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Table of Contents Table of Contents 1 Chapter 01- The Profession of Nursing 3 Chapter 02- The Nurse's Role in Healthcare Quality and Patient Safety 25 Chapter 03- Values, Ethics, and Legal Issues
35
Chapter 04- Nursing Research and Evidence-Based Care
57
Chapter 05- Nursing Process: Foundation for Clinical Judgment
77
Chapter 06- Nursing Assessment
100
Chapter 07- Nursing Diagnosis
122
Chapter 08- Outcome Identification and Planning
134
Chapter 09- Implementation and Evaluation
146
Chapter 10- Healthcare Team Communication: Documenting and Reporting
159
Chapter 11- Health, Wellness, and Integrative Healthcare
179
Chapter 12- Healthcare in the Community and Home
200
Chapter 13- Culture and Diversity
225
Chapter 14- Communication in the Nurse-Patient Relationship
246
Chapter 15- Patient Education and Health Promotion
267
Chapter 16- Caring for the Older Adult
283
Chapter 17- Safety
300
Chapter 18- Health Assessment
320
Chapter 19- Vital Signs
337
Chapter 20- Asepsis and Infection Control
350
Chapter 21- Medication Administration
365
Chapter 22- Intravenous Therapy
382
Chapter 23- Perioperative Nursing
395
Chapter 24- Hygiene and Self-Care
416
Chapter 25- Mobility
438
Chapter 26- Skin Integrity and Wound Healing
458
Chapter 27- Infection Prevention and Management
472
Chapter 28- Pain Management
485
Chapter 29- Sensory Perception
499
Chapter 30- Respiratory Function
521
Chapter 31- Cardiac Function
540
Chapter 32- Fluid, Electrolytes, and Acid-Base
559
Chapter 33- Nutrition
580
Chapter 34- Urinary Elimination
600
Chapter 35- Bowel Elimination
620
Chapter 36- Sleep and Rest
640
Chapter 37- Self-Concept
660
Chapter 38- Families and Their Relationships
681
Chapter 39- Cognitive Processes
702
Chapter 40- Sexuality
722
Chapter 41- Stress, Coping, and Adaptation
742
Chapter 42- Loss and Grieving
761
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Chapter 43- Spiritual Health
781
Chapter 01- The Profession of Nursing
1. What is the major difference between nursing students today and nursing students 50 years ago?
A)
Todays students are less caring.
B)
Todays students are more intelligent.
C)
Todays students reflect a more diverse population.
D)
Todays students are less likely to be competent nurses.
Ans:
C Feedback: Nursing students 50 years ago were mostly women and entered nursing school immediately after graduating from high school. Many of todays nursing students have pursued other career paths prior to nursing, are of various ethnic backgrounds, and have jobs and families to consider while attending nursing school. In addition, many more men have entered the field of nursing over the last 50 years.
2.
The nurse is caring for a diabetic patient who expresses the desire to learn more about a diabetic diet in an attempt to gain better control of his blood sugar. The nurses actions will be based on which non-nursing theory?
A)
Change theory
B)
Maslows hierarchy of human needs
C)
Neumans systems model
D)
Watsons theory of caring
Ans:
A Feedback: The patient has identified a need for change, which will guide the nurses actions. Maslows hierarchy of human needs helps nurses prioritize actions. Neuman and Watson are nursing theorists.
3.
The Quality and Safety Education for Nurses Initiative (QSEN) has identified which key competencies for nurses? Select all that apply.
A)
Patient-centered care
B)
Teamwork and collaboration
C)
Evidence-based practice
D)
Quality improvement
E)
Correct documentation
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Ans:
A, B, C, D Feedback: The QSEN has identified patient-centered care, teamwork and collaboration, evidence-based practice, and quality improvement as a means for nurses to improve the quality and safety of patient care wherever they work. Additional key competencies identified are safety and informatics.
4.
The nurse is caring for a patient who is on a ventilator. The nurse is bathing the patient and talking to them as she is carrying out care, as well as telling the patient what is going to happen next. The nurse speaks to the patient in a soothing manner. The nurse is acting in which role? (Select all that apply)
A)
Caregiver
B)
Decision-maker
C)
Communicator
D)
Educator
E)
Patient advocate
Ans:
A, C, D Feedback:
The nurse is fulfilling the role of caregiver by providing the care and speaking to the patient in a soothing manner. The nurse is also acting as a communicator talking to the patient even if the patient cant respond. The nurse is also acting as an educator by informing the patient of the care that will be performed. The nurse is not assisting in making any decisions or speaking on behalf of the patient.
5. The nurse offers a patient two possible times to ambulate as the physician has ordered. The nurse is acting in which nursing role?
A)
Communicator
B)
Patient advocate
C)
Manager and coordinator
D)
Caregiver
Ans:
C Feedback: While the nurse is acting in many roles, the nurse is managing and coordinating the care for the patient by giving choices on when care will be implemented.
6. The nurse is performing an extensive dressing change on a burn patient. The nurse explains each step as it is being performed. The nurse is acting in which role by providing explanation of each step?
A)
Caregiver
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B)
Patient advocate
C)
Decision-maker
D)
Educator
Ans:
D
Feedback: The nurse is acting in the role of educator by explaining each step. The act of changing the dressing and providing support is the caregiver role.
7. What type of nursing program would allow a student with a 4-year degree in psychology to enter and complete a baccalaureate degree in nursing, take the NCLEX examination, and transition into a masters in nursing program?
A)
Baccalaureate program
B)
Graduate entry program
C)
Advanced degree program
D)
Continuing education program
Ans:
B
Feedback: Graduate entry program students possess a baccalaureate degree in a field other than nursing. These students can track directly into a masters or doctorate in nursing program after successfully passing the NCLEX-RN. 8.
A prospective nursing student desires a career that will allow him to provide patient care and to assist professional nurses with routine technical procedures. The prospective student needs to be employed in a full-time position quickly due to economic hardship. What type of nursing program would best suit this student?
A)
Associate of science registered nursing program
B)
Baccalaureate of science registered nursing program
C)
Licensed or vocational nursing program
D)
Diploma nursing program
Ans:
C Feedback: A licensed practical or vocational nursing program will allow the student to earn a technical certificate in 1 year and sit for the state board of nursing examination to be licensed as an LPN or LVN. An associate program will take 2 years and a baccalaureate program will take 4 years. There are very few diploma programs remaining in the US, and these programs typically take 3 years to complete.
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9.
Nurses that enlist their services to the military are able to do so thanks to the work of which organizer of healthcare?
A)
Linda Richards
B)
Florence Nightingale
C)
Theodor Fliedner
D)
Dorthea Dix
Ans:
D
Feedback: Dorthea Dix, while not a nurse, established the Nurse Corps of the United States Army during the Civil War. Linda Richards was the first trained nurse to graduate from a nursing program. Theodor Fliedner opened the first hospital-based school of nursing, and Florence Nightingale was nursings first professional leader.
10. Due to the rising cost of healthcare services, many procedures and treatments are being delivered in what type of setting?
A)
hospital
B)
medical centers
C)
outpatient facility
D)
community healthcare center
Ans:
C Feedback: Many procedures and treatments are being delivered in outpatient settings since hospital and medical center stays significantly increase healthcare costs to the patient and insurance company. Community healthcare centers typically refer to facilities such as day care centers or ambulatory clinics.
11. The nurse in a rehabilitative facility makes certain the patient he is caring for is participating in group activities that are of interest to the patient. The nurse is ensuring which patient need is met?
A)
Love and belonging
B)
Self-actualization
C)
Safety and security
D)
Self-esteem
Ans:
A Feedback: The nurse is responsible for making sure the needs of the patient are met based on Maslows hierarchy of needs. Attending a group activity helps meet the needs of love and belonging (need to feel that one belongs and is
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loved to avoid loneliness and isolation). Self-actualization is the highest need and refers to realizing fully all of ones abilities and qualities. Safety and security refers to physical and psychological protection issues. Selfesteem indicates a feeling of self-worth.
12. The nurse is caring for a postoperative patient. The nurse administers a pain medication prescribed on a prn basis by the physician. What best describes the type of intervention the nurse is demonstrating?
A)
Physician-prescribed intervention
B)
Collaborative intervention
C)
Patient advocacy intervention
D)
Nurse-prescribed intervention
Ans:
B Feedback: Nurse initiated interventions, such as turning and repositioning a patient, are described as nurse-prescribed interventions. Physician-directed actions are described as physician-prescribed interventions. The administration of a prn medication requires a physician-prescribed intervention (the medication order) as well as a nurse-prescribed intervention (determining when the order should be carried out and proper administration of the medication); therefore, this action would be considered a collaborative intervention. Patient advocacy refers to communicating the needs and protecting the safety of the patient.
13. A nurse in the community has been asked to join an organization based on the leadership abilities she has demonstrated both in her facility of employment and community-based activities. What organization best describes this process?
A)
nurse researcher
B)
clinical nurse specialist
C)
nurse educator
D)
nurse administrator
Ans:
B
Feedback: The clinical nurse specialist has advanced experience and expertise in a specialized area of practice such as gerontology, and would be best suited to provide education on palliative care. The nurse researcher is responsible for the continued development and refinement of nursing knowledge and practice through the investigation of nursing problems. The nurse educator generally has specific clinical specialties and advanced clinical experience in a particular area. The nurse administrator is responsible for managing patient care.
14.During the Christian era, nursing care excluded which area?
A)
Nutrition
B)
Personal counseling
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C)
Comfort measures
D)
Psychiatric services
Ans:
D Feedback: During the Christian era nursing focused on many of the same areas that nursing focuses on today. Included areas of focus were nutrition, mobility, medication administration, personal counseling, hygiene, and comfort measures.
15. The nurse is caring for a postoperative patient. The physician has written orders for a pain medication. The order gives a dosage range for the amount the nurse may give depending on the severity of the patients pain. This type of functioning within the healthcare team is called:
A)
Authoritative functioning
B)
Independent functioning
C)
Assistive functioning
D)
Dependent functioning
E)
Collaborative functioning
Ans:
E
Feedback: Nurses manage collaborative problems using both nurse- and physicianprescribed interventions to reduce risk of complications (Carpenito-Moyet, 2009).
16.Which of the following is an appropriately stated nursing intervention?
A)
Ambulate in the hall
B)
Stand at bedside with assistance
C)
Ambulate 30 ft. twice a day with assistance of walker
D)
Ambulate with assistance of walker
Ans:
C
Feedback: Correctly stated patient outcomes are specific, measurable, and realistic. The other choices are poorly defined and do not specify when or how or by whom. 17. All members of the healthcare team are encouraged to read and contribute to the individual plans of care for their patients. Which of the following healthcare providers develops the plan of care?
A)
The RN
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B)
The LPN or RN
C)
The physician
D)
The patient
E)
Any licensed member of the healthcare team
Ans:
A Feedback: To serve as evaluation criteria and meet the standards of the Joint Commission (2010), the plan must be developed by a registered nurse, it must be documented in the patients health record, and it must reflect the standards of care established by the institution and the profession.
18.Current trends in nursing practice include the development of
A)
Acute care centers
B)
Birthing centers
C)
Homeless shelters
D)
Ambulatory surgery centers
Ans:
B Feedback: Current trends in nursing practice include the development of nursing centers, wellness promotion programs, care of older adults, birthing centers, and home and community healthcare.
19. The Standards of Practice provide nurses with
A)
Legislation for healthcare reform
B)
Evaluation of care provided by nurses
C)
Measurement criteria for payment
D)
Guidelines for providing care
Ans:
D Feedback: Standards of practice are essential because they serve as guidelines for providing and evaluating nursing care.
20. A nurse receives an x-ray report on a newly admitted patient suspected of having a fractured tibia. The nurse contacts the physician to report the findings. What role is the nurse engaged in?
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A)
Communicator
B)
Advocate
C)
Caregiver
D)
Researcher
Ans:
A Feedback:
Nurses are communicators when they report findings to the healthcare team. Advocacy involves actions such as protecting the patients safety or rights. Administering care measures directly to the patient and demonstrates the caregiver role. Research involves collecting and analyzing data. 21. A nurse is caring for a young victim of a terrorist attack. During the rehabilitative process, the nurse assists the patient in bathing and dressing. The role the nurse is engaged in is
A)
Advocate
B)
Caregiver
C)
Counselor
D)
Educator
Ans:
B Feedback: As providers of care, nurses assume responsibility for helping patients promote, restore, and maintain health and wellness. Communicating the patients needs and concerns, and protecting the patient and the patients rights are components of the advocacy role of nursing. The nurse is simply assisting in hygiene measures; no education or counseling is being provided.
22. A student is choosing her educational path and desires a nursing degree that has a track that contains community nursing and leadership, as well as liberal arts. The student would best be suited in which type of program?
A)
Licensed practical nursing program
B)
Certification in a nursing specialty
C)
Diploma nursing program
D)
Baccalaureate program
Ans:
D Feedback: The baccalaureate degree in nursing offers students a full college or university education with a background in the liberal arts.
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23. The director of nursing (DON) of a major hospital is searching to hire a nurse with a strong technical background to care for patients on a busy surgical unit. The DON is most likely going to hire a nurse prepared at which level of nursing?
A)
Doctoral level
B)
Masters level
C)
Baccalaureate level
D)
Associate level
Ans:
D Feedback: The ANAs 1965 resolution prompted the 1985 ANA statement adopting the titles of associate nurse (a nurse prepared in an associate degree program with an emphasis on technical practice) and professional nurse (a nurse possessing the baccalaureate degree in nursing) for these two levels. Masters and doctoral prepared nurses possess higher degrees and expertise.
24. A nursing student begins to speak using medical terminology. This is considered to be part of which process?
A)
Learning
B)
Socialization
C)
Role development
D)
Evolutionary
Ans:
B Feedback: Socialization is a process that involves learning theory and skills and internalizing an identity appropriate to a specific role.
25. Which of the following factors has most influenced how nurses practice their profession?
A)
Financial support of nursing education
B)
Professional organizations such as ANA
C)
National Commission on Nursing
D)
Increased incidence of chronic illness
Ans:
D
Feedback: Professional organizations speak to nurses on various topics and may have some influence on ideas regarding nursing care, but longer lifespans,
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increased incidence of chronic illness, and new family structures have dramatically affected where and how nurses practice.
26.The first nursing journal owned, operated, and published by nurses was
A)
American Journal of Nursing
B)
Nurse Educator
C)
Nursing Research
D)
Standards of Clinical Nursing Practice
Ans:
A Feedback: The American Journal of Nursing was first published in 1900 and was owned, operated, and published by nurses.
27. Advocating for financial support for university-based schools of nursing was noted in which government document?
A)
The Goldmark Report
B)
Hill Burton Amendment
C)
Health Care Initiative Reform Act
D)
Lysaught Report
Ans:
A Feedback: The Goldmark Report in 1923 advocated for financial support for university-based schools of nursing.
28. The need for university-based nursing education programs was brought to light during which important historical time?
A)
Spanish American War
B)
World War I
C)
World War II
D)
Korean War
Ans:
C Feedback: Esther Lucille Brown, in her report on nursing education published at that time, wrote that nursing education belonged in colleges and universities, not in hospitals.
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29.The Henry Street Settlement was founded by
A)
Dorothea Dix
B)
Lillian Wald
C)
Florence Nightingale
D)
Isabel Hampton Robb
Ans:
B Feedback: Lillian Wald and Mary Brewster established the Henry Street Settlement, which was the first public health service for the sick and poor.
30.The Nurse Corps of the United States Army was established by
A)
Dorothea Dix
B)
Lillian Wald
C)
Florence Nightingale
D)
Isabel Hampton Robb
Ans:
A Feedback:
Dorothea Dix established the Nurse Corps of the United States Army.
31. Florence Nightingale classified sick nursing as
A)
Care of the dying patient
B)
Use of patients reparative processes
C)
Addressing the community problems
D)
Implementation of restorative processes
Ans:
B Feedback: Nightingale viewed sick nursing as helping patients use their own reparative processes to get well.
32.The purpose of nursing was shaped by which of the following eras?
A)
Egyptian era
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B)
Christian era
C)
Revolutionary War era
D)
Victorian era
Ans:
B Feedback: Christianitys influence improved the status of nursing by attracting intelligent individuals from respected families.
Chapter 02- The Nurse's Role in Healthcare Quality and Patient Safety
1.
A nurse is preparing to administer a medication by using the vastus lateralis site and is unfamiliar with the process. A step-by-step reference that shows how to complete the process is called a:
A)
Deployment Flowchart
B)
Top-down Flowchart
C)
Pareto chart
D)
Control plot
Ans:
B Feedback: Correct: A top-down flowchart shows the sequence of steps in a job or process such as medication administration. Incorrect: a. A deployment flowchart shows the detailed steps involved in a process and the people or departments that are involved at each step in the process; this is not involved in this scenario. c. The Pareto chartis used in quality improvement to indicate that 80% of problemsusually stem from 20% of causes; it displays data so that a few problems are easily depicted and facilitates improvement that focuses on those few.
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d. A control plotis a run chart that has a center-line and added statistical controllimits; it helps reveal specific types of change within a process, rather than providing a sequencing of steps. 2.
A nonprofit organization that distributes to governmental agencies, the public, business, and health care professionals knowledge related to health care for the purpose of improving health is the:
A)
Institute for Safe Medication Practices.
B)
Institute of Medicine.
C)
National Committee for Quality Assurance.
D)
The Joint Commission.
Ans:
B Feedback: Correct: The Institute of Medicine is a nonprofit organization whose mission is to advance and disseminate to the government, the corporate sector, the professions, and the public scientific information that will improve human health. Incorrect: a. The Institute for Safe Medication Practices is a nonprofit organization that is an educational resource only for the prevention of medication errors. c. The National Committee for Quality Assurance is the accrediting body for healthmaintenance organizations. d. The Joint Commission is a national agency that conducts surveys and certifiescompliance with established standards for inpatient and ambulatory facilities.
3.
A nurse is assisting with the delivery of twins. The first infant is placed on the scale to be weighed. The physician requests an instrument stat. The nurse turns to hand the instrument to the physician, and the infant falls off the scale. When evaluating the incident, the nurse and her manager list contributory factors such as the need for two nurses when multiple births are known, and the location of the scale so far from the delivery field. These nurses are performing a(n):
A)
standardization of care.
B)
root cause analysis.
C)
process variation.
D)
analysis of a deployment flowchart.
Ans:
B Feedback:
Correct: A root cause analysis is a process by which factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event, are identified. The purpose of root cause analysis is to identify improvements that can be implemented to prevent future occurrences. Incorrect: a. Standardization of care is the process of developing and adhering to best known methods and repeating key tasks in the same way, thereby creating exceptional service with maximum efficiency. c. Process variation looks at the steps in a process to determine how variationaffects each step but does not identify causal events. d. A deployment flowchart analysis looks at the steps of a process and determineswhich department is responsible for each step, but it does not identify causal events.
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4. Each month data on admission assessments that are based on the following standard are entered: “All patients will be assessed by an RN within 2 hours of admission.” The target goal for this standard is 97% compliance. Data are displayed on a graph that shows number and time of admission assessments and compliance variation limits. This pictorial representation is a:
A)
Pareto chart.
B)
control chart.
C)
deployment chart.
D)
top-down flowchart.
Ans:
B Feedback: Correct: The control chart is a run chart that has a center-line and added statistical control limits that help to detect specific types of change needed to improve a process. Incorrect: a. The Pareto chart is used in quality improvement to identify that 80% of problems usually stem from 20% of causes; it displays data so that a few problems are easily depicted and facilitates improvement that focuses on those few. c. A deployment flowchart shows the detailed steps involved in a process and thepeople or departments that are involved at each step. d. A top-down flowchart shows the sequence of steps in a job or process such asmedication administration at a particular site, but it does not show variation limits.
5. Regardless of the term used to describe high-quality health care, the focus of quality is:
A)
what the consumer needs and wants.
B)
economical care.
C)
having the greatest technologic advancement.
D)
services equally distributed among populations.
Ans:
A Feedback: Correct: The customer determines quality on the basis of his or her unique perception of high-quality care. Incorrect: b. High-quality health care can be inexpensive, but if it does not meet the criteriaestablished by the consumer, then it is not high-quality health care. c. Although technologic advancements may indeed facilitate superior diagnostics,unless the patient perceives that the technology was an indicator of quality or that it improved quality, then it is not the focus. d. The perception of quality is unique among individuals.
6. In differentiating between early efforts of quality assurance and present-day quality improvement efforts, which statement is correct? Quality assurance:
A)
had a broad focus.
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B)
promoted problem-solving by all members of the health care team.
C)
was preventive in nature.
D)
tended to occur as a reaction to a specific problem.
Ans:
D Feedback: Correct: Early efforts focused on identified problems and were reactive rather than proactive. Incorrect: a. Quality assurance focused on specific incidents rather than on broad systemimprovements. b. With quality assurance, only a few people such as auditors focused on problems,and administration only later recognized the importance of proactive initiatives involving all members of the health care team. c. Early efforts of quality assurance focused on identified problems rather than onavoiding future problems.
7. An organization’s emergency preparedness task force meets to discuss how it should react in case of a terrorist attack and develops a disaster evacuation plan that details how each department will assist individuals in reaching safety. This type of diagram is referred to as a:
A)
Pareto chart.
B)
control chart.
C)
top-down flowchart.
D)
deployment chart.
Ans:
D Feedback: Correct: A deployment flowchart would show the detailed steps involved in the process and the people or departments that are to be involved at each step to assist individuals in reaching safety. Incorrect: a. The Pareto chart displays data so that a few problems that cause the greatestvariance are easily depicted and facilitates improvement that focuses on those few. b. A control chart distinguishes between common and special cause variations and isbasically a run chart with added statistical control limits. c. The top-down flowchart simply lists the main steps and substeps of a process in alinear fashion and does not detail the departments or people needed.
8. Patients with heart failure have extended lengths of stay and are often readmitted shortly after they have been discharged. To improve quality of care, a type of “road map” that included all elements of care for this disease and that standardized treatment by guiding daily care was implemented. This road map is referred to as a(n):
A)
benchmark.
B)
critical pathway.
C)
algorithm.
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D)
case management.
Ans:
B Feedback: Correct: A critical pathway determines the best order and timing of interventions provided by health care team members for a particular diagnosis. Incorrect: a. A benchmark is a process used in quality improvement to evaluate different aspects of a process in relation to best practices, with the goal of improving performance. c. An algorithm represents a decision path that a practitioner might take for aparticular condition. d. Case management is a type of health care delivery that matches the mostappropriate services to the patient’s care needs in the most efficient, effective manner, often with the use of a critical pathway or a clinical guideline.
9.
The staff on a nursing unit notes that patient satisfaction varies from month to month. They plot the degree of patient satisfaction each month for 1 year to determine when the periods of greatest dissatisfaction are occurring. The staff uses which type of graph?
A)
Time plot.
B)
Pareto chart.
C)
Flowchart.
D)
Cause-and-effect diagram.
Ans:
A Feedback: Correct: A run plot, or time plot, graphs data in time order to identify any changes that occur over time. Incorrect: b. A Pareto chart is used in quality improvement to display data so that a fewproblems that cause the greatest variance are easily depicted and facilitates improvement that focuses on those few. c. A flowchart provides pictures of the sequence of steps in a process. d. A cause-and-effect diagram lists potential causes, arranged by categories, to showtheir potential impact on a problem. It is not arranged by time.
10. The number of IV site infections has more than doubled on a nursing unit. The staff determine common causes include the site is cleaned using inconsistent methods, dressing frequently becomes wet when patient showers, IV tubing is not changed every 48 hours per protocol, and inadequate hand washing of RN prior to insertion. A bar graph demonstrates the frequency in descending order, with 80% of infections being attributed to inadequate hand washing. The quality tool used is a:
A)
cause-and-effect diagram.
B)
run chart.
C)
Pareto chart.
D)
flowchart.
Ans:
C
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Feedback: Correct: Pareto charts are bar graphs that show causes contributing to a problem in descending order so the leading cause is easily recognized. Incorrect: a. With the cause-and-effect diagram, all causes are listed but not in frequency ofoccurrence. b. Run charts show data over time. d. Flowcharts show steps in a process.
Chapter 03- Values, Ethics, and Legal Issues
1. The nurse is preparing to administer a medication ordered by the surgeon in a dose much higher than is recommended. What action should the nurse take? A) Call the surgeon to clarify the order.
B)
Administer the medication as ordered and chart the high dose.
C)
Administer the medication and stay with the patient to observe for adverse reactions.
D)
Administer the medication in the usual dosage.
Ans:
A Feedback: Under current nurse practice laws, nurses are responsible for their own actions regardless of the providers written order. If an order is ambiguous or inappropriate, the nurse must clarify the medication order with the prescribing healthcare provider. If the nurse is dissatisfied with the providers response and still believes that the order is incorrect or unsafe, he or she must notify a supervisor.
2.
A)
When the nurse inserts an ordered urinary catheter into the patients urethra after the patient has refused the procedure and the patient suffers an injury, the patient may sue the nurse for which type of tort?
Battery
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B)
Assault
C)
Invasion of privacy
D)
Dereliction of duty
Ans:
A Feedback: Battery is the actual carrying out of such threat (unlawful touching of a persons body). A nurse may be sued for battery if he or she fails to obtain consent for a procedure.
3. A baccalaureate-prepared nurse is applying for a nurse practitioner position. The nurse is
A)
Well educated and can perform these duties
B)
Able to practice as a nurse practitioner
C)
Educated to practice only with pediatric patients
D)
Practicing beyond his scope according to licensure
Ans:
D Feedback:
A nurse without an advanced practice license is not able to practice beyond his or her scope in accordance with the Nurse Practice Act.
4. A nurse fails to administer a medication that prevents seizures, and the patient has a seizure. The nurse is in violation of the Nurse Practice Act. What type of law is the nurse in violation of?
A)
Criminal
B)
Federal
C)
Civil
D)
Supreme
Ans:
C Feedback: Malpractice cases are generally the kind of civil cases that involve nurses.
5.
A post-anesthesia nurse is reporting about the patient to the intensive care unit nurse in the elevator. There are staff members and visitors in the elevator. The nurse is
A)
Implementing therapeutic communication
B)
Interacting to maintain coordination of care
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C)
Breaching the patients confidentiality
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
41
Maintaining the continuity of care
Ans:
C Feedback: The principle of confidentiality requires that information about a patient be kept private. Discussing patients outside the clinical setting, telling friends or family about patients, or even discussing patients in the elevator with other workers violates patient confidentiality and must be avoided.
6.
When the nurse informs a patients employer of his autoimmune deficiency disease, the nurse is committing the tort of
A)
Breach of contract
B)
Assault
C)
Invasion of privacy
D)
Battery Ans: C
Feedback: Nurses have access to information recorded in the medical record, information shared or observed through care or interactions with friends and family, and through access to the patients body. A loss of privacy occurs if others inappropriately use their access to a person.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D) 7. A nurse states to the patient that she will keep her free of pain. However, her family wishes to try a treatment to prolong her life that may necessitate withholding pain medication. This factor will cause an ethical dilemma for the nurse in relation to which ethical principle?
A)
Fidelity
B)
Veracity
C)
Justice
D)
Autonomy
Ans:
A Feedback: Fidelity means being faithful to ones commitments and promises.
8.
A)
An oncology patient in an outpatient chemotherapy clinic asks several questions regarding his care and treatment. The nurse explains the clinics routine, typical side effects of the chemotherapy, and ways to decrease the number of side effects experienced. What characteristic is the nurse demonstrating?
Veracity
42
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Fidelity
C)
Justice
43
Autonomy
Ans:
A Feedback: Veracity means telling the truth, which is essential to the integrity of the patientprovider relationship.
9.
The foundation for decisions about resource allocation throughout a society or group is based on the ethical principle of
A)
Veracity
B)
Autonomy
C)
Justice
D)
Confidentiality
Ans:
C
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D) Feedback: Justice is the foundation for decisions about resource allocation throughout a society or group. 10. The patient being admitted to the oncology unit conveys his wishes regarding resuscitation in the event of cardiopulmonary arrest. The nurse advises the patient that it would be in his best interest to obtain which document?
A)
A will
B)
A living will
C)
Proof of healthcare power of attorney
D)
A proxy directive
Ans:
B Feedback: A living will is an advance directive that specifies the type of medical treatment patients do or do not want to receive should they be unable to speak for themselves in a terminal or permanently unconscious condition.
44
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45
11. A legal document that states a patients health-related wishessuch as a preference for pain management if the patient becomes terminally illand also allows the patients daughter to direct his or her care, is a(an)
A)
Will
B)
Standard of care
C)
License
Advance directive
Ans:
D Feedback: Patients communicate their wishes to healthcare providers by verbally participating in healthcare decision making and by employing written documents called advance directives.
12. A patient is in a persistent vegetative state. The patient has no immediate family and is a ward of the state. Under these circumstances, who will speak on her behalf?
A)
Surrogate decision maker
B)
Church-appointed guardian
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D) C)
A significant other
D)
Her best friend
Ans:
A Feedback: Infants, young children, people who are severely mentally handicapped or incapacitated, and people in a persistent vegetative state or coma do not have the capacity to participate in decision making about their healthcare. For such people, a surrogate decision maker must be identified to act on their behalf.
13. An 83-year-old woman who has suffered a cerebrovascular accident and is unable to swallow refuses the insertion of a feeding tube. This is an example of what ethical principle?
A)
Nonmaleficence
B)
Veracity
C)
Autonomy
D)
Justice
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Test Bank - Fundamentals of Nursing (9th Edition by Craven)
Ans:
47
C Feedback:
Autonomy essentially means independence and the ability to be selfdirected.
14. An emergency department nurse and healthcare team, caring for a 2year-old, semiconscious child with numerous fractures and evidence of cigarette burns, suspect child abuse. The nurse reports the family to the child abuse hotline. The nurse is following which ethical principle?
A)
Beneficence
B)
Nonmaleficence
C)
Justice
Fidelity
Ans:
B Feedback: The principle of nonmaleficence means to avoid doing harm, to remove harm, and to prevent harm.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D) 15. A home care nurse visits a patient who is confined to bed and is cared for by her daughter. The daughter is known to suffer from chemical dependence. The home is cluttered and unclean. During the assessment the nurse notes that the patient is wet with urine and has dried feces on her buttocks, and demonstrates signs of dehydration. After caring for the patient, the nurse contacts the physician and reports the incident to Adult Protective Services. This is an example of which ethical framework?
A)
Justice
B)
Beneficence
C)
Nonmaleficence
D)
Fidelity
Ans:
C Feedback: The principle of nonmaleficence means to avoid doing harm, to remove harm, and to prevent harm. Beneficence means doing or promoting good. Nurses work to accomplish good for patients by promoting their best interests and striving to achieve optimal outcomes. The patients circumstances indicate harm.
16. A nurse is caring for a 28-year-old woman who has delivered a baby by cesarean section. She describes her pain as a 9. The nurse medicates her
48
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
49
for pain. This is an example of which of the following ethical frameworks?
A)
Justice
B)
Fidelity
C)
Beneficence
D)
Nonmaleficence
Ans:
C Feedback: Beneficence means doing or promoting good. The treatment of the patients pain is the nurses act of doing good.
17.The American Nurses Associations Code of Ethics for Nurses
A)
Serves to establish personal ethics for nurses
B)
Delineates nurses conduct and responsibilities
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Serves as a guideline for all healthcare
D)
Plays an important role in legal proceedings
Ans:
B
50
Feedback: The ANA recently revised the Code of Ethics for Nurses that delineates the conduct and responsibilities expected of all nurses in their nursing practices. 18. A nurse is caring for a patient who is a practicing Jehovahs Witness. The physician orders 2 units of packed cells based on his low hemoglobin and hematocrit levels. The nurse states to the surgeon that it is unethical to go against the patients beliefs even though his blood counts are very low. What is the best description of the nurses intentions?
A)
Acting in the patients best interest
B)
Siding with the patient over the surgeon
C)
Observing institutional policies
D)
Being legally responsible
Ans:
A Feedback:
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51
Nurses ethical obligations include acting in the best interest of their patients not only as individual practitioners but also as members of the nursing profession, the healthcare team, and the community at large.
19. To practice ethically, the nurse should
A)
Allow a committee to guide her practice
B)
Review past cases before guiding practice
C)
Avoid allowing her judgment to guide practice
D)
Ask the family their views on caring
Ans:
C Feedback: Personal convictions apply only to situations and decisions pertaining to the individual. In ethical practice, nurses avoid allowing personal judgments to bias their treatment of patients.
20. A hospital owned by a Catholic order of nuns will not allow tubal ligations to be performed. This is considered to be
A)
Personal morality
B)
Personal values
C)
Institutional policy
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Legal obligation
Ans:
C
52
Feedback: Institutional policies are guidelines developed by healthcare institutions to direct professional practice.
21.A nurse is of the Catholic faith and votes pro-life. He is considered to have
A)
Personal morality
B)
Personal values
C)
Ethics
D)
Legal obligations
Ans:
B Feedback: Personal values are ideas or beliefs a person considers important and feels strongly about.
22. A nurse believes that abortion is an acceptable option if a pregnancy results from a situation of rape. What is the best description of this belief?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Personal morality
B)
Professional values
C)
Ethics
D)
Legal obligations
Ans:
A
53
Feedback: Personal morality is the set of beliefs about the standards of right and wrong that helps a person determine the correct or permissible action in a given situation.
23. Ethics is best defined as
A)
Basis for moral reasoning
B)
Standards of conduct
C)
Dealing with conflict
D)
Decision making
Ans:
B
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54
Feedback: Ethics is the branch of philosophy dealing with standards of conduct and moral judgment. 24. A child on a pediatric unit hits one of the other children and subsequently has video game privileges revoked for the rest of the day. The next day the same child plays with the other children without any problems in order to avoid losing video game privileges again. According to Kohlberg, the child is demonstrating what stage of development?
A)
Trust versus mistrust
B)
Moralizing
C)
First-level preconventional stage
D)
Self-actualization
Ans:
C Feedback: As children progress to toddlerhood, morals and values development begins as they identify behaviors that elicit reward or punishment. Kohlberg refers to this process as the first-level preconventional stage when children learn to distinguish right from wrong and understand the choice between obedience and punishment.
25.During adolescence, values are primarily formed from
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Schools
B)
Work
C)
Parents
D)
Peers
Ans:
D
55
Feedback: In adolescence, peer groups are the primary source of value formation. The attitudes, beliefs, and behaviors that grow out of peer group relationships are powerful.
26. How are values converted from knowledge into messages which can then be processed as information?
A)
Religion
B)
Nature
C)
Time
D)
Activity
Ans:
A
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56
Feedback: Values are codified in social institutions such as family, school, and religion. Values can then be adopted, adapted, or dismissed based on the persons life experiences and social system.
27. The purpose of a values inquiry discussion with a group of nursing students is to
A)
Examine past decisions
B)
Examine social issues
C)
Alter the groups views
D)
Improve the groups image
Ans:
B Feedback: Values inquiry is a method of examining social issues and the values that motivate human choices.
28. The differences between the pro-life and abortion rights movement is an example of
A)
Values inquiry
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Social activism
C)
Ethical inconsistency
D)
Values clarification
Ans:
A
57
Feedback: Values inquiry is a method of examining social issues and the values that motivate human choices. 29. A dying patient tells the nurse that he doesnt want to see his family because he doesnt want to cause them more sadness. Which action by the nurse is most appropriate?
A)
Arrange a meeting between the family and the patient
B)
Help the patient clarify his values
C)
Educate the patient on death and dying concepts
D)
Allow the patient time for quiet reflection
Ans:
B Feedback:
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58
Values clarification is a method of self-discovery by which people identify their personal values and value rankings. The patients value of family may be obscured because of his overwhelming need to protect his family.
30. A hospice nurse is caring for a patient with terminal cancer. The family would like the patient to continue aggressive therapy to treat the cancer, but the patient has voiced to the nurse that, after much thought, he does not want to pursue any further treatment. The nurse speaks to the family about the patients wishes, condition, and terminal state. This action is most likely derived from which nursing obligation?
A)
Legal responsibilities
B)
Nursing education principles
C)
Advanced practice licensure guidelines
D)
Moral values
Ans:
D Feedback: Moral values involve correct behavior, such as having some sense of right and wrong. Moral values help direct nurses to deal with human interactions that involve the integrity of life or health.
31. A nursing students attitude is defined as:
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Belief in ones self
B)
Desire to do good
C)
Disposition toward situations
D)
Choosing between alternatives
Ans:
C
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Feedback: An attitude is ones disposition toward an object or a situation; it can be a mental or emotional mindset, and it can be positive or negative.
32. Socialization into the nursing profession may have the most significant effect on
A)
Roles
B)
Values
C)
Documentation
D)
Planning
Ans:
B
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Feedback: Values that the nurse will need to balance include truth, harmony, duty, and responsibility.
33. What are standards for decision making that endure for a significant time in ones life?
A)
Beliefs
B)
Ethics
C)
Roles
D)
Values
Ans:
D Feedback: Values are standards for decision making that endure for a significant time in ones life.
Chapter 04- Nursing Research and EvidenceBased Care
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
1.
61
In the development of a literature review, the most effective source of information for nursing research is which of the following? New England Journal of Medicine
A) Cumulative Index of Nursing and Allied Health Literature B) Journal of Nursing Research C) American Journal of Nursing D)
Ans:
B Feedback: Indexes such as the Cumulative Index to Nursing and Allied Health Literature, International Nursing Index, Index Medicus, Nursing Studies Index, MedLine, and Nursing Research Index are valuable in locating nursing-based literature and research studies.
2.
When did evidenced-based practice become an important component of the delivery of nursing care?
A)
The early 1800s
B)
The early 1900s
C)
The late 1900s
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
The early 2000s
Ans:
D
62
Feedback: In the early years of the 21st century, a heightened focus on evidence-based practice has developed, which relies on research findings to support nursing practice.
3.
Why is it important for the findings of a research study to be disseminated? Select all that apply.
A)
So that clinical application can occur
B)
To allow the nurse researcher to receive notoriety for the findings
C)
In order for research replication by other nurses to take place
D)
Because graduate-level nurses must conduct a specific number of research studies to maintain nursing licensure
E)
To strengthen and validate conclusions by similar findings in more than one research study
Ans:
A, C, E Feedback:
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63
The study and its findings must be dispersed in order to validate the findings through clinical practice and through replication of the study; hopefully, with similar findings. There is not a specified number of studies required for graduate-level nurses to conduct, and the nurse researcher should never conduct a study for the purpose of being recognized.
4.
The nurse researcher is aware that the type of variable that can be manipulated in a study is which type of variable?
A)
Dependent
B)
Independent
C)
Quantitative
D)
Qualitative
Ans:
B Feedback: The independent variable is presumed to have an effect on the dependent variable. It may be manipulated if the researcher is doing an experimental study; in a nonexperimental study, it is assumed to have occurred naturally before or during the study.
5.
The director of nurses (DON) in a long-term care facility has noticed an increased number of urinary tract infections (UTIs) on the east wing of the facility, and would like the infection control nurse to investigate this problem. What is the best problem statement for this study?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
64
A)
Is there a relationship between the personnel caring for specific patients and whether or not these patients developed UTIs?
B)
Is there an increase in the number of UTIs on the east wing of the facility?
C)
Does the east wing have a greater number of UTIs than the west wing of the facility?
D)
What is the patient census on the east wing as opposed to the other wings of the facility?
Ans:
A Feedback: The problem statement in a research study identifies the direction that a research project will take. The statement should be clear and unambiguous, express a relationship between two or more variables, identify the population to be studied, and encourage empiric testing.
6.
A nursing researcher presents the findings of his current study at a School of Nursings research conference. While there, he speaks with another nurse researcher interested in similar topics and the two decide to discuss forming a partnership for further research projects. What is this type of interaction an example of?
A)
Hypothesizing
B)
Identifying variables
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Investigating foreground questions
D)
Networking
Ans:
D
65
Feedback: Networking is a way to meet other nurses with similar interests and is a good way to disseminate and to expand ones knowledge, as well as to meet with other professional nurses.
7. What type of research study would a hospital conduct to determine additional services the community would like to see offered by the facility?
A)
Quantitative
B)
Qualitative
C)
Ordinal
D)
Interval Ans: B
Feedback:
Quantitative researchers tend to use deductive reasoning, logic, and measurable attributes of human experience, whereas qualitative researchers tend to use dynamic, individual aspects of the human
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
66
experience in a holistic approach. Ordinal and interval refers to types of variables.
8.
What are the four properties identified by Diers that comprise the holistic perspective of nursing research?
A)
The focus of nursing research must be on a variance that makes a difference in improving patient care.
B)
Nursing research has the potential for contributing to the development of theory and the body of scientific nursing knowledge.
C)
A research problem is a nursing research problem when nurses have access to and control over the phenomena being studied.
D)
A nurse interested in research must have an inquisitive, curious, and questioning mind.
E)
A nurse interested in research must be a graduate-level nurse to be able to adequately perform nursing research.
Ans:
A, B, C, D Feedback: Nursing is concerned with the whole person, which describes holistic nursing. When nurses conduct research, they tend to focus on the physiologic, psychological, sociologic, cultural, and economic factors that affect a person. They view the situation from a nursing perspective and ask questions about what they see.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
9.
67
When the nurse researcher informs the participant that his or her identity will not be linked with the information that is collected, the researcher is ensuring the participants
A)
Anonymity
B)
Protection from harm
C)
Ability to withdraw
D)
Confidentiality
Ans:
D Feedback: Confidentiality ensures that the subjects identities will not be linked with the information they provide and will not be publicly divulged.
10.The role of the institutional review boards for research studies is to
A)
Determine the worthiness of a research study
B)
Document the costs of the study
C)
Publish the research study
D)
Protect the rights of human subjects
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
Ans:
68
D Feedback: Research involving human subjects also needs approval by institutional review boards before implementation.
11. A well-constructed problem statement formulated at the beginning of a nursing research study should
A)
Incorporate nursing theory
B)
Include significant references
C)
Identify benefits of the study
D)
Indicate the population
Ans:
D Feedback: The problem statement should be clear and unambiguous, express a relationship between two or more variables, identify) the population to be studied, and encourage empiric testing.
12. A nursing instructor would like to study the effect peer tutoring has on student success. What is the independent variable?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Nursing student
B)
Nursing education
C)
Peer tutoring
D)
Student success
Ans:
C
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Feedback: The independent variable is the presumed cause or influence on the dependent variable.
13.Following the identification of a researchable problem, the nurse must
A)
Obtain a list of possible outcomes
B)
Evaluate the number of ways to collect data
C)
Select literature relevant to the problem
D)
Determine a source appropriate to collect data
Ans:
C
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70
Feedback: Literature review is the process of selecting published materials that have relevance to the potential research.
14. A nurse researcher is collecting nominal data. What type of research is being conducted?
A)
Quantitative research
B)
Qualitative research
C)
Interval research
D)
Experimental research
Ans:
A Feedback: Quantitative research involves the systematic collection of numeric information. Nominal data is of a numeric nature.
15. The nurse researcher would like to gather data on the attitudes of young adults on spirituality and healthcare. The most effective form of research on this topic is
A)
Quantitative research
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Methodologic survey
C)
A Delphi study
D)
Qualitative research
Ans:
D
71
Feedback: Attitudes on spirituality and healthcare require the nurse to interview patients or informants to obtain qualitative research. Qualitative research involves the systematic collection and analysis of more subjective narrative materials using procedures in which there tends to be a minimum of researcher-imposed control.
16. The National Institute of Nursing Research (NINR) was established following a study in 1983. The centers purpose is to
A)
Advance the level of nursing research funding
B)
Investigate and expand nursing theory
C)
Promote research for health promotion
D)
Evaluate the effect of current research
Ans:
C
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Feedback: The National Institute of Nursing Research was established under the National Institutes of Health to place nursing securely in the sphere of scientific investigation and to support research and training into patient care, health promotion, disease prevention, and the mitigation of the effects of acute and chronic disabilities.
17. From 1900 to 1940, research in nursing focused on:
A)
Cost-effectiveness of nursing care
B)
Improving patient care outcomes
C)
Nursing education and teaching
D)
Increasing workforce in the nursing profession
Ans:
C Feedback: Between 1900 and 1940, research in nursing centered on education, methods of teaching, and methods of evaluating how nurses learned.
18.Who is considered to be the first nursing researcher?
A)
Florence Nightingale
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Dorothea Dix
C)
Clara Barton
D)
Lillian Wald
Ans:
A
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Feedback: Nursing research has been an integral part of the profession since Florence Nightingale documented the care of soldiers in the Crimean War.
19. How are the first stages of the nursing process and nursing research
linked? A) They will answer a posed question.
B)
Each begins with goal development.
C)
The nurse assesses problems initially.
D)
There is a period of evaluation.
Ans:
C Feedback:
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74
The first step for the practicing nurse is to assess a problem; for the researcher, the step is to recognize the general problem area.
20. What is a systematic inquiry into the problems encountered in nursing practice and into the modalities of patient care?
A)
Nursing research
B)
Evidence-based practice
C)
Outcome criteria
D)
Scientific inquiry
Ans:
A Feedback: Nursing research is defined as a systematic inquiry into the problems encountered in nursing practice and into the modalities of patient care, such as support and comfort, prevention of trauma, promotion of recovery, health education, health appraisal, and coordination of healthcare. Evidence-based practice supports nursing care given to patients by emphasizing decision making based on the best available evidence and the use of outcome studies to guide decisions.
21. Evidence-based care emphasizes decision making based on the best available evidence and
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Use of outcome studies to guide decisions
B)
Evaluation by experts to direct specialty areas
C)
Care based on pathophysiologic factors
D)
Cost efficiency of treatment models
Ans:
A
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Feedback: Evidence-based care emphasizes decision making based on the best available evidence and the use of outcome studies to guide decisions.
22. Nursing research is linked most closely to
A)
Propositions
B)
Outcome measures
C)
Treatments
D)
Nursing process
Ans:
D
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76
Feedback: Many similarities are found between the formalized research process and the nursing process format that is an integral part of nursing education.
23. The question, Does handwashing significantly lower the rate of infection in hospitalized patients?, is an example of what research component?
A)
Hypothesis
B)
Problem statement
C)
Conclusion
D)
Implication for the future
Ans:
A Feedback: Research is defined as a formalized process of systematic investigation designed to test a research question or hypothesis and draw conclusions from collected data.
24.In what way can a nurse discriminate strong research from poor research?
A)
By conducting the research
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Through author dialogue
C)
By critiquing the study
D)
Through the nurses own informal investigation
Ans:
C
77
Feedback: Nurses must have a working knowledge of research methods and a beginning ability to read for application and to critique research.
25. One of the primary focuses of nursing research is to
A)
Quantify outcomes related to patients
B)
Determine outcomes for patients
C)
Generate knowledge to guide practice
D)
Prevent further disease and death
Ans:
C Feedback:
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One of the major reasons for conducting research is to expand a professions knowledge base. 26.What nursing activity forms the bridge between theory and practice?
A)
Theoretic writing
B)
Evidence-based research
C)
Patient-focused care
D)
Case management
Ans:
B Feedback: Evidence-based research is translational research that forms the bridge between theory and practice.
27.Which of the following terms describes or explains the nursing model?
A)
Conceptual framework
B)
Theory
C)
Construct
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Proposition
Ans:
B
79
Feedback: The nursing model or theory acts as a guide to identify and study systematically the logical relationships between variables, thus supporting nursing care.
28. A conceptual framework is defined as
A)
An explanation of nursing and nursing practice
B)
A set of phenomena and related abstractions
C)
A foundation for nursing skills and care
D)
A set of concepts and propositions
Ans:
D Feedback: A conceptual framework or model is defined as a set of concepts and the propositions that integrate them into a meaningful configuration.
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80
29. Of the following, which best explains the importance of theoretic frameworks?
A)
Theoretic frameworks guide physiologic nursing care
B)
Theoretic frameworks guide psychosocial nursing care
C)
Theoretic frameworks advance nursing knowledge and practice
D)
Theoretic frameworks advance the ethical aspects of practice
Ans:
C Feedback: Theoretic frameworks are important to the advancement of nursing knowledge and professional practice.
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81
Chapter 05- Nursing Process: Foundation for Clinical Judgment
1.
A modern approach to the development of clinical decisions and clinical judgments is the use of human patient simulators in simulation laboratories on campus. Human patient simulators are best described as
A)
Life-sized mannequins with a sophisticated computer interface
B)
Small doll-like devices used for measuring vital signs
C)
Healthcare equipment that has practice modes
D)
Life-saving equipment that resuscitates patients in cardiac arrest
Ans:
A Feedback: The human patient stimulator, a life-sized mannequin with a sophisticated computer interface, presents students with clinical scenarios that evolve based on decisions that students make.
2. What is meant by intellectual and affective activities in which individuals engage to explore their experiences in order to lead to new meanings and appreciations?
A)
Memorization
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Reflection
C)
Reminiscing
D)
Evangelization
Ans:
B
82
Feedback: Reflection is defined as those intellectual and affective activities in which individuals engage to explore their experiences in order to lead to new understandings and appreciations.
3. The nurse is caring for a newly admitted patient. How can a nurse arrive at a more complete database for this patient?
A)
Through clustering of data
B)
Analysis of lab values
C)
Review of the chart
D)
Consult with several sources
Ans:
D Feedback:
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83
By having a more complete database from several sources, including the patient, the nurse can arrive at a more accurate conclusion. The nurse can obtain data from secondary sources, such as family members, significant others, other healthcare professionals, health records, and literature review. 4.
A patient complains of weakness following his administration of insulin. The nurse decides to assess the patients blood sugar and prepare a snack in case the blood sugar is low. What action has the nurse implemented?
A)
Clinical reasoning
B)
Caring
C)
Reflection
D)
Assessment
Ans:
A Feedback: Clinical reasoning is the process of making a nursing judgement that will provide safe and quality care.
5.
A nursing student is caring for a patient who has diabetes mellitus. The patient takes insulin two times per day. Based on the students knowledge of insulins onset of action, he makes sure the patients meals arrive in coordination with the insulins effect. The knowledge used by the student is
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Evaluative
B)
Lacking
C)
Integrated
D)
Creative
Ans:
C
84
Feedback: This scenario indicates the integration of a students knowledge in the provision of safe patient care.
6.
For the nursing student to implement the most effective care for her patients, she must
A)
Have rudimentary critical-thinking skills
B)
Apply preexisting knowledge
C)
Apply clinical knowledge to theoretic knowledge
D)
Establish a clinical log for evaluation
Ans:
B
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Feedback: To deal with the patients problems appropriately, the student nurse will need to use his or her knowledge base from previous classes.
7.What type of learning best takes place in the nursing laboratory?
A)
Kinesthetic learning
B)
Auditory learning
C)
Concrete learning
D)
Collaborative learning
Ans:
A Feedback: Learning in the clinical setting or nursing laboratory may be more active, kinesthetic, and random.
8.
Which of the following learners enjoy learning that takes place in the clinical setting?
A)
Sequential thinkers
B)
Grade-oriented students
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C)
Learning-oriented students
D)
Active experimenters
Ans:
D
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Feedback: Active experimenters enjoy clinical rotations and skills laboratories. 9.
A nurse is educating a pregnant woman in preterm labor on the use of her home monitoring equipment and her medications. What factor could impede the patients ability to learn?
