved by collaboration.

REF: Page 472 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

MULTIPLE RESPONSE

The focus of quality health care should be on which of the following items?

(Select all that apply.) a.

Excellent services

Comprehensive communication

Private hospital rooms

Health team collaboration

Culturally competent care

CORRECT ANSWER: A, B, D, E Excellent services, communication, collaboration, and culturally competent care brings quality to the health care delivered to the patient. Private hospital rooms may be a preference by some patients, but they do not add to the quality of care.

REF: Page 472

OBJECTIVE: NCLEX® Client Needs Category:

Psychosocial Integrity

What are the major attributes of health care quality? (Select all that apply.)

Conforms to standards

Sound decision making

High acuity patients

Low health care costs

Identifies adverse events

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CORRECT ANSWER: A, B, E

Major attributes of health care quality include conformation to standards set by regulatory agencies, sound decision making regarding care, and identifying potential adverse events. High acuity of patients does not contribute to quality health care, because the care demand is increased, and low health care costs mean fewer services may be available.

REF: Page 473 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

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Concept 49: Care Coordination Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

Student nurses are being questioned by the nursing instructor about the

health care coordination system. The instructor knows the students understand health care delivery when making which statement? a.

“Health care is available for everyone at every time.”

“Health care needs are best met with a collaborative effort.”

“Health care is adequately meeting the needs of the homeless

populations.” d.

“Health care needs are mostly in third world countries.”

CORRECT ANSWER: B Health care needs many times are not met by one discipline. When a collaborative effort is used, the patient is better served. Health care is not

available for everyone, nor is it meeting the needs of the homeless population. Health care needs are worldwide, not just in third world countries.

REF: Page 480 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

For children and teens, which model includes school-based services?

Social

Integrated

Medically-Oriented

Nurse-Oriented

CORRECT ANSWER: A The social models focus on community-based services, and the other models do not.

REF: Page 480 OBJECTIVE: NCLEX® Client Needs Category: Psychosocial Integrity

Medical models coordinate medical services and were traditionally

designed fulfill which function? a.

Be patient specific.

Be nursing oriented.

Be diagnosis specific.

Be community oriented.

CORRECT ANSWER: C Medical models focus on the patient’s diagnosis. The medical model is not patient specific, nursing oriented, or community oriented.

REF: Page 483 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

The nurse is discussing care coordination with a patient. The patient asks

the nurse to explain care coordination. What is the nurse’s best response? a.

“Care coordination is a cost effective method created by the community.”

“Care coordination forces the health care facilities in the community to

work together.”

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“Care coordination exists for the children and uninsured in the community.”

“Care coordination allows health care services to work together in the

community.” CORRECT ANSWER: D Care coordination allows all health care/community services to work together so that patient and family needs can be met. Care coordination does not focus on cost methods. Cost coordination does not exist just for children or the uninsured. No one service is forced to work with another service.

REF: Page 483 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

Nurses work to serve the population, and they know that which priority

population needs to be served by care coordination? a.

Most vulnerable and the frail

Uninsured and the very young

Underinsured and the elderly population

Whole population of the community

CORRECT ANSWER: A The priority population is the most vulnerable and the frail, because they have the most health care needs. Other populations do need health care, but they do not always have immediate need of the health care system.

REF: Page 485 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

A nursing instructor is talking about care coordination with nursing

students. The instructor stresses which of the following to the students concerning care coordination? a.

“A patient must ask for what they need in order to coordinate care.”

“The nurse does most of the work in care coordination.”

“Medical diagnoses are an integral part of care coordination.”

“Collaboration is a significant part of care coordination.”

CORRECT ANSWER: D Collaboration is a big part of care coordination. Without the collaboration, there would be no care coordination. Patients asking for their needs to be met does not collaborate care. Nurses do not do all the work in care collaboration. Medical diagnoses are one small part that drives the need for care collaboration.

REF: Page 484 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

MULTIPLE RESPONSE

Care coordination models should be adopted in health care facilities. If

models are not put into practice, the shortcomings of the health care system may display which of the following items? (Select all that apply.) a.

Decrease in patients

Fragmented services

Low birth weight newborns

Cost inefficiencies

Poor health outcomes

Increased pharmacy costs

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CORRECT ANSWER: B, D, E Fragmented services, cost inefficiencies, and poor health outcomes may be some of the shortcomings seen in health care without the proper model in place to guide the health care delivery system.

REF: Page 484 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

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Concept 50: Caregiving Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

The community health nurse is assessing a family who has a chronically ill

child. The child needs special care, and the nurse has to coordinate the care for the home setting. What behavior will the nurse assess for to know that the family can care for the child? a.

The family is willing to learn about the care and share the caregiving

needs. b.

The mother is going to care for the child and the family herself.

The older siblings are going to care for the child while the parents are at

work. d.