A)
Preparation
B)
Intelligence
C)
Previous knowledge
D)
Anxiety
Ans:
D
Feedback: Too much anxiety can paralyze high-order thinking skills.
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10. A patient who has limited finances and limited capacity for education requires home healthcare for a chronic illness. For the nurse to provide a high level of care to this patient, she must first
A)
Implement critical-thinking skills
B)
Develop a relationship with the patient
C)
Engage the services of a social worker
D)
Determine what care has been provided
Ans:
A Feedback: Critical thinking requires nurses to choose solutions or identify options for patient care situations.
11. The nurse assesses a patients blood pressure, which was 160/90. Two hours following the administration of hydrochlorothiazide, the nurse reassesses the blood pressure at 140/78. This nursing action is
A)
Evaluation
B)
Assessment
C)
Planning
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D)
Implementation
Ans:
B
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Feedback: The nurse is collecting data when measuring the patients blood pressure. Collection of patient data is considered assessment regardless of when it occurs.
12. When the nurse assesses the patients blood sugar, the type of skill that the nurse is using is termed?
A)
Technical
B)
Therapeutic
C)
Interactional
D)
Adaptive
Ans:
A Feedback: Technical skills are used to carry out treatments and procedures.
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13. When the nurse administers pain medication to a postoperative patient, the phase of the nursing process that is occurring is which of the following phases?
A)
Assessment
B)
Nursing diagnosis
C)
Planning
D)
Implementation
Ans:
D Feedback: Implementation refers to the action phase of the nursing process in which nursing care is provided.
14. When the nurse is administering Lasix 20 mg to a patient in congestive heart failure, what phase of the nursing process does this represent?
A)
Assessment
B)
Planning
C)
Implementation
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D)
Evaluation
Ans:
C
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Feedback: Implementation refers to the action phase of the nursing process in which nursing care is provided.
15.The functional health patterns provide the nurse with a(an)
A)
Framework for collecting assessment data
B)
Method for evaluation of diagnostic testing
C)
Preparation of diagnostic statements
D)
System for documenting patient care
Ans:
A Feedback: The functional health patterns provide a framework for the collection of assessment data.
16. Clustering of data to ascertain a nursing diagnosis is accomplished through the use of:
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
general systems theory process.
B)
problem-solving process.
C)
decision-making process.
D)
information-processing theory.
Ans:
D
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Feedback: Nurses use information-processing theory to help cluster data to arrive at a diagnosis.
17. A nurse ascertains that the patient is showing signs and symptoms of dehydration due to nausea and vomiting. The nurse makes the patient NPO and calls the physician. The nursing action of making the patient NPO is
A)
General systems theory process
B)
Problem-solving process
C)
Decision-making process
D)
Information-processing theory
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C Feedback: Making decisions about patient care is the essence of nursing practice. Decision making is integral to every step of the nursing process.
18. The information that enters the system or data collected during the assessment is considered to be the:
A)
input.
B)
immediate outcome.
C)
throughput.
D)
output.
Ans:
A Feedback: Input, the information that enters a system, is the data collected during the assessment step.
19. Three weeks after surgery the nurse notes the patient has partial healing of the surgical wound. This assessment would occur in which phase of the nursing process?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Outcome
B)
Nursing diagnosis
C)
Planning
D)
Evaluation
Ans:
D
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Feedback: In the evaluation phase, nurses collect data to determine if patient goals have been met.
20. Nursing actions should be
A)
Associated with the family
B)
Goal-directed
C)
Individually attained
D)
Evaluated by team members
Ans:
B
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Feedback: Nursing actions are goal-directed, assisting the patient to reach maximum functional health.
21. The nurse changes a patients surgical dressing daily. This is considered to be part of which phase of the nursing process?
A)
Nursing diagnosis
B)
Patient goal
C)
Outcome identification
D)
Implementation
Ans:
D Feedback: Implementation is the action phase of the nursing process.
22.A written plan of care for each patient is required by what organization?
A)
The Joint Commission
B)
The National Institutes of Health
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C)
The American Association on the Accreditation of Colleges of Nursing
D)
The American Nurses Association
Ans:
A Feedback: The patient plan of care is a written summary of care that a patient is to receive. The Joint Commission requires a written plan of care for each patient.
23. When the nurse formulates three nursing diagnoses for an adult patient hospitalized for abdominal surgery, the nurse has focused on the patients
A)
Medical record.
B)
Actual health problems
C)
Medical diagnosis
D)
Past medical history
Ans:
B Feedback:
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Formulating the diagnostic statement requires knowledge of the differences among actual, risk, possible, and wellness nursing diagnoses. 24. After the nurse has formulated expected outcomes, the next step of the nursing process is to:
A)
outline evaluation strategies.
B)
prepare an oral report.
C)
document the rationale.
D)
write the plan of care.
Ans:
D Feedback: Nurses work together with patients to identify goals and intervention strategies that will address identified problems.
25.What is the primary goal of the planning phase of the nursing process?
A)
To identify goals for the patient
B)
To prepare a plan of care
C)
To establish priorities for care
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
To acknowledge patient needs
Ans:
B
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Feedback: The planning phase involves preparing a patient plan of care, which directs the activities of the nursing staff in the provision of patient care. 26. The nurse writes the following on the patients chart: The patient will have complete healing of the surgical incision on the right lower quadrant of the abdomen in 3 weeks. This is a(n)
A)
Nursing diagnosis
B)
Assessment
C)
Evaluation
D)
Outcome identification
Ans:
D Feedback: According to the ANAs Nursing: Scope and Standards of Practice, outcome identification refers to formulating and documenting measurable, realistic, patientfocused goals.
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27.Which organization defines the nursing diagnosis?
A)
American Nurses Association
B)
North American Nursing Diagnosis AssociationInternational
C)
American Association of Colleges of Nursing
D)
Sigma Theta Tau International
Ans:
B
Feedback: The North American Nursing Diagnosis AssociationInternational defines the nursing diagnosis as a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes.
28. Which of the following healthcare professionals are licensed to make a nursing diagnosis?
A)
Licensed practical nurses
B)
Registered nurses
C)
Social workers
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D)
Physicians assistants
Ans:
B
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Feedback: Registered nurses are educated and licensed to make nursing diagnoses.
29. A patient has had an appendectomy. He has an incision at the right lower quadrant of the abdomen. Nurse has written: Alteration in skin integrity related to incision at right lower quadrant of the abdomen. This is
A)
A planned outcome
B)
Subjective data
C)
A nursing intervention
D)
An actual nursing diagnosis
Ans:
D Feedback: Diagnosing human responses to actual or potential health problems is the second phase of the nursing process.
30.An in-depth history and physical builds the
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Plan of care
B)
Future interventions
C)
Database
D)
Secondary source
Ans:
C
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Feedback: An in-depth history and physical assessment are usually required at admission to a hospital or long-term care facility, or during the first visit by community or home health nurse.
31. The nurse caring for a newly admitted patient recognizes that the patients past chart at an acute care facility is considered to be the
A)
Primary source
B)
Secondary source
C)
Subjective data
D)
Nursing diagnosis
Ans:
B
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Feedback: Secondary sources include family members, significant others, other healthcare professionals, health records, and literature review.
32. A patient states, I am having a severe headache with pain over my right eye. This statement is classified as
A)
Primary source
B)
Objective data
C)
Symptom identification
D)
Planning care
Ans:
A Feedback: This patient is the primary source of information for assessment.
33.Which of the following is a distinct nursing function in the nursing process?
A)
Assessment
B)
Planning
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Nursing diagnosis
D)
Evaluation
Ans:
C
102
Feedback: In the 1980s, further support was gained for making diagnosis a distinct nursing function and a separate step of the nursing process. In the landmark Nursing: A Social Policy Statement, the ANA again identified diagnosis of actual and potential health problems as an integral part of nursing practice.
34.The term nursing process is synonymous with the
A)
Identification of health problems
B)
Verification of wellness issues
C)
Application of nursing diagnosis
D)
Problem-solving approach
Ans:
D Feedback:
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The term nursing process is synonymous with the problem-solving approach for discovering the healthcare and nursing care needs of patients.
35. In 1955, Lydia Hall introduced the nursing process. Nursing care delivery changed based on
A)
Guidelines from the medical model
B)
Information from the scientific process
C)
The patients and nurses interaction
D)
The process of pathophysiology
Ans:
C Feedback: The nursing process is that which goes on between a patient and a nurse in a given setting; it records the behaviors of patient and nurse and the resulting interaction.
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Chapter 06- Nursing Assessment
1.
During data collection the nurse may validate data by which method? (Select all that apply)
A)
Comparing cues to normal function
B)
Referring to textbooks, journals, and research reports
C)
Checking consistency of cues
D)
Clarifying the patients statements
E)
Seeking consensus with colleagues about inferences
Ans:
A, B, C, D, E Feedback: These methods of validating data and inferences are necessary before cues are clustered and analyzed for identification of nursing diagnoses.
2. When making an inference from the cues obtained during an assessment, it is important for the nurse to keep what in mind?
A)
Validate inferences with the patient
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Do not share inferences with the patient
C)
Document all inferences
D)
Avoid making any inferences
Ans:
A
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Feedback: The nurse should validate inferences made from assessment data in order to ensure accuracy. Incorrect cues and inferences lead to the development of inappropriate nursing diagnoses and patient plans of care.
3. While performing the nursing history the nurse notes that the patient states he is having very little pain, but is grimacing and holding his arm throughout the history taking. This observation takes place during which phase of the nursing history?
A)
Preparatory
B)
Introductory
C)
Maintenance
D)
Concluding
Ans:
C
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Feedback: Watching the patient to determine if nonverbal cues match their verbal communication typically occurs during the maintenance, or working, phase of the interview.
4. The home care nurse is preparing to perform a nursing history on a newly assigned adult patient with a venous stasis ulcer. Which statement by the nurse is most accurate?
A)
When I perform the nursing history I will need to ask your family to leave the room.
B)
I would like to schedule a time for me to perform a nursing history. It will take around 30 to 60 minutes.
C)
I will perform a physical assessment while I am obtaining the nursing history.
D)
I will leave a form with you to complete the nursing history information I need.
Ans:
B Feedback: Nurses are responsible for completing nursing histories, and it usually takes approximately 30 to 60 minutes to obtain data such as history of present illness, past medical history, support network, and other pertinent data. The physical is performed separately. Family members
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can offer valuable information as long as the patient gives permission for them to remain present during the history taking. 5.
The RN is admitting a patient to a medical unit. The nurse delegates the measurement of the vital signs to unlicensed assistive personnel (UAP) while she collects data. After completing the admission process, the patient complains of a severe headache so the nurse reassesses the vital signs to find the patients blood pressure extremely elevated. Whose responsibility is the accuracy of the blood pressure measurement?
A)
The company that made the blood pressure equipment
B)
The nurse
C)
The UAP
D)
The charge nurse
Ans:
B Feedback: While the nurse may delegate duties to UAP, the professional RN is ultimately responsible for the completeness and accuracy of the information. Since this was part of the admission assessment it would be advisable for the nurse to have measured the vital signs herself.
6. A novice nurse is using the assessment technique of auscultation. What assessment finding can the nurse obtain with this method?
A)
Size of the liver
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Presence of peristalsis
C)
Pupil reaction
D)
Skin temperature
Ans:
B
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Feedback: Peristalsis (bowel sounds) are assessed by auscultation with a stethoscope. The size of the liver is determined with percussion, inspection yields pupil size, and skin temperature is assessed through palpation.
7. Which of the following are examples of objective data?
A)
Patient describing his pain
B)
Laboratory results
C)
Breath sounds
D)
Mother describing her childs asthma attack
E)
a patients temperature
Ans:
B, C, E
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Feedback: Objective data from observation (e.g., posture, skin color, behavior), health records (e.g., laboratory results, reports from other healthcare team members), physical assessment (e.g., breath sounds, strength of extremities), and measurement devices (e.g., blood pressure, temperature) are collected to judge the patients behavioral responses to nursing interventions.
8.
Which of the following would be considered examples of subjective data? Select all that apply.
A)
Comments made by the patients family.
B)
Description of a symptom by a patient.
C)
A mother telling a nurse what the baby looked like when he was very ill.
D)
A nursing assessment of the patients vital signs. E) The
exam notes made by the physician.
Ans:
A, B, C Feedback:
physical
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Subjective data are collected from many sources: the patient, family members or significant others, nursing staff, and other healthcare team members.
9. The nurse has identified a priority problem on her unit. Which of the following statements is true regarding addressing a priority problem? A) Setting priorities involves skipping interventions.
B)
Priorities are set at predetermined intervals throughout the shift.
C)
A priority problem requires a nursing intervention before another problem is addressed.
D)
Priority of problems is established and continued according to the nursing plan of care.
E)
The physician is responsible for determining priority of patient needs.
Ans:
C Feedback: A priority problem requires a nursing intervention before another problem is addressed, but setting priorities does not entail skipping any interventions. Setting priorities affects only the order in which nursing interventions are performed.
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10. During the interview component of the health assessment, the nurse conveys to the patient that the information is important by
A)
Nodding frequently during the interview
B)
Sitting at eye level with the patient
C)
Standing next to the patient while interviewing
D)
Limiting questions to those with yes or no answers
Ans:
B Feedback: When the patient responds to a question, convey interest by maintaining eye contact, occasionally nodding or verbally responding to his or her remarks.
11.Before conducting a health assessment on a patient, the nurse should first
A)
Ask a family member to be present for the assessment
B)
Tell the patient the amount of time for the assessment
C)
Inform the patient of the procedure done in the assessment
D)
Introduce herself or himself to the patient
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D Feedback: Introduce yourself to the patient, and explain the nature and purpose of the health assessment.
12. A patient is receiving home care due to an unstable blood pressure. Which of the following nursing interventions is a priority?
A)
Assess the patients diet
B)
Assess the patients activity level
C)
Assess the patients blood pressure
D)
Assess the patients medication regimen
Ans:
C Feedback: While the diet, activity level, and medication regimen should be assessed, the priority intervention for the patient with an unstable blood pressure is to first measure the blood pressure.
13. After assessment of a patient in an ambulatory clinic, the nurse records the data on the computer. The nurse recognizes which of the following as objective data?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Auscultation of the lungs
B)
Complaint of nausea
C)
Sensation of burning in her epigastric area
D)
Belief that demons are in her stomach
Ans:
A
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Feedback: Objective data include techniques of inspection, palpation, percussion, and auscultation. Symptoms, values, perceptions, feelings, beliefs, attitudes, and sensations are sources of subjective data.
14. When assessing the patients pulse, the nurse is using the following assessment technique:
A)
Inspection
B)
Palpation
C)
Percussion
D)
Auscultation
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B Feedback: The pulsations of blood vessels; the outlines of organs such as the thyroid, spleen, or liver; the size, shape and mobility of masses; the temperature of the skin; vibration or movement of blood in a blood vessel; and tenderness or sensitivity of a body part are detected by palpation.
15. During the introductory phase of interviewing for the purpose of obtaining information for the nursing history, the nurse should
A)
Review literature pertinent to the patients attributes
B)
Assess his or her own feelings regarding similar clinical situations
C)
Inform the patient of the maintenance of confidentiality
D)
Implement supportive nursing interventions
Ans:
C Feedback: During the introductory phase, the nurse should inform the patient how the information will be used and that confidentiality will be maintained.
16. During the preparatory phase of interviewing for the purpose of obtaining information for the nursing history, the nurse should
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Clarify the patients health status
B)
Review as much information as possible
C)
Identify actual and potential nursing diagnoses
D)
Develop the nursing plan of care
Ans:
B
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Feedback: The preparatory or preinteraction phase occurs when the nurse meets the patient. The nurse should review as much information as possible about the patient.
17. The purpose of obtaining a nursing history is to
A)
Assist the physician to establish a medical diagnosis
B)
Minimize the time required to establish a nursing diagnosis
C)
Focus on objective physical data specific to the patient
D)
Identify actual and potential nursing diagnoses
Ans:
D
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Feedback: The nursing history focuses on the patients account of the actual or potential health problems and their impact on his or her health status.
18. Which of the following cultural groups may interpret touch by another as an invasion of privacy?
A)
Chinese American
B)
Spanish American
C)
European American
D)
African American
Ans:
A Feedback: Patients of Chinese heritage are very modest about having their bodies touched and may find it difficult to perform self-examinations for their own health promotion.
19. A patient is a poor historian of his past medical history. Whom should the nurse consult about the patients past history?
A)
Physician
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Old chart
C)
Social worker
D)
Family
Ans:
D
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Feedback: Family members or significant others, if available, can provide information for a patient who is confused or incapacitated.
20. The nurse observes the patient as he walks into the room. What information will this provide the nurse?
A)
Information regarding the patients gait
B)
Information regarding the patients personality
C)
Information regarding the patients psychosocial status
D)
Information on the rate of recovery from surgery
Ans:
A Feedback:
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Observation includes looking, watching, examining, scrutinizing, surveying, scanning, and appraising.
21. What would be a nursing priority when assessing a patient who weighs 250 pounds and stands 5 3 tall?
A)
Assess the HDL/LDL levels
B)
Obtain an electrocardiogram daily
C)
Assess blood pressure with a large cuff
D)
Begin patient teaching regarding a low fat diet
Ans:
C Feedback: When assessing an obese patient, a larger blood pressure cuff will likely be needed in order to prevent false high readings. It is not in the nurses scope of practice to determine when and if cholesterol levels and an ECG are ordered. Diet teaching may or may not be warranted depending on the cause of the obesity.
22.When assessing an infant, it is important to involve the
A)
Parents
B)
Siblings
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Physician
D)
Infant
Ans:
A
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Feedback: The assessment of a child often involves parental assistance.
23. A patient describes pain in the right leg as aching at 8/10 on a pain scale. What type of cue is a patients description of pain in the right leg?
A)
Explanatory
B)
Subjective
C)
Objective
D)
Severe
Ans:
B Feedback: Cues may be signs (objective) or symptoms (subjective). Pain is subjectively described by the patient.
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24. When collecting subjective and objective data for a database in a patients home, it is important to
A)
Ask the patient to turn off the television
B)
Ask the social worker to verify the collected data
C)
Collect a 24-hour diet recall
D)
Evaluate the care provided by the physician
Ans:
A Feedback: Distractions such as a television should be minimized.
25. A nurse is asking questions about a patients sexual history. It is important for the nurse to
A)
Evaluate the patients past history of sexual dysfunction
B)
Provide a time that enhances openness
C)
Collect data in a quiet, private environment
D)
Pull the curtains in a semiprivate room
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C Feedback: An assessment is best performed in a quiet, private setting that lends itself to the discussion of sensitive, personal, and confidential information.
26. An unconscious patient is brought to the emergency department. Which of the following assessments should be implemented first? A) The patients airway should be assessed.
B)
The nurse should determine the reason for admission.
C)
The nurse should review the patients medications.
D)
The patients past medical history is assessed.
Ans:
A
Feedback: Emergency assessment takes place in life-threatening situations in which the preservation of life is the top priority. Often, the patients difficulty involves airway, breathing, and circulatory problems.
27. A nurse practitioner has a private practice in conjunction with a physician. She is providing psychiatric care to a woman who has a past history of
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being abused by her husband. During the last visit, she stated that she was planning to leave her husband. On the next visit in 2 weeks, the nurse practitioner will assess her patients commitment to changing her life situation and her ability to feel empowered. What type of assessment is the nurse practitioner implementing?
A)
Complete
B)
Focus
C)
Time-lapsed
D)
Emergency
Ans:
C Feedback: Like the focus assessment, the time-lapsed reassessment determines the status of problems already identified. Because of varying time intervals between reassessments, a complete review of all functional health patterns is carried out.
28. When the nurse inspects a postoperative incision site for infection, which one of the following types of assessments is being performed?
A)
Complete
B)
Focus
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
General
D)
Time-lapse
Ans:
B
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Feedback: In focus assessments, the nurse determines whether the problem still exists and whether the status of the problem has changed. 29. In order for a hospital to meet criteria regarding nursing care established by the Joint Commission on Accreditation of Healthcare Organizations, the nurse must conduct which of the following types of assessment?
A)
Focus
B)
Psychosocial
C)
Physical
D)
Initial
Ans:
D
Feedback:
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The Joint Commission on the Accreditation of Healthcare Organizations has mandated that each patient have a documented nursing admission assessment that follows institutional policies.
30. A patient has been discharged from an acute care facility. The first task a home health nurse must accomplish is
A)
Care of the patients physical pain
B)
Establish the patients database
C)
Evaluate the care provided previously
D)
Receive a report from the nursing staff
Ans:
B Feedback: An initial assessment is performed when the patient enters a healthcare facility, receives care from a home health agency, or is seen for the first time in an outpatient clinic.
31. The phase of the nursing process when the nurse gathers data about the patient to establish a plan of care is the
A)
Assessment
B)
Goals
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Interventions
D)
Evaluation
Ans:
A
125
Feedback: The purpose of the nursing assessment is to gather data about the patient that can be used in diagnosing, identifying outcomes, planning, and implementing care.
32.What must the nurse do to identify actual or potential health problems?
A)
Evaluate care implemented
B)
Meet with significant others
C)
Call the physician
D)
Gather data from sources
Ans:
D Feedback: The first phase of the nursing process, called assessment, is the collection of data for nursing purposes.
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Chapter 07- Nursing Diagnosis
1.
Which of the following assessment findings would support the nursing diagnosis of acute pain? Select all that apply.
A)
Patient had an abdominal hysterectomy 1 day ago.
B)
Patient is crying in pain about 20 minutes before her pain medicine is due.
C)
Patient has a history of osteoarthritis.
D)
Patient had back surgery 2 years ago and expresses the need for ibuprofen on most days.
E)
Patient is a heavy cigarette smoker.
Ans:
A, B Feedback: The patient crying in pain one day after surgery would be expected and lead to a nursing diagnosis of acute pain. Although the patient likely experiences pain from the past back surgery and osteoarthritis, it would not support the diagnosis of acute pain. The smoking history does not support the diagnosis.
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2. What is the process of gathering and clustering data to draw inferences and propose a diagnosis?
A)
Critical thinking
B)
Analytical reasoning
C)
Diagnostic reasoning
D)
Recollection
Ans:
C Feedback: Diagnostic reasoning is the process of gathering and clustering data to draw inferences and propose diagnoses.
3. The purpose of establishing a nursing diagnosis is to
A)
Describe a functional health problem
B)
Collaborate with the physician
C)
Identify medical problems
D)
Meet accreditation criteria
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A Feedback: Establishment of a nursing diagnosis reflects the synthesis of data gathered during a nursing assessment. Gordon suggested a framework for organizing nursing diagnoses based on functional health, thus offering a convenient way to cluster similar diagnoses.
4. Why is coding important when writing a nursing diagnosis?
A)
Enhances the professionalism of the nursing process
B)
Allows for direct reimbursement for nurses
C)
Evaluates the diagnostic statement for accuracy
D)
Provides legal characteristics for licensure
Ans:
B Feedback: Coding of nursing diagnoses in computerized systems allows direct reimbursement of nurses.
5.
Which of the following statements appropriately identifies an at-risk nursing diagnosis for a 78-year-old woman who is confined to bed?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Ineffective airway clearance related to bed rest
B)
Immobility related confinement to bed
C)
Potential for pneumonia related to inactivity
D)
Risk for impaired skin integrity related to bed rest
Ans:
D
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Feedback: An at-risk nursing diagnosis, as defined by NANDA, describes human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community.
6.
A nurse sees the patient grimace and documents that the patient is in pain, without interviewing the patient to obtain further cues. The nurse has
A)
Impaired cluster interpretation
B)
A lack of cues or premature closure
C)
Ineffective database
D)
Inaccurate evaluation
Ans:
B
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Feedback: The lack of adequate cues is called premature closure.
7. The act of analyzing and synthesizing cues requires
A)
critical thinking
B)
certification
C)
advanced practice
D)
attendance at NANDA
Ans:
A Feedback:
During clustering, critical thinking is used to analyze and synthesize cues.
8.
A patient is experiencing shortness of breath, lethargy, and cyanosis. These three cues provides organization or
A)
Categorizing
B)
Diagnosing
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C)
Grouping
D)
Clustering
Ans:
D
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Feedback: Cue clustering brings together cues that if viewed separately would not convey the same meaning.
9. One major requirement of a nursing diagnosis is that it focuses on a problem that is
A)
Established by the physician
B)
Based on the patients pathophysiology
C)
Legally treatable by registered nurses
D)
Included within the diagnosis-related group
Ans:
C Feedback:
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Registered nurses are educated and licensed to make nursing diagnoses. As such, they have a duty to identify and plan care for patients based on them. 10. What information provides the nurse with accuracy when developing a nursing diagnosis?
A)
A set of lab values
B)
Abnormal diagnostic tests
C)
A set of clinical cues
D)
Specific nursing interventions
Ans:
C Feedback: Each piece of patient information is considered a clinical cue; a set of clinical cues forms a cluster that is present if the diagnosis is accurate.
11.What is meant by impaired state of equilibrium?
A)
It describes the patients condition
B)
It is common terminology
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C)
It is a nursing diagnosis
D)
It assists in planning care
Ans:
A
133
Feedback: Descriptors such as impaired state of equilibrium describe changes in condition, state of the patient, or some qualification of the specific nursing diagnosis.
12.What gives additional meaning to a nursing diagnosis?
A)
Composition
B)
Descriptors
C)
Dysfunction
D)
Qualifications
Ans:
B Feedback: Descriptors are words used to give additional meaning to a nursing diagnosis.
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13. What does the nursing diagnosis represent?
A)
Symptoms
B)
Signs
C)
Cues
D)
Maladaptation
Ans:
C Feedback: Each nursing diagnosis represents a pattern of related patient cues.
14. In the development of a nursing diagnosis for a patient who has cachexia and decreased weight, what would be an appropriate nursing diagnosis?
A)
Anorexia nervosa and bulimia
B)
Lack of adequate nutrition related to decreased calories
C)
Weight loss related to abdominal discomfort
D)
Imbalanced nutrition: less than body requirements
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135
D Feedback: Another common mistake is to write Lack of adequate nutrition as the nursing diagnosis. The most appropriate nursing diagnosis would be Imbalanced Nutrition: Less than Body Requirements.
15. Nursing diagnoses that require physician-prescribed and nurse-prescribed actions would be
A)
Independent health problems
B)
Collaborative health problems
C)
Physician-developed problems
D)
Interdisciplinary health problems
Ans:
B Feedback: If problems require physician-prescribed and nurse-prescribed actions, they are collaborative health problems.
16.Which of the following is classified as a nursing diagnosis?
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A)
Esophageal cancer
B)
Cholecystitis
C)
Grieving
D)
Pneumonia
Ans:
C
136
Feedback: Grieving is a nursing diagnosis per the latest NANDA Taxonomy. The other choices are medical diagnoses.
17.The nursing diagnosis taxonomy provides nursing with
A)
Legal information
B)
Common language
C)
Discharge planning
D)
Evaluative care
Ans:
B
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Feedback: Professions require a sound scientific base; the nursing process is nursings scientific base. To achieve this scientific foundation, nursing requires a taxonomy, or classification system, to provide a structure for nursing practice.
18.What is the nurse accountable for according to the state nurse practice act?
A)
Continuing education
B)
Nursing diagnoses
C)
Prescribing medications
D)
Mentoring other nurses
Ans:
B Feedback: State nurse practice acts have included diagnoses as part of the domain of nursing practice for which nurses are held accountable.
19.The purpose of establishing a nursing diagnosis is to
A)
Describe a functional health problem
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B)
Collaborate with physicians
C)
Identify medical problems
D)
Meet accreditation criteria
Ans:
A
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Feedback: The purpose of the nursing diagnosis is to synthesize data gathered during the nursing assessment.
Chapter 08- Outcome Identification and Planning
1.
One of the primary factors that the nurse considers when setting priorities for the patient in the acute care setting after cardiac surgery is the patients
A)
Support system
B)
Medical orders
C)
Past medical history
D)
Condition
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D Feedback: Because a persons condition changes, priorities change. Priorities are based on information collected during reassessment.
2. The clinical nursing plan of care used by the registered nurse differs from the instructional nursing plan of care prepared by nursing students in that the clinical nursing care plan usually
A)
does not contain documented scientific rationales
B)
Does not contain abbreviated nursing diagnoses
C)
Separates goal statements from the plan of care
D)
Separates outcome criteria from the plan of care
Ans:
A Feedback: In clinical settings, nurses may use rationales to illustrate research findings or support controversial approaches to problems.
3.
When a nurse assists a postoperative patient to the chair, which type of nursing intervention does this represent?
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A)
Maintenance
B)
Surveillance
C)
Psychomotor
D)
Psychosocial
Ans:
C
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Feedback: Psychomotor interventions include activities such as positioning, inserting, and applying.
4.
A nurse is demonstrating foley catheter care to a patient. Which type of nursing intervention does this best represent?
A)
Surveillance
B)
Maintenance
C)
Supervisory
D)
Educational
Ans:
D
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Feedback: Demonstrating, teaching, and observing a return demonstration are classified as educational interventions.
5.
A treatment based on a nurses clinical judgment and knowledge to enhance patient outcomes is a nursing:
A)
Diagnosis
B)
Evaluation
C)
Intervention
D)
Goal
Ans:
C Feedback: A nursing intervention is any treatment based upon clinical judgment and knowledge that a nurse performs to enhance patient/patient outcomes.
6. The most basic level of nursing interventions is
A)
Physiologic
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B)
Behavioral
C)
Safety
D)
Family
Ans:
A
142
Feedback: The most basic domain of the seven domains of Nursing Intervention Classifications is physiologic: basic.
7.What are specific measurable and realistic statements of goal attainment?
A)
Nursing diagnoses
B)
Nursing interventions
C)
Evaluation
D)
Outcome criteria
Ans:
D Feedback:
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Outcome criteria are specific, measurable, realistic statements of goal attainment.
8.
When establishing patient outcomes with the patient, what is the qualifier in the outcome?
A)
The short-term goal
B)
The long-term goal
C)
The problem statement
D)
The outcome parameter
Ans:
D Feedback: The qualifier is a description of the parameter for achieving the outcome.
9. What is the purpose of the patient outcome?
A)
To address the problem in the nursing diagnosis
B)
To evaluate the plan of care developed
C)
To provide a basis for the scientific rationale
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D)
To coordinate the nursing intervention
Ans:
A
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Feedback: A patient outcome addresses the problem stated in the nursing diagnosis. 10. For the postoperative patient, which of the following nursing diagnoses will require outcome identification that could contribute to a maladaptive postoperative recovery?
A)
Pain
B)
Ineffective breathing patterns
C)
Alteration in bowel elimination
D)
Anxiety
Ans:
B Feedback: In this scenario, ineffective breathing patterns will promote the development of pneumonia in the postoperative phase.
11.Which of the following nursing diagnosis is high priority?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Spiritual distress
B)
Stress incontinence
C)
Anxiety
D)
Ineffective breathing patterns
Ans:
D
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Feedback: High-priority nursing diagnoses are those that are potentially lifethreatening and require immediate action.
12. A patient is scheduled for surgery for an abdominal hysterectomy. During the preoperative assessment, the patient states, I am very nervous and scared to have surgery. What patient outcome is the priority?
A)
Evaluate the need for antibiotics
B)
Resolve the patients anxiety
C)
Provide preoperative education
D)
Prepare the patient for surgery
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146
B Feedback: A priority is something that takes precedence in position, deemed the most important among several items. The patients preparation for surgery is important, but to have a successful outcome, the nurse must address the psychosocial issues related to anxiety.
13.The Nursing-Sensitive Outcomes Classification system organizes outcomes by
A)
Nursing diagnosis
B)
Medical diagnosis
C)
Critical pathway
D)
Measurement activities
Ans:
D
Feedback: The outcomes are organized according to categories, classes, labels, outcome indicators, and measurement activities for outcomes.
14. A computerized information system developed to classify patient outcomes is the
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
North American Nursing Diagnoses List
B)
Nursing-Sensitive Outcomes Classification
C)
McCaffery Pain Management Scale
D)
Outcome Criteria Listing Source
Ans:
B
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Feedback: The Nursing-Sensitive Outcomes Classification system is organized according to categories, classes, labels, outcome indicators, and measurement activities for outcomes.
15. A nurse identifies outcomes of care for the hospitalized, postoperative patient primarily to
A)
Document nursing practice
B)
Evaluate nursing interventions
C)
Focus on health promotion
D)
Provide individualized care
Ans:
D
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Feedback: Outcome identification also promotes participation, provides care plans that are realistic and measurable, and allows for involvement of support people. 16. A patient is unconscious and unable to provide input into outcome identification. With which group of individuals should the nurse consult for the formulation of goals and measurable outcomes?
A)
Family
B)
Physical therapists
C)
Occupational therapists
D)
Pharmacists
Ans:
A Feedback: The family is aware of the patients past experiences and accomplishments. Thus, the nurse should allow for the involvement of support people, particularly family.
17. When a nurse notices the patient is in pain and needs to learn to walk on crutches, which outcome identification is the priority? A)
Crutch walking
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Safe walking
C)
Capillary refill
D)
Pain management
Ans:
D
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Feedback: In this scenario, pain management is the priority. In outcome identification, activities performed include establishing priorities.
18. A patient is rehabilitating from a fractured right leg. She is learning to walk on crutches. Together, the patient and the nurse have established a plan for the patient to walk with a three-point gait for 20 feet by the next day. In outcome identification, what is this termed?
A)
Establishing a patient goal
B)
Evaluation of crutch training
C)
Collaboration with physical therapy
D)
Implementation of crutch walking
Ans:
A
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Feedback: The activity in outcome identification is the establishment of patient goals and outcome criteria.
19.Planning care in the outcome identification phase allows
A)
Implementation of nursing interventions
B)
Promotion of patient participation in care
C)
The diagnostic process to progress
D)
The identification of proper diagnoses
Ans:
B Feedback: Outcome identification serves the purpose of promoting patient participation.
Chapter 09- Implementation and Evaluation
1. A new mother is having difficulty breastfeeding her newborn infant. A goal was established stating the baby would be nursing every two to three hours by age 1 week. The mother presents to the follow-up center
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at 1 week and reports the she discontinued breastfeeding. The nurse evaluates the original goal as:
A)
Met
B)
Partially met
C)
Completely unmet
D)
Inappropriately chosen for this patient
Ans:
C Feedback: After collecting data, nurses form a comprehensive picture of the patients behavioral responses. The next activity is to make a judgment about goal attainment by comparing the patients actual behavioral responses to the predicted responses or predetermined outcome criteria developed in the planning phase.
2. A patient with a recently fractured left femur has been reluctant to comply with his physical therapy for fear of the pain associated with movement. A goal for this patient is to attend therapy treatments three times each day. The nurse is evaluating the goal for this patient. The patient states, I dont like therapy, it hurts, but I have been going twice a day. The patient chart has an entry from the last shift nurse stating the patient went to therapy two times with encouragement. The nurse evaluates the goal as:
A)
Goal met
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Goal partially met
C)
Goal completely unmet
D)
New diagnoses have developed
E)
Goal revision needed
Ans:
B
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Feedback: After collecting data, nurses form a comprehensive picture of the patients behavioral responses. The next activity is to make a judgment about goal attainment by comparing the patients actual behavioral responses to the predicted responses or predetermined outcome criteria developed in the planning phase.
3.
The nurse is assessing the patients behavioral response to a nursing intervention. This type of evaluation is known as:
A)
Structural evaluation
B)
Behavior modification
C)
Outcome evaluation
D)
Process evaluation
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
E)
Goal evaluation
Ans:
C
153
Feedback: Outcome evaluation, which focuses on the patient and the patients function, is currently receiving a great deal of emphasis. Outcome evaluation determines the extent to which the patients behavioral response to nursing intervention reflects the desired patient goal and outcome criteria.
4.
The nursing supervisor is presenting the staff nurse with her yearly performance evaluation. This type of evaluation would be called:
A)
outcome evaluation
B)
technical evaluation
C)
structural evaluation
D)
process evaluation
E)
goal evaluation
Ans:
D Feedback:
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Process evaluation focuses on the nurses performance and whether the nursing care provided was appropriate and competent. The phases of the nursing process are used as the framework for the evaluation of nursing care.
5.
The nursing supervisor is evaluating how many patients each of the department nurses has been assigned for the shift. This type of evaluation would be considered:
A)
process
B)
outcome
C)
goal
D)
subjective
E)
structure
Ans:
E Feedback: Availability of equipment, layout of physical facilities, nurse-patient ratios, administrative support, and maintenance of nursing staff competence are some areas of concern for structure evaluation.
6. Which of the following describe the purpose of evaluation? Select all that apply.
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A)
To examine the patients behavioral responses to nursing interventions
B)
To appraise the extent to which patient goals were attained or problems resolved
C)
To appraise involvement and collaboration of the patient, family members, nurses, and healthcare team members in healthcare decisions
D)
To ensure the plan of care was followed as it was originally prepared
E)
To collect subjective and objective data to make judgments about nursing care delivered
Ans:
A, B, C, E Feedback: Nurses always consider evaluation in light of how the patient responded or reacted to the planned course of action. Figure 14-4 illustrates the relationship of the activities of the evaluation phase to the other phases of the nursing process. There are several purposes for carrying out evaluation: To examine the patients behavioral responses to nursing interventions; to compare the patients behavioral responses with predetermined outcome criteria; to appraise the extent to which patient goals were attained or problems resolved; to appraise involvement and collaboration of the patient, family members, nurses, and healthcare team members in healthcare decisions; to provide a basis for the revision of the plan of care evaluation; to collect subjective and objective data to make judgments about nursing care delivered; and to monitor the quality of nursing care and its effect on the patients health status (Alfaro-LeFevre, 2010; Carpenito-Moyet, 2009). Specific activities during this phase include the following: reviewing patient goals and outcome criteria, collecting data, measuring goal attainment, recording judgments or measurements of goal attainment, and revising or modifying the patients plan of care.
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7.After the nursing plan of care has been developed, the nurse knows:
A)
each encounter with the patient is an opportunity to reassess and revise the plan of care if necessary.
B)
the plan will be followed by other healthcare providers and filed with the patients chart upon discharge.
C)
the responsibility for the assessment of the patient has ended.
D)
care plans are rigid and do not change.
E)
the plan of care can only be changed by the nurse who developed it.
Ans:
A Feedback: During each encounter with patients, nurses assess function, ensuring prompt attention to emerging problems. Because a patients condition can change quickly and dramatically, astute nurses remain alert to subtle cues and inferences. As they initiate the plan of care, nurses must ensure that the planned interventions are still relevant.
8. Which of the following are the two priority nursing diagnoses?
A)
Risk for infection
B)
Anxiety
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Acute Pain
D)
Ineffective Airway Clearance
E)
Feeding Self-Care Deficit
Ans:
C, D
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Feedback: While all are important diagnoses, respiratory function and pain are priority.
9.
The primary purpose for evaluating data about a patients care according to a functional health approach is to
A)
Meet accreditation standards
B)
Determine implementation of medical orders
C)
Evaluate the need for healthcare consultations
D)
Revise or modify the nursing care plan
Ans:
D Feedback:
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Evaluation using the functional health approach provides a framework for organizing and evaluating data. 10. When a nursing supervisor evaluates the staff nurses performance with a group of patients to whom the staff nurse has provided nursing care, the supervisor is performing which type of evaluation?
A)
Outcome evaluation
B)
Summary evaluation
C)
Structure evaluation
D)
Process evaluation
Ans:
D Feedback: Process evaluation focuses on the nurses performance and whether the nursing care provided was appropriate and competent.
11. When a charge nurse evaluates the need for additional staff nurses and additional monitoring equipment to meet the patients needs, the charge nurse is performing an evaluation termed
A)
Process evaluation
B)
Structure evaluation
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C)
Outcome evaluation
D)
Summary evaluation
Ans:
B
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Feedback: Structure evaluation focuses on the attributes of the setting or surroundings where healthcare is provided.
12. What guides professional practice?
A)
ANA Standards of Nursing Practice
B)
National Institutes of Health publications
C)
Nursing Intervention Classification
D)
Risk Appraisal Index
Ans:
A Feedback:
Standards of care guide professional practice and serve as the framework for the evaluation practice.
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13. When the nurse prepares to discharge a patient, to evaluate the effectiveness of the nursing care, the nurse should determine whether the
A)
Physician orders have been completed
B)
Patients goals have been achieved
C)
Critical pathways are completed
D)
Documentation is thorough
Ans:
B Feedback: Evaluation is defined as the judgment of the effectiveness of nursing care to meet patient goals based on the patients behavioral responses. This phase involves a thorough, systematic review of the effectiveness of nursing interventions and a determination of patient goal achievement.
14. When a nurse assesses a patient and notifies the physician that the patient is demonstrating abnormal breath sounds, the nurse is performing a nursing intervention termed
A)
Supportive
B)
Surveillance
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Collaborative
D)
Maintenance
Ans:
B
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Feedback: Surveillance nursing interventions include detecting changes from baseline data and recognizing abnormal responses.
15. A nurse encourages a mother who has lost a child to attend the support group of parents with deceased children. This intervention is termed
A)
Surveillance
B)
Psychosocial
C)
Coordinating
D)
Technical
Ans:
B Feedback:
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Providing individual and group therapy is the nurses responsibility in various settings. Psychosocial nursing interventions focus on resolving emotional, psychological, or social problems.
16. A patient has terminal cancer. The medical intern has ordered an upper GI x-ray. The patient states he does not want the x-ray. The nurse speaks to the intern about the patients refusal to have the x-ray. This is what type of intervention?
A)
Surveillance
B)
Supportive
C)
Coordinating
D)
Technical
Ans:
C Feedback: Coordination involves acting as a patient advocate, making referrals for follow-up care, collaborating with other healthcare team members, and ensuring that the patients schedule is therapeutic.
17. Educating patients on their diabetic regimen of administering their insulin is the implementation of which skill?
A)
Intrinsic
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Technical
C)
Interpersonal
D)
Visual
Ans:
B
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Feedback: The administration of insulin is a technical skill. Technical competence means being able to use equipment, machines, and supplies in a particular specialty.
18.The primary purpose of nursing implementation is to
A)
Improve the patients postoperative status
B)
Identify a need for collaborative consults
C)
Help the patient achieve optimal levels of health
D)
Implement the critical pathway for the patient
Ans:
C Feedback:
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The purpose of the nursing implementation phase is to help the patient achieve an optimal level of health.
Chapter 10- Healthcare Team Communication: Documenting and Reporting
1. Which of the following statements by the student nurse demonstrates understanding of the appropriate way to document an error in her charting? A) If I make an error, I can draw a red circle around it.
B)
If I make an error, I have to rewrite the entire entry.
C)
If I make an error, I draw a single line through it and put my initials by it.
D)
If I make an error, I place an X through it.
E)
If I make an error, I use white-out on it.
Ans:
C Feedback: When an error occurs, draw a single line through the error and place your initials above it.
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2. The nurse is caring for an elderly resident in a long-term care facility. The patient is crying and states, I dont want to live anymore. I am a burden on everyone. I dont feel like doing anything at all. I dont even want to get up today. Which of the following should the nurse record in his charting? Select all that apply.
A)
Patient is crying.
B)
Patient states, I dont want to live anymore. I am a burden of everyone. I dont feel like doing anything at all. I dont even want to get up today.
C)
Patient seems depressed.
D)
Patient is suicidal.
E)
Patient is in a bad mood.
Ans:
A, B Feedback: When documenting observations of patient behavior, the nurse must maintain objectivity by describing the actual behaviors, rather than attempting to interpret the behaviors. For example, the nurse should not describe the patient as depressed or angry.
3.
The patient states, I hate this place. I want to go home. No one listens to me and my doctor has not been in to see me today. His arms are folded across his chest. His brow is furrowed and he refuses to allow his morning vital sign measurements. Which of the following should be included in the nurses charting? Select all that apply.
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A)
Seems angry today
B)
Unhappy with his care
C)
Arms are folded across his chest and brow is furrowed
D)
States, I hate this place. I want to go home. No one listens to me and my doctor has not been in to see me today.
E)
Refuses to allow morning vital sign measurements
Ans:
C, D, E Feedback: When documenting observations of patient behavior, the nurse must maintain objectivity by describing the actual behaviors, rather than attempting to interpret the behaviors. In this case, the nurse should chart that a patient is withdrawn and answers questions with one- or two-word answers. The nurse should not describe the patient as depressed or angry.
4. Which of the following describe best practices for charting? Select all that apply.
A)
Use long narratives to be sure your documentation is understood
B)
Always use complete sentences
C)
Use only approved abbreviations
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D)
Always use the patients name and words referring to the patient in each entry
E)
Use partial sentences and phrases
Ans:
C, E
Feedback: Good charting is concise and brief. In narratives, use partial sentences and phrases; drop the patients name and terms referring to the patient. Use abbreviations but only those that are commonly accepted and approved by your facility.
5.
Which of the following should the nurse include in his/her charting? Select all that apply.
A)
The nursing assistant reports the patients breath smelled of alcohol.
B)
I feel something is going on she is not telling me.
C)
The patient was overheard telling his family about more bleeding than he has reported to his physician.
D)
The incision is oozing a small amount of red blood.
E)
The patients pupils are dilated.
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Ans:
168
A, C, D, E Feedback: Entries must be accurate. Nurses must chart only observations that they have seen, heard, smelled, or felt. An observation made by another health professional must be clearly identified as such.
6.
The federally initiated goal of computer-based personal records would likely produce which of the following benefits? Select all that apply.
A)
Access to records outside of the patients home facility
B)
Increased accuracy of treatment for the patient outside their home facility
C)
Easier access to data for research
D)
Increased incidence of identity theft
E)
Greater accuracy and improved patient care
Ans:
A, B, C, E Feedback: A benefit of computer-based records would not be to increase the incidence of identity theft.
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169
The patient record is utilized for many purposes. Which of following might be uses for the patient record?
A)
Education of student nurses
B)
Reimbursement for services
C)
Research
D)
Giving information over the phone when unidentified callers call the hospital unit
E)
Education for medical students
Ans:
A, B, C, E Feedback: The patient medical record may be used for education, reimbursement, and research. The record is never used to give information to callers without written authorization from the patient.
8.
The nurse is caring for a patient with uncontrolled hypertension. His blood pressure has remained controlled for the nurses shift. At two-hour intervals the blood pressure was checked by the nurse and found to be essentially the same. The nurse, although taking the blood pressure as directed, forgets to write down the number. During the next shift, the patient has a stroke. Years later, the patient files a lawsuit blaming the hospital for his stroke. The nurse who was caring for the patient when his blood pressure was stable cannot recall the exact blood pressure she obtained, but remembers it was normal. Will this recollection suffice in court and why?
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A)
Yes, the nurse remembers the pressure as normal during her shift and can swear to it during the deposition.
B)
No, but it will relieve the nurse of any wrongdoing.
C)
No, if the blood pressure measurement was not documented, it did not happen.
D)
Yes, the nurse was not on duty when the stroke occurred.
Ans:
C Feedback: Legal cases have been argued with the principle that If it was not documented, it was not done. For this reason it is important to document normal as well as abnormal findings. Because nurses and other healthcare team members cannot remember specific assessments or interventions involving a patient years after the fact, accurate and complete documentation at the time of care is essential.
9. Which of the following flow sheets provides the reader with information on an ongoing record of fluid loss?
A)
Vital sign sheet
B)
Intake and output sheet
C)
Critical care flow sheet
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Health assessment flow sheet
Ans:
B
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Feedback: The intake and output sheet is used to maintain an ongoing record of all fluid intake and output. 10. Charting in which the nurse writes a progress note that relates to one health problem is a
A)
PIE note
B)
Flow sheet
C)
Narrative note
D)
SOAP note
Ans:
D Feedback: SOAP note is a progress note that relates to only one health problem.
11. A nurse in a nursing home is writing a note on a resident that addresses the care the resident has received during the day and the residents response to care. What type of note does this represent?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
PIE note
B)
Flow sheet
C)
Narrative note
D)
SOAP note
Ans:
C
172
Feedback: A narrative note in a skilled nursing facility might include the type of morning care, nutritional intake, patient activity pattern, and comfort measures provided, along with the patients response.
12. A concise document that provides most of the patients nursing and medical information is a(n) A)
Nursing care plan
B)
Kardex
C)
Past chart
D)
Office record
Ans:
B
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Feedback: The Kardex is a way to ensure continuity of care from one shift to another and from one day to the next.
13. During a patients hospitalization, he has developed shortness of breath, with edema. What action should the nurse take?
A)
Review the nursing care plan
B)
Implement changes in the current interventions
C)
Involve the family in changes
D)
Revise the plan of care
Ans:
D Feedback: A plan of care should be generated at admission and revised to reflect changes in the patients condition.
14. A patients record can be more accurate if the nurse
A)
Charts at least every 2 hours
B)
Uses point-of-care documentation
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Summarizes patient care at the end of the shift
D)
Delegates charting to the nurse assistant
Ans:
B Feedback: Point-of-care documentation takes place as care occurs.
15. A hospital is switching to computerized charting. The nurse recognizes that one advantage to an electronic patient chart is that A) No other charting method is necessary.
B)
Access is open to anyone.
C)
Retrieval of information is more efficient.
D)
It is less costly to maintain.
Ans:
C Feedback:
174
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175
With the advance of computer technology, many institutions are transforming the patient record to electronic format. Multiple people may access portions of the record from different sites at the same time.
16.What activity in charting will assist most in the avoidance of errors?
A)
Objectivity
B)
Organization
C)
Legibility
D)
Timeliness
Ans:
D Feedback: Documentation in a timely manner can help avoid errors.
17. The nurse is interviewing a newly admitted patient. Quoting statements made by the patient will help in maintaining
A)
Subjectivity
B)
Objectivity
C)
Organization
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Reimbursement
Ans:
A
176
Feedback: Directly quoting statements made by the patient can help in maintaining subjectivity.
18. A new graduate is working at her first job. Which of the following statements is most important for the new nurse to follow?
A)
Use abbreviations approved by the facility.
B)
Document lengthy entries using complete sentences.
C)
Use PIE charting even if it is not the institutions charting method.
D)
Only document changes in the patients status.
Ans:
A Feedback: Use abbreviations but only those that are commonly accepted and approved by the facility.
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19. When the nurse recognizes that he has documented one patients assessment data on the wrong patients medical record, the nurse should
A)
Draw a single line through the error, and initial it
B)
Use a felt tip pen to cover the error
C)
Use white out to cover the error
D)
Replace the record, rewriting the error
Ans:
A Feedback: When an error occurs, draw a single line through the error and place your initial above it.
20. Which of the following principles should guide the nurses documentation of entries on the patients medical record?
A)
Nurses may not document for another health professional.
B)
Documentation does not include photographs.
C)
Precise measurements are preferred over approximations.
D)
Nurses should not refer to the names of physicians.
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Ans:
178
C Feedback:
Precise measurements and times must be used whenever possible.
21.How can the nurse researcher obtain information from a patient record?
A)
Audit discharge records
B)
Interview nursing staff
C)
Examine institutional procedures
D)
Study patient records
Ans:
D Feedback: Nursing and healthcare research is often carried out by studying patient records.
22. Besides being an instrument of continuous patient care, the patients medical record also serves as a(an)
A)
Assessment tool
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Legal document
C)
Kardex
D)
Incident report
Ans:
B
179
Feedback: The patient record serves as a legal document of the patients health status and care received.