An outside agency will be coming to the home three times a week to give

care. CORRECT ANSWER: A The nurse will look for a family who is willing to provide care plus support each other in this need. Having a situation where just siblings or a mother or an outside agency give care puts an undue burden on the caregiver and brings disharmony to the family.

REF: Page 489 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity

A young wife is talking with the nurse about her husband who is returning

from the military. The wife confides that her husband is physically okay but is behaving differently. What is the nurse's best response? a.

"He is just trying to adjust to civilian life again; he'll be okay."

"You should observe him closely, because he could attack you."

"Many times people need care for emotional trauma."

"Talk with your physician to get medication, and then put it in his food."

CORRECT ANSWER: C The nurse is alerting the young wife to the fact that people who have experienced emotional trauma need care too. The nurse does not know how the husband is adjusting so the other options are incorrect.

REF: Page 490 OBJECTIVE: NCLEX® Client Needs Category: Psychosocial Integrity

The nurse is counseling a woman who is caring for her 83-year-old father.

The father has had mental changes and is becoming more confused. The father lives with the daughter in her home. The nurse knows the daughter understands the father's care needs when she states which of the following? a.

"Dad will only need my help for a short time, and then he will get better."

"I can leave dad alone during the day; I'll just deadbolt the door."

"I can send dad to the adult daycare; that way I can work and care for him

at night." d.

"Dad misses mom since she passed; he will be okay in a few weeks."

CORRECT ANSWER: C

The father will be cared for at the adult daycare, and it is a nice alternative for the daughter. She will be able to work and know that her father is safe during the day. The daughter thinking the father will be okay in a few days is not realistic, nor can she deadbolt the door and lock him in the house.

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REF: Page 489 OBJECTIVE: NCLEX® Client Needs Category: Psychosocial Integrity

Many middle-aged adults are called the "sandwich" generation because

they are caring for their children and their aging parents. What is the priority reason for aging parents needing care? a.

Mental clarity

Immobility

Blindness

Multiple chronic illnesses

CORRECT ANSWER: D Multiple chronic illnesses come with the aging process. Middle-aged adults are becoming the caregivers for the generation before them and the one after them.

Mental clarity is a positive aspect of aging and does not need care. Immobility and blindness do not always mean that the person needs direct care.

REF: Page 492 OBJECTIVE: NCLEX® Client Needs Category: Psychosocial Integrity

A mother is talking with the community-based nurse concerning her adult

son. The son is mentally challenged and not able to live on his own. The mother is concerned about her son's welfare when she is no longer able to care for him. What is the best response by the nurse? a.

"Let's look into the community resources that are available to assist you."

"You have raised your son well, and he will be okay on his own."

"Contact your distant relatives to see if anyone would take your son."

"There are places for mentally challenged adults; let's place him there."

CORRECT ANSWER: A The mother, with the assistance of the nurse, can research resources in the community that will service and care for her son when she is no longer able to do so. How the son is raised does not mean that he will be okay on his own. Distant relatives may not want or be able to care for the son, so this may not be a viable option. Placing the son is too general of an option, and he may not do well in this setting.

REF: Page 489 OBJECTIVE: NCLEX® Client Needs Category: Psychosocial Integrity

MULTIPLE RESPONSE

Many grandparents today are caring for grandchildren in place of a parent.

Identify the reasons why this phenomenon is happening. (Select all that apply.)

Children prefer living with their grandparents.

Parents are incarcerated.

Parents are deceased.

Grandparents are better caregivers.

Parents are mentally ill.

Parents are substance abusers.

CORRECT ANSWER: B, C, E, F Grandparents are usually caring for children because the parents are deceased, in prison, substance abusers, or mentally ill and cannot care for the children. The fact that children prefer to live with the grandparents or the grandparents may be better caregivers is not a main reason for this phenomenon to happen.

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REF: Page 489 OBJECTIVE: NCLEX® Client Needs Category: Psychosocial Integrity

Caregivers are often categorized by their relationship to the person being

cared for. Which of the following are the roles? (Select all that apply.) a.

Grandparent

Spouse

Parent

Adult children

Neighbor/friend

Young children

CORRECT ANSWER: A, B, C, D, E All of these options can provide care whether it is on a temporary or permanent basis. Young children do not provide care.

REF: Page 489 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

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Concept 51: Palliative Care Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

Palliative care used in the management of a patient with symptomatic

chronic obstructive pulmonary disease (COPD) is an example of which of the following? a.

Palliative care is used when the patient is beginning to die.

Palliative care is used to help manage the symptoms that often accompany

COPD. c.

Hospice nurses must be involved to provide palliative care in a cancer

patient. d.

Patient must be enrolled into the Medicare Hospice Benefit to receive

palliative care. CORRECT ANSWER: B Palliation is the relief or management of symptoms without providing a cure. To palliate is to reduce the severity of an actual or potential life-threatening condition or a chronic debilitating illness. Palliation is not equivalent to cure, but it is the reduction of undesirable effects resulting from the incurable disease or condition.

REF: Page 501 OBJECTIVE: NCLEX® Client Needs Category: Health Promotion and Maintenance

Today most patients are living for several years before dying with multiple

chronic conditions, such as COPD, congestive heart failure, diabetes, and obesity. These concomitant diseases contribute to multiple symptoms that

interfere with the patient's quality of life. What type of care would you consider for this patient? a.

End-of-life care

Supportive care

Comfort care

Palliative care

CORRECT ANSWER: D Palliative care provides optimal symptom management in the setting of multiple chronic conditions. The relief and management of these symptoms help to promote improved quality of life for the patient and help to maintain physical functioning.

REF: Page 497 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity

What is the most prominent goal of palliative care?

Integrate into chronic disease management sooner rather than later.

Enroll the patient into the Medicare Hospice Benefit.

Ensure that the patient has a 6-month prognosis.

Reserve this type of care until the patient is actively dying.

CORRECT ANSWER: A The goal of palliative care is to integrate symptom management interventions earlier into the course of chronic disease sooner rather than later. This helps to promote optimal quality of life.

REF: Page 498 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

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The student demonstrates a lack of understanding of palliative care when

making which statement? a.

"Palliative care is designed to promote comfort."

"Palliative care is designed to reduce disease exacerbations."

"Palliative care is designed to decrease acute care hospital admissions."

"Palliative care is designed to promote a cure for chronic disease."

CORRECT ANSWER: D Palliation is the reduction of symptoms without elimination of the cause. Palliative care refers to the provision of care for patients who are diagnosed with a disease or condition without a cure.

REF: Page 497 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity

Which is one of the biggest challenges facing current nursing practice?

The number of aging Americans living with chronic disease.

The number of patients entering into hospice programs.

The number of cancer patients receiving supportive care.

Reduced length of stay in hospice care.

CORRECT ANSWER: A Millions of Americans are living with one or more chronic debilitating diseases, and 7 out of 10 can expect to live with their diseases several years before dying. When coupled with the advancing age of the eight million baby boomers who now qualify for Medicare, this will soon create a huge demand on health care resources and community-based services.

REF: Page 499|Page 500 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

When considering the trajectory of a specific disease, what is the most

important concept? a.

Hospital admissions

Physical functioning

Quality of life

Symptom management

CORRECT ANSWER: B The disease trajectory occurs from the onset of a life-limited diagnosis until death. Physical functioning determines the decline in the patient's physical status. Decline in status is used to determine when to intervene with palliative and end-of-life care.

REF: Page 497 OBJECTIVE: NCLEX® Client Needs Category: Physiological Integrity

The interprofessional core team includes members from which disciplines?

Nursing, medicine, volunteers, and nutrition

Medicine, nursing, social work, and clergy

Medicine, nursing, physical therapists, and volunteers

Nursing, home health aides, volunteers, and clergy

CORRECT ANSWER: B

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An interprofessional team approach involving health care professionals from different disciplines is central to optimal palliative care practice and quality outcomes. The interdisciplinary core team includes members from medicine, nursing, social work, and clergy. Ancillary disciplines are also included. Volunteering is not considered a discipline in healthcare.

REF: Page 498 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

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Concept 52: Health Disparities Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

The nurse is caring for a Chinese patient diagnosed with cancer who is

suffering from pain, yet refuses analgesia administration. What type of health disparities is this patient exhibiting? a.

Avoidable and acceptable

Avoidable and unacceptable

Unavoidable and acceptable

Unavoidable and unacceptable

CORRECT ANSWER: B Health disparities that are avoidable and unacceptable unfortunately occur in healthcare settings and these are the targets of interventions. For example, a disparity in cancer pain management exists between Asians and Whites. This difference is attributable to Asian cultural values and attitudes related to cancer pain and pain medication distinguished from the cultural values of Whites. The disparity is avoidable if Asian cancer patients are adequately educated and instructed on cancer pain management strategies including pain medication and complementary and alternative medicine. Also, this disparity is unacceptable because this gives an unnecessary burden of pain to Asian cancer patients that could be easily managed by using existing strategies.

REF: Page 504 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

An experienced nurse tells the student nurse, "I have found that most

Hispanic immigrants live in unsanitary conditions but are hard workers." How should the student nurse best classify this statement? a.

Stereotyping

Prejudice

Discrimination

Misinformed

CORRECT ANSWER: A Stereotyping often leads to biased clinical decision-making. Stereotyping refers to the process by which people use social categories (e.g., gender or race/ethnicity) in acquiring, processing, and recalling information about others. Both implicit and explicit negative attitudes and stereotypes of healthcare providers significantly shape interactions with patients, influence how information is recalled, and guide expectations and inferences in systematic ways. Stereotyping often occurs subconsciously, unlike prejudice or discrimination. Prejudice, which refers to unjustified negative attitudes based on a person’s group membership, is another source of biased clinical decision-making. Discrimination refers to the actual mistreatment of individuals based on race, gender, ethnicity, etc. The nurse is not misinformed as the nurse has practiced for some time and made a statement based on observation and experience.