23. What organization audits charts regularly?
A)
Joint Commission on Accreditation of Healthcare Organizations
B)
National League for Nursing
C)
American Nurses Association
D)
Sigma Theta Tau International
Ans:
A Feedback:
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The Joint Commission on Accreditation of Healthcare Organizations audits patient records regularly and encourages institutions to set up ongoing quality assurance programs.
24. A nurse is working as a case manager, and in this role she audits charts. Audits of patient records are performed primarily for quality assurance and
A)
Reimbursement
B)
Staff development
C)
Research
D)
Change of mechanisms
Ans:
A Feedback: Audits of patient records serve a dual purpose: quality assurance and reimbursement.
25. What dual purpose does an audit serve?
A)
Communication and evaluation
B)
Knowledge and quality
C)
Education and confidentiality
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Quality assurance and reimbursement
Ans:
D
181
Feedback: Audits of patient records serve a dual purpose: quality assurance and reimbursement.
26. How can a nurse obtain additional information about a
patient? A) Read the patients history and assessment.
B)
Call the patients family.
C)
Ask the patients sister about the family history.
D)
Review nursing literature.
Ans:
A
Feedback: Nurses and other team members gather assessment data from the patient record. By reading about the patients history and initial assessment and comparing these data with additional subjective and objective information that has been obtained, current health status and progress toward goals can be determined.
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27.The highest standard for maintaining a patients condition is
A)
Reporting
B)
Documentation
C)
Confidentiality
D)
Management
Ans:
C Feedback: Documentation and reporting of the patients condition require adherence to the highest standard of confidentiality.
28.The sharing of information about a patient is
A)
Communication
B)
Documentation
C)
Reporting
D)
Verification
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Ans:
183
C Feedback: Reporting takes place when two or more people share information about patient care, either face to face, or by audiotape, voice mail, or telephone.
29. What ensures continuity of care?
A)
Reassessment
B)
Critical thinking
C)
Communication
D)
Integration
Ans:
C Feedback: Communication ensures continuity of care and provides essential data for revision or continuation of care.
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Chapter 11- Health, Wellness, and Integrative Healthcare
1.
A woman over the age of 40 years has an annual mammogram. What level of prevention does this represent?
A)
Primary prevention
B)
Secondary prevention
C)
Tertiary prevention
D)
Medical prevention
Ans:
B Feedback: Secondary prevention includes screening for those at risk to develop illness or those who could be diagnosed early in the process for prompt treatment.
2.
A)
A patient inquires about the use of herbal therapy. Which statement by the nurse is most accurate?
All herbs are equal in purity, so purchase the cheapest brand.
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185
B)
Herbs can have side effects and can interact with prescription medications.
C)
Be sure to pay attention to the packagings therapeutic and prevention information.
D)
It is best if you select a licensed herbalist as a practitioner.
Ans:
B Feedback: It is important for patients to understand that herbs can have side effects and can interact with prescription medications. Standardization of the herbs constituents is useful, but also limited because not all the compounds or the required levels are known, so the purity and dosage contents may not be equal between herbs. Herbal products cannot make therapeutic and prevention claims. There is no current licensing body for herbalists.
3. The nurse is caring for a terminally ill patient and asks the patients permission to incorporate therapeutic touch into the care provided. The nurses goal for this patient is to:
A)
Prolong life
B)
Control the dying process
C)
Bring strength
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Produce relaxation
Ans:
D
186
Feedback: While therapeutic touch does not cure the underlying disease, it does seem to decrease pain, provide relaxation, and help many dying people experience the final transformation with peace and acceptance.
4. The practitioner of therapeutic touch is listening with his/her
A)
Ears
B)
Mind
C)
Soul
D)
Hands
Ans:
D Feedback: In the second phase of therapeutic touch, the practitioner is listening with his or her hands.
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5.
187
When practicing therapeutic touch, the practitioner begins by performing which intervention?
A)
Calling to rebalance the soul
B)
Bringing the consciousness
C)
Embracing the patient for energy
D)
Moving her hands 2 to 6 inches away from the patients skin surface
Ans:
B
practitioners
attention
to
an
inward
peaceful
Feedback: The first and most significant part of the therapeutic touch is termed centering. The practitioner brings his or her attention inward to a quiet, still, peaceful state of consciousness.
6. What nurse theorist developed therapeutic touch?
A)
Dorothea Orem
B)
Martha Rogers
C)
Jean Watson
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Dolores Krieger
Ans:
D
188
Feedback: Therapeutic touch, a healing method used by thousands of nurses and other professionals, was developed more than 30 years ago by Dora Kunz, a healer, and Dolores Krieger, an emeritus member of New York Universitys nursing faculty.
7.
A patient is asking for the nurse to explain acupuncture. What would you tell the patient?
A)
Acupuncture is only done in Eastern countries
B)
Acupuncture is a dangerous option for the treatment of disease
C)
Acupuncture is beneficial to creating a mood of distraction
D)
Acupuncture is used to correct disharmony
Ans:
D Feedback: Acupuncture can be used to correct disharmony or prevent disharmony from developing.
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8.
189
A patient is in the last stage of labor. During each contraction, she is focusing on her husbands voice and a picture brought from home. She is demonstrating which type of meditation?
A)
Concentrative
B)
Receptive
C)
Reflective
D)
Expressive
Ans:
A Feedback: Concentrative meditation is probably the most familiar. The person focuses on an internal or external object. Receptive meditation refers to being mindful and aware of the present moment. Reflective meditation involves gaining insight into ones own thoughts and experiences. Expressive meditation involves actual movement, such as dance.
9.
A patient is very anxious before an invasive procedure. What CAM therapy would be most helpful to assist in decreasing anxiety?
A)
Meditation
B)
Chinese medicine
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Acupuncture
D)
Herbs
Ans:
A
190
Feedback:
Meditation is a way to tune and train the mind, leading to greater efficiency in everyday life. This will be most helpful in assisting this patient to decrease the stress level. Chinese medicine has a very broad base and includes meditation, acupuncture, and herbs.
10. Which of the following questions or statements to a patient convey
acceptance? A) You know supplements can be harmful. Do you take any
supplements?
B)
Have you ever discussed taking vitamins and supplements with your doctor?
C)
Will you please share with me the prescription medicines and vitamins you take?
D)
What helpful herbal supplements are you taking?
Ans:
C
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191
Feedback: Starting with the initial contact with a patient, the nurse includes a basic assessment of his or her use of CAM in any intake interview. The nurse asks about vitamins and supplements as well as any healing practices.
11. When obtaining information for a database, which of the following represents a nurse commitment and interest in reflected integrative medicine (CAM)?
A)
What types of foods do you consume in 24 hours?
B)
Do you take any vitamins or minerals, and if so, what?
C)
What prescription medications do you take daily?
D)
What diseases do you suffer from and what are your allergies?
Ans:
B Feedback: Starting with the initial contact with a patient, the nurse includes a basic assessment of his or her use of CAM in an intake interview. The nurse asks about vitamins and supplements as well as any healing practices.
12. Which of the following forms of medicine combines health promotion, establishment of a partnership with the patient and practitioner, and captures an evolving model of healthcare?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Integrative healthcare and medicine
B)
Homeopathic healthcare and medicine
C)
Holistic healthcare and medicine
D)
Palliative healthcare and medicine
Ans:
A
192
Feedback: Integrative medicine is the establishment of a partnership between the patient and practitioner and focuses on promoting health and preventing illnesses, as well as treating disease. Integrative healthcare more accurately reflects the crossdisciplinary reality and progressive acceptance of a broader aspect of care.
13. A patient suffers from chronic pain. The nurse suggests the patient have monthly massages. This is an example of
A)
Adjuvant medicine
B)
Palliative medicine
C)
Alternative medicine
D)
Allopathic medicine
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Ans:
193
C Feedback: The use of conventional therapy as seen with CAM includes the use of herbal medicine, massage, megavitamins, self-help groups, folk remedies, energy healing, and homeopathy.
14. What term is defined as those practices that do not form part of the dominant system for managing health and disease?
A)
Alternative medicine
B)
Complementary health
C)
Homeopathic medicine
D)
Holistic healthcare
Ans:
A
Feedback: Complementary or alternative medicine (CAM) was introduced in 1996 and generally refers to those practices that do not form part of the dominant system for managing health and disease. Holistic practitioners try to combine the proven successes of Western modern medicine and a wide range of therapies considered complementary or alternative medicine.
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15. The mind and body are connected in the provision of care. This statement describes
A)
Homeopathic care
B)
Holistic care
C)
Altruistic care
D)
Allopathic care
Ans:
B Feedback: Holistic interventions focus on the interrelated needs of body, mind, emotions, and spirit.
16. What type of practice was challenged by patients who want to be treated as whole persons, not just as a disease?
A)
Homeopathic care
B)
Holistic care
C)
Altruistic medicine
D)
Allopathic medicine
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Ans:
195
D Feedback: Allopathic medicine was challenged by patients who wanted to be treated as whole persons, not just as a disease.
17.To be an effective change agent for wellness, the nurse must
A)
Skip breakfast to reduce calories
B)
Drink caffeinated beverages
C)
Lead a sedentary lifestyle
D)
Consume a diet low in fat
Ans:
D Feedback: Nurses focused on wellness advocate the use of lifestyle modification skills that alleviate stress and promote a state less susceptible to disease.
18. An 80-year-old woman has had a cerebrovascular accident. She has flaccidity of her right side with aphasia. For this patient, which of the following activities constitutes tertiary prevention?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Assessment of her blood pressure
B)
Daily bleeding and clotting times
C)
Gait training and speech therapy
D)
Education on the symptoms of a CVA
Ans:
C
196
Feedback:
Tertiary prevention occurs when a person already has been diagnosed with a longterm disease or disability.
19. What level of prevention is noted when the nurse educates a group of women who have school-age children on self breast examinations?
A)
Educational prevention
B)
Primary prevention
C)
Secondary prevention
D)
Tertiary prevention
Ans:
B
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197
Feedback: Primary prevention focuses on the health of a person with the goal of preventing disease or illness. Self -breast examination education is primary prevention.
20. A nurse assists the patient in the development of a healthy lifestyle. The adoption of these lifestyle changes in the patients life is considered
A)
Adaptation
B)
Self-care
C)
Self-esteem
D)
Health management
Ans:
B Feedback: Self-responsibility is paramount in Dorothea Orems nursing theory, which focuses on self-care so that the person can maintain life, health, and wellbeing.
21. The bodys attempt to restore balance through self-regulatory mechanisms is termed
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Homeostasis
B)
Equilibration
C)
Self conception
D)
Biofeedback
Ans:
A
198
Feedback: Homeostasis is the organisms attempt to restore balance. Equilibration is a distractor for this question. Self-conception is related to the individuals feelings and attitudes about himself or herself. Biofeedback is a relaxation technique.
22. A patient enjoys high-calorie carbohydrates but understands that they raise her blood sugar sharply and ultimately cause the feeling of butterflies in her stomach as her blood sugar decreases. This is considered
A)
Health promotion
B)
Illness prevention
C)
Holism
D)
Self-awareness
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Ans:
199
D Feedback: Self-awareness means knowing and caring for oneself, recognizing ones strengths and limitations.
23. The concept of holism is based on the belief that
A)
Individuals can be seen in an atomistic fashion
B)
Health is achieved through medical care
C)
Health is achieved by treatment from physicians
D)
Individuals cannot be seen apart from the environment
Ans:
D Feedback: Holism is based on the belief that people cannot be fully understood if examined solely in pieces apart from their environment.
24. Traditional medicines view of health is typically explained by the health model termed
A)
High-level wellness
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Health belief model
C)
Wellness-illness continuum
D)
Holistic health model
Ans:
C
200
Feedback: Traditional medicine identifies a neutral point at which an individual is free of signs and symptoms of disease.
25. What is defined as the recognition of health as an ongoing process toward a persons highest potential of functioning?
A)
Illness
B)
Agent-host-environment
C)
Health belief model
D)
High-level wellness
Ans:
D Feedback:
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201
High-level wellness is defined as recognizing health as an ongoing process toward a persons highest potential of functioning.
26. A patient states, I must be in poor health because I am a senior citizen. Thats what my neighbor says and she is older than I am. This statement is based on which of the following factors?
A)
Age
B)
Gender
C)
Peer influence
D)
Illness factors
Ans:
C Feedback: Peer influence, personality characteristics, ethnicity, and socioeconomic factors may affect a persons response to illness.
27. When admitting an adolescent to the hospital, the nurse anticipates that the patient will respond to questions about his health beliefs based on his
A)
Age and developmental state
B)
Gender and medical history
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Peer influence and education
D)
Health promotion activities
Ans:
A
202
Feedback: Age and developmental stage are important considerations in the health belief model.
28. What is a dynamic balance among the physical, psychological, social, and spiritual aspects of a persons life?
A)
Health
B)
Wellness
C)
Holism
D)
Promotion
Ans:
B Feedback: Wellness is a dynamic balance among the physical, psychological, social, and spiritual aspects of a persons life.
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203
29. What is a dynamic state in which a person constantly adapts to changes in the internal and external environment?
A)
Health
B)
Wellness
C)
Holism
D)
Infirmity
Ans:
A Feedback: Health is a dynamic state in which a person constantly adapts to changes in the internal and external environment.
30. What is a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity?
A)
Health
B)
Wellness
C)
Holism
D)
Host
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Ans:
204
A Feedback: The World Health Organization defines health as a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity.
31. A nurse is educating women on the need for calcium to prevent bone loss. What level of prevention does this represent?
A)
Primary prevention
B)
Secondary prevention
C)
Tertiary prevention
D)
Residual prevention
Ans:
A Feedback:
Primary prevention or primary healthcare involves the education of patients in the prevention of disease. 32. A patient has had a total knee replacement and is receiving care that includes learning to walk with a walker. What level of prevention is most applicable to this patient?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Primary prevention
B)
Secondary prevention
C)
Tertiary prevention
D)
Residual prevention
Ans:
C
205
Feedback: Tertiary prevention and healthcare deals with rehabilitation of the patient. Teaching the patient to walk with a walker is tertiary prevention.
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206
Chapter 12- Healthcare in the Community and Home
1. In the provision of nursing care, it is most important to perform which of the following actions?
A)
Administration of prescribed medications
B)
Implementation of physicians orders
C)
Evaluation of patients responses
D)
Coordination of care with the healthcare team
Ans:
D Feedback: Nurses have moved from simply observing and giving prescribed medications to coordinating clinical information for the entire healthcare team.
2.
A)
A nurse is caring for a 17-year-old pregnant woman. The woman needs to buy a baby bed and obtain baby items. The nurse should encourage the patient to go to
The visiting nurse association
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
A resale shop
C)
A rental equipment store
D)
The welfare office
Ans:
B
207
Feedback: Nurses should be familiar with available emergency care, equipment rental stores, chore and homemaker services, home-delivered meals, visiting nurse services, and should know where welfare and Medicare/Medicaid offices are located. The nurse should be familiar with WIC centers and resale stores to assist new mothers.
3.
A home care nurse has completed a home assessment. Of the following findings, which should be reported to service providers immediately?
A)
Infestation with roaches
B)
The smell of natural gas
C)
Unclean environment
D)
Diminished food sources
Ans:
B
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Feedback: A comprehensive home assessment includes safety, sanitation, mobility, temperature, and personal space. All of the listed deficiencies are of a concern. The immediate concern for the nurses and patients safety is the threat of fire or explosion due to the smell of natural gas.
4. A patient is diagnosed with mild dementia while in the hospital. In preparing for discharge, the nurse should discuss with the family the: A)
Possible need for home care
B)
Legal responsibility for the future
C)
Need for transfer to a long-term care facility
D)
Lack of free resources of care
Ans:
A Feedback: The needs of the patient should be considered when making discharge plans. Common risk factors associated with the need for home care include limited social, mental, or physical functioning. Legal issues, long-term care, and free resources are not indicated in this situation.
5. The home care nurse asks the patient and family about their socioeconomic status, culture, and beliefs. This occurs during which phase of care?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Assessment
B)
Nursing diagnosis
C)
Outcome criteria
D)
Implementation
Ans:
A
209
Feedback: During the assessment phase of a home care visit, the nurse collects subjective information on how the person normally manages at home, what the home is like, and what family and community support is available. The nurse explores the patients beliefs and culture, competencies, capabilities, concerns, deficits, and limitations to understand how the patient manages at home and what she or he desires. Nursing diagnosis, outcome criteria, and implementation occur later in the nursing process as a result of assessment data.
6.When the nurse is involved in the in-home phase, the nurse should
A)
Use therapeutic communication
B)
Record findings
C)
Plan the next visit
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Summarize accomplishments
Ans:
A
210
Feedback: The in-home phase involves establishing the professional therapeutic relationship and implementing the nursing process. During the in-home phase, the nurse must use therapeutic communication skills.
7.
A home care nurse has just completed a dressing change on her patient. Which statement best describes the termination phase?
A)
You need to eat more protein to assist you with wound healing.
B)
On a scale of 0 to 10 with 0 being no pain and 10 being the worst, where would you rate your pain?
C)
Your wound is healing nicely. It is draining less and it is smaller by a half centimeter.
D)
Have you had any problems since our last visit? Is your wife doing well with your dressing changes?
Ans:
C Feedback:
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211
The summarization of the purpose of the visit is evident with the description of the accomplishments of the visit. Discussion of diet, pain, and evaluation of caregiver competency should be done before the termination of care.
8.
What is the purpose of the Standards of Care and Standards of Professional Performance?
A)
To list treatments in the home care setting
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212
To assist with virtual scenarios in the home
C)
To understand the role of the medical nurse in the home
D)
To guide the home care nurse in a collaborative role
Ans:
D Feedback: The Standards of Care and the Standards of Professional Performance guide the home care nurse in his or her collaborative role with the patient and family to identify the healthcare needs for management in the home setting.
9.
When initiating home healthcare services, during which phase is it appropriate for the nurse to implement the initial patient assessment?
A)
Initiation phase
B)
Previsit phase
C)
In-home phase
D)
Termination phase
Ans:
C
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213
B) Feedback: Initial assessment should be conducted in the in-home phase according to Stanhope and Lancaster. The initiation phase consists of clarifying the source of referral and the purpose of the visit, as well as the initial contact with the family. Reviewing records and scheduling visits occurs during the previsit phase. Summarization and determining the need for further visits occurs during the termination phase.
10. An 82-year-old woman is being discharged from the hospital following a bowel resection. The woman lives alone and her family is out of town. Which factor will have the greatest effect on her home care management?
A)
Support systems
B)
Medication management
C)
Transportation
D)
Psychosocial needs
Ans:
A Feedback:
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214
Since this woman lives alone and has no family available, the patient may not be able to stay at home and may need to be placed in a facility to provide adequate support.
11. A patient has severe pain related to degenerative joint disease. On which aspect of care will the nurse need to focus first?
A)
Patient education on pathophysiology
Ability to perform daily activities
C)
Patients financial resources
D)
The effects of social isolation
Ans:
B Feedback: Severe pain can decrease a persons ability to carry out activities of daily living and function; therefore, this is the primary concern of the home health nurse at this time since this is a basic need. The other areas can be addressed at a later time.
12. A single parent, aged 17 years with one child and pregnant with her second child, has the mental age of a 12-year-old. As the home care nurse, what is your greatest concern in caring for this woman?
A)
Her ability to bond with her children
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B) B)
Her ability to receive financial aid
C)
Her cognitive ability to understand
D)
Her physical care abilities
Ans:
C
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Feedback: The cognitive ability of this individual is of greatest concern regarding all aspects of her survival. The cognitive ability to understand how to organize work, manage financial responsibilities, and ensure safety within the home is essential.
13. A 16-year-old girl has been injured in an accident and is receiving home care due to fractures and multiple trauma related injuries. She states, I dont know why I survived and not my best friend. It is most important to
A)
Communicate her feelings to family and friends
B)
Allow the religious force in her life to visit
C)
Be certain that her educational needs are being met
D)
Increase her activity to assist in her coping ability
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A Feedback: The home care nurse can assist in coordinating care needs and encouraging family, teachers, schoolmates, and friends to understand the patients struggles and help support her needs.
14. An 18-month-old child is ventilator dependent due to infantile scoliosis. This is the first time the child has been home since birth. His parents are very concerned about providing care. It is most important to assist the parents with
A)
Financial needs of care
Prevention of infection
C)
Emotional bonding
D)
Genetic counseling
Ans:
C Feedback: The child has not been home since birth. Thus, the parents will need emotional assistance to enhance bonding. The nurse supports the parents to meet the infants physical and emotional needs and encourages them to strengthen the parent-child bond.
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B) 15. Home care nurses are required to complete the Outcome and Assessment Information Set according to
A)
Medicare
B)
Medicaid
C)
Third-party payer
D)
Insurance
Ans:
A Feedback: The Outcome and Assessment Information Set provides standardized guidelines for admission and care, as well as a national database for evaluation, reimbursement, and quality improvement. The OASIS system of data collection is used by Medicare.
16.
It is important for home healthcare nurses to remember which
point? A)
B)
The nurse is the primary caregiver.
The nurse is the guest in the patients home.
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C)
Rehabilitation is the major patient goal.
D)
The nurse should act as a counselor and advisor.
Ans:
B
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Feedback: An essential difference in home care versus acute care is that the home care nurse is a guest in the patients home. Family or other support persons are the primary caregivers, rehabilitation may not be the goal, and the nurse does not typically act as a counselor or advisor.
17. A patient is having an increasing amount of difficulty caring for herself in her home alone. She states to the nurse, I need more help. What am I going to do? It would be important for the nurse to have the
A)
Social worker visit to discuss care options
B)
Physical therapist help with rehabilitation
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C) Home health aide increase visits for bathing
D)
Ans:
Occupational therapist assess for adaptive devices
A Feedback: Services to manage healthcare needs in the home can involve a team of interdisciplinary professionals, including social workers. The social worker is able to identify resources to meet the patients needs.
18. A woman living alone has degenerative joint disease, hypertension, and neuropathy. It is difficult for her to bathe herself, and her blood pressure is unstable. What type of care would this patient benefit from most?
A)
Acute care
B)
Ambulatory care
C)
Home care
Respite care D) Ans: Feedback:
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C
Home healthcare services are delivered to persons at home who are recovering from illness, are disabled, or are chronically or terminally ill and need various services to progress, maintain function, or perform their ADLs. Acute and ambulatory care are delivered on a short-term basis, and respite cares focus is on the caregiver.
19.One of the primary advantages to the managed care model is
A)
Increased patient satisfaction
B)
Economic quality care
C)
All RN staff
D)
Distinct area of care
Ans:
B Feedback: Case management is used in such situations to ensure optimum, highquality care in the most efficient and economic manner.
20. Prior to the patients discharge from an acute care facility, the nursing case manager has the nursing staff, patient, patients family, physical therapist, and home health nurse meet. The purpose of this is to
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C) A)
Provide patient teaching
B)
Evaluate the effectiveness of the hospitalization
221
Determine hospital-based services
D)
Ans:
Prepare the patient for home care
D Feedback: Discharge planning prepares a patient to move from one level of care to another within or outside the healthcare facility.
21. A nurse is covering all aspects of admission procedures for a patient who is receiving home health services. The nurse explains what procedures will be covered during his visits. Which of the following aspects of the admission process does this represent?
A)
Establishing rapport and showing willingness to listen
B)
Clearly defining the purpose and expectations of the admission
D) Ans: Feedback:
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C)
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Documenting the procedure Assisting in participation of the care-related decisions B
During the admission to the healthcare system, patients should understand the purpose and expectations of admission.
22.Continuity of care for a particular patient is important to prevent
A)
Multiple providers
B)
Infection
C)
Fragmentation of services
D)
Rising healthcare costs
Ans:
C Feedback: Continuity of care is the provision of healthcare services without disruption, regardless of movement between settings.
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C) 23. The home care nurse is providing care and education to a woman who is pregnant with her first child. The patient states, I have no money or food. I dont know what I should do. I want to provide for my unborn child. The nurse refers the woman to the WIC program and a local food bank. This is an example of what aspect of community-based nursing?
A)
Assessment
B)
Planning
Restoration
D)
Evaluation
Ans:
B Feedback: Planning and intervention focus on using individual, family, and community resources to assist in restoring a patients health to maximum possible functioning, while continuing to monitor for possible side effects or complications to treatment.
D) Ans: Feedback:
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24. A community health nursing student is assessing the birth rates and death rates of his local municipality and comparing these rates to the nation and the world. This is an example of what type of nursing?
A)
Community-based nursing
B)
Epidemiologic nursing
C)
Community health nursing Statistical nursing C
Examining birth rates and death rates of a community is the focus of community health nursing. Community health nursing focuses on patients and populations of the community.
25.Care of women in the home prior to delivery is considered
A)
Community-based nursing
B)
Postpartum nursing
C)
Antepartum nursing
D)
Residential-based nursing
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A Feedback: Community-based nursing focuses on individuals and families within the community.
26. When educating patients in the community on health promotion and prevention of disease, it is important to stress which of the following factors?
A)
Strenuous exercise is necessary for health
B)
Education should emphasize societys needs
C)
Education should take place only in healthcare settings
D) Ans: Feedback:
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D)
Dietary needs should be covered in depth
Ans:
B
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Feedback: Common to all programs will be the need for greater individual authority, accountability, and responsibility with less reliability on institutional authority and policies. Nursing education is evolving and redirecting its emphasis to meet societys changing needs.
27. Occupational health nursing is classified as
A)
Community-based healthcare
B)
Institutional healthcare
C)
Residential healthcare
D)
Tertiary healthcare
Ans:
A Feedback: Community-based healthcare is developed within the context of a community. Care of employees in an occupational setting is considered to be community-based healthcare.
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28. Community-based healthcare is best defined as
A)
Home care in a community setting
B)
Healthcare developed in partnership with communities
C)
Patient-centered care in a senior citizen complex
D)
Healthcare directed to the community at large
Ans:
B Feedback: Community-based healthcare is developed within the context of a community.
29.An example of a secondary healthcare setting is a(an)
A)
Inpatient cardiovascular surgery unit
B)
Scoliosis screening in a school
C)
Health maintenance network
D)
Preferred physician network
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Ans:
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A
Feedback: Secondary care settings include hospitals and surgery units that provide acute care.
30.Which facility is an example of a tertiary healthcare setting?
A)
Rehabilitation facility
B)
Outpatient surgery center
C)
Medical division in the hospital
D)
Ambulatory care clinic
Ans:
A Feedback: Tertiary care settings include rehabilitation and long-term care facilities.
31. An example of primary healthcare is
A)
A hearing screening in the school setting
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B)
Care of the patient in the intensive care unit
C)
Diagnostic testing for HIV/AIDS
D)
Care of the patient on rehabilitation
Ans:
A
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Feedback: Primary prevention or primary healthcare involves the screening of patients in the prevention of disease.
32. Your hospital has decided to begin to offer home health services to its patients. What is the most likely reason for the addition of these services?
A)
The need for continuity of care
B)
The promotion of worldwide healthcare
C)
The change to shorter hospital stays
D)
The need for decreased financial expenditures
Ans:
C Feedback:
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Decreased hospital stays have led to an increase in community-based healthcare services.
33.One of the most significant trends in healthcare today is
A)
Increased length of hospital stays
B)
Shift from hospitals to community-based care
C)
Emphasis on disease management
D)
Narrowing of the areas for nursing practice
Ans:
B Feedback: The shift to community-based care is related to the publics desire to participate more actively in healthcare decisions, issues, and choices.
34. Nurses who assist patients to deal holistically with their healthcare needs at the end of their lives work primarily in which healthcare delivery system?
A)
Acute care
B)
Primary care
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C)
Hospice
D)
Rehabilitation
Ans:
C
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Feedback: The opportunity to help people maintain their ability to remain at home and deal holistically with their health and family needs at the end of their lives is home health hospice care.
35. The primary nurse shares with the healthcare team the need for her patient, diagnosed with cancer, to attend her daughters wedding. She is serving in what role as a nurse?
A)
Caregiver
B)
Educator
C)
Counselor
D)
Advocate
Ans:
D Feedback:
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The primary nurse should serve as an advocate for her patients. 36. A nurse is caring for an elderly patient in the home. He concludes that the patient needs an x-ray to determine if the patient has pneumonia and requires oxygen for shortness of breath. He calls to inform the physician of the patients status and then makes arrangements to carry out the physicians orders. In this scenario, what role does the nurse play?
A)
Case manager
B)
Nurse practitioner
C)
Clinical nurse specialist
D)
Advanced practitioner
Ans:
A Feedback: Case management means the nurse coordinates many resources to maximize the opportunity for people to manage their own healthcare at home.
37. A nurse is working in a public school as the school nurse. This nurse is considered to be working in which role?
A)
Ambulatory care
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B)
Community health
C)
Inpatient facility
D)
Rehabilitation facility
Ans:
B
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Feedback: A nursing employed as a school nurse is considered to working in community-based care.
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Chapter 13- Culture and Diversity
1.
A nurse has just been hired at a healthcare facility that performs abortions. Based on the nurses religious beliefs, she strongly feels that abortion is unacceptable. This situation will prevent the nurse from being able to practice:
A)
transcultural nursing
B)
safe and effective care
C)
efficient care
D)
holistic care
Ans:
A Feedback: Transcultural nursing refers to the nurse being able to understand the culture(s) of her/his patients, and the ability to recognize her or his own ethnocentrism and the ethnocentrism of the biomedical healthcare system. The nurses strong religious beliefs in regards to abortion will prevent transcultural nursing from occurring.
2. While studying about various cultures, the student nurse is aware that a subculture is based on which characteristic? Select all that apply.
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A)
Gender
B)
Age
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C) Profession
D)
Hobbies
E)
Sexual preference
Ans: A, B, C, D, E Feedback: A subculture is based on any common interest or identity; therefore, all of these options are examples of subcultures. 3.
The nurse caring for several patients on a surgical unit notes that one of the patients she is caring for is Muslim. The nurse decides to remove all pork from the patients meal tray prior to delivering it to his room. What best describes the nurses action?
A)
Stereotyping
B)
Racism
C)
Honoring rituals
D)
Transcultural nursing
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A Feedback: While the nurse was trying to be thoughtful (as with transcultural nursing), the action would be considered stereotyping since the nurse assumed this ritual was part of this patients practices. Racism involves negative thoughts or feelings towards a specific group of people.
4. The nurse working on a medical unit washes her hands between contact with each patient. In addition to being an infection control measure, what kind of action is this practice?
A)
A custom
B)
An obsession
C)
A habit
D)
A ritual
Ans:
D Feedback: Handwashing is one of the many nursing rituals practiced by nurses. Rituals are common, observable expressions of a culture.
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C) 5. What are characteristics of the nurse that make them a subculture within the United States? Select all that apply.
A)
Uniforms worn based on place of employment
B)
Language or medical terminology used to communicate
Legal authorization to provide health care to others
D)
View of work as a reward and shared work ethic
E)
Sensitivity to the importance of time
Ans:
A, B, C Feedback: The dominant culture of nurses in the United States is the middle-class group. Work ethic and importance of time are values of this group. Dress, terminology, and legal authority belong to the nursing subculture.
6.
A)
An African American patient refuses to allow any healthcare worker of Asian descent to care for him. This patient is demonstrating what practice?
Ethnocentrism
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Racism
C)
Stereotyping
D)
Ethnic identification
Ans:
B
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Feedback: Racism usually involves negative thoughts or actions against another individual based on skin color or ethnicity. Stereotyping does not always involve negative thoughts against others. Ethnocentrism and ethnic identification are beliefs that are within a person and not necessarily directed towards others.
7. The nurse correctly differentiates race from ethnicity by noting that race is based on which characteristics?
A)
Biological
B)
Social
C)
Spiritual
D)
Religious
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240
A Feedback: The biological characteristics of race are based on either physical appearance or place of origin.
8.
The public health nurse is preparing a presentation about disparities in healthcare in his community. What key concepts will the nurse include? Select all that apply.
A)
Information regarding minorities within the community
B)
Identifying groups that are disadvantaged within the community
Pointing out groups within the community that possess less power
D)
Differences in beliefs within a particular culture
E)
Ethnic identities within subcultures in the community
Ans:
A, B, C Feedback:
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The term minority refers to a group of people within a society whose members have different ethnic, racial, national, religious, sexual, political, linguistic, or other characteristics from the majority of that society. Racial and ethnic minorities continue to have higher rates of disease, disability, and premature death than nonminorities; therefore, these are key points that the nurse should present. 9.
The nurse is caring for two patients from an Hispanic background. The nurse notices some differences between the two in the religious practices and the slang used for communicating. What is most likely the etiology of these differences?
A)
Cultural norms
B)
Cultural relativity
C)
Ethnicity
D)
Ethnocentrism
Ans:
C
Feedback: Ethnicity or ethnic identity refers to the differences among a group who share the same cultural and/or ancestral heritage. Cultural norms are the actions that are expected by others within the culture. Cultural relativity refers to the differences between cultures in the meaning of various behaviors. Ethnocentrism is the belief that ones own practices are the only correct practices.
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C) 10. A patient tells the nurse that the only thing that helps him sleep is a glass of warm milk. The nurse caring for the patient insists that this practice is a myth and tries to convince the patient that reading a book will help to make him sleepy. What is the nurse demonstrating?
A)
Cultural pervasiveness
B)
Cultural superiority
C)
Stereotyping
D)
Ethnocentrism
Ans:
D Feedback: Sometimes healthcare providers assume they know better than their patients what will help their patients. This is an example of a form of ethnocentrism. Pervasiveness refers to learning a set of behaviors within a culture. Stereotyping refers to preconceived and untested beliefs about people.
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11. The nurse is caring for the teenage child of immigrants from China. The teenager voices distress because after living in the United States for several years, he no longer wants to participate in some of the Chinese religious rituals that are important to his parents. What is the teenager experiencing?
A)
Culture shock
B)
Cultural ethnocentrism
C)
Cultural change
D)
Cultural relativity
Ans:
C Feedback: The teenager is experiencing cultural change. This often occurs when a person changes as he or she comes into contact with new beliefs and ideas. Culture shock is a stress response that involves being unable to comprehend the culture which one is a part of. Viewing ones own culture as the only correct standard by which to view people of other cultures is ethnocentrism. Cultural relativity refers to an understanding that cultures relate differently to the same given situations.
12. The newly employed nurse working in a physicians office seeks advice on the job responsibilities and how best to implement these responsibilities. Who is the key informant for this nurse?
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A)
The physician
B)
The nurse who has been working in this office for 8 years
C)
The office manager who has been employed by this physician for 14 years
D)
The certified medical assistant who has worked in this office for 22 years.
Ans:
B Feedback: While the physician will convey expectations of the nurses role, the nurse presently working will be the key informant for the newly employed nurse. The key informant is the person who has an especially rich base of cultural knowledge, is reflective, willing to share their views, and is able to articulate their culture; in this case the responsibilities of a nurse in this setting. The office manager and certified medical assistant, while employed in this office longer, will have different roles in this office culture than will the nurse.
13. Which of the following questions should the nurse use to begin an ethnographic interview with a newly admitted adult patient from Egypt? A) How have you been feeling during the past week?
B)
Why are you here?
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C)
What is making you feel pain?
D)
Can you describe your family?
Ans:
A
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Feedback: An ethnographic interview begins with an open-ended, general question. 14. The mother of an African American newborn asks the nurse about the bluish black areas she noticed around the infants lower back and buttocks. What is the nurses best response?
A)
These areas are normal and should disappear by early childhood.
B)
It will be best if you have these areas treated with laser surgery.
C)
These spots will normally fade in about 2 weeks.
D)
This discoloration occurs in some infants and is usually permanent.
Ans:
A Feedback:
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These types of discolored areas are referred to as mongolian spots. The discolorations are clusters of melanocytes and appear as bluish-black areas typically found on an African American infants lower back and buttocks, as well as Indian and Asian infants. They are normal, occur in 80% to 90% of these populations, and typically disappear by early childhood.
15. Which of the following areas are typically included in a cultural assessment?
A)
Marital status
B)
Employment status
C)
Food preferences
D)
Ethics
Ans:
C Feedback: Dietary tolerance is associated with both cultural food preferences and biologic variation.
16. When a labor and delivery nurse tells a coworker that an Asian patient probably did not want any pain medication because Asian women typically are stoic, the nurse is expressing a belief known as
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Stigma
B)
Ethnic slur
C)
Bias
D)
Stereotype
Ans:
D
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Feedback: Stereotypes are preconceived and untested beliefs about people. Ethnic slur refers to a statement made about another according to their ethnicity; stigma refers to social disapproval; and bias refers to an inability to view someone or something without being objective.
17.How do people of Canadian Indian descent prefer to be identified?
A)
Indians
B)
Americans
C)
Canadians
D)
First Nations
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Ans:
248
D Feedback:
Although at one time Native Americans in the United States and the Native Indians in Canada all freely moved back and forth across what have become national boundaries, people of Canadian Indian descent prefer to be identified as First Nations people.
18. When a home-bound patient expresses her past-oriented ancestral heritage and family rituals, the nurse recognizes that the patient is expressing her
A)
Race
B)
Assimilation
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C) Subculture
D)
Ethnic identity
Ans:
D Feedback: Ethnicity or ethnic identity refers to self-conscious, past-oriented form of identity based on a notion of shared cultural and perhaps ancestral heritage, and current position in larger society. Race is based on biologic characteristics; assimilation refers to new customs and attitudes that are acquired through contact and communication among persons of a particular culture; and a subculture refers to group of people within a culture who have ideas and beliefs which are different from the rest of that society.
19. A nurse in the hospital is caring for a Native American male. What person is most important to include in the care of the patient?
A)
Family
B)
Physician
C)
Tribal medicine man
D)
Physical therapy aid
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Ans:
250
C Feedback: Observance of rituals in times of stress and uncertainty helps to restore a sense of control, competence, and familiarity; to that extent, these rituals are a desirable adjunct to nursing care.
20. A Catholic priest baptizes a stillborn baby of a Catholic family. What type of practice is this considered?
A)
Necessary
B)
Expected
C)
A ritual
D)
A birth rite
Ans:
C Feedback: Rituals are common and observable expressions of culture in hospitals, clinics, homes, schools, and work settings.
21. The nurse caring for several patients on a hospital unit notices that the American patient makes eye contact with the staff while an elderly
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C) patient of Japanese descent does not make eye contact when speaking to the staff. What cultural concept explains this difference?
A)
Cultural diversity
B)
Cultural negativity
Cultural relativity
D)
Cultural neutrality
Ans:
C Feedback: Cultural relativity refers to the concept that cultures relate differently to the same situations, such as the meaning of eye contact. Americans view eye contact as demonstrating engagement in a conversation, whereas elderly Japanese view avoidance of eye contact with a superior (the nurse in this scenario) as a sign of respect.
22. Healthcare facilities that sponsor health-promotion activities only in affluent areas are considered
A)
Culturally sensitive
B)
Culturally blind
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C)
Culturally affluent
D)
Culturally different
Ans:
B
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Feedback: Another way of thinking about ethnocentrism in nursing is that it can reflect an individuals, a groups, or an agencys cultural blindness, or lack of capacity to reach out effectively to minorities or culturally stigmatized groups.
23. A patient says to the nurse, Why dont you wear a white cap like nurses do on the soap operas? This is an ethnocentric statement based on the
A)
Nursing personality
B)
Past history
C)
Media
D)
Genetics
Ans:
C Feedback:
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C) Ethnocentrism is a way of looking at the world through a personal lens that has been influenced by personality, genetics, family/relationships, and media.
24. When a tpatient states, I only want an American doctor, the patient is expressing cultural
A)
Ethnocentrism
B)
Relativity
Pervasiveness
D)
Superiority
Ans:
A Feedback: Viewing ones own culture as the only correct standard by which to view people of other cultures is ethnocentrism.
25. Within a culture, the world becomes predictable and coherent for its inhabitants. This predictability has been defined as
A)
Habituation
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B)
Normalization
C)
Stereotypical
D)
Desensitization
Ans:
A
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Feedback: Culture is habituated; it reflects a usual way of doing things that people learn through socialization as they may mature and become deeply involved in different subcultures. Cultural habituation is advantageous.
26. How is the nursing profession becoming more culturally diverse? (Select all that apply) A)
By admitting a required number of foreign-born nursing students
B)
Through meeting admission quotas for Hispanic nursing students
C)
By the increased number of foreign-born nurses in the profession
D)
Through meeting the mission of Sigma Theta Tau International
E)
By the increased number of male nurses in the profession
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C) Ans:
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E Feedback: The increase in numbers of foreign-born nurses reflects a comparable growth in the size of the foreign-born populations of the country, by some 11 million between the censuses of 1990 and 2000. Cultural diversity is also achieved by the increased number of males in the profession compared to the predominantly female work force in the past.
27.A nurse educator could be considered culturally as a(an)
A)
Referral source
B)
Respondent
C)
Expert
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D)
Key informant
Ans:
D
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Feedback: People who know certain aspects of their culture better than others do are called key informants.
28. Nursing students are socialized into the
A)
Nursing specialties
B)
Healthcare culture
C)
Caring paradigm
D)
Diagnostic process
Ans:
B Feedback: Culture enables people of similar cultural heritage to understand the meanings of each others words as part of the particular context in which they are expressed, to read each others nonverbal behavior fairly accurately, and to communicate through symbols.
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29. The patient in a rehabilitation unit is having a difficult time adjusting to the scheduled activities on the unit, as well as being dependent on others for meals and medications. Which word best describes what the patient is experiencing?
A)
Anxiety
B)
Disparity
C)
Resolution
D)
Shock
Ans:
D Feedback: The acute experience of not comprehending the culture in which one is situated is called culture shock. This is often experienced by a patient who suddenly finds herself/himself in the subculture of a hospital or healthcare agency.
30. A student nurse is preparing a presentation regarding different cultures. Which definition of culture is most accurate?
A)
Belief system that guides behavior
B)
Altruistic grouping
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C)
Cluster of individuals
D)
Complete uniformity of members
Ans:
A
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Feedback: Culture is a belief system that the members of the culture hold, to varying degrees, consciously or unconsciously, as absolute truth. That belief system guides everyday behavior and makes it routine.
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Chapter 14- Communication in the Nurse-Patient Relationship
1.
The nurse completes the admission process of a patient to an acute care facility. Which statement by the nurse demonstrates the communication technique of focusing?
A)
You have been having a great deal of fatigue for the last 3 months.
B)
You are hoping to figure out the cause of your extreme fatigue during this hospital stay.
C)
You are frustrated because you are too tired to perform normal acitivities.
D)
You are unsure of what helps or prevents your fatigue.
Ans:
B Feedback: This statement focuses on what the patients chief complaint is and the goal for this admission. The other statements demonstrate the communication technique of clarifying.
2.
The nurse is communicating with a patient following a routine physical
examination. Which statement best demonstrates summarization of the appointment? A) I think all went well with your physical, dont you?
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B)
Do you have any questions about all that was discussed during the exam?
C)
We reviewed your plans for your new diet and medications. Do you have any other questions?
D)
Will we see you in 6 months to see how your diet has progressed?
Ans:
C Feedback: Summarization highlights the important points of a conversation or interaction. Reminding the patient that the diet plan and new medications were discussed best summarizes the appointment.
3.
The student nurse is practicing communication skills by talking with several different patients in the hospital. In which instances would silence be appropriate? (Select all that apply)
A)
Allowing the patient time to reflect on his or her thoughts
B)
Reflecting on the communication that has occurred
C)
After asking the patient a question
D)
When the patient is upset and needs time to compose himself
E)
When the nurse doesnt know the answer to a question
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261
A, B, C, D
Feedback: Silence allows a pause in communication that gives the nurse and patient time to reflect on the conversation that has taken place. When the nurse waits quietly and attentively, the patient feels encouraged to initiate and maintain conversation, or to simply offer support. Not knowing the answer to a question is not an appropriate use of silence.
4.
The community health nurse is preparing a campaign to educate the public about heart health. Which forms of verbal communication will be effective? (Select all that apply)
A)
Television
B)
Radio
C)
Posters
D)
Voice tone
E)
Brochures
Ans:
A, B, C, E Feedback:
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Forms of verbal communication that will convey the message in various forms include television, radio, posters, and brochures. Tone of voice is considered nonverbal communication.
5.
The nurse is providing teaching to a patient who sometimes has difficulty remembering information. Which form of communication will be most helpful for this patient?
A)
Verbal communication
B)
Meta-communication
C)
Non-verbal communication
D)
Written communication
Ans:
D Feedback: While all forms of communication can be used during teaching, it will be essential to use written communication for this patient. This will allow the patient to refer back to important points presented.
6.
The student nurse is studying the concepts of communication. Which description demonstrates the student understands the concept of feedback?
A)
The sender sends a clear message that is understood by the receiver.
B)
The receiver listens to the sender in an unassuming way.
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C)
Feedback occurs when the sender and the receiver use one anothers reactions to produce further messages.
D)
The senders message is translated into a code, using verbal and nonverbal communication.
Ans:
C Feedback: Feedback can occur when a message is decoded and received.
7.
The patient is talking to the nurse about recent health problems of immediate family members and the strain she has been under trying to care for them. She begins to cry between sentences. What response by the nurse demonstrates the most empathy?
A)
I know how you feel. I was the primary caregiver for my father when he was dying.
B)
Its okay to cry. Sometimes that helps us to feel better.
C)
Just take your time. I am listening.
D)
It is difficult when family members are ill. It helps if you take some time for yourself.
Ans:
C
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Feedback: This response allows the patient to collect her thoughts while also expressing emotion, and it lets the patient know the nurse is there for her. Using appropriate periods of silence rather than talking away the patients feelings is empathetic. I know how you feel does not focus on the patients feelings, and stating Its okay to cry or Take some time for yourself are statements that indicate the need for the patient to seek approval for her to experience her own feelings.
8.
The nurse caring for a patient with a recent head injury asks the patient to raise his left arm as high as possible. The patient repeatedly raises his right arm. What does this indicate?
A)
Difficulty with providing feedback
B)
Difficulty with decoding messages
C)
Difficulty with compliance
D)
Difficulty with following commands
Ans:
B Feedback:
Decoding refers to the receiver of communication being able to understand the senders message. This patient does not display noncompliance or difficulty following commands since he repeatedly raises the opposite arm. It is likely that the head injury has affected the patients ability to understand. The nurse is not seeking feedback.
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9.
265
The 32-year-old patient in a mental health unit discusses his personal thoughts and feelings with the nurse. The nurse is maintaining the circle of confidentiality by reporting this information to which individuals? Select all that apply.
A)
The patients physician
B)
The patients family
C)
The nurse from the oncoming shift
D)
The units mental health technicians
E)
The patients closest friend
Ans: A, C, D Feedback: Unless the patient has specifically given permission to provide information to family and friends, this information should remain among individuals on the healthcare team that are directly involved with care of the patient.
10. The nurse is talking with a patient who is thinking about obtaining a second opinion regarding the surgeons recommendation for surgery. Which response by the nurse is considered an advocacy response?
A)
You have one of the best surgeons in the area. I think it would be a waste of time to seek another opinion.
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B)
Your surgeon has always given you the best care and is genuinely concerned with your health.
C)
You can do what you want, but I would get the surgery done as soon as possible.
D)
Let us know if we can answer any further questions after you obtain your second opinion.
Ans:
D Feedback: Offering support and further assistance, as well as information, represents an advocacy response. Stating the surgeon is one of the best or advising to get the surgery done as soon as possible are authoritarian responses. Telling the patient that the surgeon has always cared for them well is using a guilt response.
11. The mother of a toddler is trying to decide if she wants to allow her child to receive the recommended immunizations. The clinic nurse responds, If you dont immunize your child you are jeopardizing the health of other children. What type of approach does this response indicate?
A)
Authoritarian
B)
Guilt inducement
C)
Advocacy
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Dictatorial
Ans:
B
267
Feedback: This response by the nurse attempts to induce guilt on the parent to make what the nurse views as the best choice. Authoritarian responses dictate what the patient should do based on the healthcare professionals professional opinion. An advocacy response supplies the patient with information to make the decision.
12. When the preoperative patient tells the nurse that he cannot sleep because he keeps thinking about the surgery, an appropriate reflection of the statement by the nurse is A) Sounds as if your surgery is a pretty scary procedure.
B)
You have a great surgeon. You have nothing to worry about.
C)
You shouldnt be nervous. We perform this procedure every day.
D)
The thought of having surgery is keeping you awake.
Ans:
D Feedback: Reflection means identifying the main emotional themes.
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13. In the provision of care and the establishment of the therapeutic relationship, the nurse must first
A)
Understand the patients response
B)
Be aware of ones own personality
C)
Avoid labeling patients
D)
Treat the patient with dignity
Ans:
B Feedback: Before a nurse can communicate therapeutically, a comfortable sense of self, such as being aware of ones own personality, values, cultural background, and style of communication, is necessary.
14. Care provided to a patient following surgery and until discharge represents which phase of the helping relationship?
A)
Orientation phase
B)
Working phase
C)
Termination phase
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Evaluation phase
Ans:
B
269
Feedback: During the working phase, the nurse and patient explore and develop solutions that are enacted and evaluated in subsequent interactions.
15. When caring for a psychiatric patient, a formal contract is made with the patient during which phase of the nurse-patient relationship? A)
Intimate phase
B)
Orientation phase
C)
Working phase
D)
Termination phase
Ans:
B Feedback: In the psychiatric setting, the orientation phase of the relationship represents the first phase of therapeutic work and involves signing of formal contracts. Formal contracts in this setting are used as a therapeutic tool to help a patient develop more insight and control over his or her own behavior.
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16. A nurse enters the patients room and introduces himself stating, Hello, Mr. Alonso. My name is Anthony Bader. I will be your registered nurse today. I will be providing your nursing care and I will be with you until 3:30 PM. If you need anything, please call me on my phone or put your light on. He then gives the patient a printed card with this information. In the helping relationship, what does this represent?
A)
Intimate phase
B)
Orientation phase
C)
Working phase
D)
Termination phase
Ans:
B Feedback: The orientation phase consists of introductions and an agreement between the nurse and the patient about their mutual roles and responsibilities.
17. When caring for a patient, nursing care will be most effective when the nurse-patient interactions are focused on which of the following circumstances?
A)
Goal achievement
B)
Compatible realities
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Common understanding
D)
Sharing values
Ans:
C
271
Feedback: The nursepatient interaction is most productive when communication is aimed toward a common understanding. Goal achievement is difficult to attain if there is not a common understanding between the nurse and patient.
18. When communicating with patients, nurses need to be very careful in their approach. This is particularly true when communicating using
A)
Written material
B)
Audiovisuals
C)
Demonstration
D)
Medical terminology
Ans:
D Feedback:
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Another filter is the particular language system into which the person is socialized. Nurses are socialized into healthcare or medical jargon. To effectively educate and communicate, the nurse should limit medical jargon.
19. While communicating with a patient who is hearing impaired, the nurse must take into account that the impairment serves as a
A)
Handicap
B)
Filter
C)
Blocker
D)
Receptor
Ans:
B Feedback: Sight, hearing, touch, taste and smell are filters of the neurologic receptor system. Stimuli processed through these receptor systems enable the person to experience the outside world.
20. A nurse touches the patients hand while discussing his diagnosis. This action is a(an)
A)
Dynamic process
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Translation
C)
Communication channel
D)
Auditory channel
Ans:
C
273
Feedback: Communication channel is the carrier of the message; touch can be a channel. 21. A nurse is interviewing a patient for the establishment of long-term care insurance. During the interview, the nurse asks questions regarding the patients past medical history. The nurse is the
A)
Sender
B)
Target
C)
Receiver
D)
Decoder
Ans:
A Feedback:
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A sender is a person or group with a purpose for the communication. 22. You are caring for a patient who has had a cerebrovascular accident, with left hemiparesis and aphasia. The patient responds to your spoken words with garbled responses. The nurse determines that the patient has difficulty with message
A)
Encoding
B)
Feedback
C)
Decoding
D)
Channeling
Ans:
A
Feedback: The patient who has suffered a cerebral vascular accident and has aphasia may understand the words spoken to him but may be unable to encode and send a message in return.
23. The patient responds to the nurses questions by stating in a loud and abrupt tone, Yes, I understand my diabetic diet and how to give my insulin. What type of message has the patient sent to the nurse?
A)
Inconclusive
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Precise
C)
Clear
D)
Incongruent
Ans:
D
275
Feedback: When the nonverbal meta-communication aspects of the message do not fit with the verbal message, the communication is considered incongruent.
24. An elderly patient who has had a colostomy for over 10 years states, I wont need any teaching about colostomies. I understand how to change the bag and care for my colostomy, but Im not sure how to best clean my stoma? What does this statement indicate?
A)
An incongruent relationship
B)
A confused relationship
C)
A non-therapeutic relationship
D)
An evaluative relationship
Ans:
A
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Feedback: The patients two statements are incongruent with each other. This indicates the need for further education.
25. A nurse communicating with a patient states, I will be changing your dressing. She is wearing sterile gloves and a mask. She is conveying a(an)
A)
Congruent relationship
B)
Incongruent relationship
C)
Non-therapeutic relationship
D)
Functional focus
Ans:
A
Feedback: The communication and protective equipment conveys messages that are congruent.
26.The term meta-communication is best defined as
A)
Congruent relationships in the spoken topics
B)
Documenting a conversation between the patient and nurse
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Contextual factors that impede communication patterns
D)
Interpersonal bridge between verbal and nonverbal communication
Ans:
D
277
Feedback: Meta-communication is communication about the communication or lack thereof. It is an implicit, but integral, part of the message and is an interpersonal bridge between the verbal and nonverbal components of communication.
27. When the nurse communicates with a newly admitted patient, the nurse must pay particular attention to nonverbal behaviors. The nurse considers which of the following as nonverbal communication?
A)
The patients accent
B)
The patients tone of voice
C)
The patients religious practices
D)
The patients ethnicity
Ans:
B Feedback:
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A person communicates by gestures, facial expressions, posture, space, appearance, body movement, touch, voice tone and volume, and rate of speech.
28. When documenting patient care, the nurse understands that the most important reason for correct and accurate documentation is which of the following?
A)
Legal representation to care
B)
Conveyance of information
C)
Assisting in organization of care
D)
Noting the patients response to interventions
Ans:
B Feedback: Documentation of care in the patients record is most important for communicating with other healthcare team members that are involved in the care of the patient.
29. Communication is the
A)
Essence of nursing
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Heart of nursing
C)
Core of nursing
D)
Integral part of nursing
Ans:
B
279
Feedback: Communication is at the heart of nursing.
30. In order to provide effective nursing care, the nurse should engage in what type of communication with the patient and significant others?
A)
Interpersonal communication
B)
Intrapersonal communication
C)
Meta-communication
D)
Therapeutic communication
Ans:
D Feedback:
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Therapeutic communication facilitates interactions focused on the patient and the patients concerns. 31. During an annual performance review with an employee, the nurse manager does not maintain eye contact and seems concerned about the time and the next appointment. This use of communication is considered
A)
Consistent
B)
Verbal
C)
Nonverbal
D)
Clarifying
Ans:
C Feedback: Listening can be hampered by the listeners lack of interest in the topic, premature interpretation of the message, or preoccupation with practice. The nonverbal cues that accompany the message are essential aspects of verbal communication.
Chapter 15- Patient Education and Health Promotion
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1.
281
An elderly woman is receiving Medicare benefits only and her source of income is Social Security. She has limited literacy skills and no family support. What is the major issue that puts her at risk for an alteration in health maintenance?
A)
Unpleasant past experience
B)
Family values
C)
Lack of motivation
D)
Knowledge deficit
Ans:
D Feedback: Knowledge deficits about health maintenance can occur due to limited education and lack of health insurance.
2. A woman is admitted to the medical division with pelvic inflammatory disease. Which of the following statements would indicate that she requires more education on health promotion and illness prevention?
A)
My sexual partner is at risk for infection when I have an infection.
B)
The number of sexual partners increases my risk for infection.
C)
Unprotected sexual intercourse increases my risk for infection.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Sexual relationships have no effect on the infections I get.
Ans:
D
282
Feedback: A persons lifestyle and habits strongly affect health maintenance.
3. An appropriate topic on secondary prevention and health maintenance for a group of middle-aged adults is
A)
Medical checkups
B)
Prenatal checkups
C)
Pregnancy prevention
D)
Medication safety
Ans:
A
Feedback: Health maintenance with adults focuses more on secondary prevention, such as exercise, nutrition, social stimulation, and regular medical checkups.
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4. A primary health-maintenance concern for adolescents is
A)
Adequate rest
B)
Alcohol abstinence
C)
Exercise regimen
D)
Job safety
Ans:
B Feedback: Primary health concerns of adolescents include prevention of sexually transmitted diseases and pregnancy, avoiding drugs and alcohol, and maintaining health.
5.
The local health department inspects restaurants and food manufacturing facilities. This is an example of
A)
Health protection
B)
Health promotion
C)
Illness prevention
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Pest surveillance
Ans:
A
284
Feedback: Health-protection activities are environmental or regulatory measures that seek to protect the health of a community or large population.
6.
The nurse instructs new mothers about illness prevention when the nurse tells the patients to be certain that their newborns are
A)
Given massages
B)
Mentally stimulated
C)
Positioned prone for sleep
D)
Immunized on schedule
Ans:
D Feedback: Avoidance behaviors (immunizations) are used to avoid illness rather than to promote health.
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7. What health-promotion activity would be the most appropriate to suggest to a 20year-old female?
A)
Aerobic exercise three times per week
B)
Yearly breast mammography
C)
Weekly blood-pressure screening
D)
Intake of a diet high in fat
Ans:
A Feedback: Health-promotion activities are behaviors that seek to expand the potential for health and are often associated with lifestyle choices.
8.
The School of Health Sciences, campus health center, and acute care facility establish a wellness center for the uninsured. This is an example of
A)
Cost containment
B)
Illness care
C)
Community partnership
D)
Mobilized healthcare
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Ans:
C
286
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287
Healthcare priorities include health development and development of community partnerships for health promotion activities.
9.
Which of the following guidelines is most important for the nurse to keep in mind when planning to teach an exercise class to a group of older adults?
A)
Allow ample time for psychomotor skills
B)
Keep the session at 2 to 3 hours
C)
Allow for long-term memory loss
D)
Provide information in a structured format
Ans:
A
Feedback: Older adults need more time to learn psychomotor skills. Sessions of 2 to 3 hours are too long; short-term rather than long-term memory loss affects older adults; and information can be structured or non-structured, depending on the content. 10. What is the most appropriate teaching strategy for the nurse to use for a 1-hour presentation on the prevention of osteoporosis to a group of 30 college-age women?
A)
Role play
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Feedback: Lecture/discussion
C)
Demonstration
D)
Test taking
Ans:
B
288
Feedback: Lecture/discussion is appropriate for this topic, audience, and group size. A lecture is a formal presentation of information by a teacher to a group of learners. This format is most effective when communicating facts.
11. When the newly diagnosed insulin-dependent diabetic patient tells the nurse that he has never received instruction on the administration of injections, an appropriately stated nursing diagnosis for the patient is
A)
Self-care deficit related to lack of knowledge about injections
B)
Knowledge deficit related to lack of knowledge about injections
C)
Deficient knowledge of injection administration as verbalized by the patient related to the lack of instruction and experience
D)
Ineffective healthcare maintenance related to diabetic instructions
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Ans:
289
C
Many factors can contribute to a knowledge deficit, such as a lack of exposure, lack of recall, information misinterpretation, cognitive limitations, lack of interest in learning, and unfamiliarity with information resources.
12. A home health nurse is visiting a 40-year-old man who has had abdominal surgery. He is unable to change his dressing because of obesity. The nurse is to instruct his wife on the sterile dressing technique. During the visit, the nurse notes that the wife has limited abilities due to mental disabilities. One assessment to determine the wifes literacy would be
A)
To assess her motivation to provide care
B)
To assess her educational records
C)
To assess her manner of speech
D)
To assess her reading with WRAT
Ans:
D Feedback: Tools to determine literacy include reading tests such as the Wide Range Achievement (WRAT) and Rapid Estimate at Adult Literacy in Medicine (REALM), which ask a person to read a passage out loud.
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Feedback: 13. The parents of an infant suffering from apnea need to be educated on the apnea monitor and cardiopulmonary resuscitation. What should the nurse assess first regarding the parents?
A)
Educational levels
B)
Home environment
C)
Infant bonding
D)
Baseline knowledge of these concepts
Ans:
D Feedback: Before educating parents on the apnea monitor and cardiopulmonary resuscitation, the nurse should determine the parents baseline knowledge so that the nurse knows where to begin. Educational level would be the next assessment in order to plan the appropriate teaching delivery method.
14. When the nurse instructs a patient about breast self-examination, the primary purpose of the patient education is
A)
Wellness promotion
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Restoration of function
C)
Illness prevention
D)
Promotion of coping
Ans:
C
291
Patient education also focuses on teaching patients the knowledge and skills for early detection or prevention of disease and disability. Studies have proven the importance of early detection and support of teaching breast self-examination.
15. Educating women on diet and exercise is an example of what type of patient education?
A)
Health promotion
B)
Disease prevention
C)
Health protection
D)
Health restoration
Ans:
A Feedback:
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Feedback: Health promotion activities are general recommendations and concentrate on improving someones overall well-being.
16. When providing patient teaching it is essential for the nurse to incorporate what action so that learning can be optimized?
A)
Have the patients read material after patient teaching
B)
Be sure that patients are formally engaged
C)
Include teaching strategies that encourage patients to be active participants
D)
Administer tests to evaluate learning
Ans:
C Feedback: The teachinglearning relationship is a dynamic, interactive process that involves active participation from the nurse and patient.
17. When establishing a teaching-learning relationship with a patient, it is most important for the nurse to remember that effective learning can best be achieved through which concept?
A)
The nurse is the expert in the teaching-learning environment
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
The nurse must be able to handle criticism during the process
C)
The patient and the nurse are equal participants
D)
Assimilation and application of psychomotor concepts is essential
Ans:
C Feedback:
293
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Effective learning occurs when patients and healthcare professionals are equal participants in the teaching-learning process.
18. A nurse assisting a new mother in the act of breast feeding is represented by which form of learning?
A)
Affective
B)
Psychomotor
C)
Cognitive
D)
Simplistic
Ans:
B Feedback: Psychomotor refers to the muscular movements learned to perform new skills and procedures.
19. A patient shares with the nurse how much she appreciates understanding the physiology of her breastfeeding. She states, I felt very comfortable with what you explained to me and I feel I will be successful at breastfeeding. In affective learning, this represents
A)
Creating a teaching opportunity for the future
B)
Creating an atmosphere for discussion of feelings
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Creating specific learning sessions for new information
D)
Creating rational thought and learning
Ans:
B
295
Feedback: When working with patients to change beliefs, values, and attitudes, the nurse creates an atmosphere in which patients can honestly and freely discuss their feelings and emotions. 20. A patient states to the nurse, I understand that I need a mastectomy for the treatment of my breast cancer, but I am fearful of learning about the drains I will need to empty. This is an example of
A)
Affective learning
B)
Psychomotor learning
C)
Cognitive learning
D)
Behavioral learning
Ans:
A Feedback:
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Affective refers to emotions or feelings. Affective learning changes beliefs, attitudes, or values.
21. Which learning domain is the focus for instruction when the nurse teaches a new mother about the breast and its role in milk production for feeding the newborn?
A)
Affective
B)
Psychomotor
C)
Cognitive
D)
Behavioral
Ans:
C Feedback: Teaching a new mother about the physiology of the breast and its role in milk production is an example of cognitive learning.
22. The nurse has educated the patient on the pathophysiology of osteoarthritis and degenerative joint disease. This is an example of what learning theory?
A)
Adaptive learning theory
B)
Behavioral learning theory
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Cognitive learning theory
D)
Developmental learning theory
Ans:
C
297
Feedback: Cognitive learning theory is the result of people wanting to make sense of the world around them by assimilating and processing information to gain new understandings and insights.
23. A home health nurse states to her patient, I am very proud of you. You gave your first insulin injection without a problem. You have done wonderfully and are learning fast. What technique is the nurse using to compliment the patients progress?
A)
Reinforcement
B)
Motivation
C)
Health promotion
D)
Positive feedback
Ans:
D Feedback:
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Important keys to success when evaluating learning are consistent, immediate, and frequent positive reinforcement, and teaching a small number of skills at any one time, thus creating a high possibility that the learner will master them.
24. To meet accreditation standards regarding patient care, a healthcare facility must show evidence of A)
Employee satisfaction surveys
B)
Financial accounts and statements
C)
Documentation of indigent care
D)
Patient education documentation
Ans:
D Feedback: The Joint Commission also has established standards for patient education that healthcare agencies must meet to receive accreditation.
Chapter 16- Caring for the Older Adult
1. The nurse is caring for an elderly patient on the medical unit admitted for diagnostic testing. He is alert and oriented and lives independently in his own home. Which nursing intervention will be most effective in the prevention of falls for this patient?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Using a gait belt each time he ambulates
B)
Ensuring his glasses are close by his bed
C)
Placing a bed alarm on his bed
D)
Moving him to a room close to the nurses station
Ans:
B
299
Feedback: This patient does not require aggressive fall prevention measures since he lives independently, is only having diagnostic testing, and is alert and oriented. Keeping his glasses close by will ensure the use of sensory appliances necessary to prevent falls.
2. The nurse in a community health clinic is aware of the significant problems with nutrition in the elderly population. What percentage of the eldery living on their own consume fewer than 1,000 calories per day?
A)
8%
B)
16%
C)
24%
D)
32%
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Ans:
300
B Feedback: Approximately 16% of community-dwelling older adults consume fewer than 1,000 calories per day. Due to various factors of people 75 years or older, an estimated 40% of men and 30% of women are at least 10% underweight.
3. The nurse performs an assessment on a newly admitted elderly patient. The patient receives a score of 12 on the Braden scale. What is the risk for impaired skin integrity for this patient?
A)
No risk
B)
Low risk
C)
Moderate risk
D)
High risk
Ans:
D Feedback: The Braden scale is used to assess the risk for the development of pressure ulcers. A score of 15-16 indicates a low risk, 13-14 indicates a moderate risk, and a score of 12 or less is indicative of a high risk for pressure ulcer development.
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4. The home care nurse is aware of the growing problem of the mistreatment of the elderly population. How many elderly in the United States are estimated to be mistreated every year?
A)
700,000 to 1.2 million
B)
1.2 to 1.7 million
C)
1.7 to 2.2 million
D)
2.2 to 2.7 million
Ans:
A Feedback: As of 2008 it was estimated that 700,000 to 1.2 million elderly adults were the victims of physical, sexual, psychological, or financial mistreatment or neglect.
5. Which group of individuals in the elderly population are most likely to be widowed?
A)
Women under the age of 65
B)
Men under the age of 70
C)
Men over the age of 75
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D)
Women over the age of 75
Ans:
D
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Feedback: Loss and grief are a significant factor in the elderly population. In 2008, almost half of women (42%) were widowed by age 65, compared with 14% of men. Of women 75 years or older, only 28.9% lived with a spouse (AOA, 2009). 6.
The nurse is preparing a presentation on chronic pain management to a group of elderly members of a community senior citizens center. Which chronic disease should the nurse focus on in her presentation?
A)
Rheumatoid arthritis
B)
Amputation
C)
Neuropathy
D)
Osteoarthritis
Ans:
D Feedback:
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The nurse should focus on pain control for individuals with osteoarthritis since this disorder is the most frequent cause of chronic pain in the elderly population.
7. The student nurse is conducting an informal study on pain management in the elderly population in a local long-term care facility. Which elderly patient population will the student most likely find to receive the least effective pain management?
A)
Residents 85 years or older
B)
Residents that have unaffected cognition
C)
White females
D)
Residents with chronic illness
Ans:
A Feedback: Studies indicate that an estimated 80% of nursing home residents have substantial, often unrecognized, and undertreated pain (National Pain Foundation, 2010). Older adults least likely to receive analgesics include those 85 years or older, those of a minority race, and those with low cognitive performance.
8.
An elderly patient tells his home care nurse that he doesnt seem to sleep as well as he used to. The nurse is aware that the sleep changes that occur in the elderly patient that cause a less restful sleep include:
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
A decrease in stage I of the sleep cycle
B)
A decrease in the deep sleep stage of the sleep cycle
C)
A change in the normal progression of the sleep cycle
D)
An increase in stage II of the sleep cycle
Ans:
B
304
Feedback: The changes to the sleep cycle that usually occur in the elderly are an increase in stage I and a decrease in deep sleep. These changes lead to a less restful sleep and more frequent awakenings during the night. 9.
The unit manager at a long-term care facility is concerned with the recent weight loss of several residents. The nurse plans a staff inservice to discuss weight loss in the elderly, including identifying what possible causes? Select all that apply.
A)
Decreased thirst and smell
B)
Alterations in taste
C)
Early satiation (feeling full)
D)
Anorexia
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E)
Decline in physical activity
Ans:
A, B, C, D, E
305
Feedback: According to the IOM (2010), various physiologic processes are identified as causes for decreased nutrition intake in the elderly. These processes include decreased thirst and smell, alterations in taste, early satiation (feeling full), and anorexia. Decreased dietary intake is also associated with a decline in physical activity that further limits the intake of essential micronutrients. 10. A nursing student is looking at the demographics related to the older adult and finds that what percent of the elderly population that is institutionalized falls into the age range of 85+ years?
A)
1.3%
B)
2.4%
C)
3.8%
D)
15.4%
Ans:
D Feedback:
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Of the elderly population that is institutionalized, as of 2008 the percentage increases with age with 1.3% of persons 65-74 years, 3.8% of persons 75-84 years and 15.4% of persons 85+ years institutionalized. Approximately 2.4% of the elderly lived in senior housing with at least one supportive service available to their residents.
11. An elderly patients daughter asks if the doctor can prescribe an antipsychotic medication for her father because he is so confused and agitated much of the time. The nurse is aware that the patient should only be prescribed this medication when which of the following strategies has failed? (Select all that apply)
A)
Behavioral
B)
Environmental
C)
Perceptual
D)
Chemical
E)
Social
Ans:
A, B, E Feedback: Due to the side effects and adverse reactions that may occur with antipsychotic medications, behavioral, environmental, and social strategies should be attempted to help improve cognition.
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12. The hospice nurse is visiting the elderly wife of a patient 4 weeks after the patient died. Which of the following comments by the wife concerns the hospice nurse the most?
A)
I havent started cleaning out my husbands closet yet.
B)
It is so hard to think that I wont see my husband again.
C)
Sometimes I just sit and cry.
D)
Eating alone is so lonely. I just lose my appetite when I think about it.
Ans:
D Feedback: The psychosocial aspects of eating alone after the death of a spouse can lead to problems in maintaining adequate nutrition. Leaving the closet untouched, missing her husband, and crying 4 weeks after the loss are normal grieving responses.
13. A 76-year-old man is recovering from a myocardial infarction. In regards to his recovery, it is important for the nurse to
A)
Address any questions about sexuality
B)
Have a male counterpart address sexuality
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Refer the patient to a therapist
D)
Instruct him to eliminate sex for 1 month
Ans:
A
308
Feedback: With regard to sexuality, the nurse should spend time with the older adult; use clear, easy-to-understand language; help the patient feel more comfortable talking about sex; be open minded and talk openly; listen, encourage discussion; give advice or suggestions as needed; and understand that sex is not just for the young.
14. Which of the following factors contributes to sleep disturbances in older persons?
A)
Exercise
B)
Regular bedtime
C)
Decreased caffeine
D)
Beta-blockers
Ans:
D Feedback:
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Older persons experience impairment of sleep. Beta-blockers contribute to sleep disturbances.
15.Changes in T-cell function in the elderly will result in
A)
Active immunity
B)
Inadequate nutrition
C)
Risk of infection
D)
Onset of chronic disease
Ans:
C Feedback: Humoral immunity declines because of changes in T-cell function, and older adults have lower antibody response to microorganisms that cause pneumonia and infection.
16. A patient has an unsteady gait related to arthritis. His daughter states he walks better when he is at the grocery store pushing a cart. The nurse should recommend
A)
A total knee replacement
B)
An appointment with the orthopedist
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C)
The patient use a wheeled walker
D)
The physician review the medications
Ans:
C
310
Feedback: Instituting appropriate interventions relies on a thorough assessment of the persons mobility impairments. Interventions may include muscle strengthening, range-ofmotion exercises, gait and balance training, and assistive devices such as canes or walkers.
17. Which of the following activities performed by an elderly patient would make the patients family suspicious of the onset of dementia?
A)
The patients air conditioning is broken and he has not reported it
B)
The patient is an accountant and has had three episodes of bookkeeping errors
C)
The patient has not attended church services for one month
D)
The patient has become confused with medications since two new medications were added
Ans:
B
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Feedback: Conditions that mimic dementia or depression present distinct challenges because they impair thinking, mood, and communication. Such conditions also affect the older adults ability to manage self-care.
18. Which group of individuals has the highest rate of suicide in the United States?
A)
Older white men
B)
Older white females
C)
Older African American males
D)
Older Hispanic males
Ans:
A Feedback: Currently, older white men have the highest rate of suicide in the United States.
19. An elderly patient is being treated with a tricyclic antidepressant medication. What adverse reaction should the home care nurse observe for?
A)
Syncope
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B)
Atrial fibrillation
C)
Falls
D)
Polyphagia
Ans:
B
312
Feedback: Tricyclic antidepressants may induce arrhythmias or may worsen preexisting heart failure.
20. An elderly patient informs the nurse, I just dont feel like myself. I cry so easily and my mobility is so bad from my degenerative disc disease in my back. What factor is most likely contributing to the patients depression?
A)
Pain
B)
Shortness of breath
C)
Hearing loss
D)
Diminished vision
Ans:
A Feedback:
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Many factors place an older adult at risk for depression, including recent bereavement, a change in environment, alcohol or substance use, and chronic pain. 21. When the home care nurse visits a 78-year-old female patient who is recently widowed and finds that the home is cluttered with trash and the patient appears sad and disheveled, the nurse should assess the patient for symptoms of
A)
Fatigue
B)
Presbyopia
C)
Drug overdose
D)
Depression
Ans:
D
Feedback: Symptoms of depression include poor cognitive performance, sleep problems, and lack of initiative. 22. A patient with Alzheimers disease becomes agitated and is unable to communicate. The nurse notes that this is a change from his regular demeanor. The nurse performs a thorough assessment of the patient, determining that he has an abscessed tooth. This assessment can be termed
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Health promotion
B)
Illness prevention
C)
Validation therapy
D)
Restorative therapy
Ans:
C
314
Feedback: Validation therapy is a type of interpersonal interaction in which the health professional attempts to understand and validate the patients current needs.
23. A patient is in the postoperative phase of an abdominal resection and colostomy. When educating the patient on his ostomy care by providing him with educational materials to read, it is important to assess the patients
A)
Hearing
B)
Vision
C)
Pain
D)
Gait
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315
B Feedback: Appropriate sensory appliances (glasses and hearing aids) assist older adults in interacting appropriately with their environment.
24.In 2008, what percentage of older adults resided in nursing homes?
A)
2.5%
B)
3.5%
C)
4.1%
D)
5.5%
Ans:
C Feedback: In 2008, 4.1% of older adults resided in nursing homes.
25. The largest growing population of individuals over 65 years in both the United States and Canada is
A)
65 to 70 years
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
70 to 79 years
C)
80 to 84 years
D)
85 years and older
Ans:
D
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Feedback: In 2002, the number of people 65 to 74 years was eight times larger than in 1900, the number of people 75 to 84 years was more than 16 times larger, and the number of people 85 years or older was 38 times larger.
Chapter 17- Safety
1.
The occupational health nurse is planning a safety inservice for a group of clerical workers. Which of the following topics would be most beneficial?
A)
Principles of body alignment
B)
The use of protective clothing
C)
The use of ear plugs
D)
Appropriate storage of combustable cleaning solutions
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Ans:
317
A Feedback: The clerical worker is primarily sedentary. The greatest concern would relate to body alignment and positioning. Ear plugs would be most appropriate for the factory worker. The use of protective clothing and the storage of hazardous materials would be topics best suited for janitorial workers.
2. A patient has presented to the Emergency Department after splashing a chemical in the eyes. When managing the injury, which of the following should be included in the plan of care?
A)
Wash the eyes with a hypertonic solution for at least 30 minutes.
B)
Advise the patient to avoid blinking until after the eyes are irrigated.
C)
Flush the eyes with water for 10 minutes.
D)
Flush the eyes with a cool saline solution for a 10-minute period.
Ans:
C Feedback: If poisonous substances have been instilled into the eye or on the skin, immediate irrigation with lukewarm water for 10 to 15 minutes may reduce harmful effects.
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3. The nurse is discussing car safety with the mother of a 6-year-old child. The childs mother questions the need for the use of special car seats for her child. What information can be provided to her?
A)
Car seats are only recommended until children are 3 years old.
B)
At the age of 6 your child should be using a booster seat.
C)
Car seats are recommended until children are at least 10 years old.
D)
Your child will be safe in the car using the provided shoulder harness and lap belts.
Ans:
B Feedback: When children outgrow standard car seats, parents and caregivers should use booster seats, preferably those that use combination shoulder and lap belts, until the car seat belt fits appropriately, typically when they have reached 4 feet, 9 inches in height and are between 8 and 12 years of age.
4.
A)
After identifying a medication error, the nurse completes an incident report. The nurse correctly recognizes which of the following about the use of these documents? Select all that apply.
The incident report should be placed with the patients medical records.
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B)
Incident reports provide a clear, concise recording of the situation that can be provided to the patients legal representative in the event of a lawsuit.
C)
The incident report should include factual information about the incident.
D)
The nurse should include their own personal perception about the cause of the incident in the report.
E)
Completion of the incident report should be noted in the nurses notes.
Ans:
B, C Feedback: An accident, or injury, occurring in the hospital necessitates the filing of an incident report. The document remains confidential and is not part of the patients medical record. It completely describes all the aspects of the event that occurred. Specifically, the report should include the accident, patient assessment, and interventions provided for the patient. The report is used for internal review to improve the system to prevent similar errors and cannot be subpoenaed by a court of law.
5.
The nurse is assessing the patients sensory input. Which of the following assessments should be included? Select all that apply.
A)
Assessment of sensitivity to touch
B)
Assessment of sensitivity of sharp to dull stimulation
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Assessment of ability to maintain balance
D)
Assessment of pupil sensitivity to light changes
E)
Assessment of ability to recall information
Ans:
A, B, C
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Feedback: Examination of sensory function allows the nurse to verify the accuracy and quality of sensory input. Testing should include ability to balance, sensitivity to sharp versus dull stimulation, and sensitivity to light touch of the extremities.
6.
The nurse is assessing a patients mental health competence and
decision-making ability. What activities will best provide the needed information to the nurse? A) Ask the patient to read and discuss a passage from a pamphlet.
B)
Ask the patient what if questions to determine level of thought organization.
C)
Ask the patient to review his medical health history to assess for the level of organization of his thought processes.
D)
Discuss with the patients family any concerns about his mental stability.
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Ans:
321
B Feedback: When reviewing mental health and level of decision-making ability, the best method is to ask the patient what if type of questions. Assessing the patients reading ability and understanding of passages read will not provide the needed information. Asking the patient to discuss his medical history will provide some information but will not provide information on his ability to reason and make clear decisions. Questioning the family provides only a secondary source of information and will not be as effective.
7.
A nurse is completing an intake assessment. The nurse notes that an older
adult male patient appears to have bruises in varying stages of healing. Which of the following actions by the nurse indicates an understanding of her responsibilities? A)
The nurse should notify the primary care physician
about the bruises.
B)
The nurse should contact the facilitys social services department.
C)
The nurse should question the patient about the source of the bruises.
D)
The nurse should request permission from the patient to photograph the bruises.
Ans:
C
Feedback:
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The initial action by the nurse would be to determine the source of the bruises. If suspicion remains, the nurse should question the patient. If the nurse feels there is potential abuse the nurse is obligated to report it.
8.
The nurse is preparing to discuss safety with a group of parents of infants. When planning the program, which of the following topics would be most important to include?
A)
The use of skid-proof mats for the bath tub
B)
The use of safety gates at stairwells
C)
Correct placement of booster seats for the car
D)
The use of flame retardant pajamas
Ans:
D Feedback: Infant safety education should include car seats, the use of electrical outlet covers, and flame retardant clothing. The use of skid-proof mats in the bathtub, safety gates, and booster seats are topics more suited to the parents of preschool children.
9.
A)
The nurse manager is reviewing the QSEN quality and safety competencies for nurses. Which of the following are included in this initiative? Select all that apply.
Patient-centered care
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B)
Teamwork and collaboration
C)
Establishment of clinical career ladders
D)
Development of multidisciplinary committees to review patient satisfaction
E)
Quality improvement (QI)
Ans:
A, B, E Feedback: The Quality and Safety Education for Nurses (QSEN) project has been designed to provide a framework for the knowledge, skills, and attitudes necessary for future nurses. The six competencies include: Patientcentered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics.
10. The facility is conducting an educational seminar for newly employed nurses. The program addresses the reporting of sentinel events. Which of the following occurrences qualify for this criteria? Select all that apply.
A)
A patient reports plans to file a complaint concerning the amount of time it took for a nurse to respond to a call light.
B)
A patients baby is misidentified and receives breast milk from another mother.
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C)
A patient experiences a reaction to a unit of blood, resulting in itching and hives.
D)
A patient faints during ambulation with the nurse, resulting in a concussion.
E)
The nurse administers a lethal dosage of medication in error.
Ans:
B, D, E Feedback: A sentinel event is one in which a patient experiences death or serious injury.
11. The nurse has committed a medication error. The nurse administered an antibiotic dosage greater than the dosage prescribed. The patient did not experience any adverse effects. What initial action by the nurse is most appropriate?
A)
Report the actions as a sentinel event
B)
Contact the nursing supervisor
C)
Notify the physician
D)
Complete an incident report
Ans:
C
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Feedback: Notification of the physician is an initial action after a medication error of this nature has taken place. A sentinel event is one that results in death or serious injury. The nursing supervisor may require notification but after the physician has been contacted.
12. The health department is reviewing community health initiatives for the year. During the summer, health department focuses infection control activities on which of the following programs?
A)
Administering immunizations
B)
Administering free antibiotics
C)
Using pesticides for mosquitoes
D)
Delivering fans to elderly residents
Ans:
C Feedback: Community problems such as water supply contaminated with sewage or tick infestations near residential areas also can result in infection. Immunization administration projects are not limited to the summer months. Antibiotic administration is not a prevention program but one geared to disease treatment. Fans may be delivered to the elderly but this intervention will not reduce infection.
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13. The facility risk management team is preparing an inservice to nursing staff members. The presentation will highlight risk factor increase related directly to the type of patientele on a nursing unit. The presenter will correctly explain that which of the following risks is increased for female nurses who work on an oncology care unit?
A)
Back injuries
B)
Bloodborne pathogens
C)
Adverse reproduction
D)
Neurologic disorders
Ans:
C Feedback: Common risks in healthcare facilities are exposure to bloodborne pathogens from stick injuries via used needles, back injuries caused by heavy lifting, and potential adverse reproductive outcomes as a result of overexposure to antineoplastic medications. On oncology divisions, the nurse is continually exposed to antineoplastic agents.
14. The nurse instructs the family of an elderly patient with a visual impairment and decreased mobility that the most common problem for these patients is related to which of the following?
A)
Electrical cords
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Medication errors
C)
Falls
D)
Aspiration
Ans:
C
327
Feedback: The risk of falls increases when a person of advanced age, impaired mobility, or both encounters these hazards.
15.In large metropolitan areas, patients who suffer from asthma will be affected by
A)
Air pollution
B)
Noise pollution
C)
Radiation
D)
Asbestos contamination
Ans:
A Feedback:
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Air pollution increases the risk for and severity of respiratory problems, such as asthma and chronic bronchitis.
16. A patient has developed neuropathy as he has aged. What would be the most important teaching intervention for the patient and family?
A)
Provide a comfortable temperature in the home
B)
Reduce the temperature on the water heater
C)
Keep the environment warmer in winter
D)
In high temperatures, have adequate ventilation
Ans:
B Feedback: The principles of a safe environment for older adults follow the same general guidelines as those for all ages: comfortable temperature range; adequate clothing; bath water of the right temperature (the setting on the hot water heater may need to be reduced); adequate ventilation; and lighting that allows for safe navigation throughout the house at all times of day. Patients with neuropathy will definitely need the hot water heater temperature reduced.
17. The older adult will have an increased risk for developing which of the following?
A)
Fire hazards
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Gun shot wounds
C)
Heatstroke
D)
Poisoning
Ans:
C
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Feedback: The ability to thermoregulate may become impaired; older adults are at higher risk than younger adults for hypothermia and heatstroke.
18. Which of the following statements should the nurse include in the teaching plan regarding safety issues that she is preparing for a group of adult patients?
A)
In most age groups, motor vehicle accidents are major causes of death
B)
Suicide is the leading cause of death in adults and adolescents
C)
Occupational safety controls for all workplace hazards
D)
Environmental lead is a primary cause of death in adult patients
Ans:
A Feedback:
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Motor vehicles continue to be the major cause of deaths related to unintentional injuries for all age groups up to 80 years.
19. Which of the following reasons best explains why adolescents behave in an unsafe manner despite knowledge of a particular activitys risk?
A)
Past experience
B)
Poor judgment
C)
Social pressure
D)
Normal rebellion
Ans:
C Feedback: As adolescents explore opportunities, they may know that certain behaviors are unsafe, but social pressure can persuade them to act against their better judgment.
20. A group of girls are camping in the woods with camp counselors. They should be instructed to
A)
Get adequate amounts of sleep
B)
Use the buddy system
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Eat nutritious foods
D)
Run on smooth surfaces
Ans:
B
331
Feedback: The buddy system, a prearranged agreement between two or more people to provide mutual companionship and to monitor each others whereabouts and well-being during certain high-risk activities, is an important outdoor and water safety strategy.
21. A child is learning to ride a bicycle. He should be instructed to use which of the following protective devices?
A)
Helmet
B)
Wrist guard
C)
Knee pads
D)
Light
Ans:
A Feedback:
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Children should wear properly fitted helmets when cycling, riding, or playing contact sports. Helmets will help to protect against head injury. Knee pads and wrist guards will protect but not with the same degree of importance as a helmet.
22.When educating families on fire safety, it is important to
A)
Have a meeting place outside the home
B)
Account for all members and then exit
C)
Use extension cords to prevent shock
D)
Keep a fire extinguisher in a closet
Ans:
A Feedback: The whole family should regularly practice crawling on the floor, using escape routes, and having a meeting place outside the home in case of fire. Attempting to account for all family members before exiting the burning structure is dangerous and may result in the loss of life. Shock is possible with extension cords. Having a fire extinguisher is important but it should be kept in an area with access and not a closet.
23. A nurse instructs a group of parents of preschool-age children that the rules of safe social interaction for this age group are often learned by
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Trial and error
B)
Interaction with parents
C)
Interaction with peers
D)
Through preschool
Ans:
A
333
Feedback: Preschoolers learn the rules of safe social interaction by trial and error.
24. Which of the following safety topics is the most appropriate for the nurse to discuss with mothers of preschoolers?
A)
Taking baths alone
B)
Bicycle safety
C)
Crossing streets alone
D)
Safety zones
Ans:
D
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Feedback: Preschoolers usually can avoid bumps and learn to climb safely up and down stairs. They also benefit from learning about safety zones, which are safe places to stand or sit when potentially dangerous activity is underway.
25. When educating parents of preschoolers, what is most important to include in your presentation?
A)
Use wrist guards with rollerblades
B)
Teach preschoolers to tread water
C)
Keep chemicals in a locked cabinet
D)
Strict discipline with potty training
Ans:
C Feedback: Increasing mobility, lack of life experience and judgment, and still immature musculoskeletal and neurologic systems lead to potentially hazardous encounters for toddlers and preschoolers.
26. What national organization determined that unintentional injuries were the fifthleading cause of all deaths in the United States?
A)
Centers for Disease Control and Prevention
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
American Medical Association
C)
American Nurses Association
D)
National Patient Safety Foundation
Ans:
A
335
Feedback: The Centers for Disease Control and Prevention determined that unintentional injuries were the fifth-leading cause of all deaths in the United States in 2002.
27. Which of the following items would alert the home care nurse to a safety hazard threatening to a young child?
A)
Three blankets in a crib
B)
A gated stairway
C)
Padded child safety seat
D)
Dangling blind cords
Ans:
D Feedback:
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As babies gain neurologic and musculoskeletal functions, they learn and explore by pulling objects to themselves and placing almost everything in their mouths. Cords, tablecloths, plastic bags, bottles, and cans are tempting, dangerous objects that caregivers must strive to keep out of reach.
28. One of the leading causes of death in the United States, particularly in southwestern states, is drowning. How can the nurse assist in lowering this statistic?
A)
Educate children in cardiopulmonary resuscitation
B)
Begin swim lessons with toddlers
C)
Implement drowning-prevention strategies
D)
Require fencing around all pools
Ans:
C Feedback: The principles of injury control have interventions centered at three primary levels: the individual level, providing education about safety hazards and prevention strategies; the design phase, using engineering and environmental controls; and the regulatory level, creating, monitoring, and enforcing regulations to ensure safe products and environments among manufacturers, retailers, employers, workers, and product users.
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Chapter 18- Health Assessment
1.
A parent of a school age child is told her child has normal vision. The school nurse explains the childs vision is
A)
20/20
B)
20/40
C)
20/60
D)
20/200
Ans:
A Feedback: Normal vision is associated with at or near 20/20, full field of vision, and tricolor vision (red, green, blue).
2. Peripheral cyanosis and clubbing of the nails are symptoms of
A)
Normal aging
B)
Increased cholesterol
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C)
Hypertension
D)
Chronic hypoxia
Ans:
D
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Feedback: Hypoxia of the tissues changes normal pink-color skin to a grayish or bluish color.
3. A nurse auscultates the right carotid artery in an elderly client and identifies a bruit. What does this assessment finding mean?
A)
It is normal
B)
It is distended
C)
It is dissecting
D)
It is inflamed
Ans:
B
Feedback:
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Bruits occur when the artery is partially obstructed or distended, which prevents blood flow from moving straight through the vessel.
4.
To assess an adult clients hearing, the nurse performs the Rinne test by activating the tuning fork and placing it first at the
A)
Front of the ear
B)
Mastoid process
C)
Top of the head
D)
Affected ear
Ans:
B Feedback: Strike the tuning fork and place its stem firmly against the mastoid process.
5. A grating feel and noise with joint movement, particularly in the temporomandibular joint, is called
A)
Inflammation
B)
Arthritis
C)
Crepitus
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Fremitus
Ans:
C
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Feedback: Problems with the temporal mandibular joint include pain or a grating feeling called crepitus.
6. When performing a cranial nerve assessment on an adult client, the nurse assesses the trigeminal nerve by
A)
Asking the client to smile
B)
Eliciting the clients gag reflex
C)
Having the client turn his head
D)
Eliciting the clients blink reflex
Ans:
D Feedback: To assess the trigeminal or cranial nerve V, the nurse should elicit the blink reflex with a cotton swab.
7. To assess a clients visual accommodation, the nurse has the client
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Stand 20 feet from the Snellen chart
B)
Sit still while a penlight is shined at the pupil
C)
Look straight ahead with one eye covered
D)
Look at a close object, then at a distant object
Ans:
D
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Feedback: Accommodation can be tested by having the client look at a close object and then look at a distant object.
8.
While assessing a 48-year-old clients near vision, you can anticipate the client will state that her vision is
A)
Clear
B)
Blurred
C)
Clouded D) 20/20
Ans:
B Feedback:
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Visual problems with close objects occur more frequently after the age of 40.
9. When percussing the liver, the sound should be
A)
Resonant
B)
Hyperresonant
C)
Dull
D)
Flat
Ans:
C Feedback: The percussion of the abdomen is tympanic, hyperinflated lung tissue is hyperresonant, normal lung tissue is resonant, the liver is dull, and bone is flat.
10.During a health assessment, the nurse uses deep palpation to assess a clients
A)
Skin turgor
B)
Finger nodules
C)
Perspiration
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Liver
Ans:
D
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Feedback: The purpose of deep palpation is to locate organs, determine their size, and detect abnormal masses.
11. A nurse collects objective data on a client during a health assessment that includes the clients
A)
Blood pressure
B)
Fatigue level
C)
Presence of pain
D)
Symptoms of nausea
Ans:
A Feedback: Fatigue, pain, and nausea are subjective symptoms. Blood pressure is measured through auscultation and is an objective assessment.
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12. To obtain data about an adult clients sexuality and reproductive pattern, the nurse should ask the client
A)
How often do you have sexual intercourse?
B)
What arouses you when you have intercourse?
C)
How many children do you have, both living and dead?
D)
Has anything changed your sexual performance?
Ans:
D Feedback: The sexual assessment is not meant to illuminate nonexistent problems. Rather, the client is, in effect, given permission and encouragement to present sexually related questions.
13. To obtain subjective data about a newly admitted clients sleep pattern, the nurse
A)
Inspects the clients eyes for redness
B)
Asks the client what promotes sleep
C)
Documents the clients affect and yawning
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Determines how frequently the client naps
Ans:
B
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Feedback: The assessment of sleep and rest focuses on the clients normal sleep patterns, alterations from the normal pattern, and satisfaction with quality of rest and sleep.
14.To assess subjective data related to a clients elimination pattern, the nurse
A)
Reviews the latest laboratory report of the urine
B)
Asks the client about changes in elimination patterns
C)
Notes the frequency, amount, and time the client voids
D)
Palpates the abdomen for pain or distention
Ans:
B Feedback: Focus the interview on the clients normal urinary and bowel patterns, noting any recent changes.
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15. A client had a cerebrovascular accident yesterday and is currently comatose. What type of scale should the nurse use to weigh the patient?
A)
Bathroom scale
B)
Large floor scale
C)
Chair scale
D)
Bed scale
Ans:
D Feedback: A bed scale is used for clients who are too weak or immobile to use other scales safely.
16.What percentage of weight change in 6 months is considered abnormal?
A)
1%
B)
2%
C)
5%
D)
10%
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D Feedback: A 10% change in weight in 6 months is considered abnormal.
17. To gather subjective data on a clients nutrition and metabolic pattern, the nurse should
A)
Weigh the client and measure his height
B)
Ask the client for a 24-hour diet recall
C)
Examine the hygiene of the clients teeth
D)
Inspect the clients abdomen for symmetry
Ans:
B Feedback: Interview questions to focus a nutritionmetabolism assessment might include asking the client to tell you what has been eaten in the last 24 hours.
18. A client states during the interview that he has pain in his lower back. He states it is a 10 on a scale of 1 to 10 when he is asked to turn. The nurse should
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Avoid a position change that requires turning
B)
Have the client turn from side to side and assess pain
C)
Have the client lay on his right side, then palpate the area
D)
Elevate the legs, bending at the knee while the client is supine
Ans:
A
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Feedback: Addressing pain early in the health assessment allows the nurse to individualize the rest of the assessment, avoiding positioning and techniques that are especially uncomfortable for the client.
19. Upon admission to the hospital, the client states, I am having surgery to correct my back. I have pain in the lower back and the doctor is going to do a lumbar laminectomy. This statement reflects the clients
A)
Symptoms
B)
Review of systems
C)
Chief complaint
D)
Objective assessment
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C Feedback: The first subject discussed in a client interview is the clients specific reason for seeking care. The subject is often called the clients chief complaint or chief concern.
20.When examining a client upon admission to the hospital, it is important to
A)
Provide privacy and confidentiality
B)
Assess for fear and anxiety
C)
Assess in a semi-private room
D)
Have the family present
Ans:
A Feedback: Privacy and confidentiality are important concerns for the client.
21. A nurse is using the assistance of an interpreter. When interviewing a client who does not speak English, the nurse should
A)
Assess the clients vital signs first
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Interpret the effect of deep palpation
C)
Inspect the symmetry of the facial features
D)
Observe the clients body language
Ans:
D
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Feedback: When using an interpreter, the nurse should observe the cues the client expresses with body language, and listen to the tone of voice.
22. An intensive care unit nurse reports the clients condition to the nurse on the medical unit. This is a(an)
A)
Primary source
B)
Secondary source
C)
General report
D)
Informational report
Ans:
B Feedback:
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Secondary data sources include sources of data other than the client, such as the chart or other healthcare providers.
23.Which framework is used during the focused assessment?
A)
Functional health assessment
B)
Head-to-toe framework
C)
Conceptual framework
D)
Body systems framework
Ans:
D Feedback: Body systems approach is used during the focused assessment of an acutely or critically ill client to determine function of a particular body system.
24. The nurse assesses the clients lung sounds following the clients period of coughing. This is a(an) example of
A)
Subjective data
B)
Objective data
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Focused data
D)
Comprehensive data
Ans:
B
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Feedback: Objective data can be directly observed or measured, such as vital signs or appearance.
25. A client states, I have trouble sleeping. I only sleep about 2 hours and then I wake up. This is
A)
Subjective data
B)
Objective data
C)
Focused data
D)
Comprehensive data
Ans:
A Feedback:
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Subjective data are those symptoms, feelings, perceptions, preferences, values, and information that only the client can state and validate.
26. During a nurses visit to the clients home, the client states, I have pain in my right knee. The nurse assesses the clients right knee. This is a
A)
Focused assessment
B)
Spiritual assessment
C)
Social assessment
D)
Comprehensive assessment
Ans:
A Feedback: Often, nurses must select the most important interviewing questions or assessment techniques to use and perform a focused health assessment based on the clients problem.
27.When a client enters the acute care facility, the nurse should perform a
A)
Focused health assessment
B)
Spiritual health assessment
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Physical health assessment
D)
Comprehensive health assessment
Ans:
D
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Feedback: A comprehensive health assessment encompasses the physical, psychological, social, and spiritual dimensions of living.
Chapter 19- Vital Signs
1.
The nurse is taking the apical pulse of a 6-month-old infant. Upon completion, the nurse tells the parent the babys pulse is 140 beats per minute. The parent is concerned, stating, That seems kind of high! The nurse responds:
A)
Yes, this is termed tachycardia. I will let the doctor know right away.
B)
Yes, it seems fast but actually, normal infant heart rates are 150-200 beats per minute so it is a bit slow.
C)
I know it seems fast, but normal infant heart rates are 100-160 beats per minute.
D)
Yes, this is termed tachypenia. I will let the doctor know right away.
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355
C Feedback:
The average pulse rate of an infant ranges from 100 to 160 beats per minute.
2.
A patient has had a left-side mastectomy. How does this affect the blood pressure assessment?
A)
Assess the blood pressure in the wrist
B)
There is no effect on the blood pressure
C)
Assessment of blood pressure is impeded
D)
The blood pressure stays within normal range
Ans:
C Feedback: If the patient has had a mastectomy, blood-pressure monitoring on the same side can further impede circulation, contributing to lymphedema.
3.
A)
A patient has smoked most of his life and has labored respirations. He is experiencing
Dyspnea
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Fremitus
C)
Stridor
D)
Wheeze
Ans:
A Feedback: Dyspnea describes respirations that require excessive effort.
4. Patients demonstrating apnea have
A)
Usually have a temporary cessation of breathing
B)
Decreased rate and depth of respirations
C)
Increased rate and depth of respirations
D)
Normal respiratory rate of 20
Ans:
A Feedback:
356
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Apnea, the absence of respirations, is often described by the length of time in which respirations do not occur.
5. A pulse deficit is the difference between
A)
The systolic and diastolic blood pressure readings
B)
Palpated and auscultated blood pressure readings
C)
The radial pulse and the ulnar pulse rates
D)
The apical pulse and the radial pulse rate
Ans:
D Feedback: When a pulse deficit is present, the radial pulse is always lower than the apical pulse rate.
6. An adult pulse greater than 100 beats per minute is
A)
Bradycardia
B)
Bradypnea
C)
Tachycardia
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Tachypnea
Ans:
C
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Feedback: Adult pulse rates above 100 beats per minute are termed tachycardia.
7.
An ultrasonic Doppler is used for
A)
Auscultating a pulse that is difficult to palpate
B)
Auscultating diastolic blood pressure
C)
Aiding palpation of pulse and rhythm
D)
Aiding palpation of diastolic blood pressure
Ans:
A Feedback: A Doppler device can be used to detect a pulse that is not easily palpable.
8. A nurse can most accurately assess a patients heart rate and rhythm by which of the following methods?
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A)
Listen with the stethoscope at the fifth intercostals space left midclavicular line
B)
Listen with the stethoscope at the fifth intercostals space at the sternum
C)
Listen with a stethoscope at the neck to the right of the cricoid process
D)
Listen with a stethoscope at the second intercostal space left sternum
Ans:
A Feedback: To assess the apical pulse, the nurse places the stethoscope over the left ventricle. The stethoscope is placed at the level of the fifth intercostals space left midclavicular line.
9. A nurse is assessing an apical pulse on a cardiac patient. The patient is taking digoxin. The nurse can anticipate that the digoxin will
A)
Decrease the blood glucose
B)
Decrease the blood volume
C)
Decrease the apical pulse
D)
Decrease the respiratory rate
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360
C Feedback: Certain cardiac medications, such as digoxin, decrease the heart rate.
10.Infants and childrens pulses vary most with
A)
Respirations
B)
Rest
C)
Eating
D)
Sleep
Ans:
A Feedback: The heart rhythm in infants and children varies markedly with respiration, increasing during inspiration and decreasing with expiration.
11. To assess the patients pulse, the nurse knows the normal range for pulse rate of a healthy adult is
A)
50100 beats per minute
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
60100 beats per minute
C)
60120 beats per minute
D)
70120 beats per minute
Ans:
B
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Feedback: In adults, the SA node initiates the impulse 60 to 100 times per minute.
12. Of the following patients, who should not have a temperature assessed rectally?
A)
Patient with ALS
B)
Patient with cancer
C)
Patient with diarrhea
D)
Patient with a herniated disc
Ans:
C Feedback:
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The rectal route is contraindicated in patients with diarrhea, those who have undergone rectal surgery, those with rectal diseases, and those with cancer who are neutropenic.
13. Based upon circadian rhythms, when would the nurse note the highest temperature during a 24-hour period?
A)
3:00 AM
B)
11:00 AM
C)
3:00 PM
D)
5:00 PM Ans: D Feedback:
Body temperature fluctuates throughout the day. Temperature is usually lowest around 3 AM and highest from 5 to 7 PM.