REF: Page 506 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

Which type of health disparities are most frequently encountered by nurses

in clinical and community settings? a.

Avoidable and acceptable

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Avoidable and unacceptable

Unavoidable and acceptable

Unavoidable and unacceptable

CORRECT ANSWER: B Although there are many types of health disparities, the avoidable and unacceptable health disparities are the ones that healthcare providers, including nurses, frequently encounter in clinical and community settings. Furthermore, these are the health disparities that healthcare providers need to target to intervene.

REF: Page 504 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

The nurse is caring for diverse population groups at a health clinic. Which

of the following patients demonstrates a potential health disparity group? a.

A 26-year-old woman who is receiving follow-up after a car accident.

A 30-year-old immigrant who does not speak English.

A 28-year-old man who needs a tetanus booster.

A 12-month-old with an appointment for immunizations.

CORRECT ANSWER: B Poor health literacy skills are an example of a health disparity that limits an individual’s ability to access or communicate about health care needs. Patients who are receiving needed care are not experiencing a gap between health need and actual care. REF: Page 506 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

Which is the best strategy the nurse manager should include when working

to reduce health care disparities on a medical-surgical unit? a.

Less diverse workforce

Increase interpreter availability

Authoritarian leadership

Annual staff training

CORRECT ANSWER: B Key elements are cultural competence that can reduce health disparities include: a diverse workforce; interpreter availability; finding common ground versus authoritarian leadership; frequent staff training and updating staff as needed throughout the year.

REF: Page 506|Page 507 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

A new nurse requires further teaching when failing to identify which

practice as a health disparity? a.

Annual mammogram

Early prenatal care

Blood pressure screening

Frequent fast food meals

CORRECT ANSWER: D

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Preventive care, screening, and health promotion activities are not considered health disparities. Examples include mammograms, prenatal care, and blood pressure checks. Frequent fast food meals, containing high fat content, is considered a health disparity due to possible lack of money or access to healthy meals.

REF: Page 504|Page 505 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

Before beginning work on a culturally diverse hospital unit, the nurse

should perform which action first? a.

Improve self-awareness of one’s own biases

Attend an anti-discrimination rally or march

Build rapport and trust with the patients

Take a foreign language class

CORRECT ANSWER: A Before working with culturally diverse groups, the nurse should first identify own biases and assumptions in order to objectively and competently care for patients. Attending a rally or march may not raise awareness of various biases. The nurse should establish rapport and trust when working with patients, after self-

awareness is appreciated. Taking a foreign language may be helpful; however the first step is self-awareness.

REF: Page 506 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

The nurse who has been hired to work on an oncology unit identifies which

group of women as being at highest risk of developing breast cancer? a.

African

Caucasian

Asian

Hispanic

CORRECT ANSWER: C Breast cancer is the most common cancer in Asian women in the U.S., but Asian women have relatively lower rates of breast cancer screening than African American and white women in the U.S. Furthermore, disparities in breast cancer screening reportedly result from: low income, lack of a local mammography center, lack of transportation to a mammography center, lack of a usual healthcare provider, lack of a recommendation from a healthcare provider to get mammography screening, lack of awareness of breast cancer risks and screening methods, and cultural and language differences.

REF: Page 506 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

MULTIPLE RESPONSE

A healthcare provider whose native country is India is explaining the

treatment plan to a patient. The patient tells the nurse she is having trouble

understanding the provider but is embarrassed about asking to repeat the information over and over. The nurse should assess for which results due to this disparity in provider-patient communication? (Select all that apply.) a.

Patient dissatisfaction

Optimal health outcome

Poor adherence

Increased patient confidence

Improved communication

CORRECT ANSWER: A, C When sociocultural differences between healthcare providers and patients are not appreciated or communicated effectively in clinical encounters, patient dissatisfaction, poor adherence, poorer health outcomes, and racial/ethnic disparities in healthcare easily happen.

REF: Page 507 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

The nurse in the immunization clinic should place emphasis on educating

and reaching which groups about the disease preventing effects of immunizations? (Select all that apply.) a.

Caucasian

African American

Low income

Middle income

High income

CORRECT ANSWER: B, C, D The 2013 National Healthcare Disparities Report documented that African American children or children from poor, low-income, and middle-income households were less likely to receive all the recommended vaccinations compared with white children or children from high- income households in 2011.

REF: Page 507 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

Concept 54: Health Care Organizations Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

A nurse is interviewing at an agency owned by a national religious

organization that serves homeless and uninsured patients. A large poster display shows a proposed addition that would add 16 beds to the facility that will be

funded from profits of the previous 3 years of operation. The nurse recognizes that the agency is most likely what type of agency? a.