14. An 80-year-old patient has a body temperature of 97F. Which condition best accounts for this patients temperature reading?
A)
Altered endocrine function
B)
Hypothyroidism
C)
Temperature drops with age
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
The patient is anemic
Ans:
C
363
Feedback: It is not uncommon for elderly persons to have body temperatures less than 97.6 because normal temperature drops as a person ages.
15.Body temperature regulation occurs in a part of the brain known as the
A)
Hypophysis
B)
Hypothalamus
C)
Pineal gland
D)
Thalamus
Ans:
B Feedback: The hypothalamus, located in the pituitary gland in the brain, is the bodys built-in thermostat.
16.When assessing an infants axillary temperature, it will be
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
One degree lower than an oral temperature
B)
One degree higher than a rectal temperature
C)
One degree higher than an oral temperature
D)
The same as the tympanic temperature
Ans:
A
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Feedback: Rectal temperatures may be one degree higher than oral temperatures, and axillary temperatures are one degree lower than oral temperatures.
17. The temperature is 102 during a heat wave. The nurse can expect admissions to the emergency room to present with
A)
Increased temperature
B)
Increased cardiac output
C)
Decreased heart rate
D)
Decreased respirations
Ans:
A
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Feedback: Body temperature can fluctuate with exercise, changes in hormone levels, changes in metabolic rate, and extremes of external temperature.
18.The normal adult temperature obtained through the oral route ranges from
A)
96.698.6 F
B)
97.699.6 F
C)
98.6100.4 F
D)
98.2100.2 F
Ans:
B Feedback: Normal adult oral temperature ranges from 97.699.6 F.
19. A patient in the acute care setting is noted with a rapid, thready pulse. This patient will require
A)
Transfer to the critical care unit
B)
Assessment of cardiac output
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Vital sign assessment every hour
D)
An EKG ordered by the physician
Ans:
C
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Feedback: The nurse caring for the patient may decide to monitor vital signs more frequently if the patients condition changes.
20. During a routine vital sign assessment, you note the patients blood pressure is 212/110. Why is this finding particularly significant?
A)
It allows the nurse to have a baseline value
B)
It deviates from normal and is significant
C)
It is due to the fact the patient is fearful
D)
It is related to a tumor of the adrenal
Ans:
B Feedback: Vital sign trends that deviate from normal are much more significant than isolated abnormal values.
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Chapter 20- Asepsis and Infection Control
1. The nurse explains to the patient the first line of defense against infection
is: A) frequent hand washing with soap and water.
B)
early intervention with antibiotics.
C)
staying home when sick.
D)
intact skin and mucous membranes.
E)
low levels of normal flora.
Ans:
D Feedback:
The first line of defense against infection is intact skin and mucous membranes covering body cavities. 2.
A)
A patient has an inguinal hernia repair and later develops a methicillinresistant Staphylococcus aureus infection. What is the most important factor to prevent this infection?
Surgical asepsis
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Increased T cells
C)
Decreased antibiotics
D)
Increased vitamin C
Ans:
A
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Feedback: Patients are at risk for nosocomial infections when the healthcare staff does not follow safety guidelines. Medical and surgical asepsis is the primary safety intervention for preventing disease in the healthcare environment.
3. A patient has a draining wound that is contaminated with Staphylococcus aureus. The nurse should observe
A)
Droplet precautions
B)
Universal precautions
C)
Reverse precautions
D)
Body-substance isolation
Ans:
D Feedback:
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Body-substance isolation involves the use of barriers to provide protection from all moist body secretions.
4.
When the patient who has been diagnosed with hepatitis B has been hospitalized, the type of isolation the nursing staff should observe is
A)
Droplet precautions
B)
Universal precautions
C)
Reverse precautions
D)
Body-substance isolation
Ans:
B Feedback: Universal precautions relate to blood and certain body fluids to protect healthcare workers from patients possibly carrying HIV, hepatitis B virus, or other bloodborne pathogens.
5.
Disinfectants are used
A)
To prepare instruments for surgery
B)
To sterilize surgical drapes
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
To clean rooms between patients
D)
For preoperative bowel preparations
Ans:
C
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Feedback: A chemical used on lifeless objects is called a disinfectant.
6.
Surgical asepsis is defined as
A)
Absence of all virulent microorganisms
B)
Absence of all microorganisms
C)
Slowed growth of microorganisms
D)
Use of handwashing, gowning, and gloving
Ans:
B Feedback: Surgical asepsis refers to sterile technique and indicates procedures used to eliminate any microorganisms.
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7. To eliminate needlesticks as potential hazards to nurses, the nurse should
A)
Place the uncapped needle on a tray, carry it to the medicine room for disposal
B)
Immediately deposit uncapped needles into puncture-proof plastic container
C)
Stick the uncapped needle into a Styrofoam block and deposit in a plastic container
D)
Slide the needle into the cap and deposit it in a puncture-proof plastic container
Ans:
B Feedback: All uncapped needles should be placed in puncture-proof plastic units immediately after use.
8.
To protect the school-age children from communicable disease, the school nurse maintains records on the childrens
A)
Allergies
B)
Medications
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Diabetes
D)
Immunizations
Ans:
D
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Feedback: The incidence of communicable illness is high among children grouped together for study and play. Schools often employ nurses to teach classes, monitor immunization schedules, and develop and monitor infection control practices and outbreaks of communicable diseases.
9. What is the most common patient site for development of nosocomial infections?
A)
Surgical wound
B)
Respiratory tract
C)
Bloodstream
D)
Urinary tract
Ans:
D Feedback:
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
The urinary tract is the most common site for nosocomial infections.
10. When a nurse picks up a patients contaminated tissue without gloves and fails to wash his hands sufficiently, the nurse provides for the patients organisms to be spread by which type of transmission?
A)
Airborne
B)
Contact
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374
C) Vector
D)
Vehicle
Ans:
B Feedback: Direct contact involves body surfacetobody surface contact, causing the physical transfer of organisms between an infected or colonized host and a susceptible host.
11. A patient has sexual intercourse with someone infected with HIV. The vehicle of transmission is
A)
Semen
B)
Blood
C)
Wound drainage
D)
Sputum Ans: A
Feedback: Vehicle transmission involves the transfer of microorganisms by way of vehicles, or
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contaminated items that transmit pathogens. For example, food can carry Salmonella. In this case, semen can carry human immunodeficiency virus.
12.A patient with HIV is the
A)
Pathogen
B)
Virulence
C)
Specificity
D)
Carrier
Ans:
D Feedback: Patients may become infected from people who have active disease, people in the incubation portion of their disease, or people who harbor pathogens but have no symptoms of disease.
13. Which of the following factors have contributed to resistant microbial strains?
A)
Use of antibiotics for bacterial infections
B)
Use of antibiotics for viral infections
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C) Use of Neosporin with abrasions
D)
Ans:
Use of vitamins with animals
B Feedback: The overprescribing of antibiotics for viral infections has contributed to the evolution of resistant microbial strains.
14. Recently the United States and Canada have seen the development of West Nile virus. It is carried to humans by
A)
Mosquitoes
B)
Humans
C)
Deer
D)
Elk
Ans:
A Feedback:
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Parasites are multicellular organisms that live on other organisms without contributing anything to their hosts. Examples of parasites include protozoa, helminth, and arthropod species. Sexual contact, insects, and domestic animals frequently carry parasites to humans.
15.Hepatitis is classified as a virus that
A)
Is localized in the liver
B)
Causes decreased urine
C)
Results in pallor
D)
Causes tissue damage
Ans:
D Feedback: Some viral infections are acute and controlled by the hosts defense mechanisms; others spread throughout the body and cause severe tissue damage or result in chronic illness.
16. A patient suffers from bloody diarrhea after eating at a local restaurant. The patient has been infected with a(an)
A)
Bacteria
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C) B)
378
Virus
Fungi
D)
Protozoa
Ans:
A Feedback:
Bacteria may be transmitted through air, food, water, soil, vectors, or sexual activity.
17.Before and after doing aseptic techniques with a patient, the nurse should
A)
Sterilize equipment
B)
Apply clean gloves
C)
Replace equipment
D)
Wash hands
Ans:
D Feedback:
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Aseptic techniques, which start and end with handwashing, include the processes of cleaning, disinfection, and sterilization.
18. A nursing student comes to the university health center complaining of a sore throat, malaise, and loss of appetite. The nurse assesses the student and determines she has large white yellow exudates in the back of the throat and a fever. The student is presenting with a/an
A)
Infectious disease
B)
Viral illness
C)
Throat mass
D)
Mononucleosis
Ans:
A Feedback: Infectious disease refers to the pathology or pathologic events that result from the invasion and multiplication of microorganisms in a host. Toxins and enzymes produced by the microorganisms cause tissue injury. The injury produces manifestations of infection: fever, rashes, malaise, nausea, vomiting, diarrhea, purulent discharge from wounds; a hot, red tender area around wounds or puncture sites; aches and pains; or total body collapse.
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C) 19. An infection or the products of infection carried throughout the body by the blood is called
A)
Contamination
B)
Infectious disease
Septicemia
D)
Viral illness
Ans:
C Feedback: Sepsis, a term that means poisoning of tissues, often is used to describe the presence of infection. Transport of an infection or the products of infection throughout the body by the blood is known as septicemia.
20. A patient develops a high fever and has a urinary tract infection. The patient has malaise and is confused. The patient is
A)
Septic
B)
Anorexic
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Lethargic
D)
Apneic
Ans:
A
381
Feedback: Sepsis, a term that means poisoning of tissues, often is used to describe the presence of infection.
21. Any microorganism capable of disrupting normal physiologic body processes is a
A)
Bacterium
B)
Fomite
C)
Pathogen
D)
Virus
Ans:
C Feedback:
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C) Microorganisms that are capable of harming people are called pathogens or are pathogenic.
22. The nurse washes her hands for 1 minute before caring for her patient. The rationale for this is
A)
To provide safe and effective nursing care
B)
To prevent her from developing disease
C)
Freedom from disease-producing organisms
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
The sterilization of her hands to prevent infection
Ans:
C
383
Feedback: Asepsis means to make free from disease-producing organisms.
23.What is the most common reason people contact healthcare providers?
A)
Sleeplessness
B)
Infectious disease
C)
Anxiety
D)
Pain
Ans:
B Feedback: Infectious disease is the most common reason people contact healthcare providers and accounts for more clinic and physician office visits than any other cause in the United States.
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Chapter 21- Medication Administration
1. When administering heparin subcutaneously, the nurse should
A)
Aspirate after injection
B)
Aspirate before the injection
C)
Vigorously massage the site
D)
Never aspirate
Ans:
D Feedback: When administering heparin subcutaneously, never aspirate before administration.
2.
When the nurse administers the morning dose of a medication during the evening, which of the rights of medication administration has she failed to follow?
A)
Patient
B)
Medication
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Dose
D)
Time
Ans:
D
385
Feedback: When the nurse administers the right medication to the right patient at the wrong time, the nurse has failed to follow the right time.
3.
Childrens medication dosages are most often calculated using the childs body surface area and
A)
Age
B)
Diagnosis
C)
Height
D)
Weight Ans: D
Feedback: Childrens dosages are most often calculated using the childs weight or body surface area.
4. Drugs known to cause birth defects are called
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Pregnancy sensitivity
B)
Umbilical cross
C)
Teratogenic
D)
Nosocomial
Ans:
C Feedback: Drugs known to cause birth defects are called teratogenic.
5. A severe allergic reaction from a medication requires
A)
Asprin
B)
Atarax
C)
Dopamine
D)
Epinephrine
Ans:
D
386
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Feedback: A severe allergic reaction, called an anaphylactic reaction, requires immediate medical intervention because it can be fatal. Treatment includes discontinuing the medication and administering epinephrine, IV fluids, and antihistamines.
6. Following an allergic reaction to a medication, the nurse should
A)
Instruct the patient to wear an identification addressing the allergy
B)
Instruct the patient to be sure the allergy is on his medical record
C)
Inform the patient that an allergic reaction can be transient
D)
Inform the patient that the medication may cause an allergy only one time
Ans:
A Feedback: Allergic reactions result from an immunologic response to a substance to which the patient is sensitized. The patient should wear identification noting the medication to which the patient is allergic.
7. When the patient demonstrates a rash 30 minutes after she has taken a dose of penicillin, the nurse recognizes that the patient is likely demonstrating which type of drug reaction?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Allergy
B)
Anaphylaxis
C)
Antagonistic
D)
Idiosyncratic
Ans:
A
388
Feedback: Allergic reactions result from an immunologic response to a substance to which the patient is sensitized.
8.
Which of the following patients is likely to have altered metabolism of medications?
A)
School-age children
B)
Adolescents
C)
Middle adults
D)
Elderly Ans: D
Feedback:
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Metabolism is the process of chemically changing the drug in the body. Metabolism takes place in the liver. Alterations in liver function, including decreased functions that occurs with aging or disease, affect the rate at which drugs are metabolized.
9.
What is involved in the absorption, distribution, metabolism, and excretion of medication?
A)
Pharmacology
B)
Pharmacotherapeutics
C)
Pharmacokinetics
D)
Pharmacodynamics
Ans:
C Feedback: Pharmacokinetics involves the absorption, distribution, metabolism, and excretion of a medication.
10.The physiologic and biochemical effects of a drug on the body defines
A)
Pharmacology
B)
Pharmacotherapeutics
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Pharmacokinetics
D)
Pharmacodynamics
Ans:
D
390
Feedback: Pharmacodynamics refers to the physiologic and biochemical effects of a drug on the body.
11. The process by which a drug moves through the body and is eventually eliminated is
A)
Pharmacology
B)
Pharmacotherapeutics
C)
Pharmacokinetics
D)
Pharmacodynamics
Ans:
C Feedback: Pharmacokinetics is the process by which a drug moves through the body and is eventually eliminated.
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12. In administering medications, the five rights include patient, drug, route, and time. What is the fifth right?
A)
Heart rate
B)
Dosage
C)
Intrathecal
D)
Pain level
Ans:
B Feedback: The five rights for administering medications are the right patient, drug, dosage, route and time.
13.If the dosage is inappropriate for a patient, who is responsible?
A)
Physician
B)
Pharmacist
C)
Nurse
D)
Medical technician
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392
C Feedback: Whereas physicians and other healthcare providers prescribe and pharmacists dispense therapeutic agents, it is the nurses legal domain to administer medications in a safe and timely manner.
14.According to the nurse practice act, the nurse is liable for
A)
Writing a physician order
B)
Clarifying a physician order
C)
Administering what is written
D)
Determining the dosage
Ans:
B Feedback: The nurse is responsible to determine if the medication order is ambiguous or inappropriate. The nurse must clarify the medication order with the prescribing healthcare provider.
15. Regarding medication administration, what must occur at the change of shifts?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
The patients medications must be drawn up
B)
The medications for the division are counted
C)
The narcotics for the division are counted
D)
The LPNs only on the division count medications
Ans:
C Feedback: Healthcare facility personnel perform a count of controlled medications at specified times (each shift or when removed from an automated dispensing machine).
16.The primary reason for the Controlled Substances Act is
A)
To regulate the purchase of antibiotics
B)
To regulate the purchase of narcotics
C)
To prevent overuse of antibiotics
D)
To prevent drug abuse
Ans:
D
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Feedback: The primary reason for the Controlled Substances Act is to prevent drug abuse and dependence, provide treatment and rehabilitation for people who are dependent on drugs, and strengthen drug abuse laws.
17. In terms of categories of controlled substance, which of the following descriptions reflects schedule IV drugs?
A)
May lead to severe psychological dependence
B)
Has the highest potential for abuse
C)
May lead to limited physical dependence
D)
deemed safe for use in pregnancy
Ans:
C Feedback: Schedule IV drugs may lead to limited physical and psychological dependency.
18.Which of the following medication dosages is properly written?
A)
.8 mg
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
.125 mcg
C)
00.125 mg
D)
0.25 mg
Ans:
D
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Feedback: A recommended mistake-proof practice is always to use leading zeros for doses less than one measurement unit.
19. What electronic medical record advance helps the nurse recognize when a generic drug has been ordered?
A)
The computer verbally pronounces the medication
B)
The computer displays the trade name, generic name, and chemical name
C)
The computer uses Tall-man letters to identify generic drugs.
D)
The computer will bold the medication for enhanced clarity
Ans:
C Feedback:
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Electronic medical records may automatically enter Tall-man lettering on the computer screen when generic drug names are ordered.
20. Which of the following patients would be most likely to use a selfadministered medication system?
A)
A patient who is alert and in an area where other patients wont disturb the drugs
B)
A 10-year-old child who is ambulatory on a pediatric unit of multiplebed rooms
C)
An elderly patient in a semiprivate room with another patient who is
confused D)
A patient who is restrained to the bed as a safety
measure against falling
Ans:
A Feedback: The self-administered system allows the patient independence and responsibility while simultaneously allowing nursing supervision, teaching, and evaluation for patient compliance and safety medication management prior to facility discharge.
21. A medication order has a.c. written after the medication dosage. What does a.c.
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stand for?
A)
Before meals
B)
After meals
C)
Before
D)
After
Ans:
A Feedback: The abbreviation a.c. means before meals.
22. A physician writes an order for ampicillin 1 gram every 6 hours for Mr. Jameson Owens. What is missing in this order?
A)
Time
B)
Amount
C)
Route
D)
Frequency
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Ans:
398
C Feedback: The medication order does not identify a route.
23. The nurse should assess the patient for the use of herbal and botanical supplements. What botanical medication is used to treat mild depression?
A)
Echinacea
B)
Ginkgo biloba
C)
St. Johns wort
D)
Green tea
Ans:
C Feedback: Some of the most common botanicals are St. Johns wort (Hypericum perfoliatrum), used for mild depression.
24. Ibuprofen 200 mg is obtained
A)
By prescription
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Over-the-counter
C)
As an herb
D)
As a supplement
Ans:
B Feedback: Ibuprofen 200 mg is an example of an over-the-counter medication.
25.Which medication system allows for patient independence?
A)
Unit dose system
B)
Self-administered medication system
C)
Automated medication-dispensing system
D)
Bar Code Medication Administration
Ans:
B Feedback:
399
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The self-administered system allows the patient independence and responsibility while simultaneously allowing nursing supervision, teaching, and evaluation for patient compliance and safety medication management prior to facility discharge.
26. Which of the following medication-administration systems protects the patient by identifying the rights of medication administration?
A)
Unit dose system
B)
Self-administered medication system
C)
Automated medication-dispensing system
D)
Bar Code Medication Administration
Ans:
D Feedback: The Bar Code Medication Administration system will warn of a potential error if the action does not meet the rights of medication administration.
27. The maintenance of patient safety with medication administration is of primary importance in healthcare. The most commonly used system for billing and record keeping is the
A)
Unit dose system
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Self-administered medication system
C)
Automated medication-dispensing system
D)
Administration for an entire patient team
Ans:
C
401
Feedback: Nurses access the system by using a password or by scanning a finger to identify the fingerprint. The medication is delivered in a unit-dose package. The automated dispensing system keeps an account of all medication used for billing and controlled substance record keeping.
Chapter 22- Intravenous Therapy
1. The nursing instructor is discussing IV fluid overload with the nursing students. Which of the following will the nurse include in her discussion? Select all that apply.
A)
The use of packed cells instead of whole blood will decrease the fluid volume delivered to the patient.
B)
A symptom of fluid overload is distended neck veins.
C)
The patient will likely develop a fever in the presence of fluid overload
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D)
Fluid overload is more likely in very young children
E)
The infusion rate must be carefully monitored during the administration of blood.
Ans:
A, B, D, E Feedback: Fluid overload can occur if blood components are infused too quickly or too voluminously. Transfusion-associated circulatory overload is more likely in the very young patient or the older adult with poor cardiac or renal function. Symptoms include increased venous pressure, distended neck veins, dyspnea, coughing, and abnormal breath sounds. Circulatory overload can be minimized by infusing packed RBCs (rather than whole blood) and volume-reduced platelets for high-risk patients and carefully monitoring the infusion rate of blood components.
2. The nurse is administering blood to the patient. During the infusion, the patient reports a headache and feeling very tired. Which of the following will the nurse do first?
A)
Notify the physician
B)
Notify the blood bank
C)
Check the patients vital signs
D)
Check the patients temperature
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
E)
Stop the infusion
Ans:
E
403
Feedback: If symptoms occur after the infusion of blood has started, stop the transfusion immediately and keep the IV open with normal saline.
3.
The chemotherapy patient has been admitted for thrombocytopenia. Which of the following blood products will the nurse anticipate administering?
A)
Platelets
B)
Fresh frozen plasma
C)
Whole blood
D)
Packed cells
E)
White blood cells
Ans:
A Feedback: One common indication for platelet transfusion is thrombocytopenia following chemotherapy.
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4. A patient with chronic anemia is admitted for the administration of blood. Which of the following would the nurse expect the physician to order?
A)
Whole blood
B)
Packed cells
C)
White blood cells
D)
Platelets
E)
D5W 1000 mL
Ans:
B Feedback: Packed cells are especially useful in the treatment of chronic anemia.
5. A 2-year-old child has been injured in a motor vehicle accident and is in immediate need of a blood transfusion for profuse bleeding. Which of the following access sites might the nurse expect to use for the infusion?
A)
Antecubital
B)
Dorsalis pedis
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Great saphenous vein
D)
Scalp vein
E)
Intraosseous access
Ans:
E
405
Feedback: Intraosseous access with a large-bore rigid needle inserted into the medullary cavity of a long bone may be required for the critically injured child who needs emergency fluid, medication, or blood administration, if adequate venous access is not accessible. 6.
The nurse is discussing epidural analgesia with the nursing student. Which of the following statements by the nursing student indicate a need for additional education?
A)
Epidural analgesia is always administered in a continuous infusion to prevent or treat the patients pain.
B)
The patient may be able to control the epidural analgesia infusion.
C)
The epidural analgesia may be used in the laboring patient.
D)
The epidural is always discontinued after delivery of the newborn.
Ans:
A
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Feedback: The infusion can be set on a continuous rate (basal mode) or an intermittent mode controlled by the patient (patient-controlled epidural analgesia [PCEA]). 7.
The charge nurse on the medical/surgical unit is reviewing physician orders for a patient with a diagnosis of congestive heart failure. Which of the following infusion orders would the nurse question?
A)
50 mL D5W to run in 60 minutes
B)
250 mL 0.9 NaCl to run in 60 minutes
C)
1000 D5W to run in 30 minutes
D)
20 mL 0.9 NaCl to run in 20 minutes
Ans:
C
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Feedback: Medications administered by intermittent infusion are supplied either in bags that contain 50 to 250 mL of IV fluid (0.9 normal saline or 5% dextrose in water) or in 20- to 60-mL syringes to be used with an infusion pump.
8. Which of the following are required to manually regulate an IV drip? Select all that apply.
A)
A clock
B)
A minimum of 1000 cc of fluid
C)
Tubing with a roller clamp
D)
An antecubital access site
Ans:
A, C Feedback: A roller clamp adjusts the flow rate according to drops per minute counted in the drip chamber. Count the drops as they fall into the drip chamber for 15 seconds, then multiply this number by 4 to determine the rate of flow for 1 full minute. Use the roller clamp to adjust the flow rate until it corresponds with the prescribed rate of flow.
9.
The nurse is preparing to insert an intravenous needle in a 1-year-old child for a one-time administration of fluids due to dehydration. Which of the following needles would the nurse likely select?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
A 22-gauge intravenous catheter
B)
A 19-gauge winged infusion set
C)
A 23-gauge winged infusion set
D)
An 18-gauge intravenous catheter
Ans:
C
408
Feedback: Winged infusion or small vein needles may be used for short-term or one-time infusion therapies or may be used with infants and small children. These are short, beveled needles with plastic flaps or wings.
10. A patient suffers from a genetic bleeding deficiency. What blood product will be administered?
A)
Whole blood
B)
Albumin
C)
Platelets
D)
Cryoprecipitate
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
Feedback: Ans: D
Cryoprecipitate may be pooled from several units of blood and administered to patients with fibrinogen deficiencies who are predisposed to bleeding problems because genetically they lack Factor VII. 11. A patient suffers from infectious diarrhea. Based on her loss of fluid, her protein level is below normal. What blood product will the physician order to restore intravascular volume?
A)
Whole blood
B)
Packed red cells
C)
Platelets
D)
Albumin
Ans:
D Feedback: Albumin is a plasma protein contained within the plasma. It is used to restore intravascular volume and to maintain cardiac output in patients with hypoproteinemia.
409
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410
12. A central line is inserted by the medical resident on an elderly patient. During the insertion, you assess the patients sudden shortness of breath. What does this symptom indicate?
A)
Pneumothorax
B)
Myocardial infarction
C)
Hemothorax
D)
Pulmonary embolism
Ans:
A Feedback: Pneumothorax may occur during insertion of a central venous catheter if the catheter inadvertently punctures the pleural membrane. Symptoms of a pneumothorax include chest or shoulder pain, sudden shortness of breath, tachycardia, and absence of breath sounds on the affected side.
13. Which of the following nursing actions is appropriate in the care of a patient with an implanted vascular access device?
A)
Cleanse around the site of insertion with an antibacterial solution
B)
Clean the external portion of the catheter after infusion is complete
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Feedback: Maintain patency by routine flushing with a heparinized solution
D)
Observe the site only; only the physician will assess the site
Ans:
C
411
Most central line catheters and implanted vascular devices are flushed with a heparinized solution.
14. A young woman has an IV infusing for magnesium sulfate to treat preterm labor. The woman develops a fever. What is the first assessment the nurse should make?
A)
Monitor the IV infusion rate
B)
Assess the vaginal mucosa
C)
Assess the IV site for redness
D)
Assess the patients blood pressure
Ans:
C Feedback:
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If tenderness, fever without obvious source, or symptoms of local or bloodstream infection are present, remove the dressing and inspect the site directly.
15. When preparing to start an intravenous infusion on an adult, the nurse should
A)
Prepare the skin with 70% alcohol and povidone-iodine
B)
Apply sterile gloves before inserting the intravenous device
C)
Place a cold cloth over the intended site for greater access
D)
Place a tourniquet 2 below the selected site
Ans:
A Feedback: Prepare the site using a vigorous circular motion, with 70% alcohol as a defatting agent; work from the center outward to a diameter of 2 to 3; follow with an application of povidone-iodine.
16. The nurse is educating a patient with a peripheral intravenous infusion of dextrose 5%. What is the most important information to share with the patient who has an IV infusing in the right hand?
A)
Keep the IV fluids 18 inches above the extremity
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Feedback: Caution the patient not to bend the right wrist
C)
Instruct on ambulating with an IV pole
D)
Instruct the patient on fluid volume excess
Ans:
B Feedback:
413
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Bending the extremity at a point of flexion, such as the wrist or elbow, or leaning on the arm can slow the rate of infusion. 17. The nurse has an order to infuse 1000 mL of dextrose 5% with 0.45 normal saline. The infusion is ordered over 8 hours. The solution set delivers 10 gtt/cc. How many drops per minute will the nurse need to infuse the intravenous fluids?
A)
5 gtts/minute
B)
15 gtts/minute
C)
21 gtts/minute
D)
30 gtts/minute
Ans:
C Feedback: The drip rate of an IV that is to infuse 1000 mL in 8 hours using a 10-gtt infusion set is 21 gtts/minute.
18.A patient requiring frequent chemotherapeutic products will require a(an)
A)
Multilumen central catheter
B)
Central venous access
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Over-the-needle catheter
D)
Hickman catheter
Ans:
D
415
Feedback: When IV therapy is needed for a long time, a more permanent catheter is used. Hickman, Groshong, and Broviac are common brand names of these catheters.
19. Total parenteral nutrition is hypertonic. What is the percentage of dextrose in these solutions?
A)
2.5% dextrose
B)
5% dextrose
C)
10% dextrose
D)
50% dextrose
Ans:
D Feedback:
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Total parenteral nutrition is a hypertonic solution containing 20% to 50% dextrose, proteins, vitamins, and minerals that is administered into the venous system.
Chapter 23- Perioperative Nursing
1. The recovery nurse is caring for a surgical patient in the PACU. The patients blood pressure is dropping and their heart rate is increasing. The nurse suspects the patient is:
A)
overmedicated.
B)
experiencing normal adaptation to the postoperative period.
C)
allergic to the anesthesia.
D)
developing shock.
Ans:
D Feedback: Decreasing blood pressure and an increased pulse rate in the postoperative patient are significant because they may signify hemorrhage or shock.
2. Following a surgical procedure, which of the following are generally responsible for moving the patient to the recovery area?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
The surgeon
B)
The orderly
C)
The recovery nurses
D)
The anesthesiologist, circulating nurse, and surgeon
Ans:
D
417
Feedback: After the intraoperative phase of the surgical procedure has been completed, the circulating nurse, the anesthesia provider, and the surgeon safely transport the patient to the PACU, taking care to maintain the patients airway during this critical time. 3.
The nurse is caring for the postoperative patient in the PACU. The patient is concerned about the abdominal staples closing her wound for fear they will open and her insides will fall out. Which of the following is the best response by the nurse?
A)
Dont worry, the staples are properly placed and will not come out until they are removed by the physician.
B)
If you are very careful and follow your postoperative instructions, there is no need to worry.
C)
There are sutures in various levels below the staples that assist in keeping your wound intact.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Would you tell me why you are worried about that?
E)
That is possible, but we will keep a close eye on the staples.
Ans:
C
418
Feedback: A patient may have absorbable sutures closing the viscera and staples approximating the wound edges. 4.
The nursing instructor is discussing the role of the circulating nurse in the operative suite with the student nurses. Which of the following would the nursing instructor include as duties of the circulating nurse? Select all that apply.
A)
The circulating nurse is included in the responsibility of accounting for all sponges and instruments following the surgical procedure.
B)
The circulating nurse is responsible for preparing the surgical table for the procedure.
C)
The circulating nurse is responsible for assisting the surgeon with instruments during the procedure.
D)
The surgical nurse is responsible for maintaining the patients rights during the surgical procedure.
Ans:
A, D
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Feedback: The circulating nurse ensures that the patients rights are protected and coordinates patient care in the operating room. The circulating nurse and the scrub person are responsible for accounting for all sponges and instruments at the close of surgery. 5.
The adult male patient with significant body hair is being prepared for abdominal surgery. The patient states his dad had the same surgery many years ago and was shaved prior to the procedure. The nurse would explain to the patient:
A)
That practice is no longer standard as shaving may cause breaks in the skin.
B)
We no longer shave skin before procedures but we will apply a lotion that will remove the hair.
C)
Your abdomen will be shaved in the operating room.
D)
You will be shaved as well.
Ans:
A Feedback: A surgical prep, or shaving of the hair in the affected area, was a common preoperative procedure a decade ago. Current research indicates that preoperative shaving increases the risk for surgical site infection by causing tiny breaks in skin integrity.
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6. The nurse is preparing to start an IV in the preoperative adult patient. The nurse would likely choose which gauge of IV catheter?
A)
22 gauge
B)
25 gauge
C)
18 gauge
D)
14 gauge
Ans:
C Feedback: For any surgical patient, a large-gauge (e.g., 18-gauge) IV device should be used in case a blood transfusion is necessary during the surgical or postoperative period.
7.
The healthy adult patient is given a narcotic prior to a surgical procedure. The nurse is completing the chart and notices the consent form was not signed by the patient. Which of the following should the nurse do first?
A)
Immediately have the patient sign the consent form.
B)
Have the patients family member sign the consent form.
C)
Ask the patient if he still wants to proceed with the procedure.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Notify the physician of the oversight.
Ans:
D
421
Feedback: Do not administer any medications that might alter judgment or perception before the patient signs the consent form because many drugs commonly administered as preoperative medications, such as narcotics or barbiturates, can alter cognitive abilities and invalidate informed consent.
8.
The patient has been transported to the operating suite and positioned
on the operating table. Suddenly, the patient states, I dont want to do this. Get me out of here now! Which of the following actions should occur? A) The patient should be given the anesthesia.
B)
The surgeon should tell the patient to remain calm and the procedure will be over soon.
C)
The patient should be told it is too late to change his mind.
D)
The procedure should be stopped.
Ans:
D Feedback: The patient has the right to ask any questions and to withdraw consent at any point before the surgery begins.
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422
Which of the following personnel are legally responsible for obtaining the patients informed consent for a surgical procedure?
A)
The surgeon
B)
The registered nurse
C)
The admissions clerk
D)
The licensed practical nurse
E)
Any licensed person
Ans:
A Feedback: The surgeon is legally responsible for obtaining the patients informed consent.
10. The preoperative patient has called the nurse about his upcoming surgical procedure, which will be six weeks from now. He is concerned about receiving blood after surgery for fear of acquiring a bloodborne disease. Which of the following might the nurse do?
A)
Instruct the patient to notify the physician.
B)
Remind the patient that blood is tested prior to administration, making it safe and free of disease.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Ask the patient if he has ever had any blood products.
D)
Explain to the patient the use of autologous blood donation.
E)
Instruct patient to refuse transfusion.
Ans:
D
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Feedback: Because of the fears of hepatitis B and human immunodeficiency virus infection associated with blood transfusion, donation of autologous blood (ones own blood) for surgery is becoming a common practice. If the patient wishes, provide the necessary information about blood donation if the patient is seen a number of weeks before surgery.
11. The nurse is caring for a patient admitted for an outpatient surgical procedure. Which of the following will the nurse include in the care?
A)
Begin discharge teaching as soon as the procedure is completed.
B)
Allow family members to be present during discharge teaching.
C)
Begin discharge teaching in the preoperative period.
D)
Investigate the patients home care and discharge transportation following the procedure.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
E)
Discuss discharge transportation during the preoperative period.
Ans:
B, C, E
424
Feedback: Patient teaching begins during the preoperative period and continues throughout all perioperative phases of care. In the preoperative phase, assess the patients and familys readiness to learn and their knowledge base so that teaching can be individualized. If the patient will be discharged on the day of surgery, be sure to identify someone who can take the patient home and assist during the postoperative recovery period.
12. When an elderly client is brought to the recovery room and presents with irregular, loud respirations, the nurse determines that this most likely a result of
A)
Effects of anesthesia
B)
Normal return of reflexes
C)
Partial airway obstruction
D)
Type of surgery
Ans:
C Feedback:
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425
Loud, irregular respirations may indicate obstruction of the airway, possibly from emesis, accumulated secretions, or client positioning that allows the tongue to fall to the back of the throat.
13.A client states he has a latex allergy. What action should the nurse take?
A)
Inform the client to tell the anesthesiologist
B)
Have the client take a Benadryl before surgery
C)
Send the client to the OR with epinephrine
D)
Place an allergy identification band
Ans:
D Feedback: Assist client with allergies to medications, food, and latex before the surgical procedure, and clearly mark them on the client record and on the client identification band.
14. A client has been taking aspirin since his heart attack in 1997. The client is at risk for
A)
Infection
B)
Thrombophlebitis
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Hemorrhage
D)
Blood clots
Ans:
C
426
Feedback: Current medication use, especially use of medications that can affect coagulation status (warfarin, nonsteroidal anti-inflammatory drugs, aspirin) is important and should be reported to the surgeon.
15. The removal of a toddlers clothing and application of monitoring equipment after anesthesia is administered will
A)
Minimize blood loss
B)
Ensure temperature control
C)
Provide baseline vital signs
D)
Allow sufficient relaxation
Ans:
D Feedback:
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Relaxation can be enhanced by removing the childs clothing, applying the grounding pad, and applying monitoring devices after the child is anesthetized.
16. A client is being discharged following surgery for cancer care. The client will require extensive dressing changes two times per day. The client is on a fixed income and cannot afford to purchase dressing supplies. The nurse contacts the local Peregrine Society to assist in the provision of dressings. This contribution in care will assist in improving the clients
A)
Family relationships
B)
Return to daily activities
C)
Decision making
D)
Self-concept
Ans:
D Feedback: In addition to providing the client with the necessary technical care, teaching, extensive rehabilitation, and emotional support, nursing interventions may also include referral to agencies and support groups that can benefit the client after surgery and discharge from the acute care facility.
17. What nursing action will assist in pain management for a client in the postoperative phase?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Client teaching
B)
Relaxation techniques
C)
Dim lighting
D)
Provide food and medication
Ans:
B
428
Feedback: Nursing interventions vital in helping clients cope with pain include administering medications, positioning, relaxation techniques, psychological support, distraction techniques, and appropriate referrals to other health professionals.
18. Which of the following nursing actions provides the greatest assistance in healing?
A)
Maintaining a restful environment
B)
Providing solid food in the first day
C)
Allowing family members to visit often
D)
Keeping the client recumbent
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429
A Feedback: The nurse should plan for adequate periods of rest and sleep, maintaining a quiet, restful environment.
19. In the postoperative phase of abdominal surgery, the client complains of severe abdominal pain, and in the second postoperative day, the clients bowel sounds are absent. What does the nurse suspect?
A)
Normal response
B)
Abdominal infection
C)
Hernia development
D)
Paralytic ileus
Ans:
D Feedback: A potential complication after surgery is paralytic ileus, a condition in which there is decreased bowel functioning.
20.What is the rationale for having the client void before surgery?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
To assess for pregnancy in women
B)
To assess for urinary tract infection
C)
To prevent bladder distention
D)
To prevent electrolyte imbalance
Ans:
C
430
Feedback: Having the client void before surgery will assist in the prevention of bladder distention during or after the procedure. 21. The nurse-anesthetist is monitoring his client during surgery. He notices a ventricular dysrhythmia and unstable blood pressure. He notifies the surgeon. The operative team suspects
A)
Myocardial infarction
B)
Malignant hyperthermia
C)
Mitral valve prolapse
D)
Major blood loss
Ans:
B
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Feedback: The symptoms of malignant hyperthermia are masseter muscle rigidity, ventricular dysrhythmia, tachypnea, cyanosis, skin mottling, and unstable blood pressure.
22. Surgery can lead to hypothermia. Of the following clients, who is at greatest risk for hypothermia?
A)
A woman delivering by C-section
B)
An adolescent for arthroscopic surgery
C)
A young adult with a fractured leg
D)
An elderly man with a fractured hip
Ans:
D Feedback: The risk of hypothermia increases in the very young and the very old.
23. Which of the following statements, if made by an adolescent preparing for abdominal surgery, would indicate to the nurse that the client requires additional instruction?
A)
I can have a hamburger and French fries as soon as I wake up.
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B)
The better I eat before surgery, the more likely I will heal.
C)
I might be sick to my stomach and throw up after surgery.
D)
When I can eat again, the best meal would be steak and orange juice.
Ans:
A Feedback: Oral fluid and food may be withheld until intestinal motility resumes.
24. What is the rationale for the administration of IV cephalosporin antibiotic before surgery?
A)
To prevent the development of strep
B)
To prevent the development of pneumonia
C)
To allow for decreased level of white blood cells
D)
To allow the client high levels of medication
Ans:
D Feedback:
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A cephalosporin antibiotic is administered just before the surgical procedure so that the level of medication circulating in the clients blood will be high during surgery.
25. A client in the immediate postoperative period begins to complain of nausea and ultimately begins vomiting. The nausea and vomiting is most likely related to
A)
Movement of bowels during surgery
B)
Inactivity and emotional upset
C)
The effects of anesthetic agents
D)
Severe pain at the operative site
Ans:
C Feedback: Nausea and vomiting can occur postoperatively from the effects of anesthetic agents.
26. When educating a client in the postoperative period, it is important to educate the client to consume a diet high in
A)
Protein
B)
Calcium
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Bicarbonate
D)
Potassium
Ans:
A
434
Feedback: After surgery, a diet with sufficient amounts of protein and vitamins A and C helps rebuild tissues and promotes wound healing.
27. Which of the following clients will see the greatest permanent changes in lifestyle following surgery?
A)
Right total knee replacement
B)
Left mastectomy
C)
Ileostomy
D)
Appendectomy
Ans:
C Feedback:
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Permanent changes in the clients activity level may occur as a result of surgery. The client with an ileostomy will encounter the greatest changes in lifestyle.
28. A client has arrived in the same-day surgery suite. He states to the nurse, I am so worried about being put to sleep and having the surgery. What would be the nurses best response?
A)
You dont have to worry. It will be fine.
B)
Tell me what you are most worried about.
C)
I will have the anesthesiologist talk to you.
D)
Have you ever had surgery before?
Ans:
B
Feedback: The nurse should first assess what the client is most worried about or fearful of and then provide emotional support.
29. Which of the following surgical clients will return to activities in their everyday lives more quickly?
A)
Vaginal hysterectomy
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Laparoscopic cholecystectomy
C)
Right nephrectomy
D)
Open-heart surgery
Ans:
B
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Feedback: Clients who have surgery using a laparoscope are able to return to previous activity levels much sooner.
30. The nurse knows the term perioperative phase refers to care given to the client
A)
Before, during, and after the operative phase
B)
From the start of surgery until its conclusion
C)
Immediately before an operative procedure
D)
Immediately after the operative phase
Ans:
A Feedback:
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Perioperative nursing includes three distinct phases: preoperative, intraoperative, and postoperative.
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Chapter 24- Hygiene and Self-Care
1. A patient reports having a history of gingivitis. The nurse correctly recognizes that this condition may be caused by which of the following? Select all that apply.
A)
Thermal extremes
B)
Poor oral hygiene
C)
Heredity
D)
Adverse reaction to medications
E)
Bacteria
Ans:
A, B, D, E Feedback: The gums are made up of the oral mucosa, which covers the bone supporting the tooth; the alveolar bone, which forms sockets around the teeth; and the periodontal ligament, which joins the teeth to the bone. Inflammation in these tissues, called gingivitis or periodontitis, can be caused by local irritation from bacteria, plaque, tartar, and food impaction. Mechanical, chemical, or thermal extremes may also contribute to inflammation of the oral mucosa.
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2.
The parents of three young children have discussed the dental health needs of their children with the nurse. Which of the following statements indicates the need for further instruction?
A)
Brushing is important to remove bacteria from the mouth and teeth.
B)
Tartar cannot be brushed or flossed way.
C)
Flouride treatments are needed until my children reach the age of 14.
D)
If my children do not have cavities by the age of 10, fluoride treatments can be discontinued.
Ans:
D Feedback: When plaque remains on the teeth, it hardens into tartar, which cannot be removed by simple brushing; a professional must scrape it off with dental instruments. Fluoride in small amounts strengthens teeth during their formation and helps prevent caries. Fluoride is added to most watertreatment systems at the appropriate concentration of 1 part per million. Adult caregivers may want to ask their dentist how to give children appropriate supplements of fluoride until the age of 14 if their water system is not fluoridated.
3.
The nurse is discussing hygiene with a group of adolescent males. A
participant states he does not see the importance of daily bathing or the use of antiperspirants. What information should be provided by the nurse? Select all that apply. A) Perspiration may result in fungal growth if not managed frequently.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Excessive perspiration will result in potentially offensive odor
C)
Bacteria can flourish in the presence of excessive perspiration
D)
There is no medical rationale to avoid excessive perspiration
E)
Perspiration promotes skin breakdown.
Ans:
B, C, E
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Feedback: Keeping skin intact and healthy is important in preventing infection. Perspiration interacts with bacteria on the skin to cause body odor, which can be offensive, may decrease patient comfort, promote bacterial growth, and increase the likelihood of skin breakdown. Regular bathing removes excess oil, perspiration, and bacteria from the surface of the skin.
4.
The nurse is discussing hygiene with a group of adolescent males. A
participant states he does not see the importance of daily bathing or the use of antiperspirants. What information should be provided by the nurse? Select all that apply. A) Perspiration may result in fungal growth if not managed frequently.
B)
Excessive perspiration will result in potentially offensive odor.
C)
Bacteria can flourish in the presence of excessive perspiration.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
There is no medical rationale to avoid excessive perspiration.
E)
Perspiration promotes skin breakdown.
Ans:
B, C, E
441
Feedback: Keeping skin intact and healthy is important in preventing infection. Perspiration interacts with bacteria on the skin to cause body odor, which can be offensive and may decrease patient comfort, promote bacterial growth, and increase the likelihood of skin breakdown. Regular bathing removes excess oil, perspiration, and bacteria from the surface of the skin. 5.
The student nurse is discussing the use of massage with the instructor. Which of the following statements by the student indicate the need for further instruction? Select all that apply.
A)
The benefits of massage may last up to 5 days.
B)
Elderly people on bed rest can benefit most from massage.
C)
The use of rubbing alcohol during a massage may be cooling.
D)
Massage has been demonstrated to promote increased restful sleep patterns.
E)
Massage may result in increased blood pressure and heart rate in a patient recovering from a stroke.
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Ans:
442
A, B, E Feedback: Benefits of massage include increased comfort, relaxation, and improved sleep. In addition, research has demonstrated that the therapeutic effects of massage on patients who have had a stroke include improvements in blood pressure and heart rate. Effects have been seen to last up to 3 days after a massage. To prevent pressure ulcers, massage is no longer indicated for high-risk patients because vigorous pressure over bony prominences can damage the underlying tissue. An elderly person on bed rest would be considered at high risk for skin breakdown. People with oily skin find that alcohol is a cooling and refreshing lubricant.
6.
The nurse has provided instruction to the patient concerning the use of the sitz bath. After the instruction the nurse is evaluating the patients understanding of the teaching. Which of the following findings indicate the need for further instruction? Select all that apply.
A)
The patient uses cool water for the treatment.
B)
The patient heats the water to a temperature between 115 and 120 degrees.
C)
The patient reports that the treatment will take approximately 20 minutes.
D)
The patient explains to the nurse that the treatment will result in a reduction of discomfort for her hemorrhoids as a result of vessel constriction.
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E)
The patient reports the treatment will promote circulation to the problem area.
Ans:
A, B, D Feedback: A sitz bath can be helpful in soaking a patients pelvic area in warm water to decrease inflammation after childbirth, rectal surgery, or to decrease the inflammation of hemorrhoids. Immersing only the pelvic region allows for application of local heat without widespread vasodilation that results when the entire body is placed in warm water. A sitz bath can be given in a special chair or tub in which the patient sits. A portable device placed in the toilet also can be used and is illustrated in Figure 23-5. <F 23-5> Warm water circulates gradually into the disposable device through tubing attached to a bag of warm water. The sitz bath usually lasts 20 minutes; the temperature of the water should be maintained at 105F to 110F, with care taken not to burn the patient.
7. The nurse is reviewing the medication history for a newly admitted patient. The nurse correctly recognizes that xerostomia may be noted with which of the following?
A)
NSAID therapy
B)
Narcotic use
C)
Antihistamine use
D)
Antifungal medication use
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Ans:
444
C Feedback: Xerostomia can be caused by many factors but is commonly a side effect of medications (diuretics, antidepressants, antiparkinsonian drugs, antihistamines, angiotensin-converting enzyme [ACE] inhibitors).
8. The mother of a school-aged child voices concern to the nurse about her 4year-old son continuing to wet the bed at night. What information should be provided by the nurse?
A)
It is very uncommon for a child of this age to have bedwetting issues.
B)
Did any of your other children have this problem?
C)
While this is distressing it is not completely uncommon but interventions are not normally introduced until age 6.
D)
You will need to strictly restrict intake in the afternoon and evenings to prevent this from happening.
Ans:
C Feedback: Many children achieve daytime bowel and bladder control between 2 and 3 years. They usually stay dry through the night by 4 years, but
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some children still wet the bed at night until 6 years, after which time nursing intervention may be necessary
9. The nurse working in the long-term care facility correctly recognizes that most falls are related to which of the following?
A)
Toileting
B)
Confusion
C)
Polypharmacy
D)
Impaired sleep patterns
Ans:
A Feedback: More than 42% of falls in an acute care agency were toileting related, often involving getting out of bed or ambulating to the bathroom, slipping from the toilet or commode, or standing to use the urinal.
10. A parent reports that her water is not fluoridated and questions the nurse whether she should start giving fluoride supplements to her 9-year-old child. Which response by the nurse is most appropriate?
A)
Fluoride supplements are not needed until your child is 13 years of age.
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B)
Using a fluoride-containing toothpaste and mouthwash products eliminates the need for supplementation.
C)
In the absence of fluoridated water supplies, supplementation is recommended.
D)
Recommendations about using fluoride supplements are overrated.
Ans:
C Feedback: Supplements of fluoride until the age of 14 are recommended if the local water system is not fluoridated. Brushing teeth with a fluoride toothpaste twice daily, and additional fluoride measures for those at high risk, are recommended to reduce risk of dental caries in all age groups.
11. The nurse is caring for a patient who voices concerns about the development of her 8-month-old daughter. Which of the following findings would be a source of concern?
A)
The child is unable to feed herself finger foods.
B)
The child has begun to eat some solid foods.
C)
The child is unable to hold a spoon to attempt self-feeding.
D)
The child has not been introduced to finger foods for self-feeding.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
Ans:
447
C
Feedback: By 3 to 4 months, infants begin to develop eyehand coordination; by 5 to 6 months many children have been introduced to solid foods. As gross motor function develops around 7 to 9 months, children can hold a spoon or drink from a cup with help. At 9 to 12 months, children can usually pick up finger food and feed themselves, and hold and drink from a bottle.
12. The patient questions the nurse about the best manner to clean the ears. Which of the following should be included in the information provided to the patient?
A)
A toothpick wrapped in several folds of tissue
B)
A long-tip syringe to irrigate with peroxide
C)
A cotton swab and pull the pinna upward and cleanse the ear
D)
The twisted end of clean washcloth and pull auricle down
Ans:
D Feedback: Excessive cerumen can be removed with the twisted end of a washcloth while pulling down the auricle. Placing objects such as toothpicks or
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swabs in the ears may result in perforation and should be avoided. There is no need to routinely irrigate the ears. 13. The nurse is caring for a woman who informs the nurse that she needs assistance to remove and clean her glass eye. What actions by the nurse are most appropriate to accomplish the task?
A)
Apply pressure over the eye with your index finger and thumb under the eye
B)
Pull up the upper lid and place your index finger under the glass edge
C)
Pull the inner canthus toward the bridge of the nose and lift under the glass
D)
Pull down on the lower lid and exert slight pressure below the lid
Ans:
D Feedback: To remove an artificial eye, pull down on the lower eyelid and exert slight pressure below the eyelid to overcome the suction holding the eye in place.
14. What should the nurse do to prepare the unconscious patient for oral care? The nurse should
A)
Use small amounts of water and oral suction device
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Place the patient in high Fowlers position
C)
Place the patient in the supine position with head lowered
D)
Put the patient in the Fowlers position and turn head to side
Ans:
A
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Feedback: To prevent aspirations, use only small amounts of water and an oral suction device. 15. A woman is being treated for breast cancer with 5-FU and Cisplatin in large doses. She should expect
A)
Anxiety
B)
Alopecia
C)
Dandruff
D)
Seborrhea
Ans:
B Feedback:
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450
Most commonly, hair loss (alopecia) is caused by cancer treatment.
16.Which of the following medications is used to treat head lice?
A)
Keratolytic shampoo
B)
Fluoride
C)
Antiseborrhea shampoo
D)
Kwell
Ans:
D Feedback: The treatment choice for pediculosis corporis or pediculosis pubis is lindane (Kwell).
17. What type of bath is preferred to decrease the inflammation after rectal surgery?
A)
Bed bath
B)
Tub bath
C)
Whirlpool bath
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Sitz bath
Ans:
D
451
Feedback: A sitz bath can be helpful in soaking a patients pelvic area in warm water to decrease inflammation after childbirth or rectal surgery or to decrease inflammation of hemorrhoids.
18. An elderly patient is complaining of dry, itching skin. The nurse should assess
A)
How often the patient is bathing
B)
When the patients last tub bath was
C)
What linens they are using
D)
When the severe itching occurs
Ans:
A Feedback: Frequent bathing for the older patient can dry skin and contribute to skin breakdown.
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19. A nurse is assisting a patient with his bed bath. The patient states, I can do it myself. The nurses best response is
A)
I really have limited time. Let me give you your bath right now.
B)
I will set up your bath for you. I will come back and help you with your back.
C)
You will need to sit up for your bath, and then I will change your bed.
D)
You will be able to take your bath by yourself tomorrow when you can get up.
Ans:
B Feedback:
The nurse must value and support the patient becoming independent in care.
20. When an adult patient from Indonesia refuses a complete bath on the day after abdominal surgery, the nurse should
A)
Understand that his culture may influence his hygiene and ask him his preference
B)
Ask another nurse to assist in giving the patient a complete bath every other day
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C)
Give the patient a bath pan and tell him she will return when he has finished
D)
Encourage the patient to bathe daily as part of protection from infection
Ans:
A Feedback:
Preferences for hygiene vary widely among individuals and across cultures.
21. A 78-year-old patient with diabetes needs to have his toenails trimmed. It is important for the nurse to
A)
Remove ingrown toenails
B)
Cut the nail straight across
C)
Protect the foot from blisters
D)
Soak the foot in witch hazel
Ans:
B Feedback: The feet of older adults require special attention, because foot problems may relate to reduced peripheral blood flow. Poor circulation makes the
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feet more vulnerable to infection and skin breakdown, particularly after trauma. By cutting the nail straight across, the nurse can protect the toes from trauma. 22. A grandmother visits the pediatric clinic with her daughter and 18month-old granddaughter. The grandmother states, I told my daughter she needs to get that baby potty trained. She is too old to be messing in her pants. What is the best response the nurse can make?
A)
To help with potty training, the child should be placed on the toilet in the morning.
B)
The child should have fluids limited after 7:00 PM to help decrease the chance of nighttime accidents.
C)
A child her age should have control of the bladder by now, but her bowels wont be trained until next year.
D)
You should start potty training at age 2 to 3 years. At 18 months, she will not be ready to be potty trained.
Ans:
D Feedback: Many children achieve daytime bowel and bladder control between age 2 and 3 years. They usually stay dry through the night by 4 years.
23. A new mother has brought her infant into the pediatric clinic. The infant has an excoriation on the buttocks. What should the nurse instruct the mother?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Leave the babys buttocks open to air for 2 hours each day
B)
Apply gentian violet to the buttocks with every diaper change
C)
Change diaper as soon as it is soiled and apply cornstarch
D)
Keep the diaper and buttocks clean and dry and apply zinc oxide
Ans:
D
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Feedback: Keeping the skin as dry and clean as possible helps preserve its integrity. The diaper area should be inspected with each change. Topical products, such as those containing zinc oxide, may need to be applied in cases of rash or excoriation.
24. On the first postoperative day, the patient is assisted to the bathroom. It is important to
A)
Allow the patient privacy
B)
Assess the patients safety
C)
Assess the patients pain
D)
Allow sufficient time
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Ans:
456
B Feedback:
Toileting often is associated with falls; the nurse must ensure the patients safety.
25. A pediatric nurse is providing a health promotional education program to a group of preschool parents. One parent asks the nurse the following question: I have started buying bottled water. How will this affect my children? It is important for the nurse to educate the mothers that
A)
There is a need to determine if the bottled water has fluoride
B)
The preschool child should not drink bottled water
C)
The preschool child should only drink milk
D)
The parent should alternate bottle and tap water
Ans:
A Feedback: Fluoride strengthens teeth during their formation and helps prevent dental caries. Children need both milk and water. There is no reason for alternation between tap and bottled water if the bottled source has adequation flouride.
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26. When an African American adolescent patient asks the nurse how to care for her long hair, which is braided into small braids, the nurse should instruct the patient that
A)
Braids should be undone every day
B)
Combs should be washed as often as necessary
C)
Hair should be washed as often as necessary
D)
Lubricants or oils should not be used on the braids
Ans:
C
Feedback: Shampooing removes dirt and oil from the hair and scalp. Clean hair makes patients feel good about their appearance and enhances feelings of self-worth.
27. A patient complains of foot pain while ambulating in his shoes. The nurse assesses the patients feet and determines they are flat. The nurse should
A)
Call the patients physician and report the pain
B)
Inform the patient to walk barefoot while in the home
C)
Instruct the patient to have his feet measured to determine size
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Instruct the patient to make an appointment with a podiatrist
Ans:
C
458
Feedback: Shoes should accommodate the size and shape of the foot and should be large enough so that the toenails do not rub on the shoes, causing skin breakdown or ingrown nails. 28. When the nurse observes slight bruising on the patients left thigh during the bed bath, he takes a closer look and palpates a lump on the anterior surface of the thigh. The nurse has used the bath activity for
A)
Assessment of tissues
B)
Increasing circulation
C)
Promotion of conversation
D)
Relaxation of muscles
Ans:
A Feedback: Bathing promotes assessment of the patients physical condition by noting injured areas, bruises, rashes, or any other unusual signs.
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29.When the nurse cleanses the patients leg during a bed bath, it will allow for
A)
Assessment of pain
B)
Increased circulation
C)
Decreased restless leg syndrome
D)
Promotion of social interaction
Ans:
B Feedback: Bathing increases circulation and helps maintain muscle tone and joint mobility.
30. The first line of defense against microorganisms and infection entering the body is the persons
A)
Gastrointestinal tract
B)
Mucous membranes
C)
Hair
D)
Skin
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Ans:
460
D Feedback:
The skin is the first line of defense against microorganisms entering the body.
31. The ability to bathe and perform normal grooming functions, and to dress, feed, and toilet oneself is
A)
Hygiene
B)
Activity
C)
Caring
D)
Health
Ans:
C Feedback: Caring related to hygiene is the ability to bathe and perform normal grooming functions and to dress, feed, and toilet oneself.
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461
Chapter 25- Mobility
1.
To assess a potential injury to a patients wrist, the examiner asks the patient to turn the hand and forearm upward. This movement is referred to as which of the following?
A)
Pronation
B)
Supination
C)
Inversion
D)
Exversion
Ans:
B Feedback: Pronation refers to turning a body or a body part to face downward. Turning the body or a body part to face upward is known as supination. Inversion refers to the turning of the feet inward so toes point toward the midline. Exversion refers to turning the feet outward so toes point away from the midline.
2.
A)
The nurse is assessing a patient who has presented at the ambulatory care unit. The nurse notes the patient has impaired muscle coordination. The nurse correctly documents the presence of which of the following?
Ataxia
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Tremors
C)
Chorea
D)
Athetosis
Ans:
A
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Feedback: Ataxia refers to a lack of muscle coordination. Tremors are rhythmic repetitive movements. Chorea is spontaneous, brief, involuntary muscle twitching of the limbs or facial muscles. Athetosis refers to movement characterized by slow, irregular, twisting motions. 3.
The nurse is caring for a patient who had surgery 2 days ago. The nurse correctly recognizes which of the following as having the greatest ability to reduce the incidence of deep vein thrombosis (DVT)?
A)
Early ambulation
B)
Bedrest
C)
Preoperative exercise
D)
Frequent turning in bed in the postoperative period
Ans:
A
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Feedback: Immobility promotes venous stasis, which contributes to the development of DVT. When leg muscles are inactive, venous return to the heart decreases. Ambulation will reduce the incidence of DVT. Bedrest increases the incidence of DVT. Exercising prior to surgery does reduce complications but not as much as early ambulation in the postoperative period. Frequent turning is helpful to reduce respiratory complications and the onset of pressure ulcers.
4.
A patient is discharged to his daughters home. He weighs 250 pounds and is immobile. The nurse should instruct the daughter on the use of a
A)
Three-person lift
B)
Transfer with a gait belt
C)
Hydraulic lift
D)
Stand-up assist lift
Ans:
C Feedback:
A hydraulic lift is a mechanical device that permits a patient to be transferred from the bed to a chair.
5.Which nursing strategy will prevent the dislocation of the hip prosthesis?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Turning on the affected side
B)
Crossing the legs when sitting
C)
Sitting at a 90-degree angle
D)
Maintaining abduction
Ans:
D
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Feedback: The nurse should take special care to prevent adduction of the affected leg and hip. To avoid this, some orthopedic surgeons order abductor pillows.
6. A patient who is postoperative from a hip fracture repair should be turned on the
A)
Unaffected side
B)
Affected side
C)
Stomach
D)
Back
Ans:
A
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
465
Feedback: Turn patients who have had hip replacement surgery on the nonoperative side only.
7. Log rolling requires the nurse to use supportive devices in turning the patient to
A)
Maintain the natural alignment of the body
B)
Allow the patients leg to rest on the bed
C)
Decrease the chance for skin breakdown
D)
Prevent the stasis of urine in the bladder
Ans:
A Feedback: Logrolling is a technique used for turning patients who have had surgery or an injury involving the back or spine.
8.
A)
A patient who is immobile complains of severe pain in the right flank. The physician diagnoses the patient with renal calculi. This condition often results from
Increased serum calcium
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Decreased serum calcium
C)
Increased serum phosphorous
D)
Decreased serum phosphorous
Ans:
A
466
Feedback: Urinary stasis and an increased serum calcium level promote the formation of renal calculi.
9.
An elderly man who suffered a hip fracture and is 1 day postoperative is to receive heparin 5,000 Units subcutaneous daily. This is administered to
A)
Increase circulation
B)
Decreasing blood pooling
C)
Enhance mobility
D)
Prevent DVT
Ans:
D Feedback:
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
467
Use of heparin prophylactically has been shown to decrease the incidence of DVTs in the immobile patient. 10. A young adult woman has had orthopedic surgery on her right knee. The first time she gets out of bed, she describes weakness, dizziness, and feeling faint. The nurse correctly recognizes which of the following conditions is likely affecting the patient?
A)
Thrombophlebitis
B)
Anemia
C)
Orthostatic hypotension
D)
Bradycardia
Ans:
C Feedback: Orthostatic hypotension refers to a reduction in blood pressure with position changes from lying to sitting or standing. Blood pooling in the legs increases, thus increasing the postural hypotension. Thrombophlebiits refers to an inflammation of the veins. It manifests with redness and swelling. Anemia refers to a reduction in hemoglobin. This may present with feelings of weakness. Bradycardia refers to a reduced heart rate.
11. A nurse applies padded boots to maintain the foot in dorsiflexion on a patient who is comatose. The nurse is protecting the patient from
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Decubitus ulcers
B)
Pooling of blood
C)
Blood pressure changes
D)
Foot drop
Ans:
D
468
Feedback: A footboard or boots should be applied to maintain dorsiflexion and tendon flexibility. Foot drop is a contracture in which the foot is fixed in plantar flexion.
12.A flexion contracture occurs because of inactivity and
A)
Extensor muscles being stronger that flexors
B)
Flexor muscles being stronger than extensors
C)
Cartilage and bone changes occurring inside the joints
D)
Synovial fluid decreases related to age
Ans:
A
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
469
Feedback: Flexion contractures are most common in immobilized patients. Flexor muscles are usually stronger than their extensor counterparts. Common flexor contractures occur at the joints of the elbow, hip, knee, shoulder, wrist, and ankles.
13. A patient with asthma tries to jog a mile but cannot finish and complains of fatigue. An appropriate nursing diagnosis would be
A)
Activity intolerance related to fatigue
B)
Activity intolerance related to poor conditioning
C)
Activity intolerance related to limited range of motion
D)
Activity intolerance related to heat
Ans:
A Feedback: Commonly, disorders that affect oxygenation, such as respiratory or cardiac problems, decrease a patients ability to tolerate increases in activity.
14. Which of the following gaits is characterized by one leg being dragged and swung forward by hip motion?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Festinating
B)
Spastic
C)
Hemiplegic
D)
Waddling
Ans:
C
470
Feedback: A hemiplegic gait occurs when one leg is paralyzed or neurologically damaged, so that the leg is dragged or swung around to propel it forward.
15. The nurse is caring for a patient who is on strict bed rest. Her medical history includes partial paralysis from a stroke suffered several years ago. There is also evidence of early dementia. The nurse correctly recognizes the patient is at an increased risk for which of the following complications?
A)
Altered gait
B)
Prone to fractures
C)
Suffer from edema
D)
Muscle atrophy
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
Ans:
471
D Feedback:
Disuse may be accompanied by muscle atrophy, which is a decrease in muscle size. 16. When the home care nurse notes that a widow of 3 months is not sleeping well, has no appetite, and does not attend activities outside the home, the nurse suspects the patient is experiencing
A)
Depression
B)
Dementia
C)
Sensory overload
D)
Sensory deprivation
Ans:
A Feedback: Severe affective disorders can hinder mobility. Depression and catatonic states result in limited mobility not because of physical impairments, but because the person lacks the desire to move.
17. A 20-year-old man driving a motorcycle loses control and hits a tree. He states I cannot feel my arms or legs. He will likely receive the diagnosis of
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Paraplegic
B)
Hemiplegic
C)
Monoplegic
D)
Tetraplegic
Ans:
D
472
Feedback: Tetraplegia describes paralysis of the arms and legs.
18. An 82-year-old woman is taking medication for her blood pressure and is suffering from syncope. She is at risk for
A)
Edema
B)
Stroke
C)
Fractures
D)
Paralysis
Ans:
C
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473
Feedback: Motor ability depends on the integrity of the multisynaptic pathways of the afferent and efferent nerves and the central integration provided by the cerebral cortex. Balance and stability are the products of equilibrium, which can be affected by some medications.
19. When an elderly patient walks with her knees slightly flexed and body leaning, the nurse determines that the patient
A)
Should have an orthopedic consultation
B)
Is demonstrating a common gait for the elderly
C)
Requires a better walking shoe
D)
Requires crutches for mobility
Ans:
B Feedback: Many older people have more difficulty overcoming inertia and using gravity efficiently. One contributing factor is the shift in the center of gravity. To compensate for this shift, the knees flex slightly for support.
20. A patient has been smoking for more than 40 years. He developed a bone tumor in the right hip. What is the greatest risk the patient may experience?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Fracture
B)
Pain
C)
Immobility
D)
Numbness
Ans:
A
474
Feedback: The bone tumor may cause pain, but the demineralization of the bone will cause hip fracture.
21.To compensate for the shift in the center of gravity, an older adult will
A)
Shift weight to the right side
B)
Shift weight to the left side
C)
Use a wider base of support
D)
Flex the knees for support
Ans:
D
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
475
Feedback: Many older people have more difficulty overcoming inertia and using gravity efficiently. One contributing factor is the shift in the center of gravity. To compensate for this shift, the knees flex slightly for support.
22. An infant develops one extremity that is shorter than the other. This occurs with
A)
Bone tumors
B)
Hip fractures
C)
Loss of calcium
D)
Hip dislocation
Ans:
D
Feedback: Hip dislocation/subluxation can occur any time during the first year of life. Assessing all infants for hip abnormalities during well-baby examinations is crucial.
23. An orthopedic patient is instructed to tighten the gluteus muscles and relax. This is an example of an
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Isometric exercise
B)
Isotonic exercise
C)
Anaerobic exercise
D)
Aerobic exercise
Ans:
A
476
Feedback: Isometric exercise is static exercise by which the patient tenses a muscle, holding it stationary while maintaining tension.
24. Patients with fractures, back surgeries, or joint replacements should be instructed to
A)
Use a pull sheet with movement
B)
Log roll to the side of the bed
C)
Use the overhead trapeze
D)
Pull up with the headboard
Ans:
C
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
477
Feedback: Overhead trapezes may provide handholds for orthopedic patients.
25. When a patient is lifted or held by a nurse, the additional weight becomes a part of the nurses weight and should be
A)
Supported with a narrow base
B)
Counterbalanced by a horizontal adjustment
C)
Controlled with the upper arm muscles
D)
Balanced over the center of gravity
Ans:
D Feedback: Maintaining balance involves keeping the spine in vertical alignment, the feet positioned for a broad base of balance, and the body weight close to the center of gravity.
26.The proper use of the principles of body mechanics
A)
Acts as a safeguard against legal action by the patient
B)
Acts to prevent injury to the patient and/or nurse
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Primarily protects the patient from injury
D)
Primarily protects the nurse from injury
Ans:
B
478
Feedback: When nurses use their bodies to perform therapies, to assist patients with movement, or to move equipment, they benefit from the effective use of body mechanics to prevent injury to themselves and others.
27. When the patient has been diagnosed as having an infection in the semicircular canals in the vestibular apparatus of the ear, the nurse should assess the patient for
A)
Instability when walking, because the semicircular canals maintain equilibrium
B)
Anxiety, because the semicircular canals maintain psychological understanding
C)
Ability to lift because the semicircular canals control gravitational pull
D)
Confusion because the semicircular canals control understanding
Ans:
A Feedback:
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
479
Equilibrium is provided mainly by the vestibular apparatus consisting of the cochlear duct, the three semicircular canals, and two large chambers known as the utricle and saccule.
28. When the patient restricts use of her dominant arm because of pain and the nurse notes that the measurement of the circumference of the patients nondominant arm is greater than her dominant arm, the nurse determines that the lack of use has resulted in the dominant arms
A)
Atrophy
B)
Hypertrophy
C)
Dystrophy
D)
Malrotation
Ans:
A Feedback:
Atrophy causes the muscle to decrease in strength and size because of disuse.
29. When the muscle contracts, which element is released into the sarcoplasmic reticulum?
A)
Potassium
B)
Calcium
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Sodium
D)
Chloride
Ans:
B Feedback: The transmitting activity occurs when calcium is released into the sarcoplasmic reticulum (site of storage and release for calcium in the muscle), which initiates a complex series of biochemical events that result in muscle contraction.
30. A homecare nurse is assessing a patient in the home. The patient had a cerebrovascular accident and has right side paralysis. After 6 weeks of rehabilitation, the patient has increasing mobility when
A)
She can lift the right arm inch
B)
She can move the right arm with the left
C)
She can chew and swallow food
D)
She can smile and open her right eye
Ans:
A
Feedback:
480
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
481
Permanent changes in mobility occur when physiologic dysfunction that interferes with normal body movement cannot be reversed (e.g., spinal cord injuries that result in paralysis or cerebrovascular accidents that cause weakness or paralysis on one side of the body). Rehabilitation is the key to restoring a person with certain disabilities to optimal health.
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482
Chapter 26- Skin Integrity and Wound Healing
1.
An obese patient on the unit has demonstrated difficulty healing a large pressure ulcer. The nurse correctly recognizes that this is most likely because of which of the following factors?
A)
The patients size limits his activity level.
B)
Adipose tissue is poorly vascularized.
C)
Obesity is linked to impaired white blood cell function.
D)
The amount of tissue needing healing will increase the amount of time needed to adequately heal the wound.
2.
A patient has been admitted to the acute care unit after surgery to debride an infected skin ulceration. The surgeon reports plans to leave the wound open to promote drainage and later close it. This represents what type of wound healing?
A)
Primary intention
B)
Secondary intention
C)
Tertiary intention
D)
Quadratic intention
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
483
3. The nurse is caring for a patient who has reported to the Emergency Department with a steam burn to the right forearm. The burn is pink and has small blisters. The burn is most likely which of the following?
A)
First degree
B)
Second degree
C)
Third degree
D)
Fourth degree
4. A patient with a history of pressure ulcers is discussing nutrition with the nurse. The patient correctly indicates plans to include which of the following in the diet to promote wound healing? Select all that apply.
A)
Vitamin D
B)
Vitamin B3 (niacin)
C)
Vitamin B6 (pyridoxine)
D)
Vitamin B7 (biotin)
E)
Vitamin B9 (folic acid)
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
484
5. The nurse is discussing traditional cultural beliefs relating to skin care and healing with a group of nursing students. Which of the following remarks by a participant indicates the need for further instruction?
A)
Canadians traditionally are concerned about the cost of medical treatment.
B)
Native Americans often believe in the use of herbal or spiritual therapy.
C)
Body image is of little importance to the traditional French cultural beliefs.
D)
Asian culture often embraces the use of acupuncture.
6.
The nurse is discussing home remedies for insect bites with a group of college students. The nurse correctly includes which of the following in the presentation?
A)
Chamomile
B)
Lavender
C)
Aloe vera
D)
Tea tree oil
7. The nurse is providing education to a patient recently diagnosed with psoriasis. The patient questions the nurse about the potential for curing the
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
485
condition. What response by the nurse is most appropriate? A) The condition is hard to cure.
B)
You will likely experience periods of increased skin outbreaks and periods of remissions.
C)
You will have this disease for life.
D)
Your personal health habits will dictate how well you handle this condition.
8.
The nurse is performing an admission assessment on a patient being admitted to a long-term care facility. The nurse notes the patient has a history of psoriasis. Which of the following locations on the body is the nurse most likely to find manifestations consistent with the condition? Select all that apply.
A)
Trunk
B)
Elbows
C)
Knees
D)
Soles of the feet
E)
Neck
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
9.
486
The nurse is caring for a patient who has recently noted abnormal pigmentation in his skin. Which of the following is most likely deficient in the patients diet?
A)
Vitamin A
B)
Vitamin B12
C)
Zinc
D)
Magnesium
10. The nurse is caring for a woman has a labile carbuncle. Which of the following interventions will most likely be included in the plan of care?
A)
Cleanse labia with scented soap
B)
Soak in a warm bath for drainage
C)
Apply an ice pack to relieve pain
D)
Expose the area to a heat lamp
11. A patient has developed blisters around the tape that secures the dressing. The nurse should
A)
Apply tape to the side of the blisters
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Use Montgomery straps
C)
Apply the dressing with a binder
D)
Apply skin barrier to protect skin
487
12. A patient has a small wound with moderate drainage. The nurse should apply
A)
Hydrophilic polyurethane
B)
Collagens
C)
Hydrogels
D)
Silver dressings
13. A woman fell from a truck and required abdominal surgery to repair lacerations of the abdomen and bowel. The patient now has constant drainage from a wound that will not heal on the surface of the abdomen. The patient has a(an)
A)
Infection
B)
Dehiscence
C)
Evisceration
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
488
Fistula
14. A postoperative patient describes the following during a transfer, I feel like something just popped. The nurse immediately assesses for
A)
Infection
B)
Herniation
C)
Dehiscence
D)
Evisceration
15. A patient has a fissure on her finger due to chafing. The patient asks How long will it be painful? The nurse explains that the inflammation phase will last
A)
3 days
B)
5 days
C)
7 days
D)
2 weeks
16. Which of the following activities should the nurse implement to decrease shearing force on the patient with a stage II pressure ulcer?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Support the patient from sliding in bed
B)
Lubricate the area with skin oil
C)
Improve the patients hydration
D)
Pull patient up under the arms
489
17.A full-thickness burn develops a leathery covering called a(an)
A)
Eschar
B)
Static
C)
Abrasion
D)
Erythema
18.A skin infection caused by beta-hemolytic streptococci common in children is
A)
Acne vulgaris
B)
Impetigo
C)
Scabies
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
490
Herpes
19. A child is brought to the clinic by his mother. The mother states he has been at Boy Scout camp. The child has a rash on his face, arms, and legs. The child states it itches severely. The child has probably come in contact with
A)
Latex gloves
B)
A food that he is allergic to
C)
Chlorine in the pool
D)
Poison ivy
20. A nursing student is providing a complete bed bath to a 60-year-old diabetic patient. The student is conducting an assessment during the bath. The student observes a red raised rash under the patients breasts. This manifestation is most consistent with which of the following conditions?
A)
An allergic reaction to medications
B)
An allergic reaction to detergent
C)
A rash related to a yeast infection
D)
A rash related to immobility
21.Which of the following nutrients will prevent abnormal pigmentation?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Copper
B)
Vitamin D
C)
Vitamin E
D)
Fat
491
22. An elderly patient has edema of the right lower extremity with redness and clear drainage. This is most likely related to
A)
Beta-hemolytic streptococcus
B)
Age
C)
Venous insufficiency
D)
Hemangioma
23.In the elderly patient, wrinkling is related to
A)
Loss of protein
B)
Loss of elasticity
C)
Loss of fat
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
492
Loss of circulation
24. A nursing student visits a nursing instructors office and the nursing instructor states, Gina, are you tanning in a tanning booth? The nursing student says yes. The nursing instructors best response would be to instruct her on
A)
The rate of cancer from exposure to sun and tanning beds
B)
The need to apply sunscreen after tanning sessions
C)
The application of skin lotions to protect from skin ulcers
D)
The need to consume milk products to enhance bone development
25. You are instructing mothers of toddlers on the care of skin and the prevention of injury. The nurse should include which of the following teaching interventions?
A)
Protect from burns by covering electric outlets and have a safe zone
B)
Be sure the child receives three servings of dairy products daily
C)
Read to the child daily to enhance intellectual development
D)
Provide time for interaction with other children to assist with socialization
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
493
26. A new mother is asking the nurse about care of her babys skin. The nurse should instruct the mother
A)
Only use cloth diapers, since disposable ones can cause eczema
B)
Apply sunscreen when exposed to ultraviolet rays
C)
Lanugo is hair of a different color that is permanent
D)
Never trim the babys nails due to susceptibility to infection
27. An infant has sebaceous retention cysts in the first few weeks of life. The nurse documents these cysts as
A)
Milia
B)
Prickly heat
C)
Acne vulgaris
D)
Lanugo
28.The cells in the epidermis that provide protection from microorganisms are
A)
Macrophages and mast cells
B)
Melanin and sebum
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Langerhans and keratinocytes
D)
Granulocytes and agranulocytes
Answer Key 1.
B
2.
C
3.
B
4.
B, C
5.
C
6.
C
7.
B
8.
B, C, D
9.
C
10. B
11. C
494
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
12. A
13. D
14. C
15. A
16. A
17. A
18. B
19. D
20. C
21. A
22. C
23. B
24. A
25. A
495
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
26. B
27. A
28. C
496
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
497
Chapter 27- Infection Prevention and Management
1.
A patient is discharged from the hospital and will need to change his left leg dressing using sterile technique two times per day. To prevent the development of further infection, the patient will need to
A)
Wash hands for 1 minute, apply nonsterile gloves, remove the dressing, apply antibacterial waterless soap, and sterile gloves
B)
Wash hands for 30 seconds, remove the old dressing, rewash hands for 30 seconds, and apply a new dressing using forceps
C)
Cleanse hands with antibacterial waterless soap, apply sterile gloves and remove the old dressing, and apply the new dressing
D)
Wash hands for 1 minute, apply sterile gloves to remove the dressing, apply a new dressing, following cleansing with soap and water
Ans:
A Feedback: Decreasing the number of microorganisms present on body surfaces can help prevent and fight infection.
2.
The laboratory calls the nurse to report the patient has a shift of the differential count to the left. The nurse knows this indicates the patient most likely suffers from
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Viral infection
B)
Bacterial infection
C)
Chickenpox
D)
Hepatitis
Ans:
B
498
Feedback: If the infection is severe or prolonged, the body cannot manufacture neutrophils quickly enough, resulting in the release of immature granulocytes into the blood. This increase in the number of immature cells is called a shift to the left or leftward shift in the granulocyte differential count.
3. The nurse of a local university is examining a student who has swollen glands and small painful lesions of the mouth. The nurse expects to palpate swelling in the neck area because
A)
Lymphedema has been caused by lymphatic obstruction
B)
Lymphocytes and macrophages invade the lymph nodes
C)
There will be tumor formation in the lymph nodes
D)
The tonsils are the likely source of infection
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
Ans:
499
B Feedback: The swelling indicates that lymphocytes and macrophages in the lymph nodes are fighting the infection and trying to limit its spread.
4. When an 86-year-old patient complains of inability to concentrate, uneasiness, lightheadedness, weakness, muscle and joint discomfort, and demonstrates normal temperature, the clinic nurse recalls that
A)
Without an elevated temperature, infection is not present
B)
The patients symptoms are typical of an elderly patient
C)
The elderly can have an infection without a fever
D)
An infection was present and has dissipated
Ans:
C Feedback: Older people may not show a fever or may produce only a low-grade fever when an infection is present.
5. A patient is experiencing generalized weakness and body aches. In the progress of infection, the patient is in the
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Incubation period
B)
Prodromal period
C)
Acute period
D)
Convalescent period
Ans:
B
500
Feedback: The prodromal period is characterized by nonspecific symptoms such as nausea, fever, general weakness, or aches and pains.
6.Most nosocomial infections involve which of the following systems?
A)
Intravascular line
B)
Gastrointestinal
C)
Central nervous system
D)
Peripheral lines
Ans:
A
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
501
Feedback: Most nosocomial infections involve the urinary tract, surgical or traumatic wounds, the respiratory tract, or bacteremia, in association with intravascular lines.
7. A 70-year-old patient with chronic obstructive pulmonary disease has a respiratory infection being treated with antibiotics. He is also taking oral corticosteroids to assist in decreasing the inflammation in the lungs. The patient is prone to
A)
Superinfection
B)
Respiratory distress
C)
Nausea and vomiting
D)
Purpura
Ans:
A Feedback: Drug therapy can cause defects in the hosts response to infection. Steroids, chemotherapy, antimetabolites, and inappropriate or prolonged use of antibiotics can increase the risk of infection.
8. An elderly hospitalized man develops severe diarrhea from gram-negative rods that compromised the normal flora of the bowel. What is the cause of the infection?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Helminth
B)
Protozoa
C)
Nosocomial
D)
Virus
Ans:
C
502
Feedback: Gram-negative rods, which comprise much of the bowels normal flora, are associated with nosocomial infections caused by self-contamination.
9. Viruses invade living cells. Which of the following diseases is caused by a virus?
A)
Myocardial infarction
B)
Hepatitis B
C)
Colitis
D)
Cholecystitis
Ans:
B
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
503
Feedback: Viruses cause AIDS, chickenpox, colds, cold sores, encephalitis, hepatitis, herpes influenza, measles, mononucleosis, mumps, polio, rabies, shingles, pneumonia, and many other diseases.
10.Gram-negative organisms are the most often cause of:
A)
Gastrointestinal infections
B)
Respiratory infections
C)
Urinary tract infections
D)
Skin infections
Ans:
C Feedback: The most common causes of UTIs are gram-negative organisms.
11.The most lethal infection in an elderly patient is
A)
Skin
B)
Optic
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Otic
D)
Urinary
Ans:
D
504
Feedback: Urinary tract infections and respiratory infections are most common and most lethal for elderly patients.
12. In adulthood, what factor makes individuals, particularly the elderly, susceptible to infections?
A)
Poor nutrition
B)
Increased exercise
C)
Communal living
D)
Decreasing thymus
Ans:
D Feedback:
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
505
The thymus begins to shrink in late adolescence and continues to diminish into middle age, leading to a decline in cell-mediated and humoral immunity.
13. The most common infections in children are
A)
Respiratory
B)
Gastrointestinal
C)
Neurologic
D)
Urinary Ans: A
Feedback: The most common infections in early childhood are respiratory infections.
14. Otitis media occurs in children because the
A)
Eustachian tube is long and twisted
B)
Eustachian tube has a downward turn
C)
Eustachian tube is shorter and straighter
D)
Eustachian tube is widened
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
Ans:
506
C Feedback:
The most common infections in early childhood are respiratory infections. In children, the eustachian tubes are shorter and straighter; middle ear infections (otitis media) are common because bacteria can easily pass from the nasopharynx to the ear canal.
15.Which of the following statements about neonatal development is accurate?
A)
Neonates may have an infection without fever
B)
Breast-fed infants do not become ill due to immunity
C)
Neonates prefer sleeping and often refuse to eat
D)
Neonates have defense to communicable disease
Ans:
A Feedback: Newborns have immature thermoregulatory mechanisms and do not become febrile.
16. A nurse instructs a new mother on immunizations. An immunization produces
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Active immunity
B)
Humoral immunity
C)
Passive immunity
D)
Antigen immunity
Ans:
A Feedback: Active immunity can be produced by vaccination. Vaccination is the process of injecting weakened or killed organisms into a person, stimulating antibody production.
17. Which of the following is considered the building block of the immune system?
A)
Red blood cells
B)
Macrocytes
C)
Macrophages
D)
T lymphocytes
Ans:
D
507
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Feedback: T and B lymphocytes are the building blocks of the immune system, accumulate in lymph nodes along lymphatic vessels, and are exposed to all antigens except those that enter the bloodstream directly.
18. Which of the following terms describes foreign particles that enter a host and stimulate the bodys immune response?
A)
Macrophage
B)
Phagocyte
C)
Antibody
D)
Antigen
Ans:
D Feedback:
Antigens are foreign particles, such as microbes, that enter a host.
19. The process of phagocytosis involves
A)
Secretion of a nonspecific chemical inhibitor
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Depletion of serotonin in the brain cells
C)
Digestion of microbes by WBCs
D)
Breakdown of proteins into amino acids
Ans:
C
509
Feedback: Many leukocytes function as phagocytes, digesting and destroying microbial invaders.
20.What is the second line of defense in microbial invasion?
A)
Inflammation
B)
Infection
C)
Disease
D)
Disability
Ans:
A Feedback:
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The inflammatory response makes up the second line of defense to microbial invasion.
Chapter 28- Pain Management
1.
The nurse is administering medications to a patient with
neuropathic pain. The patient asks why he is getting an antidepressant medication because he is not depressed. Which of the following is the best response by the nurse? A)
All patients with pain have at least
some depression.
B)
Antidepressants have been shown to have pain-relieving qualities in patients with neuropathic pain.
C)
Treating your depression, even if you dont think you have it, will help control your pain.
D)
The doctor thinks it will help with your pain.
Ans:
B Feedback: Antidepressants are helpful in treating neuropathic and persistent pain. All patients with pain dont necessarily have depression.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
2.
511
A nurse is evaluating the effectiveness of the pre-operative teaching
regarding pain control. Which statement by the patient would indicate a need for further education? A)
I will push my PCA button before I get up to go
to the bathroom.
B)
I will have my wife push the PCA button when Im asleep.
C)
I will bring my favorite music to listen to after my surgery.
D)
I will make sure to drink plenty of water so I dont get constipated from the pain medication.
Ans:
B Feedback: The patient should be the only one to administer medication via the PCA pump. Using the pump prior to getting out of bed and/or ambulating will help decrease the pain. Distraction is an effective nonpharmacologic means of dealing with pain. Constipation is a common side effect from many pain medications. Increasing fluid intake is one way of attempting to prevent it.
3.
A)
A nurse is caring for a patient who is receiving morphine via a patient controlled analgesia (PCA) pump. When assessing the patient, she notes that his respiratory rate is 4. What should the nurse do first?
Notify the physician
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Stop the PCA pump
C)
Administer naloxone
D)
Increase the primary IV rate
Ans:
B
512
Feedback: A side effect of morphine is respiratory depression. In this situation, the nurse should first stop the PCA pump and then notify the physician. Naloxone is used to reverse the sedative effects of opioids but this is not the first step.
4. A student nurse is preparing a presentation on pain management. What information regarding nonpharmacological interventions should he include? Select all that apply. A) Use cold packs for muscle spasms and surgical site pain.
B)
Dry heat penetrates deeper than moist heat.
C)
Ice packs should not be left on longer than 20 minutes.
D)
Massage can stimulate circulation.
E)
Distraction is useful for short pain periods.
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Ans:
513
A, C, D, E Feedback: Moist heat penetrates deeper than dry heat. Cold packs are useful for muscle spasms, back pain, and surgical site pain. Cold packs should not be left in place for greater than 20 minutes at a time. Massage can stimulate circulation and aid in relaxation. Distraction is a useful tool for short pain periods such as starting an IV or changing a dressing.
5. The physician has ordered a patient controlled analgesia (PCA) pump for a patient. Which assessment finding would cause the nurse to question the order?
A)
B/P 178/92 and pulse 118
B)
Confused to time and place
C)
Right shoulder immobilizer in place
D)
Rates pain an 8 on a 1 to 10 scale
Ans:
B Feedback: Patients must be cognitively and physically capable of using the PCA equipment safely. Confusion in a patient would lead the nurse to question the patients ability to correctly use the PCA.
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6. The action of ibuprofen is to
A)
Provide narcotic pain relief
B)
Have a antiprostaglandin effect on the CNS
C)
Close the gate of the A-delta fibers
D)
Enhance the endorphins of the CNS
Ans:
B
Feedback: NSAIDs are generally effective for pain-related tissue damage. The analgesic action of these drugs has antiprostaglandin effects on both the peripheral and central nervous systems.
7. Besides controlling pain of the post-abdominal surgery patient with narcotics, the nurse suggests to the patient that he
A)
Focus on pain relief
B)
Use distraction
C)
Describe the pain
D)
Think about the next dose
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
Ans:
515
B Feedback: Distraction is useful when patients are undergoing brief periods of sharp, intense pain such as dressing changes, wound debridement , biopsy, or incident pain from shifting positions.
8. An 80-year-old woman has been suffering from knee pain for the past 3 years. The patient requires a knee replacement and has diminished mobility. The most appropriate nursing diagnosis is
A)
Chronic pain related to knee disability as defined by guarded gait
B)
Acute pain related to degenerative joint disease as evidenced by static gait
C)
Altered mobility related to pain as defined by guarded gait
D)
Inability to perform activities of daily living related to chronic pain
Ans:
A Feedback: The most appropriate nursing diagnosis is Chronic pain related to knee disability as defined by guarded gait.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
9.
516
Which of the following actions is most appropriate for the nurse to take in response to the patients request for pain medication on his first postoperative day? The patient has an order for a narcotic analgesic every 3 to 4 hours and he received his last dose 3 hours earlier.
A)
Provide the patient with pain medication
B)
Tell the patient that the pain cannot be severe
C)
Document and ask the patient to wait 1 hour
D)
Contact the physician for a change in medication
Ans:
A Feedback: Inadequate or poor pain assessment is a leading factor in poor pain control because the healthcare professional may not know a patient has pain. The nurse must provide the next dose of pain medication.
10. A nurse is assessing a patients pain. The nurse notes which of the following database findings that is indicative of acute pain?
A)
Pupil constriction
B)
Decreased pulse rate
C)
Increased blood pressure
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Decreased respiratory rate
Ans:
C
517
Feedback: The increase in blood pressure that may accompany acute pain is believed to be due to overactivity of the sympathetic nervous system.
11. When the male patient on his first postoperative day after chest surgery appears stoic and does not ask for any pain medication, the nurse should
A)
Document the patients lack of medication
B)
Assume the patient does not need medication
C)
Ask the patients family if he ever uses pain medicines
D)
Actively solicit information about the patients pain level
Ans:
D Feedback: Some cultures see pain tolerance as a virtue; often men are expected to tolerate pain more stoically than women do. Healthcare providers need to recognize the patients cultural beliefs and not impose their own judgments.
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12. A child describes intense pain in the chest and head while eating a popsicle. The pain the child is experiencing is termed
A)
Fear
B)
Allodynia
C)
Thermal stimulation
D)
Hyperalgesia
Ans:
B
Feedback: Allodynia is a pain sensation produced by an innocuous stimulus such as light touch. 13. When a 17-year-old male athlete injures his knee during basketball practice and refuses to go to the school nurse, he states he does not have pain. The school nurse assesses the students knee and recognizes that by stating he does not have pain the student is
A)
Not injured
B)
In need of counseling
C)
Not showing weakness to his peers
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Ignoring the pain
Ans:
C
519
Feedback: To recognize or give in to pain may seem like a sign of weakness in the adolescent.
14. When parents of a preschool child who is experiencing pain from ear surgery inform the nurse that the child is withdrawn from them and acts ambivalent, the nurse responds that the preschoolers behavior
A)
Is a normal response
B)
Needs further evaluation
C)
Demonstrates regression
D)
Indicates potential abuse
Ans:
A Feedback: Although parents are childrens greatest source of comfort and support, children may appear ambivalent toward them, as though they blame them for pain. Encourage and support parents in such instances, helping them understand childrens responses.
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15. Which of the following guidelines regarding pain should be included in the nurses teaching plan for a group of parents with infants and toddlers?
A)
Pain can be a source of fear and threat to the toddlers security
B)
Toddlers are often reluctant to express pain
C)
Infants cannot express pain until 8 months of age
D)
Toddlers often try to be brave and not cry
Ans:
A Feedback: During the toddler and preschool years, children are achieving a sense of autonomy. Because pain can be a source of fear and threat to security, children respond with crying, anger, physical resistance, or withdrawal.
16. The nurse identifies the pain described by a patient whose back discomfort began after an automobile accident and has persisted for 8 months as
A)
Acute
B)
Recurrent
C)
Chronic
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Malignant
Ans:
C
521
Feedback: Chronic pain lasts for a prolonged period, and its cause is not amenable to specific treatment.
17. Two hours after receiving a pain medication, the patient states he still is suffering from pain. Which question is appropriate to ask the patient first? A) Do you need your pain medication now?
B)
Please describe your pain on a scale of 0 to 10.
C)
Tell me where your pain is located.
D)
Tell me more about your pain.
Ans:
D
Feedback: Pain intensity indicates the magnitude or amount of pain perceived. Terms used to describe pain intensity include none, mild, slight, moderate, severe, and excruciating. Pain intensity also may be described on a numeric scale. The most appropriate assessment question is one which allows for all information and is a broad question.
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18. When assessing a patients pain, the nurse should question the patient about location, intensity, quality of the pain, and
A)
Pain tolerance
B)
Level of consciousness
C)
Temporal pattern
D)
Objective signs
Ans:
C Feedback: Verbal reports by the patient indicate more clearly its location, intensity, quality, and temporal pattern. Level of consciousness and objective signs are assessments the nurse makes.
19. Endogenous opioids such as endorphins
A)
Excite neural pathways
B)
Contribute to analgesia
C)
Cause muscle spasms
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Release neurotensin
Ans:
B
523
Feedback: The opioid receptors, important for the inhibition of pain perception, are sites where endogenous opioids and exogenous opioids bind. Three groups of endogenous opioids relieve pain: enkephalins, endorphins, and dynorphins.
20.The most important pathway for pain sensation is the
A)
Corticospinal tract
B)
Dorsal horn neural tract
C)
Afferent tract
D)
Spinothalamic tract
Ans:
D Feedback: The spinothalamic tract appears to be the most important pathway for pain sensation.
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524
21. A sudden blow to the head results in pain that is transmitted by which type of fibers?
A)
A-delta
B)
B-gamma
C)
C fibers
D)
D-delta Ans: A
Feedback: A-delta fibers give rise to bright, sharp, well-localized pain that is immediately associated with injury.
Chapter 29- Sensory Perception
1.
A patient is refusing to take his prescribed medication. The patient states that the government is out to get him and is poisoning all of his medication. The nurse understands that the patient is experiencing
A)
an illusion.
B)
a delusion.
C)
an hallucination.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
confusion.
Ans:
B
525
Feedback: Hallucinations, sensory impressions that are based on internal stimulations, have no basis in reality. Hearing voices when no one is there is a typical auditory hallucination. Delusions, beliefs not based in reality, reflect an unconscious need or fear. Illusions are misinterpretations of actual stimuli. 2.
The nurse is preparing a care plan for a patient with a nursing diagnosis of Disturbed Sensory Perception. Which of the following would be appropriate goals for this diagnosis? Select all that apply.
A)
The patient will demonstrate an understanding of contributing factors to disturbed sensory perceptions by reducing or eliminating them during the hospital stay.
B)
The patient will not fall during the hospital stay.
C)
The patient will develop an effective communication mechanism during the hospital stay.
D)
The nurse will use a communication board when speaking with the patient.
E)
The nurse will assist the patient with ADLs as needed during the hospital stay.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
Ans:
526
A, B, C Feedback: Goals are patient-directed statements, not nurse directed. Examples of appropriate patient goals for Disturbed Sensory Perception may include the following: the patient will remain safe, the patient will demonstrate an understanding of contributing factors to disturbed sensory perceptions by reducing or eliminating them, the patient will maintain the functioning of existing senses, or the patient will develop an effective communication mechanism.
3.
The nurse understands that when a patient is talking about the voices in their head, the patient is experiencing
A)
a delusion.
B)
an hallucination.
C)
an illusion.
D)
confusion.
Ans:
B Feedback: Hallucinations, sensory impressions that are based on internal stimulations, have no basis in reality. Hearing voices when no one is there
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527
is a typical auditory hallucination. Delusions are fixed beliefs, not based in reality. Illusions are misperceptions of actual stimuli.
4.
The nurse is caring for a patient at risk for sensory overload. What interventions should the nurse implement? Select all that apply.
A)
Remove clutter from the patients room
B)
Implement measures to reduce the patients pain
C)
Assist with all ADLs
D)
Limit interruptions to the patients rest/sleep times
E)
Limit extraneous noise
Ans:
A, B, D, E Feedback: If the patient is experiencing sensory overload, interventions should focus on reducing stimulation involving information, the environment, and internal factors. Limiting extraneous noise, bright lights, room clutter, interruptions, pain, and stress reduces stimulation. Patients with sensory overload may neglect their ADLs to the point that they need assistance. Such assistance can be problematic because it can add to sensory overload. With this in mind, assist the patient only with the immediately essential ADLs (moving, eating, toileting, and resting). Additional tasks may be added as the patient is able to cope.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
5.
528
The nurse is caring for a patient at risk for sensory deprivation. What
interventions should the nurse implement to decrease the patients risk? Select all that apply. A) Encouraging the patients family to bring in personal objects.
B)
Keeping the television on at all times
C)
Placing a clock and calendar in the patients room
D)
Brushing the patients hair
E)
Speaking slowly and clearly to the patient
Ans:
A, C, D, E Feedback: Measures to provide stimulation include playing the television or the radio occasionally, playing music for brief periods, encouraging use of a clock and calendar, encouraging the patient to dress for the days activities, putting up colorful pictures, encouraging visitors, encouraging family to bring in personal items such as photographs, opening the drapes, and turning on lights. Place the bed or chair so the patient can see or hear activities in the area and when someone enters the room. Frequent interaction with the patient also may help. Discussing scheduling of care and placement of equipment, encouraging self-care activities, providing tactile stimulation through backrubs, combing and brushing the patients hair (or encouraging the patient to do so), reading to the patient, speaking slowly and clearly, and identifying yourself verbally and with a name tag are meaningful interactions.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
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6.Which of the following patients is at greatest risk of sensory overload?
A)
A 17-year-old on bedrest after a surgical procedure
B)
A 55-year-old, newly diagnosed with diabetes, in a private room in a hospital
C)
An 88-year-old on a ventilator in an intensive care unit
D)
An 8-year-old in isolation in a private room in a hospital
Ans:
C Feedback: Private rooms, mobility restraints (such as traction or bedrest), isolation, and few visitors are all risk factors for sensory deprivation. Intensive care units, mechanical ventilators, lengthy verbal explanations prior to procedures and decreased cognitive ability (e.g., head injury) are all risk factors for sensory overload.
7. Which patient is at greatest risk of developing sensory deprivation?
A)
An 84-year-old with progressive hearing loss living in an assisted living facility
B)
A 50-year-old newly diagnosed with breast cancer and having first chemotherapy treatment today
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
530
C)
A 32-year-old with a fractured pelvis, on bedrest in a private room
D)
An 18-year-old with a traumatic head injury who is in an intensive care unit
Ans:
C Feedback: Private rooms, mobility restraints (such as traction or bedrest), isolation, and few visitors are all risk factors for sensory deprivation. Intensive care units, lengthy verbal explanations prior to procedures, and decreased cognitive ability (e.g., head injury) are all risk factors for sensory overload.
8. A nurse has just finished a presentation to a group of nursing assistants on ways to assist patients with sensory perception issues, such as low vision or hearing. What statement by a nursing assistant suggests a need for further education? A) I will stand directly in front of the patient and speak slowly.
B)
I will move the furniture around depending on what activities are planned for the day.
C)
I will use bright contrasting colors when making signs.
D)
I will keep fresh flowers in the television room.
Ans:
B
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
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Feedback: Examples of sensory aids include using large print materials, bright contrasting colors in the environment, uncluttered environment with no furniture rearranging, speaking slowly and distinctly while standing directly in front of the patient, and keeping fresh flowers in the room.
9. A patient has received morphine for complaints of pain at a recent surgical incision site. After receiving the medication, the patient starts picking at the bedsheets and saying, Get the bugs off my bed, I can feel them crawling on me! Which nursing diagnosis is appropriate for this patient?
A)
Disturbed Sensory Perception: Kinesthetic related to side effects of medication as evidenced by patient statement of Get the bugs off my bed, I can feel them crawling on me.
B)
Disturbed Sensory Perception: Tactile as evidenced by patient statement of Get the bugs off my bed, I can feel them crawling on me.
C)
Disturbed Sensory Perception related to patient statement of Get the bugs off my bed, I can feel them crawling on me
D)
Disturbed Sensory Perception: Tactile related to side effects of medication as evidenced by patient statement of Get the bugs off my bed, I can feel them crawling on me.
Ans:
D Feedback:
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
532
Disturbed Sensory Perception: Tactile related to side effects of medication as evidenced by patient statement of Get the bugs off my bed, I can feel them crawling on me is the correctly written nursing diagnosis. Since the nursing diagnosis is not a risk for diagnosis, it must have a related to and as evidenced by statement.
10. The student nurse is preparing a presentation on sensory perception. What symptoms of sensory deprivation should the student include? Select all that apply.
A)
Depression
B)
Increased appetite
C)
Sleeplessness
D)
Decreased interest in activities
E)
Increased interest in interactions with others
Ans: A, C, D Feedback: Depression may result from sensory deficits or sensory deprivation. Helplessness and loss of self-esteem lead to depression and withdrawal. The patient who is placed on isolation precautions may show signs of poor appetite, sleeplessness, and loss of interest in activities or interaction with others as he or she becomes depressed, leading to further sensory deprivation.
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11. A student nurse is preparing a presentation on sensoryperception . What symptoms of sensory overload should the student include? Select all that apply.
A)
Disorientation
B)
Sleeplessness
C)
Confusion
D)
Increased work performance
E)
Fatigue
Ans:
A, B, C, E Feedback: Disturbances in remembering, reasoning, and problem solving can occur with sensory overload. Decision making may be irrational or dysfunctional. Other common behaviors indicative of cognitive dysfunction include disorientation; verbalizing disconnected thoughts; complaining of too much going on, sleeplessness, and fatigue; inability to think; and poor work performance.
12. The nurse is caring for a patient who has been placed in respiratory isolation. The nurse understands that the patient is at risk for:
A)
Sensory overload
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Sensory deprivation
C)
Sensoristasis
D)
Sensory perception
Ans:
B
534
Feedback: Deprived environments can have negative effects on a persons sensoristasis. A person who is immobilized or isolated for any reason is deprived of the usual amount of stimulation and may show manifestations of sensory deprivation. 13. A patient has just been told that he has lung cancer. The physician then describes several potential courses of treatment to the patient. When the physician leaves the room, the patient asks the nurse, What did he just say? The nurse understands that the patient is experiencing ____________.