For-profit

Not-for-profit

Publicly-owned

Investor-owned

CORRECT ANSWER: B Many religious organizations are privately owned and administer not-for-profit health facilities, where profits are returned into the facility for improvements or equipment. For- profit agencies distribute profits to shareholders. Publicly-owned facilities are government supported and not linked to religious organizations. Investor-owned agencies would be for- profit agencies with profits distributed to investors.

REF: Page 512 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

A nurse is reported for taking prescribed patient medications for their

personal use. Who has direct authority over deciding if the nurse may keep their professional license to continue practicing as a nurse? a.

The hospital where the nurse is currently employed

The American Nurses Association

The National League for Nursing

The State Board of Nursing who issued the license

CORRECT ANSWER: D Decisions related to practice are the responsibility of the licensing body, or State Board of Nursing, who is charged with protecting the public. The hospital does not determine who is eligible for a professional license. The National League for Nursing is active in nursing education standards. The American Nurses

Association helps develop standards of care and is politically active, but it does not enforce standards for individuals.

REF: Page 516 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

The annual report for a hospital shows that external environment factors

are affecting the amount of new staff hired. What is a likely factor contributing to this outcome? a.

The recent implementation of becoming a not-for-profit institution

The implementation of a hospital electronic medical record system

A national recession that has been occurring for 3 years

The closure of a hospital-based school of nursing due to lack of funding

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CORRECT ANSWER: C External environmental factors that affect organizations are conditions or events that occur outside the control of the agency, such as new health laws, governmental regulations, or economic trends. Internal environmental factors

occur within the organizational structure and include such factors as technology issues, changes in personnel roles, or the implementation of new policies.

REF: Page 513 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

A nurse manager recognizes that systems theory identifies that there is a

social component within an organization that affects the overall functioning of the system. What indicator would demonstrate to the nurse manager that the social needs of an organization are being met? a.

Most employees from the organization attend an annual holiday

celebration. b.

Separate eating areas for each discipline are set up in the cafeteria.

Nurse managers are planning to move to a centralized area away from the

care units. d.

The summer softball teams are canceled due to lack of interest.

CORRECT ANSWER: A Systems theory focuses on the needs and desires of people who work in the organization. Good attendance at a work-sponsored function indicates that staff enjoy interacting and are meeting social and relationship roles. Separating disciplines does not foster a sense of team. Moving administration away from staff limits interaction and informal conversations that build trust. Lack of participation in sponsored events such as a softball team indicates that staff relationships are not strong, and a social component is not being achieved within the work environment.

REF: Page 513 |Page 514 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

A hospital organization is working to improve a feeling of being valued and

respected among all staff members. Which action by administration would reinforce the feeling of being valued? a.

Create professional pathways that require advanced education for any

advancement of staff. b.

Seek staff input when planning a remodeling project of patient rooms.

Form committees that consist of upper management to plan organizational

goals. d.

Consistently schedule required staff meetings at the same time each

month. CORRECT ANSWER: B Including staff at all levels of an organization in planning and projects demonstrates respect for the intelligence and creativity of the individual. Requiring advanced education for any advancement limits those with barriers to attending additional schooling; advancement should be available in a variety of ways to show the value of the individual. Committees that only consist of upper management cause a feeling of disconnect between staff and administration. Scheduling meetings at the same time does not consider those who work shifts and either have to come in on their day off or must disrupt sleep to attend.

REF: Page 513 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

A quality improvement committee is reviewing discharge surveys. Results

show that patients and their families have difficulty finding departments and

areas of the hospital. What action by the committee would best address this concern for the organization? a.

Continue to review future surveys to monitor the situation.

Give additional training to the receptionists and switchboard personnel to

give better directions. c.

Form a multidisciplinary committee to identify options to help travel through

the hospital. d.

Send a work order to the maintenance department requesting that brighter

lights be installed. CORRECT ANSWER: C Successful organizations respect the input of all disciplines when searching for solutions for problems. Continuing to gather data delays solving a problem. There is no indication that verbal directions will solve the problem; additional measures may be required. Merely providing additional light may not solve the problem—multi-language signs or even remodeling may be identified by the committee as being needed.

REF: Page 516 |Page 517 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

A nurse manager finds an unsigned note reporting that patient care

standards are not consistently being followed. Within the organizational structure, what is the best action for the manager? a.

Schedule a staff meeting to ask staff who left the note.

Send an email reminder that all staff need to review the policy and

procedure book. c.

Wait for a staff member to come forward who is willing to be identified.

Form a small group to explore why staff are not comfortable reporting

errors. CORRECT ANSWER: D There are significant problems in an organization where staff are not willing to openly discuss problems, especially problems that affect patient care. A focus group can help identify what is preventing a sense of comfort to reveal problems. Scheduling a meeting is unlikely to have the person admit to complaining about care provided by coworkers in front of coworkers. A request to review policies and procedures is so broad the staff will not be able to identify a specific problem that needs to be corrected. Unless organizational changes are made, it is unlikely that staff will decide to come forward when they would not do so in the first place.