A)
sensory overload
B)
sensory deprivation
C)
sensoristasis
D)
sensory perception
Ans:
A
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535
Feedback: Sensory overload occurs when a person is unable to process or manage the intensity or quantity of incoming sensory stimuli. Imparting information to a patient may lead to sensory overload. Some examples include teaching a patient about a procedure, informing a patient about a diagnosis, making requests of a patient, or helping the patient solve a problem.
14. A patient with hearing loss gets very frustrated trying to carry on conversations with friends. Which type of stressor is the patient experiencing?
A)
Physical
B)
Psychological
C)
Sensory deficits
D)
Sociocultural
Ans:
C Feedback: Sensory deficits in vision and hearing interfere with ones ability to interact with other people and with the environment.
15. A sensory deficit that may arise from the patients eyes being bandaged after eye surgery can result in
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Depression
B)
Psychic blindness
C)
Compensation
D)
Total disorientation
Ans:
D
536
Feedback: A sudden loss of sensory perception through a sensory deficit can cause total disorientation because compensation does not occur immediately.
16. A hospitalized patient who refuses to eat because she fears that the kitchen personnel are poisoning her food is experiencing
A)
Hallucinations
B)
Anorexia
C)
Agoraphobia
D)
Delusions
Ans:
D
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
537
Feedback: Delusions, beliefs not based in reality, reflect an unconscious need or fear.
17. When admitting a wheelchair-bound paraplegic patient to the hospital, the nurse assesses the patient for injuries that may occur as a result of sensory
A)
Alteration
B)
Overload
C)
Deprivation
D)
Progression
Ans:
A Feedback: Altered sensory reception occurs in such conditions as spinal cord injury, brain damage, changes in receptor organs, sleep deprivation, and chronic illness.
18.A patient in the intensive care unit will experience less sensory overload
A)
If a clock displays date, time, AM/PM
B)
If the nurse silences the alarms
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
If the nurse provides touch every hour
D)
If the family visits at all times
Ans:
A
538
Feedback: Disorientation can occur when expected day/night differences in levels of general activity are lost. To reduce such disorientation, provide a clock displaying a clear distinction of AM/PM time, day, and date. Silencing the alarms could compromise the patients care. 19. The nurse determines that when a female patient who underwent a mammogram earlier in the day is asked to have a breast ultrasound and is informed that she demonstrates signs of breast malignancy, the patient is at risk for experiencing sensory
A)
Adaptation
B)
Deprivation
C)
Stimulation
D)
Overload
Ans:
D Feedback:
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539
When the reticular activating system (RAS) is overwhelmed with input, a person may experience sensory overload and feel confused, anxious, and unable to take constructive action. 20. When the patient who has been hospitalized for 8 days for skin grafting tells the nurse that he is bored, depressed, and restless, the nurse determines that the patient is experiencing sensory
A)
Deprivation
B)
Adaptation
C)
Perception
D)
Overload
Ans:
A Feedback: When the RAS fails to recognize a stimulus because it is below the threshold level or lacks relevant meaning to the person, sensory deprivation may occur, and the person experiences boredom, depression, restlessness, and vivid sensual imagery, including hallucinations.
21. The nurse taking care of a 3-year-old who is on a 10-regimen dose of gentamicin should instruct the mother to
A)
Have the vision tested in 6 weeks
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Have the gentamicin levels tested in 6 weeks
C)
Have the peripheral nervous system tested in 6 weeks
D)
Have the hearing tested in 6 weeks
Ans:
D
540
Feedback: Some antibiotics, including streptomycin and gentamicin, can damage the auditory nerve, impairing hearing.
22. An intensive care unit nurse does not notice the noise within her environment. However, the patients family member states, How can you stand it in here? The lights, sounds, and activity would drive me crazy and I couldnt take it. The nurse has adapted to her
A)
Intensive care unit work
B)
Intensive care unit environment
C)
Threatening stimuli
D)
Nursing career
Ans:
B
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Feedback: Sensory stimulation in the environment effects sensory perception. After routine exposure to stimulation, the body adapts.
23. To meet the learning needs of the older adult, the nurse incorporates which of the following considerations in planning to teach a 73-year-old diabetic patient about insulin administration?
A)
Requesting hearing aids to help the patient receive information
B)
Using numerous handouts and detailed teaching plan
C)
Allowing more time for the processing of the information
D)
Demonstrating a wide variety of syringes and techniques
Ans:
C Feedback: As a person approaches 60 to 70 years of age, marked decrements in sensory/perceptual behaviors begin. This reduction in efficiency means that older people cannot process sensory input as rapidly as they did when they were young.
24. When a new mother asks the nurse whether her newborn infant can see her, the best response by the nurse is to tell the mother that her infant
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Cannot see for 2 weeks of age
B)
Can differentiate objects only
C)
Can differentiate colors only
D)
Can see light and dark patterns
Ans:
D
542
Feedback: Newborns see only gross patterns of light and dark or bright colors. As they grow, vision becomes more discriminating. 25. In the process of adaptation, the nursing student prepares for her day in her mind. She tells herself that she can overcome her fears and anxiety to give good care. This is an example of
A)
Emotional stability
B)
Sensory deprivation
C)
Lead time
D)
Afterburn
Ans:
C
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Feedback: Lead time is the time each person needs to prepare for an event emotionally and physically.
26. A nursing student is attending her first day of clinical. She is very alert to the workings of the clinical division and the care of her patient. This is an example of
A)
Sensoristasis
B)
Stimulation
C)
Arousal
D)
Adaptation
Ans:
A Feedback: Sensoristasis is a state of optimum arousalnot too much and not too little.
27. When a person selects, organizes, and interprets sensory stimuli, the process is termed
A)
Adaptation
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Perception
C)
Stimulation
D)
Preoccupation
Ans:
B
544
Feedback: Sensory perception is a conscious process of selecting, organizing, and interpreting sensory stimuli that requires intact and functioning sense organs, nervous pathways, and the brain. 28. During a patient assessment, the nurse has the patient close his eyes. She then places her finger on his right thigh. She asks the patient where he is being touched and he answers my right thigh. This is an example of which sense?
A)
Auditory
B)
Visual
C)
Kinesthetic
D)
Olfactory
Ans:
C
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Feedback: The kinesthetic sense influences the awareness of placement and action of body parts.
29. A patient who has awakened from a coma after a car accident states he knew about a news story reported during the time he was in the coma. The is an example of the
A)
Reticular-activating systems stimulation
B)
Sleep-latency phase of sleep-wake cycle
C)
Circadian rhythm for 24 hours
D)
Sensory perception in a conscious process
Ans:
A Feedback: Destruction of the reticular-activating system (RAS) produces a coma and an electroencephalograph pattern consistent with sleep. When the nervous system is oriented to a stimulus and receptive toward it, the neurons of the RAS arouse the brain, facilitating information reception (Widmaier, Raff, & Strang, 2008). The RAS is highly selective.
30. A patient in the intensive care unit becomes very cognizant of the nurses touch. This is a function of which system?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
General adaptation syndrome
B)
Local adaptation syndrome
C)
Reticular activating system
D)
Peripheral nervous system
Ans:
C
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Feedback: The reticular activating system (RAS) is responsible for bringing together information from the cerebellum and other parts of the brain with that obtained from the sense organs. Awareness of the world depends on the RAS, which is located between the nerve centers of the medulla oblongata in the brain stem. Sensory, visceral, kinesthetic, and cognitive input stimulate the RAS.
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Chapter 30- Respiratory Function
1.
A patient who is scheduled for a bronchoscopy has arrived at the
clinical facility. When preparing for the test, the patient reports feeling hungry and asks the nurse when he will be able to eat. What information should be provided by the nurse? A) You will not be allowed to eat or drink until the physician has seen you.
B)
You may immediately resume your normal diet after the test.
C)
You will not be able to eat or drink until your gag reflex has returned.
D)
It will be at least 8 hours after the procedure before you are allowed to eat or drink.
Ans:
C Feedback: The bronchoscopy allows for the visualization of the airways. Nursing interventions for a bronchoscopy include ensuring informed consent, teaching before the procedure, and maintaining NPO status until the gag reflex returns after the procedure.
2.
The nursing assessment reveals reduced fremitus. This manifestation is consistent with which of the following conditions? Select all that apply.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Right-sided heart failure
B)
Left-sided heart failure
C)
Pneumonia
D)
Pulmonary edema
E)
Bronchial obstruction
Ans:
B, D, E
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Feedback: Fremitus refers to the vibration of air movement through the chest wall. It is best felt by placing the balls of the palms of your hand on the patients back as he or she says 99. The intrascapular space is a good area to feel tactile fremitus because it diminishes as you move out in the lung fields. Decreased fremitus may occur with pleural effusion, pulmonary edema, emphysema, or bronchial obstruction. Leftsided heart failure will result in pulmonary edema, causing decreased fremitus.
3. The nurse is reviewing the pulse oximeter readings from a postoperative patient. The nurse correctly recognizes that readings below what level indicate the need for oxygen therapy and further assessment?
A)
97%
B)
95%
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
93%
D)
90%
Ans:
C
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Feedback: An SaO2 greater than 95% is considered normal, whereas values lower than 93% usually indicate the need for oxygen therapy and further assessment.
4. The nurse is talking with a patient who has COPD. The patient reports her chest shape seems to have changed over the past year. What information should be provided by the nurse?
A)
Your chest diameter has increased as the musculature has matured in an effort to obtain increased amounts of oxygen.
B)
Your lung condition limits the ability of the lungs to fully exhale, causing this change in shape.
C)
Chronic lung conditions such as this are associated with fluid retention in the lower lung fields, causing the change in the chest shape.
D)
The corticosteroids prescribed to manage the condition have caused a change in the shape of the chest wall.
Ans:
B
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Feedback: In COPD, the patients chest becomes overinflated over time because of an inability to exhale fully. This increases the anteriorposterior chest diameter, resulting in a barrel-shaped appearance.
5. A patient has edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. The patient is suffering from
A)
Pulmonary embolism
B)
Myocardial infarction
C)
Lung cancer
D)
Congestive heart failure
Ans:
D Feedback: A patient who has edema and a cough that is productive with frothy sputum is manifesting heart failure.
6.
The patient has an increased anteroposterior chest diameter, dyspnea, and nasal flaring. The most appropriate nursing diagnosis is
A)
Hypoxia related to pneumonia and ineffective airway clearance related to dyspnea edema
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B)
Ineffective breathing pattern related to hyperventilation related to increased anteroposterior diameter
C)
Risk for ineffective airway clearance related to infection as evidenced by dyspnea and yellow-green sputum
D)
Impaired gas exchange related to increased carbon dioxide and irritability Ans:B Feedback: Ineffective breathing pattern is the state in which a persons inspiration and/or expiration pattern does not provide adequate ventilation.
7.
A patient with chronic obstructive pulmonary disease requires low flow oxygen. How will the oxygen be administered?
A)
Nasal cannula
B)
Simple oxygen mask
C)
Venturi mask
D)
Partial rebreather mask
Ans:
A Feedback:
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Nasal cannula and tubing administers oxygen concentrations at 22% to 44%.
8.
When the emergency room nurse assesses the pulse oximeter on a patient and it reveals 105%, the nurse determines that the most likely explanation for the value is
A)
Carbon monoxide poisoning
B)
Edema at the sensor site
C)
High oxygen level
D)
Low carbon dioxide levels
Ans:
A Feedback: Carbon monoxide poisoning results in false high readings; edema at the sensor site produces false low readings.
9. The home care nurse visits a patient with compromised lung function. She has greenish-yellow sputum with a musty odor. This is indicative of
A)
Allergy
B)
Congestive heart failure
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Asthma
D)
Infection
Ans:
D
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Feedback: Sputum that is yellow or greenish or has a musty odor usually indicates an infection. The sputum associated with congestive heart failure is frothy or pink tinged. Sputum associated with asthma is thick and mucoid, not yellow or green in color.
10. Which of the following medications are administered in the home or the hospital to relieve inflammation in the lung tissue?
A)
Antibiotics
B)
Bronchodilators
C)
Expectorants
D)
Corticosteroids
Ans:
D Feedback:
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In many cases, bronchodilators and corticosteroids are required to open airways and ease breathing. Corticosteroids relieve inflammation.
11. When the patient demonstrates loud, coarse breath sounds on inspiration, the nurse documents the breath sounds heard as
A)
Crackles
B)
Vesicular
C)
Wheezes
D)
Rales
Ans:
A Feedback: A coarse crackle is a low-pitched, rumbling sound in airways. When they are coarse and loud and occur with severe dyspnea, crackles may be a telling sign of pulmonary fibrosis, congestive heart failure, and pulmonary edema.
12.What skin disorder is associated with asthma?
A)
Seborrhea
B)
Psoriasis
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Abrasions
D)
Eczema
Ans:
D
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Feedback: The patient with asthma often recalls childhood allergies and eczema.
13. The nurse is assessing a patient with lung cancer. What manifestations may be noted that are indicative of hypoxia?
A)
Edema
B)
Cyanosis
C)
Constipation
D)
Clubbing
Ans:
D Feedback: Clubbing refers to the rounding and enlargement of the tips of the fingers and toes. It is a common phenomenon seen in many patients with
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respiratory or cardiac disease. Clubbing is believed to be caused by longterm tissue hypoxia which causes the release of a substance that causes dilation of the vessels of the fingertips (Lewis, et al., 2007). Clubbing occurs in lung cancer, cystic fibrosis, and lung diseases such as lung abscess and chronic obstructive pulmonary disease.
14. A child is admitted to the pediatric division with an acute asthma attack. The nurse assesses the lung sounds and respiratory rate. The mother asks the nurse, Why is his chest sucking in above his stomach? The nurses most accurate response is A) He will require additional testing to determine the cause.
B)
He is using his chest muscles to help him breathe.
C)
His infection is causing him to breathe harder.
D)
His lung muscles are swollen so he is using abdominal muscles.
Ans:
B Feedback: The patient will use accessory muscles to ease dyspnea and improve breathing.
15. The home care nurse visits a patient who has dyspnea. The nurse notes the patient has pitting edema in his feet and ankles. What additional assessment would the nurse expect to observe?
A)
Crackles in the lower lobes
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Inspiratory stridor
C)
Expiratory stridor
D)
Wheezing in the upper lobes
Ans:
A
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Feedback: People with chronic congestive heart failure often experience shortness of breath because of excess fluid in the lungs and low oxygen levels. Stridor is associated with respiratory infections such as croup. Wheezing may be heard in individuals who use tobacco products.
16. A patient suffering from chronic obstructive pulmonary disease complains that it is hard to cough up secretions and they are thick and sticky. The nurse should instruct the patient to
A)
Increase her fluid intake to thin secretions
B)
Eat small frequent meals to conserve energy
C)
Decrease exercise and increase rest periods
D)
Take a cough suppressant to decrease coughing
Ans:
A
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Feedback: When a cough is productive, it is important to establish the source of the sputum and assess its color, volume, consistency, and other noteworthy characteristics. The nurse should instruct the patient to increase fluid intake to thin secretions.
17. A woman comes to the emergency room with her 2-year-old. She states he woke up and had a loud barking cough. The child is suffering from
A)
Atelectasis
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Pulmonary fibrosis
C)
Asthma
D)
Croup
Ans:
D Feedback: Croup and epiglottitis are common in young children. The child has an obstruction of the upper airways, with swelling of the throat tissue. Atelectasis results when the lungs collapse as a result of the alveoli being unable to expand. Symptoms include difficulty breathing and discomfort. Pulmonary fibrosis is a condition in which the lung tissue becomes stiff and unable to expand appropriately. Asthma is a condition associated with bronchoconstriction. The symptoms include nonproductive cough, dyspnea, and wheezing.
18. The nurse is caring for a postoperative adult patient who has developed pneumonia. The nurse should assess the patient frequently for symptoms of
A)
Atelectasis
B)
Bronchospasm
C)
Croup
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B) D)
Epiglottitis
Ans:
A
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Feedback: Stiffer lungs tend to collapse and their alveoli also collapses. This condition is called atelectasis. 19. Which of the following dietary guidelines would be appropriate for the elderly homebound patient with advanced respiratory disease who informs the nurse that she has no energy to eat?
A)
Snack on high-carbohydrate foods frequently
B)
Eat smaller meals that are high in protein
C)
Contact the physician for Ensure
D)
Eat one large meal at noon
Ans:
B Feedback:
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The patient should consume a diet in which the body can produce plasma proteins. The patient should have sufficient caloric and protein intake for respiratory muscle strength.
20. A nurse is volunteering at a day camp. A child is stung by a bee and develops wheezing in the upper airways. The child is experiencing
A)
A bronchospasm
Bronchitis
C)
Bronchiectasis
D)
Bronchiolitis
Ans:
A Feedback: When allergic responses take place in the lungs, breathing difficulties are far more severe. Small airways become edematous, mucous production increases, and inflammatory chemical mediators cause bronchospasm.
21. Which one of the following problems occurs among individuals exposed to automobile pollutants
A)
Atelectasis
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B) B)
Bronchitis
C)
Bronchiectasis
D)
Croup
Ans:
B
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Feedback: Air pollution and high humidity are respiratory irritants. Pollutants cause increased mucous production and contribute to bronchitis and asthma.
22. It is a red air-quality day in your city. This means the air is stagnant, with high pollution levels and high humidity. Which patient is most likely to experience shortness of breath?
A)
Child with asthma
B)
Middle-aged adult with hypertension
C)
Teenager with contact dermatitis
D)
Young adult without disease
Ans:
A
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Feedback: Air pollution and high humidity are respiratory irritants. Pollutants cause increased mucous production and contribute to bronchitis and asthma. While pollution is not good for any group of individuals it would be less of an impact on the person with hypertension or dermatitis.
23.
A patient with chronic obstructive pulmonary disease
complains of severe shortness of breath when it is raining. The nurse instructs the patient A) The airway becomes occluded during periods of rain.
The air is thicker or more viscous with humidity, thus it is harder for you to breathe.
C)
You should use your inhaler during this time to help your breathing.
D)
Have you had a stress test to determine if your airway is obstructed?
Ans:
B Feedback: People with chronic respiratory diseases often find breathing more difficult when the weather is hot and humid because humidity contributes to air viscosity.
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B) 24.
564
During a routine prenatal care visit, a pregnant woman in her last
trimester of pregnancy complains of shortness of breath. The nurse instructs her that: A)
Her breathing is normal but if it continues to
call her physician.
B)
If she has pneumonia she should have a chest X-ray.
C)
The nurse will assess her lung sounds and determine presence of congestion.
D)
Her breathing will become increasingly difficult as the diaphragm is displaced upward.
Ans:
D Feedback: During the last weeks of pregnancy, breathing may become increasingly difficult in a supine position because the fetus displaces the diaphragm upward.
25. The nurse determines that the student who has been instructed about lung function and smoking requires additional teaching when the student says
A)
A physically fit athlete breathes more slowly than a sedentary person.
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B)
Smoking only once in a while will not make a person addicted to smoking.
C)
An older person may breathe more shallowly than a younger person.
D)
An upright position will help someone breathe with less effort.
Ans:
B Feedback: During adolescence, more than 3000 young men and women begin smoking every day, and most will become addicted before age 20. One reason for this finding is that adolescents dont believe they will become addicted to tobacco when they start to smoke.
26. The nurse is assessing a newborn in the nursery. The nurse notes the infant has episodes in which breathing ceased for 20 seconds on twooccasions . The nurse correctly recognizes this condition as which of the following?
A)
Dyspnea
B)
Apnea
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Orthopnea
D)
Hypercapnea
Ans:
B
566
Feedback: The newborns breathing pattern is characterized by occasional pauses of several seconds between breaths. This periodic breathing is normal during the first 3 months of life, but frequent or prolonged periods of apnea (cessation of breathing 20 seconds or longer) are abnormal. Dyspnea refers to a shortness of breath. Orthopnea refers to difficulty breathing when lying flat. An excess of carbon monoxide is termed hypercapnea.
27. When the nurse observes a newborn infant demonstrating an irregular abdominal breathing pattern, with a respiratory rate of 50 breaths/minute with occasional pauses in breathing of 5-second durations, the most appropriate action by the nurse is to
A)
Begin resuscitation efforts
B)
Elevate the head of the crib
C)
Continue to assess the infant
D)
Position the infant side-lying
Ans:
C
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Feedback: Newborns breathe rapidly at 30 to 60 breaths per minute and may have occasional pauses of several seconds between breaths.
28.Oxygen and carbon dioxide move between the alveoli and the blood by
A)
Osmosis
B)
Hyperosmolar pressure
C)
Diffusion
D)
Negative pressure
Ans:
C Feedback: Oxygen and carbon dioxide move between the alveoli and the blood by diffusion, the process in which molecules move from an area of greater concentration or pressure to an area of lower concentration or pressure.
Chapter 31- Cardiac Function
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
1.
568
A patient planning air travel for lengthy periods should be advised to do
which of the following to prevent complications such as blood clots? Select all that apply. A)
Sit as far back in the seat as possible to reduce venous
pooling.
B)
Perform leg pump exercises frequently.
C)
Avoid crossing legs at the ankles.
D)
Rest calves against the back of the chair when possible to promote venous exchange.
E)
Ambulate as much as possible.
Ans:
B, C, E Feedback: Limitations in movement as in during air travel may increase the patients risk for the development of DVT. Efforts to reduce this include the performance of leg pumping, avoiding sitting with legs crossed, and ambulation. Sitting with the legs against the back of the seat may compress vessels and be a complication.
2. A nurse has been assigned to work on a pediatric care unit. When performing shift assessments, the nurse recognizes which of the following about patients in this age group? Select all that apply.
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A)
In the weeks after birth, the infants heart rate will normally be between 70 and 90 beats per minute.
B)
Blood pressure assessments are not routinely performed on children under the age of 5.
C)
As children grow and mature physiologically, their heart rates will decrease.
D)
Boys will typically have a higher blood pressure reading than girls of the same age.
E)
Toddlers may normally have heart rates below 100 beats per minute.
Ans:
C, D, E Feedback: The heart rate of infants may range from 110 to 130 beats per minute. Rates below 100 beats per minute in the infant should be reported. Blood pressure readings in children under the age of 3 are not routinely performed. After the age of 3, blood pressure readings are evaluated annually. Heart rates will decline with aging until the age of 19 years, at which time they normalize to adult readings.
3.
The nurse is caring for a patient admitted for observation after having
experienced a transient ischemic attack. What statement by the patient indicates the need for further teaching concerning the condition? A) will recover from the attack.
I
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B)
Experiencing another attack is not uncommon.
C)
This is a wake-up call because I am at an increased risk for a stroke.
D)
Once I have completely recovered from this I will not have further problems.
Ans:
D Feedback: Transient ischemic attacks are warnings of an increased risk for a stroke and should be taken seriously.
4.
The nurse is caring for a patient who is suspected of having a rupturing abdominal aortic aneurysm. What manifestations are consistent with early onset of the phenomena? Select all that apply.
A)
Elevated temperature
B)
Complaints of leg pain
C)
Abdominal pain
D)
Low back pain
E)
Pulsating, palpable abdominal mass
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
Ans:
571
C, D Feedback: Abdominal or low back pain may signal the beginning of rupture. Sudden severe back pain, shock, and pulsatile palpable abdominal mass are classic symptoms during rupture.
5.
The nurse is reviewing the medication listing of a patient recently admitted to the acute care facility. The patient reports taking Ephedrine. Which other medication, if noted, will need to be reported to the physician?
A)
Iron supplements
B)
Diuretics
C)
Anticoagulant medications
D)
Antihypertensive medications
Ans:
D Feedback: Ephedrine can interact with BP medications or antidepressants to dangerously elevate BP and heart rate.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
6.
572
The nurse is reviewing the patients medical history and notes he takes herbal supplements to help in the management of his hypertension. Which of the following supplements does he most likely take?
A)
Garlic
B)
Ginseng
C)
Soy
D)
Rosemary
Ans:
A Feedback:
Herbal remedies, such as garlic, may be used by some to lower cholesterol and BP.
7. A 24-year-old female in good health has begun an exercise program. The patient correctly recognizes that to promote cardiac health, the following regimen is needed:
A)
Mild intensity aerobic exercise lasting 45 minutes at least three days per week
B)
Moderate intensity aerobic exercise lasting 30 minutes five times per week
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C)
Moderate intensity aerobic exercise lasting 1 hour four times per week
D)
High-intensity aerobic exercise lasting 30 minutes at least five times per week
Ans:
B Feedback: The AHA recommends that individuals between the ages of 18 and 65 engage in aerobic activity of moderate intensity for a duration of 30 minutes five times a week.
8.
A patient who is planning a diet questions the nurse about the role of sugar in the development of heart disease. What response by the nurse is most appropriate?
A)
Salt and not sugar is a dietary culprit in the development of cardiovascular disease.
B)
Sugar is associated with the development of diabetes and not cardiovascular disease.
C)
Increased intake of sugar is associated with elevated cholesterol levels.
D)
The only way that sugar will cause heart disease is if you gain too much weight.
Ans:
C
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Feedback: Sugar consumption exists in epidemic proportions in the United States. High amounts of sugar consumption increase the risk of coronary artery disease by increasing triglyceride levels. Increased sugar consumption has also been linked to hypertension, diabetes, and obesity.
9. The nurse is reviewing the history of a patient who has been diagnosed with hypertension. When planning care for the patient, which of the following risk factors are nonmodifiable? Select all that apply.
A)
Weight
B)
Age
C)
Family history
D)
Sedentary lifestyle
E)
History of type 1 diabetes
Ans:
B, C, E Feedback: Nonmodifiable risk factors are those elements of the patients history that cannot be changed. Age, family history, and a diagnosis of diabetes are permanent factors and cannot be modified. Weight and level of activity can be changed.
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10. Which of the following statements is an appropriate nursing diagnosis for the homebound cardiac patient who has become fatigued upon minimal exertion?
A)
Activity intolerance related to decreased cardiac output as evidenced by fatigue
B)
Decreased cardiac output related to advanced cardiac disease
C)
Fluid volume excess related to immobility and fatigue
D)
Immobility related to advanced cardiac disease and frequent fatigue.
Ans:
A
Feedback: Activity intolerance is a significant problem for patients with cardiovascular dysfunction, although it is not exclusively a cardiovascular problem.
11. The nurse explains to the patient scheduled to undergo a cardiac catheterization that the test involves the use of
A)
A Doppler instrument to determine coronary blood flow
B)
A venous catheter to measure cardiac output
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
High-frequency sound waves to detect coronary blood flow
D)
Radiopaque dye injected into an artery to visualize heart function
Ans:
D
576
Feedback: Catheterization of the heart and large vessel is used to determine precise information concerning valve function and cardiac muscle strength. 12. A patient asks the nurse what atherosclerosis is. The nurse states A) It is the buildup of fat on the walls of the arteries.
B)
Atherosclerosis is thickening of the pulmonary artery.
C)
A patient with atherosclerosis has no pulse in the feet.
D)
Atherosclerosis causes pain in the lower extremities.
Ans:
A Feedback: Atherosclerosis is characterized by fatty deteriorations of the arterial smooth muscle walls, causing arterial occlusion.
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13. A patient who was in an automobile accident has a deep laceration in the left arm at the brachial artery. The blood pressure is 70/30, with pulse of 120 and thready. The patient is suffering from
A)
Septic shock
B)
Hypovolemic shock
C)
Cardiogenic shock
D)
Anaphylactic shock
Ans:
B Feedback: Dehydration or hemorrhage causes a decrease in circulating volume. Because tissue perfusion depends on a sufficient volume of circulating blood, any decrease in volume can lead to tissue hypoxia. This occurs in the condition commonly called hypovolemic shock. Septic shock results from infection. It is associated with elevations in heart rate and temperature. Cardiogenic shock results when the heart is unable to meet the demands of the body. Anaphylactic shock results when the body is introduced to a substance to which it is highly allergic. Symptoms include tachycardia and difficulty breathing.
14. When a 60-year-old patient asks the nurse what a dysrhythmia is, the nurse explains that it is an irregular heart rhythm that can be caused by
A)
Increased white blood cells
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Diminished coronary blood flow
C)
Deep-vein thrombosis
D)
Cerebrovascular accident
Ans:
B
578
Feedback: Dysrhythmias range from minor, clinically insignificant abnormalities to lifethreatening conditions. Dysrhythmias may be caused by damage to the heart muscle or conduction system, diminished coronary blood flow, decreased blood oxygen levels, medications, alterations in serum electrolytes, stress, or overstretching of the heart muscle.
15. Illicit use of which of the following substances is associated with sudden cardiacarrest ?
A)
Heroin
B)
Angel dust
C)
Marijuana
D)
Cocaine
Ans:
D
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Feedback: Cocaine use has been increasingly associated with sudden cardiac arrest, because it increases oxygen demand and reduces supply to the myocardium.
16. A patient is on hormone therapy in her postmenopausal years. What changes in blood levels can occur?
A)
Increased HDL
B)
Diminished white blood cells
C)
Increased LDL
D)
Decreased sodium
Ans:
A
Feedback: The use of hormone replacement therapy in postmenopausal women reduces LDL cholesterol and raises HDL cholesterol.
17. Which of the following education interventions should the patient implement to improve heart function?
A)
The patient should consume a diet high in sodium
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
An exercise plan to reduce blood glucose and eliminate acetone
C)
Exercise initiatives to lower triglycerides and raise HDL
D)
Implementation of 20 minute rest periods after meals
Ans:
C
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Feedback: Exercise protects the cardiovascular system and promotes weight reduction by raising the good HDL cholesterol and reducing triglycerides. Sodium is traditionally restricted in patients with cardiovascular health concerns. Excessive sodium intake will result in fluid retention. Exercise acts to reduce blood glucose.
18.Which of the following foods are low in sodium?
A)
Fresh fruit
B)
Lunch meat
C)
Hot dogs
D)
Canned soup
Ans:
A
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Feedback: Convenience foods and preserved foods often contain large amounts of sodium.
19. A 40-year-old man has been told he has a high level of low-density lipoprotein (LDL). How will you explain this factor?
A)
High levels of LDL increase the risk of a heart attack
B)
High levels of LDL are good to fight the formation of plaque
C)
High levels of HDL will increase your risk of high blood pressure
D)
High levels of HDL will cause you to have a stroke
Ans:
A Feedback: High levels of LDL cholesterol lead to peripheral vascular disease and hypertension, which greatly increases the chance of myocardial infarction.
20. Which of the following individuals is at risk for the development of blood clots?
A)
18-year-male who runs daily
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
25-year-old female on birth control pills
C)
30 year-old male who takes aspirin daily
D)
38-year-old female who exercises daily
Ans:
B
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Feedback: Women who take birth control pills are at risk for the development of blood clots. Regular exercise will reduce the incidence of cardiovascular complications. Aspirin is an anticoagulant and reduces the risk of blood clots. Daily exercise in any age group is associated with the lowering of risk factors.
21. When the nursery nurse auscultates a newborns heart rate at 138 beats per minute, the nurse should
A)
Document the normal finding
B)
Notify the pediatrician
C)
Assess for respiratory distress
D)
Assess for rhythm
Ans:
A
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Feedback: The newborns heart rate is normally 130 to 160 beats per minute.
22. A woman is being seen in the nurse practitioners office for her yearly gynecologic examination. She states, I think I am beginning menopause. My periods have been very light and irregular, and I am always hot. The nurse would expect what finding in her vital signs?
A)
Pulse of 160
B)
Blood pressure elevation
C)
Increased respiratory rate
D)
Decreased pulse rate
Ans:
B Feedback: In women, BP may increase slightly after menopause, probably as a result of hormonal changes.
23.Cardiac output is a function of the heart rate and A)
Sinoatrial node
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Electrical impulses
C)
Autonomic nervous system
D)
Stroke volume
Ans:
D
584
Feedback: Cardiac output is a function of the heart rate and stroke volume. Stroke volume refers to the amount of blood the heart ejects with each beat.
24. The period of contraction of the heart muscle when blood is ejected from the atria into the ventricles, and from the ventricles into the arteries is called
A)
Diastole
B)
Conductivity
C)
Repolarization
D)
Systole
Ans:
D Feedback:
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Contraction of the atria and the ventricles is called systole. Diastole refers to the period of time between heart contractions. Conductivity refers to the ability of the heart to contract. Repolarization refers to the return of ionic concentrations to conditions prior to contraction.
25.The valve that is located between the left atrium and the left ventricle is the
A)
Mitral
B)
Aortic
C)
Pulmonic
D)
Tricuspid
Ans:
A Feedback: The mitral valve separates the left atrium from the left ventricle. The aortic valve separates the left ventricle from the aorta. The pulmonic valve separates the right ventricle from the pulmonary system. The tricuspid valve separates the right atrium from the right ventricle.
26.The valve that is located between the right atrium and the right ventricle is the
A)
Mitral
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Aortic
C)
Pulmonic
D)
Tricuspid
Ans:
D
586
Feedback: The heart has four valves that allow blood to flow in one direction, maximizing efficiency and preventing the backflow of blood. Two valves separate the atria from the ventricles. The tricuspid valve separates the right atrium from the right ventricle; the mitral valve separates the left atrium from the left ventricle. The other two valves separate the ventricles from the large blood vessels they fill. The pulmonic valve separates the right ventricle from the pulmonary system, and the aortic valve separates the left ventricle from the aorta.
27. Calcium assists in the contraction of a muscle. In which area of the heart is the impulse to contract stimulated?
A)
Sinoatrial node
B)
Atrioventricular node
C)
Tricuspid valve
D)
Mitral valve
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587
A Feedback: Impulses that stimulate contraction normally originate in specialized cells (sinoatrial node) near the top of the right atrium.
28.Which part of the heart produces the muscular contraction of the heart?
A)
Pericardium
B)
Sinoatrial node
C)
Myocardium
D)
Atrioventricular node
Ans:
C Feedback: The thick muscular middle layer is called the myocardium.
Chapter 32- Fluid, Electrolytes, and Acid-Base
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1.
588
Which of the following statements accurately describes the role of antidiuretic hormone in the regulation of body fluids? When antidiuretic hormone is present,
A)
The renal tubules become impermeable to water
B)
The renal tubules become permeable to water
C)
Urine output is increased and diluted
D)
The frequency of voiding increases
Ans:
B
Feedback: When antidiuretic hormone is present, the distal tubule of the nephron becomes more permeable to water.
2. The process of filtration begins at the
A)
Glomerulus
B)
Loop of Henle
C)
Bowmans capsule
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Collecting ducts
Ans:
A
589
Feedback: The process of filtration begins at the glomerulus.
3.The passageways of the kidney permit the urine to flow to the bladder and
A)
Act as a valve that covers the junction between the ureters and the bladder
B)
Surround the Bowmans capsule, which is where the formation of urine begins
C)
Selectively reabsorb or secrete substance to maintain fluids and electrolytes
D)
Control external sphincter of the urethra and permit the control of urination
Ans:
C Feedback: The capillaries of the glomerulus are porous, and, as the blood passes through the glomerular capillaries, some constituents of the blood are filtered out.
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4. Which of the following statements is an appropriate nursing diagnosis for an 80year-old patient with the diagnosis of congestive heart failure with symptoms of edema, orthopnea, and confusion?
A)
Extracellular volume excess related to heart failure as evidenced by edema and orthopnea
B)
Congestive heart failure related to edema
C)
Fluid volume excess related to loss of sodium and potassium
D)
Fluid volume deficit related to congestive heart failure as evidenced by shortness of breath
Ans:
A Feedback: Extracellular volume excess is the state in which a person experiences an excess of vascular and interstitial fluid.
5.
A young man has developed gastric esophageal reflux disease. He is treating it with antacids. Which acid-base imbalance is he at risk for developing?
A)
Respiratory alkalosis
B)
Metabolic alkalosis
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Respiratory acidosis
D)
Metabolic acidosis
Ans:
B
591
Feedback: Endocrine disorders and ingestion of large amounts of antacids cause metabolic alkalosis. 6.
The nurse is reviewing the patients arterial blood gas results. The test reveals a pH of 7.52, a PaO2 level of 49 mmHg and an HCO3 level of 28 mEq/L. The nurse suspects the patient is most likely experiencing which of the following conditions?
A)
Metabolic alkalosis
B)
Metabolic acidosis
C)
Respiratory acidosis
D)
Respiratory alkalosis
Ans:
A
Feedback:
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Metabolic alkalosis occurs when there is excessive loss of body acids or with unusual intake of alkaline substances. It can also occur in conjunction with an ECF deficit or potassium deficit (known as contraction alkalosis). Vomiting or vigorous nasogastric suction frequently causes metabolic alkalosis. Endocrine disorders and ingestion of large amounts of antacids are other causes. The loss of stomach acid or taking in of base causes H+ shifts in the blood, and pH increases.
7.
When an 80-year-old patient who takes diuretics for management of hypertension informs the nurse she takes laxatives daily to promote bowel movements, the nurse assesses the patient for possible symptoms of
A)
Hypocalcemia
B)
Hypothyroidism
C)
Hypoglycemia
D)
Hypokalemia
Ans:
D Feedback: The frequent use of laxatives and diuretics promotes the excretion of potassium and magnesium from the body, increasing the risk for fluid and electrolyte deficits.
8. A 50-year-old patient with hypertension is being treated with a diuretic. The patient complains of muscle weakness and falls easily. The nurse should assess which electrolyte?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Sodium
B)
Chloride
C)
Phosphorous
D)
Potassium
Ans:
D
593
Feedback: Diuretics, commonly given to treat high blood pressure and heart failure, can cause an extracellular deficit or loss of electrolytes including potassium, calcium, and magnesium.
9.Which of the following individuals will take longer to sense thirst?
A)
18-year-old
B)
30-year-old
C)
50-year-old
D)
70-year-old
Ans:
D
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Feedback: When adults older than 65 years of age were compared with younger adults, the plasma osmolarity at which the older group experienced thirst was increased, indicating an increased risk for development of a water deficit.
10. Which of the following age groups is at risk for fluid and electrolyte imbalances resulting from fad dieting?
A)
Adolescents
B)
Young adults
C)
Middle-aged adults
D)
Older adults
Ans:
A Feedback: Fad diets or purging to lose weight can cause severe fluid and electrolyte imbalances.
11. A student has joined the marching band at his high school. The band begins practicing outside in August. This student and other band members need to be instructed that
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A)
This exercise will have a minimal effect on fluid and electrolytes
B)
The band members should drink large amounts of water
C)
Endurance increases as time increases on the field with heat
D)
The hot weather will assist in building them up for the marching season
Ans:
B Feedback: Caution children and adolescents against the potential dangers of excessive exercise without adequate fluid replacement, especially in hot weather, because muscle damage and fluid and electrolyte imbalances can occur.
12. A mother of an infant calls the pediatric nurse and asks which fluids she should provide her baby since he is suffering from diarrhea. The nurse would inform the mother not to give
A)
Pedialyte
B)
Formula
C)
Breast milk
D)
Bottled water
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596
D Feedback: Hyponatremic seizures among infants fed with commercial bottled drinking water has been noted.
13. Which of the following individuals with diarrhea for 3 days are more likely to suffer from fluid and electrolyte imbalance?
A)
Infant
B)
School-age child
C)
Adolescent
D)
Young adult
Ans:
A Feedback: The very young child and older adults are at greatest risk for fluid or electrolyte imbalances.
14. You are educating elementary school teachers on dietary requirements for students. You instruct them that phosphorous is important for bone structure. What food is a significant source of phosphorous?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Cake
B)
Steak
C)
Butter
D)
Nuts
Ans:
B
597
Feedback: Good dietary sources of phosphorous include dairy products, meats, vegetables, fruits, and cereals.
15. A patient reports she has lactose intolerance and questions the nurse about alternative sources of calcium. What options can be provided by the nurse? A)
Eggs
B)
Chicken
C)
Apples
D)
Spinach
Ans:
D
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Feedback: Sardines, whole grains, and green leafy vegetables also provide calcium.
16. A child is eating a peanut butter sandwich. He is ingesting an excellent source of
A)
Potassium
B)
Sulfate
C)
Calcium
D)
Magnesium
Ans:
D
Feedback: Good dietary sources of magnesium include green leafy vegetables, legumes, citrus fruit, peanut butter, and chocolate.
17. You are instructing a young woman on her dietary needs for calcium in the prevention of osteoporosis. What food supplies the greatest amount of calcium?
A)
Cheese
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Meat
C)
Cauliflower
D)
Salad
Ans:
A
599
Feedback: Dairy products are excellent sources of calcium.
18. When the nurse reviews the patients laboratory reports revealing sodium, 140 mEq/L; potassium, 4.1 mEq/L; calcium, 7.9 mg/dL; and magnesium, 1.9 mg/dL; the nurse should notify the physician of the patients
A)
Low potassium
B)
Low calcium
C)
High sodium
D)
High magnesium
Ans:
B Feedback:
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Normal total serum calcium levels range between 8.9 and 10.1 mg/dL.
19. Potassium is needed for neural, muscle, and
A)
Optic function
B)
Auditory function
C)
Cardiac function
D)
Skeletal function
Ans:
C Feedback: Potassium is essential for normal cardiac, neural, and muscle function and contractility of all muscles.
20. Major control over the extracellular concentration of potassium within the human body is exerted by insulin and
A)
Aldosterone
B)
Albumin
C)
Progesterone
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Testosterone
Ans:
A
601
Feedback: Two hormones exert major control over the extracellular concentration of potassium: insulin and aldosterone. Aldosterone enhances renal secretion of potassium.
21.When atrial pressure is increased, then sodium
A)
Decreases
B)
Increases
C)
Maintains the same
D)
Is unchanged
Ans:
A Feedback: When atrial pressure is increased, ANP released by the atrial and ventricular myocytes acts on the nephron to increase sodium excretion.
22.A decrease in arterial blood pressure will result in the release of
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Protein
B)
Thrombus
C)
Renin
D)
Insulin
Ans:
C
602
Feedback: Decreased arterial blood pressure, decreased renal blood flow, increased sympathetic nerve activity, and/or low-salt diet can stimulate renin release.
23.A patient with dehydration will have an increase in
A)
Albumin
B)
Potassium
C)
Glucose
D)
Aldosterone
Ans:
D
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Feedback: The renin-angiotensin aldosterone and natriuretic peptide hormone systems regulate the volume within narrow limits by adjusting fluid intake and the urinary excretion of sodium, chloride, and water.
24. Which patient has more extracellular fluid?
A)
Adult woman
B)
Adolescent man
C)
Female school-age child
D)
Newborn
Ans:
D Feedback: Newborns have more extracellular fluid than intracellular fluid.
25.Which patient will have more adipose tissue and less fluid?
A)
A woman
B)
A man
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
An infant
D)
A child
Ans:
A
604
Feedback: Women have a lower fluid content because they have more adipose tissue than men.
26. The primary extracellular electrolytes are
A)
Potassium, phosphate, and sulfate
B)
Magnesium, sulfate, and carbon
C)
Sodium, chloride, and bicarbonate
D)
Phosphorous, calcium, and phosphate
Ans:
C Feedback:
The primary extracellular electrolytes are sodium, chloride, and bicarbonate.
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27. When an elderly patient receiving a blood transfusion presents with an elevated blood pressure, distended neck veins, and shortness of breath, the patient is most likely experiencing
A)
Allergic reaction
B)
Pulmonary embolism
C)
Fluid overload
D)
Anaphylaxis
Ans:
C Feedback: Fluid overload can occur when blood components are infused too quickly or too voluminously. Symptoms include increased venous pressure, distended neck veins, dyspnea, coughing, and abnormal breath sounds.
28. Which of the following solutions should be administered slowly to prevent circulatory overload?
A)
0.9% NaCl
B)
0.45% NaCl
C)
Dextrose 5%
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
5% NaCl
Ans:
D
606
Feedback: When a hypertonic solution is infused, it raises serum osmolarity, pulling fluid from the cells and the interstitial tissues into the vascular space. Examples of hypertonic solutions include 3% (NaCl) and 5% saline (NaCl). 29. Which of the following solutions is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume?
A)
Hypertonic
B)
Colloid
C)
Isotonic
D)
Hypotonic
Ans:
C
Feedback: Isotonic fluids have an osmolarity of 250375 mOsm/L, which is the same osmotic pressure as that found within the cell.
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30. A patient has a physicians order for NPO (nothing by mouth) following abdominal surgery to repair a bowel obstruction. The patient has a nasogastric tube inserted to low intermittent suction. The patient requires intravenous therapy to
A)
Replace fluid and electrolytes
B)
Administer blood products
C)
Provide protein supplements
D)
Treat the patients infection
Ans:
A Feedback: The therapeutic goal may be maintenance, replacement, treatment, diagnosis, monitoring, palliation, or a combination. This patient requires intravenous fluids for replacement of those lost due to the NPO order and the loss of fluid and electrolytes due to the nasogastric suctioning.
31. A 58-year-old woman is suffering from food poisoning after eating at a local restaurant. She has had nausea, vomiting, and diarrhea for the past 12 hours. Her blood pressure is 88/50 and she is diaphoretic. She requires
A)
An access route to administer medications intravenously
B)
Replacement of fluids for those lost from vomiting and diarrhea
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C)
An access route to replace fluids in combination with blood products
D)
Intravenous fluids to be administered on an outpatient basis
Ans:
B Feedback: The therapeutic goal may be maintenance, replacement, treatment, diagnosis, monitoring, palliation, or a combination. This patient requires intravenous fluids for replacement of those lost from vomiting and diarrhea.
32. A patient is taking a diuretic such as Lasix. When implementing patient teaching, what information should be included?
A)
Increased sodium levels
B)
Increased potassium levels
C)
Decreased potassium levels
D)
Decreased oxygen levels
Ans:
C
Feedback:
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Many diuretics such as Lasix are potassium wasting; hence, potassium levels are measured to detect hypokalemia.
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Chapter 33- Nutrition
1. The patient reports to the nurse that she feels as if her eyes are persistently dry. This symptom is consistent with a deficiency in which of the following dietary elements?
A)
Protein
B)
Vitamin D
C)
Calcium
D)
Vitamin A
Ans:
D Feedback: Dryness of the eyes (xerophthalmia) is associated with a deficiency of vitamin A.
2.
The nurse is providing an education program to teens. When discussing the role of fat in our bodies, which of the following functions can be attributed to fat? Select all that apply.
A)
Vitamin absorption
B)
Protection from injury
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Absorption of water soluble vitamins
D)
Energy
E)
Cellular transport
Ans:
A, B, D, E
611
Feedback: Fat is a component of all body cells and ideally makes up approximately 20% of the body weight of healthy, nonobese people. Fat performs many important functions, including cellular transport, insulation, protection of vital organs in the form of padding, provision of energy, energy storage of adipose tissue, vitamin absorption, and transport of fat-soluble vitamins (vitamins A, D, E, and K).
3. During an annual physical examination, the patient reports feeling a lack of muscle energy when walking and doing simple chores around the house. When reviewing the patients diet, deficiencies in which of the following would be associated with the symptoms reported? Select all that apply.
A)
Vitamin C
B)
Vitamin D
C)
Folic acid
D)
Niacin
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
E)
Thiamine
Ans:
D, E
612
Feedback: Vitamins in the B complex such as niacin and thiamine are associated with confusion and motor weakness.
4. The nurse is caring for a patient who has been experiencing prolonged wound healing from a surgical procedure. A deficiency in which of the following nutrients would be associated with this condition?
A)
Vitamin B1
B)
Calcium
C)
Folic acid
D)
Vitamin C
Ans:
D Feedback:
Poor wound healing is associated with deficiencies in vitamin C and protein.
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5.
613
The nurse is providing education about nutrition and feeding to the mother of a toddler. Which of the following statements by the childs mother indicates understanding of the teaching?
A)
It is important for my child to avoid finger feeding and use utensils.
B)
Providing small finger snacks such as grapes is a good idea.
C)
Fruit slices with the skins will be a healthy choice for my child. D)
Boiled eggs and pieces of cheese are good snacks for my child.
Ans:
D Feedback: Toddlers are often independent and insist on feeding themselves. Appropriate finger foods include meatballs, hard-boiled eggs, cooked carrots, fruit slices (without skins), cheese pieces, dry cereal, and crackers. Avoid whole grapes, hard candy, and other foods that could cause choking.
6. The nurse should include which of the following in the plan of care for the patient receiving enteral feedings? Select all that apply.
A)
Position head of bed in semi-Fowlers during feeding.
B)
Check placement of tube before initiating feeding.
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C)
Maintain head of bed elevated between 30 and 45 degrees at least 30 minutes after feeding.
D)
Allow at least 90 minutes for each feeding.
E)
Notify primary care physician for gastric residuals of 100 to 200 cc.
Ans:
B, C Feedback: Minimize the risk of aspiration by checking proper tube placement before initiating feedings and at frequent intervals and by keeping the patient in Fowlers position (head of bed elevated at least 30 to 45 degrees) at all times when feedings are infusing and for 30 minutes after completion of intermittent or continuous feeding.
7.
The nurse is assessing the gastric residual volume of a patient receiving enteral feedings. The nurse notes there is a residual of 250 cc. Which of the following actions by the nurse is most appropriate?
A)
Reduce the amount of the next feeding by 250 cc.
B)
Contact the primary care physician.
C)
Document the findings.
D)
Slow the next feeding to promote improved absorption.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
Ans:
615
C Feedback: Assessment of gastric residual volume (GRV) is a nursing function. Feedings should generally not be stopped for GRVs of more than 400 to 500 mL unless the patient exhibits signs of intolerance. Patients at high risk for aspiration should be monitored based on their disease process, not solely on their GRVs.
8.
The nurse is reviewing a patients laboratory report. The report indicates the patients albumin level is 2.89g/dL. Which of the following inferences can the nurse make about the laboratory result?
A)
The patient has an infection.
B)
The patient has been taking steroids.
C)
The patient has likely been on a high protein diet.
D)
The patient may be overhydrated.
Ans:
D Feedback: Serum albumin values reflect protein intake or absorption. Values of less than 3.5 g/dL (35 g/L) may indicate nutritional deficits. Such protein changes take more than
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2 weeks to appear in serum albumin values because the half-life of albumin is about 18 days. A low albumin level also can be related to overhydration and may not necessarily indicate malnutrition. 9. The nurse is caring for a patient on a telemetry unit following a myocardial infarction. The patient has undergone numerous medication changes since the event. Which of the following foods should be avoided when a patient is taking Coumadin following a myocardial infarction?
A)
Spinach
B)
Milk
C)
Orange juice
D)
Wheat bread
Ans:
A Feedback: Spinach is an essential source of vitamin K. Since vitamin K is essential for clotting, it should be consumed sparingly with anticoagulant therapy.
10. You are the nurse caring for a patient with an enlarged thyroid. What nutritional deficiency is linked to an enlarged thyroid?
A)
Potassium
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Sodium
C)
Magnesium
D)
Iodine
Ans:
D
617
Feedback: A chronic deficiency of iodine can lead to endemic goiter. The major initial symptom is an enlarged thyroid gland.
11. The nurse is providing education to a patient concerning calcium intake. During the discussion the nurse addresses a potential health concern related to inadequate calcium intake. Which of the following conditions is most impacted by inadequate calcium intake?
A)
Dental caries
B)
Anemia
C)
Osteoporosis
D)
Dry eyes
Ans:
C
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Feedback: Osteoporosis is a condition in which there is a reduction in bone density. Factors contributing to the development of osteoporosis may include chronically insufficient calcium intake, decreased estrogens, heredity factors, smoking, race, and decreased physical activity.