REF: Page 516 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

A hospital is experiencing a drop in patient admissions, resulting in the

implementation of a hiring freeze. What is a potential critical consequence of this internal organizational decision? a.

A decrease in the availability of future nurses to hire

A savings of salaries and benefits

Increased scholarships to nursing students from the local high school

Increased cross-training of current staff

CORRECT ANSWER: A In an economic climate where hospitals are not hiring, nursing schools may limit enrollment which will limit the availability of future nurses available to be hired

when the current nurses retire or reduce their hours. Salary savings is minimal as the number of patients, staffing, and revenue are closely aligned. Scholarships will decrease as hiring commitments to scholarship holders will no longer be in effect. Cross-training may occur, but it is not a critical consequence of a hiring freeze.

REF: Page 516 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

MULTIPLE RESPONSE

in nursing practice. What components would indicate that the hospital is meeting Magnet© principles? (Select all that apply.) a.

The education budget for nursing has been cut to provide for new

laboratory equipment. b.

On average, 40% of new nurses are leaving within 1 year of hire.

Nurses are active participants on all major hospital committees.

Quality improvement projects are planned and evaluated by nurses.

Patient care outcome data are reported in the annual executive board

meeting. CORRECT ANSWER: C, D To gain Magnet© status, an organization must show that nurses are active participants in the organization administrative structure, fully involved in quality improvement projects, and are recognized as a valuable resource.

REF: Page 517 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

Concept 55: Health Care Economics Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

What do the economics of health care include?

Medicare and Medicaid dollars

Patients’ rights

Equal distribution of health care

Nurse salaries

CORRECT ANSWER: C The economics of health care include the equal distribution of health care services so everyone may be served when services are needed. Medicare and Medicaid, patients’ rights, and nurse salaries do not factor into the economics of health care; they are only parts of the health care system.

REF: Page 520 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

A student asks the instructor about health care economics. The instructor

knows the student understands when the student makes which statement? a.

“The elderly population uses most of the health care services.”

“Everyone should have health insurance to obtain services.”

“Health care dollars should be partitioned by the government.”

“Resources will be needed to serve health care issues.”

CORRECT ANSWER: D Every health care issue needs resources to bring it to fruition. Without the resources, the health care issue would not be served. The elderly are a large part of the population, but that does not change the economics of health care. Everyone does not have health insurance, so that statement would not enter into health care economics. Last, all health care dollars are not partitioned by the government; third party payers exist.

REF: Page 520 OBJECTIVE: NCLEX® Client Needs Category: Psychosocial Integrity

The US health care system is different from that of other countries in which

way? a.

The US charges money from the private sector only.

US health care is funded from private organizations.

The US health care system is not entirely government funded.

The US health care treats the older person first.

CORRECT ANSWER: C

Other countries fund the health care system so that every citizen may have health care. In addition they provide the option that citizens may purchase private health care too. The US has a combination of private companies and government agencies funding health care, so money is not coming from just the private sector. The older person in the population receives care according to the insurance coverage they have, but the care is not before anyone else.

REF: Page 520

OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

Which of the following statements is true about health care in the US?

The US spends more money on health care than any other nation.

The US provides health care to every citizen.

The US relies on government funding to treat most citizens.

The US spends less money on pediatric care than other nations.

CORRECT ANSWER: A The US spends more money on health care than any other country. The US does not provide health care to every citizen, nor does it rely entirely on government funding. The US does not spend less money on pediatric care but usually more than other countries.

REF: Page 520 |Page 521 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

Two nurses are discussing health care in the past and the present. The

two nurses know which to be true about health care in the present? a.

Health care in the present is mostly provided by nurses.

Health care in the present is controlled by third party payers.

Health care in the present is controlled by physicians.

Health care in the present is dictated by the patient.

CORRECT ANSWER: B Health care in the past was controlled by physicians, because they provided the care. Health care in the present is controlled by third party payers, because they finance the care. Health care is provided by nurses, but patient care requires a team of health care workers to assist the patient. The patient is part of the team,

but they do not dictate the health care. The patient works with the physician to bring about a good outcome.

REF: Page 520 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

MULTIPLE RESPONSE

A student nurse is discussing Medicare coverage with the clinical

instructor. The instructor knows the student understands Medicare when the student makes this which statement(s)? (Select all that apply.) a.

Medicare covers all patients while they are in the hospital.

Medicare is funded by the federal government.

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Medicare is for persons 65 years old and older.

Medicare is partially funded by private third-party payers.

Medicare is for patients who are disabled and/or have end-stage renal

disease.

CORRECT ANSWER: B, C, E Medicare is funded by the federal government. It covers people who are 65 years old and older, disabled people, and patients who have end-stage renal disease. It does not cover all patients in the hospital, because some patients do not qualify for Medicare. It is not funded by third-party payers.

REF: Page 521 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

An accountable care organization (ACO) seeks to deliver which of the

following aspects of health care? (Select all that apply.) a.

Lessen Medicare payments

Integrate care

Enhance evidence-based practices

Manage acute conditions

Support hospice charges

CORRECT ANSWER: B, C ACOs work to integrate care, manage chronic conditions, and enhance the use of evidence- based practices. They do not have any involvement with Medicare payments, the management of acute conditions, or hospice care.

REF: Page 521 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment: Management of Care

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Concept 56: Health Policy Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

A definition of health policy includes which of the following elements?

Funding for public education

Appropriation of funds for roadwork

Selection of congressional members of committees

Public policy made to support health-related goals

CORRECT ANSWER: D Health policy is defined as public policies pertaining to health that are the result of an authoritative public decision-making process. Public education funding, appropriation of funding for roads, and selection of members of committees are not part of health care policy. They are under a different funding arm of the government.

REF: Page 525 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

Which branch of government is responsible for the execution of laws

passed by legislatures? a.

Legislative

Judicial

Executive

Local

CORRECT ANSWER: C The executive branch of federal and state governments is responsible for execution of laws passed. The legislative branch is responsible for passing laws.

The judicial branch of government determines if rights are being upheld. Local governments are not considered a branch of the government.

REF: Page 526 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

Which level of government is responsible for the regulation of a nurse’s

license? a.

Federal government

State government

Local government

International coalition

CORRECT ANSWER: B State boards of nursing oversee the regulation of nursing practice. These agencies are established by legislatures to implement and enforce laws through a rule-making process. Federal, local, and international coalitions are not correct, because they do not have control of the state boards of nursing.

REF: Page 526|Page 527 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

Which of the following components are included in health policy at the

state level? a.

Americans with Disabilities Act of 1990

Scope of nursing practice

Health Insurance Portability and Accountability Act (HIPAA) of 1996

Patient Safety and Quality Improvement Act of 2005

CORRECT ANSWER: B The scope of nursing practice is correct, because it is controlled at the state level by state boards of nursing. The Americans with Disabilities Act of 1990, the HIPAA of 1996, and the Patient Safety and Quality Improvement Act of 2005 are all regulated at the national level.

REF: Page 531 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

Which of the following is the intent of HIPAA?

Release of patient information for purposes of insurance reimbursement.

Prevent health care providers from billing for procedures done for the

insured person. c.

Protect patients from reviewing their own medical records.

Limit the ability of health care providers to sell patient information to

outside sources. CORRECT ANSWER: D The intent of HIPAA is to protect patient information and prevent it from being sold to outside agencies. The right of heath care providers to bill for services is necessary for patient payment is and not prohibited. Patients have the right to view their own patient information. REF: Page 531

OBJECTIVE: NCLEX® Client Needs Category: Safe and

Effective Care Environment

MULTIPLE RESPONSE

Nurses can be health advocates in which of the following ways? (Select all

that apply.)

Supporting their professional nursing organization when discussing

upcoming legislation b.

Discussing the upcoming classes with a neighbor

Rallying for coverage for childhood immunizations

Arranging for a patient to meet with case management for home health

care e.

Discussing a patient they are concerned about with a fellow student in the

public cafeteria CORRECT ANSWER: A, C, D Supporting a professional nursing organization, rallying for coverage for childhood immunizations, and arranging for a patient to meet with case management are examples of how nurses can be a positive influence on health care policy. Discussing an upcoming class with a neighbor is not effective because it could be determined to be negative. Talking about a patient in a public area is an example of inappropriate communication between health care workers and is a violation of patient confidentiality.

REF: Page 531

OBJECTIVE: NCLEX® Client Needs Category: Safe and

Effective Care Environment

A nursing student is preparing a care plan for an assigned patient. When

accessing the electronic medical record, what is acceptable information to view? (Select all that apply.) a.

Laboratory data of the assigned patient

Admission diagnosis for a patient who is a former neighbor

The patient’s age, date of birth, and gender

The history and physical of the assigned patient

A classmate’s brother’s chest x-ray report

CORRECT ANSWER: A, C, D The laboratory data, age, date of birth, gender, history, and physical of an assigned patient are necessary for identification and care of the patient so it is acceptable to view this information in the electronic medical record. The patient information in the medical record, whether electronic or print, is only to be viewed by those who have a legitimate role in the patient's care. Viewing information on patients other than the assigned patient is not appropriate, because the student does not have a need to view the information for patient care. These are violations of patient privacy.

REF: Page 531 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

Concept 57: Health Care Law Giddens: Concepts for Nursing Practice, 3rd Edition

MULTIPLE CHOICE

The new nurse correctly defines a law when stating which information?

"Law is a fundamental concept for health care professionals."

"Law’s rule is developed by the employee's organization."

"Law’s rule is enacted by a government agency that defines what must be

done in a given circumstance." d.

"Law is a mandate from the Joint Commission or other accrediting

agency." CORRECT ANSWER: C

This is the correct definition of a law.

REF: Page 533 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

Which of the following is true about health care legislation?

The US Constitution addresses health care law specifically to give the

federal government the ability to license professionals and institutions. b.

The power of the US Constitution does not have a direct relationship to

health care and reserves most of the power to the states. c.

State laws are considered the highest source of health care law and trump

the federal laws. d.

The federal government asserts its power over health care legislation

through the US Constitution. CORRECT ANSWER: B The power of the US Constitution does not have a direct relationship to health care and reserves most of the power to the states. The other statements are false. The US Constitution does not address health care specifically. Either state or federal laws can be considered the highest source of law depending on which law has the stricter regulation or rule.

REF: Page 533 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

Which is an example of the regulatory power to make law?

Joint Commission establishing a medication reconciliation standard.

Centers for Disease Control and Prevention (CDC) developing

recommendations for childhood immunizations.

Institute of Medicine (IOM) defining the approximate number of medication

errors that result in significant patient harm or death. d.

Centers for Medicare and Medicaid Services (CMS) enacting rules for

restraint and seclusion for participating hospitals. CORRECT ANSWER: D

2024

The Centers for Medicare and Medicaid Services (CMS) enacting rules for restraint and seclusion for participating hospitals refers to the enactment of law, while the other answers discuss the development of standards and recommendations that do not have the authority of law. There are some health care rules that may define expected behavior, but if these rules were not created by a government entity with legal authority, then they are not health care laws.

REF: Page 535 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

What is one of the major attributes of health care law?

It defines the expected behavior of persons in the business of health care.

The law or rule is easy to interpret and comply with.

It is established by any health care authority.

The creator must be an expert in health care.

CORRECT ANSWER: A A health care law or rule defines expected behavior of persons in the business of health care or in health care relationships. Health care law is not easy to interpret or comply with and can only be established by organizations with legal authority for law making. Creators of health care law are often not experts in health care.

REF: Page 535 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

The admission personnel working to comply with the Patient Self

Determination Act of 1991 would do which of the following? a.

Request identification from the patient to complete the registration process.

Ask the patient if they would like a private or semi-private room.

Inquire about the patient's reason for their visit.

Ask the patient or representative if the patient has an advanced directive

and inform them of their right to participate in their medical decisions. CORRECT ANSWER: D Inquiring about a patient’s advanced directive is a requirement of the Patient Self Determination Act of 1991. Inquiring about identification, type of room requested, and reason for visit are not addressed by the Patient Self Determination Act.

REF: Page 535 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

Which of the following is an example of a nurse violating the Health

Insurance Portability and Accountability Act (HIPAA) of 1996? a.

The nurse asks the unit clerk to look up lab values for her relative recently

admitted to the hospital. b.

A group of fellow employees are discussing a patient's clinical status in a

public place. The nurse manager requests that they step into private room to complete the discussion. c.

After entering the progress notes on a patient's electronic medical record,

the nurse logs off the computer to allow her coworker to use the terminal. d.

As a family approaches the nursing desk, the nurse removes the patient

census sheet from view on the counter. CORRECT ANSWER: A

2024

When the nurse asks the unit clerk to look up lab values for her relative recently admitted to the hospital, the nurse is accessing protected health information not required for the nurse to perform his or her job. This is a violation of privacy even if it is a relative. The other choices are all actions that are consistent with protecting a patient’s privacy right as defined by HIPAA.

REF: Page 538|Page 539

OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

In which of the following answers is the hospital in compliance with the

Consolidated Omnibus Budget Reconciliation Act and Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA)? a.

The emergency department staff asks a patient to stay in the waiting room

until the patients with insurance are treated. b.

The emergency registration personnel explain to a patient that they must

have proper identification to receive treatment. c.

A patient with chest pain is triaged directly to a room for evaluation and

registration information is obtained after the patient is stabilized. d.

The emergency department physician discharges and instructs a patient

who is actively suicidal to go the neighbor facility that has psychiatric services. CORRECT ANSWER: C EMTALA requires that any hospital that operates an emergency department and receives Medicare funds provide an appropriate screening exam to anyone who presented and stabilize any emergency medical condition prior to transfer to another facility. The other choices are in conflict with EMTALA because a medical screening exam must be provided without consideration of the patient’s insurance, whether the patient has identification, or the facility’s services.

REF: Page 538 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment

Which of the following is false regarding state licensure laws?

These laws establish the requirements for licensure to practice.

Licensure is not necessary if the individual has completed training.

The state regulatory agencies such as the state board of nursing are

responsible for creating and enforcing these rules. d.

The scope of practice defines what the professional can and cannot do

within the scope of their licensure. CORRECT ANSWER: B Licensure is required to practice after the completion of all required training for the profession. The state laws establish the requirements to practice and the state regulatory agencies are responsible for creating and enforcing the rules. The scope of practice defines what activities the professional is legally authorized to perform.

REF: Page 535 OBJECTIVE: NCLEX® Client Needs Category: Safe and Effective Care Environment