12. To promote health of the fetus the nurse should instruct the woman in the first trimester of pregnancy to do which of the following?
A)
Eliminate high-fiber foods
B)
Eat foods high in folic acid
C)
Consume saturated fats
D)
Consume milk products in the last trimester
Ans:
B Feedback: Folic acid deficiency in pregnant women can lead to neural tube deficits in the fetus. Women during pregnancy may experience constipation. Increased fiber intake is recommended. Saturated fats are to be eaten only in moderation. Milk products are important during the entire pregnancy.
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13. A woman complains of cracking fissures in the corner of her mouth. Which of the following instructions should the nurse include in the information provided to the patient?
A)
Increase intake of eggs and milk
B)
Avoid citrus fruits for the next few weeks.
C)
Nuts and legume intake should be increased.
D)
Potatoes and other starch containing foods should be restricted.
Ans:
A Feedback: The patient has presented with symptoms consistent with cheilosis. This may be the result of a Vitamin B2 deficiency. Good sources of this vitamin include milk and eggs.
14.Which vitamin is found only in animal foods?
A)
Vitamin C Vitamin B12
B)
C)
Vitamin A
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Vitamin D
Ans:
B
620
Feedback: Vitamin B12 functions in the formation of mature red blood cells and in synthesis of DNA and RNA. This vitamin is only found in animal foods (meats, fish, poultry, milk, and eggs).
15.A patient who has bleeding tendencies has a deficiency in which vitamin?
A)
Vitamin A
B)
Vitamin B
C)
Vitamin C
D)
Vitamin K
Ans:
D Feedback: Vitamin K deficiencies are manifested in two ways: an increased tendency to hemorrhage and hemorrhagic disease of the newborn, which is common in premature or anoxic newborns.
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16. When planning interventions in the immediate hours after birth the nurse recognizes the need to provide an injection of which of the following to manage bacteria in the intestinal tract?
A)
Vitamin K
B)
Vitamin A
C)
Vitamin C
D)
Vitamin D
Ans:
A Feedback: Approximately half of the bodys requirement of vitamin K is synthesized by bacteria in the lower intestinal tract.
17. The nurse is reviewing the health assessment of a patient. The nurse is concerned that the patient may have a deficiency of Vitamin D. Which of the following conditions most supports this suspicion?
A)
Night blindness
B)
Clotting disorder
C)
Rickets
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Dental decay
Ans:
C
622
Feedback: Signs of vitamin D deficiency are rickets in children, poor dental health, tetany, and osteomalacia.
18. You are educating a group of adolescent girls on bone and teeth growth. Which fatsoluble vitamin assists to build bone and teeth?
A)
Vitamin A
B)
Vitamin E
C)
Vitamin C Vitamin B1
D)
Ans:
A Feedback: Vitamin A is important for the promotion of normal skeletal and tooth development.
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19. The nurse is providing teaching to a patient with high triglyceride and cholesterol levels. Which of the following foods should the patient be cautioned to avoid?
A)
Coconut
B)
Fish
C)
Chicken
D)
Sunflower
Ans:
A Feedback: Coconut oil, palm oil, and palm kernel oil are highly saturated fats.
20. The nurse is reviewing a patients understanding of dietary choices that will help reduce high triglyceride and cholesterol levels. Which statement by the patient indicates an understanding of the best options to be included in the diet? A)
I plan to use more sunflower oil in my diet
selections.
B)
Coconut oil has shown to be a good choice for people hoping to reduce cholesterol levels.
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C)
I am using palm oil in most of my cooking right now.
D)
Palm kernel oil is a smart choice because it is one of the oils lowest in triglyceride and cholesterol.
Ans:
A Feedback: Coconut oil, palm oil, and palm kernel oil are highly saturated fats.
21. Which of the following is a fat-soluble vitamin?
A)
Vitamin C Vitamin B12
B)
C)
Vitamin E Vitamin B6
D)
Ans:
C Feedback: Vitamin E is a fat-soluble vitamin.
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22. An elderly patient has a decubitus ulcer with drainage, dysphagia, and immobility. She consumes less than 300 calories per day and has a large amount of interstitial fluid. She is in a state of
A)
Positive nitrogen balance
B)
Anabolism
C)
Negative nitrogen balance
D)
Digestion
Ans:
C Feedback:
A negative nitrogen balance exists when excretion of nitrogen exceeds the intake.
23. Which of the following foods eaten with peanut butter would provide the patient with complete protein?
A)
Wheat bread
B)
Milk
C)
Jelly
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D)
626
Carrots Ans: B
Feedback: Peanut butter is an incomplete protein and milk is a complete protein. Combining the two would improve the diet in terms of protein value. 24. A patient has just had abdominal surgery, and the nurse is consulting with him about his diet now that he is allowed to eat. Which nutrient is most important for wound healing?
A)
Carbohydrates
B)
Protein
C)
Fats
D)
Vitamins
Ans:
B Feedback:
Complete proteins contain sufficient amounts of the essential amino acids to maintain body tissues and to promote growth.
25. A 40-year-old man has consumed a breakfast consisting of cereal, milk, orange juice, and coffee. His blood sugar in 2 hours should be
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
6080 mg/dL
B)
100120 mg/dL
C)
140180 mg/dL
D)
200220 mg/dL
Ans:
C
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Feedback: Normal blood glucose should be between 80 mg/dL and 110 mg/dL. Blood glucose 2 hours after a meal can rise to between 140 and 180 mg/dL, depending on the persons age. 26. An athlete wants to increase her intake of complex carbohydrates and asks the nurse about potential sources. Which of the following foods is considered a complex carbohydrate?
A)
Molasses
B)
Syrup
C)
Brown sugar
D)
Bread
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628
D Feedback: Bread, cereal, potatoes, rice, pasta, crackers, flour products, and legumes contain complex carbohydrates.
27.What vitamin is synthesized with an adequate supply of carbohydrates?
A)
Vitamin A
B)
Vitamin D
C)
Vitamin E
D)
Vitamin K
Ans:
D Feedback:
Carbohydrates are important for the synthesis of vitamin K and vitamin B12.
28.A woman consumes pasta, grains, and other carbohydrates for
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A)
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Weight gain B)
Energy
C)
Weight loss
D)
Source of fiber
Ans:
B Feedback: The main function of carbohydrates is to provide energy.
29. The average dietary nutrient intake level that meets the nutritional requirement of almost all healthy people in a selected age and gender group is the
A)
AI level
B)
UL level
C)
EAR level
D)
RDA level
Ans:
D
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Feedback: The RDA level is the average dietary intake level that meets the nutritional requirement of almost all healthy people in a selected age and gender group.
30. The average daily nutrient intake value estimated to meet the needs of 50% of healthy people in a selected age and gender group is
A)
AI level
B)
UL level
C)
EAR level
D)
RDA level
Ans:
C Feedback: The EAR level is the average dietary nutrient intake value estimated to meet the needs of 50% of healthy people in a selected age and gender group.
Chapter 34- Urinary Elimination
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Information needed to calculate glomerular filtration rate (GFR) includes which of the following? Select all that apply.
A)
The patients normal daily fluid intake range.
B)
The patients age.
C)
The patients gender.
D)
The patients serum creatinine levels.
Ans: B, C, D Feedback: The glomerular filtration rate (GFR) is the amount of plasma filtered through glomeruli per unit of time and is the best indicator of kidney function. Many labs now calculate an estimated GFR for all patients who have a serum creatinine test. To calculate the GFR you need the patients age, race, gender, and serum creatinine levels. 2.
A patients BUN test results are significantly elevated. When reviewing the patients history, which of the following findings is consistent with BUN elevation other than renal compromise?
A)
The patient is on a low protein diet.
B)
The patient is dehydrated.
C)
The patient has a history of osteoarthritis.
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D)
The patient is lactose intolerant.
Ans:
B
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Feedback: The BUN test measures the amount of urea nitrogen in the blood. Urea, the major nitrogenous end waste product of metabolism, is formed in the liver. The bloodstream carries urea from the liver to the kidneys for excretion. When the kidneys are diseased, they are unable to excrete urea adequately, and urea begins to accumulate in the blood, causing BUN to rise. Normal BUN is 8 to 25 mg/100 mL. Because other factors, such as high dietary intake of protein, fluid deficit, infection, gout, or excessive breakdown of protein stores, can also elevate BUN, it is not a highly sensitive indicator of impaired renal function.
3.
A patient who is a paraplegic as a result of an auto accident has incontinence. The nurse correctly recognizes which type of incontinence is most likely?
A)
Stress
B)
Urge
C)
Reflex
D)
Functional
Ans:
C
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Feedback: An involuntary loss of urine that occurs at somewhat predictable intervals when a specific bladder volume is reached is called reflex incontinence. The person is unable to sense bladder fullness because of neurologic impairment, and the bladder simply empties when a certain degree of bladder stretch occurs. Bladder emptying occurs at the sacral reflex level because of impairment of the connection to the cerebrum that allows voluntary inhibition of voiding. Reflex incontinence is seen in patients with neurologic impairment, such as a spinal cord lesion, cerebrovascular accident, or brain tumor.The sudden, involuntary loss of small amounts (less than 50 mL) of urine that accompanies a sudden increase in intraabdominal pressure is called stress incontinence. The person with urge incontinence is unable simultaneously to perceive a full bladder and to hold urine until reaching the bathroom. Functional incontinence involves the inability or unwillingness of a person with normal bladder and sphincter control to reach the bathroom in time to void. 4.
The nurse is preparing to provide education to a patient concerning prescribed medications to manage incontinence. The prescribed medication is Oxybutynin. What information can be provided?
A)
The medication will reduce the amount of urine being produced by the body, thereby lessening incontinence.
B)
The medication will help to stimulate contraction of muscles involved in voiding, thereby lessening incontinence.
C)
The medication will be used to reduce overactivity of muscles involved in voiding, thereby lessening incontinence.
D)
The medication will increase the amount of fluids retained by the body, thereby lessening the incidence of incontinence.
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B
Feedback: Oxybutynin (an antispasmodic) may be used to treat urinary urgency and frequency caused by overactive detrusor muscle activity. 5.
The nurse is caring for an older adult patient suspected of having a urinary tract infection. What manifestation is most associated with the development of this condition in the older adult?
A)
High fever
B)
Dysuria
C)
Acute confusion
D)
Nausea
Ans:
C Feedback: Symptoms of UTI are different in the older adult, especially if their immune system is depressed. Rather than experiencing painful urination and a high fever, the older adult will become acutely confused.
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During the well-child checkup for 2-year-old twins (one boy, one girl), their mother asks the nurse about preparing to toilet train her children. What information can be provided to the parent? Select all that apply.
A)
It is typically more difficult to toilet train a female child.
B)
Nighttime continence will occur in some children after age 4 or 5 years.
C)
Daytime continence is normal in a 3-year-old child.
D)
Children who are able to remain dry for a few hours at a time may be signaling readiness for toilet training.
E)
Children old enough to undress themselves will have increased abilities to toilet train.
Ans:
C, D, E Feedback: Beginning sometime between 2 and 3 years of age, The American Academy of Pediatrics advises parents to watch for signs that a child may be ready for toilet training. These signs include staying dry for two hours at a time or dry after naps, as well as being able to walk to the bathroom and ability to help undress themselves. Most children will achieve daytime urinary control by 3 to 4 years of age. Sometimes, toddlers need to experience outdoor playtime without diapers to see what happens when they experience bladder fullness followed by urethral relaxation and bladder emptying. They begin to understand the relationship between bladder fullness and voluntary bladder emptying and are ready for toilet training. Nighttime continence may not occur until 4 or 5 years of age.
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7.
A female infant has voided for the first time. The nurse notes the urine is light pink tinged. What actions by the nurse are indicated?
A)
Document the finding as normal, recognizing that they have been caused by the withdrawal of maternal hormones.
B)
Document the findings as normal, recognizing that they have been caused by an accumulation of uric acid crystals.
C)
Document the abnormal finding and report it to the charge nurse.
D)
Document the finding and report it to the attending physician.
Ans:
B Feedback: The first voiding may be of slightly pink-tinged urine, caused by an accumulation of uric acid crystals.
8. You are the guest speaker at a womens club. Most of the women are over the age of 40 years. The women have asked you to speak on health promotion topics. In the area of urinary urgency, you instruct the women to
A)
Limit fluid intake
B)
Increase caffeine daily
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C)
Take an antispasmodic
D)
Perform Kegel exercises
Ans:
D
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Feedback: Pelvic floor exercises or Kegel exercises strengthen the pubococcygeal muscles and effectively promote urinary control. 9.
The nurse is reviewing the urinalysis of a patient suspected of having a urinary tract infection. The presence of which of the following will support the potential diagnosis?
A)
Protein
B)
Calculi
C)
Pus
D)
Casts
Ans:
C Feedback:
Pyuria is the presence of pus in the urine. Pyuria occurs in the presence of any UTI.
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10. A patient has a urinary tract infection. The patient is told to take phenazopyridine (Pyridium) to decrease urinary discomfort. The patient should be instructed that her urine will turn
A)
Orange
B)
Pink
C)
Blue
D)
Green
Ans:
A Feedback: Phenazopyridine (Pyridium) causes urine to turn bright orange.
11. An elderly patient has come to the emergency room stating she has not voided for 24 hours. Which of the following statements by the patient contributes to her inability to void?
A) My physician has prescribed a diuretic and potassium supplement to manage my hypertension. I take Maxidex for my high blood pressure. B) I drink eight glasses of water per day.
C)
Yesterday I was congested so I took several doses of Benadryl.
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D)
I have a bowel movement every day.
Ans:
C
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Feedback: Diphenhydramine (Benadryl) is an antihistamine agent that can cause urinary retention. The use of a diuretic will promote voiding. Potassium supplementation will ensure potassium levels remain within desired ranges. Neither medication will result in urinary retention. 12. The nurse is caring for a patient who has been experiencing difficulty voiding since her vaginal birth. The patient voices concern to the nurse. What information should be provided to the patient?
A)
The delivery can cause perineal swelling
B)
A neurogenic bladder results from local anesthesia
C)
A urinary tract infection results from the birth process
D)
Catheterization is necessary for 1 week
Ans:
A Feedback:
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Trauma from vaginal delivery causes swelling in the perineal area, which can obstruct the flow of urine and cause urinary retention during the early postpartum period.
13. A patient has a cerebrovascular accident and is incontinent of bowel and bladder. Incontinence of urine in this patient is related to a
A)
Cystocele
B)
Enuresis
C)
Overactive bladder
D)
Neurogenic bladder
Ans:
D Feedback: Neurologic injury after a stroke or spinal cord injury can disrupt normal patterns of urinary elimination. This condition is called neurogenic bladder. A cystocele is a herniation of the urinary bladder. Enuresis is the clinical term for bedwetting. An overactive bladder is the term used when a person has increased urinary urge, increased urinary frequency, or both.
14. The nurse should instruct the female patient who has experienced two urinary tract infections within the past year to
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Void following sexual intercourse
B)
Use shower gels and bubble bath
C)
Avoid drinking cranberry juice
D)
Apply powder to the perineum
Ans:
A
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Feedback: Factors that increase the incidence of urinary tract infections include incorrect wiping of the anal area after bowel movements; sexual intercourse, which can bring perineal microorganisms into closer contact with the urethral meatus; and any procedure that places an object in the urethra or bladder for diagnostic procedures or therapeutic reasons.
15. Which of the following terms describes obstruction within the urinary system leading to distention of the renal pelvis?
A)
Pyuria
B)
Hematuria
C)
Hydronephrosis
D)
Urethritis
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C Feedback: One of the complications of obstruction within the urinary system is hydronephrosis, which is distention of the kidney pelvis with urine secondary to the increased resistance caused by obstruction to normal urine flow. Pyuria refers to the presence of pus in the urine. This manifestation is associated with an infection. Hematuria is the presence of blood in the urine. Urethritis is the inflammation of the urethra .
16. A woman informs the nurse that when she is experiencing stress it is difficult to void and wonders why this happens. The nurse explains A) Stress causes the muscles to become tense.
B)
You require greater privacy to void.
C)
You might have a neurologic condition.
D)
What medications are you taking?
Ans:
A Feedback: A persons muscles may become so tense that relaxation of the perineal muscles does not occur, and voiding is inhibited.
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17.A woman complains of bladder urgency. It is most important to assess
A)
Exercise
B)
Weight
C)
Caffeine intake
D)
Vitamin supplements
Ans:
C Feedback: Alcohol and caffeine-containing fluids or food, such as coffee, tea, cola, or chocolate, irritate the bladder and contain a diuretic that can increase urine output when ingested in large amounts.
18. Which of the following symptoms will have a great impact on the extracellular fluid for water conservation?
A)
Burns
B)
Fracture
C)
Small laceration
D)
Pain
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A Feedback: The water saving to regulate the concentration of solutes in the ECF results in decreased urine output. Increased loss of body fluids can occur with vomiting, diarrhea, excessive diaphoresis secondary to fever or exercise, excessive wound drainage, extensive burns, or blood loss from trauma or surgery.
19. Which of the following statements should be included in the nurses teaching plan for older adults regarding urinary elimination?
A)
Most older adults experience an increased blood flow to the kidneys
B)
Kidney function progressively increases as the body ages
C)
The kidneys become more effective in filtration with age
D)
Nocturia and urinary retention are more common in older adults
Ans:
D Feedback: Nocturia and urinary retention are more common in older adults.
20. Which of the following statements should the nurse convey to the mother of a 3year-old son who has not achieved urinary continence?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Incontinence after the age of 3 years is not normal
B)
Boys may take longer for daytime continence than girls
C)
Boys may walk by 1 year and should be continent by 3 years
D)
Daytime continence is usually not achieved by boys until age 5
Ans:
B
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Feedback: Children in North American cultures usually achieve daytime urinary continence by 3 years of age; boys may take longer than girls. Nighttime continence may not occur until 4 or 5 years of age.
21.An infant is born with spina bifida. She may have
A)
Alterations in urinary elimination
B)
Increased urine production
C)
Renal failure
D)
Excessive loss of sodium in the urine
Ans:
A
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Feedback: Congenital malformations of the central nervous system may cause serious alterations in urinary elimination.
22. Which of the following ranges for urine output in 24 hours is considered normal for an adult?
A)
1,0001,200 cc
B)
1,2001,500 cc
C)
1,6001,900 cc
D)
2,0002,400 cc
Ans:
B Feedback: The total amount of urine voided during a 24-hour period usually ranges between 1,200 and 1,500 mL.
23. When a patient is diagnosed with a urinary tract infection, the nurse anticipates that the patients urine will be
A)
Transparent with an aromatic odor
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Light yellow with a faint ammonia odor
C)
Cloudy with an offensive odor
D)
Greenish with a strong ammonia odor
Ans:
C
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Feedback: A strong, offensive odor is not normally present in urine that is free of infection. 24. A patient has been NPO after midnight for surgery. It is 11:00 AM and the nurse has asked her to void before being transferred to the surgical suite. The nurse should expect her urine to be
A)
Pale yellow
B)
Colorless
C)
Dark amber
D)
Tea colored
Ans:
C Feedback:
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Urine may be dark amber or orange-brown if it is very concentrated secondary to a decreased fluid intake. Urine is lighter than normal if it is diluted. Foods or drugs can also alter the color of urine. Tea-colored or very dark urine is a sign of dehydration.
25. The micturition reflex is the
A)
Process of filtration beginning with the glomerulus
B)
Act of bladder contraction and perceived need to void
C)
Reabsorption of the substances the body wants to retain
D)
Secretion of electrolytes that are harmful to the body
Ans:
B
Feedback: Several words are used to describe the process of excreting urine from the body, including urination, voiding, and micturition.
26. A patient is suspected of having a disease process affecting the functional unit of the kidney. The nurse correctly recognizes which of the following structures is most likely involved?
A)
Glomerulus
B)
Bowmans capsule
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Loop of Henle
D)
Nephron
Ans:
D
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Feedback: The functional unit of the kidney is called the nephron. Each kidney has more than 1 million nephrons, and each nephron is capable of forming urine. The nephron consists of the glomerulus, Bowmans capsule, proximal convoluted tubules, loop of Henle, distal tubule, and collecting duct. The glomerulus is a network of blood vessels, surrounded by Bowmans capsule, where urine formation begins. The tubules, loop of Henle, and collecting ducts are passageways that permit urine to flow to the renal pelvis and then to the ureters.
27. Which type of incontinence is caused by an overactive detrusor muscle causing involuntary bladder contractions?
A)
Urge
B)
Stress
C)
Overflow
D)
Functional
Ans:
A
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Feedback: Urge incontinence is caused by an overactive detrusor muscle causing involuntary bladder contractions.
28.Which type of incontinence is caused by pelvic floor muscle weakness?
A)
Urge
B)
Overflow
C)
Functional
D)
Stress
Ans:
D
Feedback: Stress incontinence is caused by pelvic floor muscle weakness. Urge incontinence is the inability to suppress urination after sensing the need to do so; many physical and psychological issues can be related to this problem. Overflow incontinence is related to overdistention or overflow of the bladder. Causes of functional incontinence include environmental barriers, physical limitations, memory loss, and disorientation.
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Chapter 35- Bowel Elimination
1. In the nursing care plan for constipation, the nurse should have an intervention that addresses the number of grams of cellulose that are needed for normal bowel function. How many grams should be in the daily diet?
A)
2030 g
B)
4050 g
C)
6070 g D) >80g
Ans:
A Feedback: A person who consumes approximately 20 g to 30 g of dietary fiber from fruits, vegetables, and grains will most likely have sufficient bulk in the stools to allow for easy defecation.
2. A patient reports constipation. Which of the following assessment questions should the nurse initially ask when completing the patients health history, including bowel habits?
A)
Do you have a daily bowel movement?
B)
How do you handle stress?
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C)
Do you eat fiber foods every day?
D)
What medicines do you take?
Ans:
B
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Feedback: This represents a broad opening statement that allows for greater subjective information. Chronic exposure to stress can slow bowel activity, resulting in decreased frequency of bowel movements.
3. The student nurse has completed a presentation to a group of senior citizens on colorectal screening. Which statement by a participant suggests a need for further education?
A)
I will need yearly screenings for colon cancer.
B)
I will have a fecal occult blood test done every 5 years.
C)
I will have a flexible endoscopic exam done every 5 years.
D)
My mother had colon cancer so I am at a greater risk for also developing colon cancer.
Ans:
B Feedback:
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Yearly screenings, including a fecal occult blood test, should be done on all patients over the age of 50. A flexible endoscopic exam should be done every 5 years. A family history of colorectal cancer increases the risk of developing colorectal cancer.
4.
A patient is complaining of increased flatulence. Which of the following may be a cause of his flatulence? Select all that apply.
A)
Carbonated beverages
B)
Caffeinated beverages
C)
Smoking
D)
Drinking straws
E)
Rapid ingestion of food
Ans:
A, C, D, E Feedback: Rapid ingestion of food, improper use of straws, smoking, and excessive carbonated beverages may all be causes of flatulence. Caffeinated beverages typically do not cause flatulence.
5.
A nurse is providing education to an elderly patient concerning ways to prevent constipation. Which diet choices would support that the education was successful?
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Select all that apply
A)
Hot tea with meals
B)
A turkey sandwich with whole-grain bread
C)
Prune juice with breakfast
D)
Ice cream with lunch and dinner
E)
Diet soda with lemon
Ans:
A, B, C Feedback: A glass of prune juice is equivalent to more than one serving of the dried fruit, has high magnesium content, and is an excellent source of fluid to promote bowel elimination. Hot fluids, such as coffee, tea, or hot water with lemon juice, may also increase intestinal motility. High fiber foods such as whole-grain bread provide bulk for the stool. Ice cream and diet soda do not provide any preventative measures for constipation.
6.
A)
The student nurse is preparing a presentation on bowel elimination. Which of the following would be a potential cause of diarrhea that the student should include? Select all that apply.
Opioids
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Antibiotics
C)
Acute stress
D)
Depression
E)
Increased physical activity
Ans:
B, C
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Feedback: Acute stress, anxiety, and antibiotic use can all cause diarrhea. Opioid use and depression can cause constipation. Increased physical activity can increase peristalsis but this does not necessarily cause diarrhea.
7. The nurse is assisting an elderly patient into position for a sigmoidoscopy. Which position would the nurse place the patient in?
A)
Right lateral
B)
Left lateral
C)
Prone
D)
Semi-Fowlers
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B Feedback: The left lateral or knee to chest position is the most common position for sigmoidoscopies or colonoscopies. If the patient is not able to tolerate this position, Sims position may also be used. The right lateral, prone or semi-Fowlers positions are not routinely used for this procedure.
8.
The student nurse is administering a large-volume enema to a patient. The patient complains of abdominal cramping. What should the student nurse do first?
A)
Increase the flow of the enema for approximately 30 seconds then decrease it to the prior flow rate.
B)
Stop the administration of the enema and notify the physician.
C)
Stop the administration of the enema momentarily .
D)
Increase the flow of the enema until all of the solution has been administered.
Ans:
C Feedback: If the patient complains of abdominal discomfort or cramping, the nurse should momentarily stop the flow of solution. Increasing the flow of the enema may cause more cramping and discomfort. Cramping and
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discomfort are common complaints during enema administration so there is no need to notify the physician.
9. When caring for a patient with a new colostomy, which assessment finding would be considered abnormal and need to be reported to the physician?
A)
The stoma is pink.
B)
The stoma has a small amount of bleeding.
C)
The stoma is prolapsed.
D)
The stoma is on the abdominal surface.
Ans:
C Feedback: The stoma should be pink and remain on the abdominal surface. The mucosal tissue is fragile, so a small amount of bleeding may be normal. If the stoma is found to be prolapsed, the surgeon must be notified immediately.
10. An elderly woman who is incontinent of stool following a cerebrovascular accident will have the following nursing diagnosis
A)
Bowel incontinence related to loss of sphincter control as evidenced by inability to delay the urge to defecate
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B)
Diarrhea related to tube feedings as evidenced by hyperactive bowel sounds and urgency
C)
Constipation related to physiologic condition involving the deficit in neurologic innervation as evidenced by fecal incontinence
D)
Fecal retention related to loss of sphincter control and diminished spinal cord innervation related to hemiparesis
Ans:
A
Feedback: The most appropriate nursing diagnosis addresses the patients fecal incontinence related to loss of sphincter control innervation.
11. When the nurse performs a Hemoccult test on a stool specimen, blood in the stool will change the color on the test paper to
A)
Blue
B)
Brown
C)
Green
D)
Red
Ans:
A
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Feedback: Blue is a positive diagnostic finding, indicating the presence of blood in the stool sample.
12. A patient has had abdominal surgery and in 72 hours develops abdominal distention and absence of bowel sounds with pain. The nurse suspects the patient has
A)
A wound infection
B)
Need of greater pain relief
C)
Increased activity
D)
Paralytic ileus
Ans:
D Feedback: An obstruction that blocks the passage of flatus and intestinal chime or feces is a primary cause of abdominal distention. Paralytic ileus and abdominal tumors are types of bowel obstruction that produce distention.
13. You are educating a new colostomy patient on gas-producing foods. Which of the following are gas-producing foods the patient may choose to avoid?
A)
Lettuce
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Rice
C)
Brussels sprouts
D)
Green peppers
Ans:
C
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Feedback: Certain foods (e.g., cabbage, onions, legumes) often increase the amount of flatus produced in the intestine.
14. The proliferation of Clostridium difficile causes A)
Antibiotic-associated diarrhea Escherichia coli diarrhea
B)
C)
Urinary Clostridium infection
D)
Anal yeast infection
Ans:
A Feedback:
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Normal intestinal flora inhibit the growth of Clostridium difficile. When broadspectrum antibiotics, especially third-generation cephalosporins, are administered, normal flora is altered and C. difficile can proliferate and release toxins that cause antibiotic-associated diarrhea. 15. An elderly patient who is wheelchair bound following a cerebrovascular accident is being assessed by the nurse. The nurse notes the patient has seepage of stool from the anus. The nurse knows this is indicative of
A)
Constipation
B)
Diarrhea
C)
Fecal impaction
D)
Intestinal infection
Ans:
C Feedback: Suspect a fecal impaction when there is a history of absence of a regular bowel movement for several days (35 days or more) followed by the passage of liquid or semi-liquid stool.
16.Which of the following diversions is considered a continent ostomy?
A)
Colostomy
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B)
Ileostomy
C)
Ileoconduit
D)
Ileoanal
Ans:
D
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Feedback: A continent fecal diversion is the ileoanal diversion. With this type of diversion, feces can be drained at the patients convenience rather than having it continually draining into an external pouch, as occurs in the traditional ileostomy or colostomy.
17. The type of stool that will be expelled into the ostomy bag by a patient who has undergone surgery for an ileostomy will be
A)
Bloody
B)
Mucus filled
C)
Soft semi-formed
D)
Liquid consistency
Ans:
D
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Feedback: Stool produced from an ileostomy is liquid and contains large quantities of electrolytes. 18. A patient has completed an upper gastrointestinal x-ray, small bowel series, and lower gastrointestinal x-ray. Following these x-rays, the nurse will need to administer
A)
A low-residue diet
B)
An antibiotic
C)
A laxative
D)
High-fiber diet
Ans:
C Feedback: Barium is ingested during these exams. Barium can cause constipation. Therefore, laxatives are commonly ordered after the diagnostic test to facilitate barium removal.
19.Which of the following symptoms is a known side effect of antibiotics?
A)
Diarrhea
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Constipation
C)
Fecal impaction
D)
Abdominal bloating
Ans:
A
664
Feedback: A side effect of taking antibiotics is diarrhea. Constipation, fecal impaction and abdominal bloating are not common side effects of antibiotics.
20.Which of the following medications causes constipation?
A)
Magnesium antacids
B)
Dulcolax
C)
Aspirin
D)
Iron supplements
Ans:
D Feedback:
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
665
A common side effect of iron supplements is constipation. Dulcolax is a stool softener. Aspirin is an analgesic that does not typically cause constipation. Magnesium antacids help to decrease heartburn and do not typically cause constipation.
21. The nurse needs to assess the patients elimination patterns. Which of the following patients will most likely deny the urge to defecate?
A)
Patient with anxiety and depression
B)
Patient who consumes >30 g of fiber
C)
Patient who has a colostomy
D)
Patient 3 days post-vaginal delivery
Ans:
D Feedback: People who experience pain during defecation may choose to deny the urge to defecate, which can lead to constipation. The patient with anxiety and depression typically does not have pain upon defecation. The patient with a colostomy will also typically not have pain upon defecation. The patient consuming >30 g of fiber will typically not be constipated.
22.Ignoring the urge to defecate on a continual basis leads to
A)
Sudden increase in stool with mucus
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Constipation and hard stool
C)
Need to increase milk intake
D)
Total loss of bowel control
Ans:
B
666
Feedback: The longer feces remain in the large intestine, the more water is absorbed; the result is harder, drier stool.
23. A young woman has just consumed a serving of ice cream pie and develops severe cramping and diarrhea. The school nurse suspects the woman is
A)
Allergic to sugar
B)
Lactose intolerant
C)
Experiencing infectious diarrhea
D)
Deficit in fiber
Ans:
B Feedback:
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667
Many people have difficulty digesting lactose (the sugar contained in milk products). The breakdown of lactose into its component sugars, glucose and galactose, requires a sufficient quantity of the enzyme lactase in the small intestine. If a person is lactose-deficient, alterations of bowel elimination, including formation of gas, abdominal cramping, and diarrhea, can occur after ingestion of milk products.
24. When educating an elderly patient on the prevention of constipation, the nurse should provide which of the following educational interventions?
A)
Drink three glasses of milk per day
B)
Eat six servings of bread or pasta
C)
Consume antacids to decrease reflux
D)
Increase intake of fresh vegetables
Ans:
D Feedback: Educate older persons to recognize that decreased frequency of bowel movements is usually a normal result of aging. Nurses should encourage a change in dietary habits to increase the amount of fluids and high-fiber foods in the diet and to increase activity to prevent constipation.
25. Which of the following factors is related to developmental changes in bowel habits for elderly patients?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Increase in dietary fiber can decrease peristalsis
B)
Milk products cause constipation in lactose intolerance patients
C)
Weakened pelvic muscles lead to constipation
D)
The elderly should peel fruits before eating
Ans:
C
668
Feedback: Weakened pelvic muscles and decreased activity levels contribute to constipation in older adults. Increasing dietary fiber does not decrease peristalsis. Lactose intolerance is not a developmental change in the elderly. Peeling fruit does not impact bowel habits in the elderly.
26. In a toddler, a good indication of spinal cord maturation and ultimate bowel control is
A)
Use of the flexor and extensor
B)
The ability to walk
C)
Parallel play
D)
Recognition of peristalsis
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
Ans:
669
B Feedback: Myelinization of the sacral spinal cord segments, which control the anus, becomes complete between 12 and 18 months. When this occurs, toddlers can recognize that stool is present in the rectum. A good indicator of spinal cord maturation is the ability to walk independently.
27. The postpartum nurse is instructing a new mother that her infant will pass meconium for
A)
1 day
B)
2 days
C)
3 days
D)
4 days
Ans:
C Feedback: By the 3rd day after birth, the stools characteristics begin to reflect the type of milk in the diet.
28. When educating a breast-feeding mother on the characteristics of the stool of her newborn, the nurse should inform her that the stool will be
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Dark yellow
B)
Bright yellow
C)
Beige
D)
Brown
Ans:
B
670
Feedback: If newborns are fed breast milk, the stools will be bright yellow, soft, and unformed with an unobjectionable odor.
29. What is meconium?
A)
Semi-digested food
B)
Soft brown stool
C)
Secreted liquid mucus
D)
Dry intestinal secretions
Ans:
D
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Feedback: Meconium is the partially dried intestinal secretions that accumulate in the large intestine before birth.
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Chapter 36- Sleep and Rest
1.
The nurse is preparing a care plan for a patient with insomnia. Which of
the following would be an appropriate outcome criteria for the goal that the patient will report fewer problems falling asleep. A)
The patient will fall
asleep faster.
B)
The patient will report a decrease in sleep latency to 10 to 15 minutes within 30 days.
C)
The nurse will administer the patients hypnotic at bedtime each night.
D)
The nurse will give the patient a backrub at bedtime each night.
Ans:
B Feedback: Outcome criteria for the goal should be patient focused, measurable and with a specific time frame.
2. A student nurse is preparing a presentation regarding hypnotic medications. What information should the student nurse include? Select all that apply. A) Hypnotics induce a normal sleep pattern.
B)
Hypnotics may impair waking in a patient.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Hypnotics are safe for long-term use.
D)
Hypnotics may be addictive.
E)
Tapering of doses may be required after long-term use.
Ans:
B, D, E
673
Feedback: Hypnotics do not induce a normal sleep pattern and are not indicated for long-term use. Hypnotics may impair waking functions, which can cause daytime sleepiness. Due to the potentially addictive qualities of hypnotics, tapering of doses may be required after long-term use. 3.
The nurse is preparing a care plan for a patient recently diagnosed with obstructive sleep apnea. The patient complains of daytime sleepiness, fatigue and excessive snoring that wakes me up. What nursing diagnosis would be appropriate for this patient?
A)
Disturbed Sleep Pattern as evidenced by complaints of daytime sleepiness
B)
Disturbed Sleep Pattern related to obstructive sleep apnea as evidenced by excessive snoring
C)
Disturbed Sleep Pattern related to periods of apnea as evidenced by excessive snoring
D)
Disturbed Sleep Pattern related to obstructive sleep apnea
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
Ans:
674
C Feedback: Disturbed Sleep Pattern related to periods of apnea as evidenced by excessive snoring is the correct nursing diagnosis. The medical diagnosis of obstructive sleep apnea should not be used in the nursing diagnosis.
4. A school nurse is speaking to a group of parents regarding the sleep needs of adolescents. Which statement by a parent indicates a need for further education?
A)
Adolescents naturally develop an owl like sleep pattern in which they go to bed later and sleep later in the morning.
B)
Academic performance in adolescents is good when they sleep about 7 hours per night.
C)
Adolescents catch up on sleep on the weekends, when they typically sleep later.
D)
Adolescent girls are more likely to develop insomnia than boys.
Ans:
B Feedback: Adolescents need about 9 hours of sleep per night. Academic performance is negatively impacted when adolescents get less sleep. Due to irregular sleep patterns, adolescents typically sleep later on weekends
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in an attempt to catch up on sleep. Adolescent sleep patterns change to a more owl-like pattern in which they rise later and go to sleep later. Adolescent girls have a higher risk of developing insomnia than adolescent boys.
5. A student nurse is preparing a presentation on sleep hygiene practices. What information should the nurse include? Select all that apply. A) Eliminate caffeine intake 6 hours prior to bedtime.
B)
Do not watch television in bed.
C)
Use blackout or other types of curtains/blinds to keep the room as dark as possible.
D)
Take a warm bath prior to bedtime.
E)
Do 15 to 30 minutes of exercise prior to bedtime.
Ans:
A, B, C Feedback: Caffeine is a stimulant and can interfere with sleeping. Establishing a routine of only sleeping, not reading or watching television, in bed and keeping the room as dark as possible may help decrease insomnia. Taking a warm bath or doing exercise prior to bedtime may increase the time it takes to fall asleep. These activities should be done at least 1 to 2 hours prior to bedtime.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
6.
676
A patient has voiced concerns about her inability to fall asleep. When reviewing her history, what information would the nurse expect to find? Select all that apply.
A)
Smokes 1 pack of cigarettes daily
B)
Drinks coffee with all meals
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History of hyperthyroidism Exercises 30 to 60 minutes daily
E)
Works 30 hours per week
Ans:
A, B, C Feedback: Insomnia is associated with the consumption of stimulants (e.g., caffeine, nicotine, methamphetamine, and other drugs of abuse). Insomnia is also a side effect of hyperthyroidism . Exercising 30 to 60 minutes daily can help a patient fall asleep faster.
7. A nursing instructor is speaking to a group of students regarding the effects of shift work on sleep patterns. Which pattern of work shifts has been shown to enhance work production?
A)
Working multiple night shifts in a row
B)
Working one week of day shifts then one week of night shifts
C)
Clockwise rotation of shifts
D)
Rotating between day and night shifts each week.
Ans:
C
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C) D) Feedback: Research has shown that clockwise rotation of shifts is preferable and that short naps during breaks enhance work performance. Recent studies have shown a negative relation between the number of consecutive night shifts worked and urinary levels of melatonin metabolites.
8.
When a nurse notes that the patient appears to be sleeping, is demonstrating irregular respirations, and is showing eye movement, the nurse identifies the stage of sleep the patient is experiencing as
A)
Transitional
B)
Rapid eye movement (REM)
C)
Light sleep
D)
Slow wave
Ans:
B Feedback: In REM sleep, respirations are irregular and oxygen consumption increases.
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9. Which of the following problems is associated with obesity, heavy snoring, and shallow breathing?
A)
Sleep apnea
B)
Narcolepsy
Hypersomnia Hyperpnea
Ans:
A Feedback: Sleep apnea refers to recurrent periods of absence of breathing for 10 seconds or longer, occurring at least five times per hour.
10. When a patient tells the clinic nurse that he has irresistible sleep attacks throughout the day lasting from 10 to 15 minutes, the nurse suspects that the patient may be experiencing
A)
Cataplexy
B)
Narcolepsy
C)
Insomnia
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C) D) D)
Prolonged latency
Ans:
B Feedback: Narcolepsy is a disorder of excessive daytime sleepiness characterized by short, almost irresistible daytime sleep attacks, usually lasting 10 to 15 minutes, and abnormal manifestations of REM sleep.
11. A nurse instructor is instructing her students on the role of hormones in sleep patterns. Which statement would indicate to the nursing instructor that the student needs additional teaching?
A)
A hyperactive thyroid can make the patient sleepy all the time.
B)
Women often experience fatigue due to loss of estrogen.
C)
Estrogen has been shown to decrease sleep latency.
D)
Hypothyroidism may contribute to a lack of slow-wave sleep.
Ans:
A Feedback:
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Hyperthyroidism causes fragmented, short-wave stages, whereas hypothyroidism seems to cause excessive sleepiness and a lack of slowwave sleep. 12. When the newly admitted patient with chronic obstructive pulmonary disease informs the nurse that she frequently awakens during the night, the nurse may notify the physician for which of the following interventions?
A)
A hypnotic medication
B)
A narcotic medication
Low-flow oxygen Warm milk
Ans:
C Feedback: The pattern of frequent arousals seen in people with chronic obstructive lung disease may result from the bodys adaptation to maintain adequate oxygenation. Usually, these patients require low doses of oxygen at night.
13. While instructing young adults about the need for adequate sleep, the nurse instructs the group that to improve sleep quality, individuals should
A)
Take an afternoon nap whenever possible
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C) D) B)
Catch up on sleep on days off from work
C)
Stay awake until midnight consistently
D)
Have a consistent time for arising
Ans:
D Feedback: A regular time of rising is one of the most effective means of improving sleep quality and synchronizing circadian rhythms with clock time.
14. The student nurse is providing an education program for preschool parents. The nursing student should include which of the following interventions to improve the childs sleep?
A)
Have the child limit fluids after supper
B)
The child should drink milk at bedtime
C)
The parents should keep the child up until 10 PM
D)
The child should sleep with the parents
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
Ans:
683
A Feedback: Parents and other caregivers can assist children in establishing the habit of voiding as part of preparing for bedtime. Drinking milk at bedtime, keeping the child up until 10 PM and sleeping with the parents will not improve the childs sleep.
15. Which of the following activities would be appropriate to suggest to the patient who states that she has difficulty falling asleep every evening?
A)
Take a warm shower before bedtime
B)
Drink a glass of milk with a turkey sandwich
C)
Exercise vigorously for 30 minutes before sleep
D)
Clean the bedroom prior to falling asleep
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
Ans:
684
B Feedback: Hunger disturbs sleep of some people, whereas others have difficulty sleeping after large meals. Ingestion of L-tryptophan, a precursor of serotonin found in foods such as milk, beef, eggs, wheat flour, turkey, and corn, has been found to decrease sleep latency and increase stage 4 sleep. The bodys temperature drops during sleep; therefore taking a warm shower prior to bedtime may increase the time it takes to fall asleep.
16. A nurse working the night shift understands the importance of enhancing the sleep patterns of his patients. In order to do so, he should
A)
Only wake them for the 12:00 AM and 4:00 AM vital signs
B)
Allow the patient time to sit at the desk to enhance better rest
C)
Evaluate the sleep response of the patient with a polysomnogram
D)
Cluster activities to allow 90 to 120 minutes of sleep
Ans:
D Feedback: When possible, the nurse should cluster activities at night to provide periods of 90 to 120 minutes of uninterrupted sleep.
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685
17. Nurses who experience no difficulty working a variety of shifts are generally viewed as which type of person?
A)
Evening
B)
Afternoon
C)
Morning
D)
Nighttime
Ans:
A Feedback: Evening people find they function best late in the day and are usually wide awake and ready for activity in the evening.
18. What factor has been hypothesized by researchers regarding current thoughts on sleep?
A)
The current population requires less sleep
B)
More sleep is obtained through napping
C)
Population is healthier due to sleep
D)
Chronic sleep deprivation is present
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
Ans:
686
D
Feedback: Most recently, researchers have hypothesized that much of the population in industrialized nations may be chronically sleep deprived.
19. Which of the following guidelines does the nurse apply to the discussion of sleep patterns with elderly patients?
A)
Circadian rhythms become more prominent as patients age
B)
The amount of stage 4 sleep increases as patients age
C)
Total sleep time decreases as the patients age
D)
Older patients fall asleep more quickly than younger
Ans:
C Feedback: As people age, the amount of stage 4 sleep decreases significantly. Sleeping patterns may become polyphasic, with a shorter nocturnal period plus daytime naps.
20. Which of the following statements about the sleep patterns of toddlers should the nurse incorporate into a teaching plan for parents?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Getting the child to sleep can be difficult
B)
Most toddlers fall asleep easily
C)
Nightmares are rare in toddlers
D)
Slow-wave sleep is less than in adults
Ans:
A
687
Feedback: Getting the child to fall asleep is the most commonly reported problem, but frequent awakenings and occasional night terrors may also occur.
21. REM sleep in a toddler is about
A)
10%
B)
20%
C)
30%
D)
40%
Ans:
C
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Feedback: REM sleep in the toddler and preschooler drops to about 30%, which is still higher than adults.
22. The parents of a newborn ask when they can expect the baby to sleep through the night. The nurse responds that the baby will most likely sleep through the night by
A)
6 weeks of age
B)
3 months of age
C)
6 months of age
D)
1 year of age
Ans:
B Feedback: Most infants sleep through the night by 3 months of age, but nocturnal awakenings continue to be frequent during the latter half of the first year.
23. The nurse is caring for new parents. During her education session, the nurse instructs the parents on a newborns sleep patterns. Newborns
A)
Have shorter periods of REM sleep
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Are inactive when awake
C)
Will nap two times per day
D)
Sleep 16 to 17 hours per day
Ans:
D
689
Feedback: Newborns sleep an average of 16 to 17 hours per 24 hours a day, divided into about seven sleep periods distributed fairly evenly throughout the day and night.
24. A patient states to the nurse during a sleep assessment that it takes her more than 30 minutes to fall asleep. The patient states it increases her anxiety. This is considered
A)
Sleeplessness
B)
Sleep anxiety
C)
Sleep disturbance
D)
Sleep latency
Ans:
D
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Feedback: The range of normality with respect to sleep patterns is also broad. Most people require 10 to 30 minutes to fall asleep; this period is called sleep latency. 25. When a newly admitted patient informs the nurse that he averages 6 hours of sleep per night, the nurse determines that this patient is most likely
A)
In need of sleeping pills
B)
Sleep deprived
C)
Getting efficient sleep
D)
In need of a sleep clinic visit
Ans:
B Feedback: Optimum daytime performance with minimal sleepiness and no accumulation of sleep debt in adults is related to obtaining 8 hours of sleep each night. Sleeping less than 6 hours and more than 9 hours per night has been linked to an increase in morbidity and early mortality.
26.During the first cycle of sleep, the patient will be in REM sleep for
A)
1 hour
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
3 minutes
C)
15 minutes
D)
6 minutes
Ans:
B
691
Feedback: The time spent in REM sleep in the first cycle may only be 3 to 4 minutes.
27. In Stage 4 sleep, the
A)
Blood pressure is elevated
B)
Pulse rate is slow
C)
Respirations are irregular
D)
Temperature increases
Ans:
B Feedback:
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During slow-wave sleep, the muscles are relaxed, but muscle tone is maintained; respirations are even; and blood pressure, pulse, temperature, urine formation, and oxygen consumption by muscle decreases.
28.During stage 3 sleep, the patient may experience
A)
Enuresis
B)
Anxiety
C)
Diaphoresis
D)
Shortness of breath
Ans:
A Feedback: Stages 3 and 4 are the stages during which snoring, sleepwalking (somnambulism), and bed-wetting (enuresis) are most likely to occur.
29.A patient begins snoring and is sleeping lightly. The stage of sleep is
A)
Stage 1
B)
Stage 2
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Stage 3
D)
Stage 4
Ans:
B
693
Feedback: Stage 2 is relatively light sleep from which the patient is easily awakened. Rolling eye movements continue, and snoring may occur.
30. When the nurse attempts to wake a patient who has just closed his eyes and appears asleep, the patient states he is not asleep. The stage of sleep the patient is in is
A)
Stage 1
B)
Stage 2
C)
Stage 3
D)
Stage 4
Ans:
A Feedback:
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Stage 1 is the transitional stage between drowsiness and sleep, indicated by a shift from alpha waves to low-voltage, fast theta on the EEG. This stage usually lasts only a few minutes, and, if awakened, the person may say he or she was not asleep.
Chapter 37- Self-Concept
1.
Assessment findings that indicate a potential self-concept dysfunction include which of the following? Select all that apply.
A)
Depersonalization
B)
Feelings of inadequacy
C)
Preoccupation with affected body part
D)
Inability to make decisions
E)
Refusal to make eye contact
Ans:
A, B, D, E Feedback: Emotional changes with self-concept dysfunction include depersonalization, hopelessness, helplessness, alienation, fear of rejection, anger, sadness, shame, guilt, inadequacy, worthlessness, and suspicion of others. Behavioral changes indicating self-concept
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dysfunction include lack of interest in activities, inability to make decisions, withdrawal from social situations, isolation, refusal to look in the mirror, refusal to look at an affected body part or discuss a limitation, avoidance of responsibility, show of hostility toward others, refusal to make eye contact, and negative verbalizations about self.
2.
Objective data that may suggest a patient has altered self-concept may include which of the following? Select all that apply.
A)
Lack of eye contact
B)
States, Im worthless.
C)
Hand-wringing
D)
States, I dont want anyone to see me like this.
E)
Below-the-knee amputation of the right lower extremity
Ans:
A, C, E Feedback: Objective data about the patients self-concept are gathered through direct observation. Patient statements are subjective data.
3.
A nurse is attempting to provide education to a newly diagnosed diabetic. The patient states, It doesnt matter what I eat, my future health is up to God. The nurse understands that this patient has which of the following?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Internal locus of control
B)
External locus of control
C)
Self-esteem deficit
D)
Self-concept deficit
Ans:
B
696
Feedback: A person with external locus of control perceives that outcomes happen because of luck, chance, or the influence of powerful others. A person with internal locus of control believes that personal behavior influences the outcome, and that he or she can achieve desired results. 4.
The nurse is preparing a care plan for a patient with the nursing diagnosis of Ineffective Coping. The patient has had a mastectomy and refuses to participate in the care of the surgical site. What would be an appropriate short-term goal for the patient?
A)
The patient will look at the surgical site in a mirror within 2 days.
B)
The patient will assist with the dressing change.
C)
The nurse will change the dressing while the patient is hospitalized.
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D)
The nurse will take a picture of the site to allow the patient to view it when she wishes.
Ans:
A Feedback: Goals are patient focused and must have a time frame. The patient looking at the surgical site in the mirror within 2 days is a proper short-term goal.
5. A student nurse is preparing a care plan for a hospitalized school-aged patient focusing on ways to promote self-concept. Which intervention would not be appropriate?
A)
Allow for privacy.
B)
Limit visitation of friends.
C)
Provide age-appropriate activities.
D)
Teach parents about the need for socialization.
Ans:
B Feedback: Interventions that focus on supporting self-concept in school-aged children include allowing for privacy. Teach parents about the need for
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socialization and belonging. Allow liberal visitation and age-appropriate activities if hospitalized.
6.
A school-aged child is attending an afterschool function without her parents. Which stage, according to Erickson, is the child in?
A)
Industry vs. inferiority
B)
Initiative vs. guilt
C)
Identity vs. role confusion
D)
Autonomy vs. shame
Ans:
A Feedback: School-age children are in the stage of industry vs. inferiority, in which socialization and competence are developing.
7.
Nursing interventions to address poor self-concept include which of the following? Select all that apply.
A)
Offer praise honestly
B)
Role model self-confidence
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Emphasize positive attributes in patients
D)
Assist patients in setting goals that may be tough to reach
E)
Teach patients to accept responsibility for themselves
Ans:
A, B, C, E
699
Feedback: Nursing interventions that assist patients with positive self-evaluation can help change poor self-concept. Nursing interventions aimed at changing behavior also assist patients with self-concept problems. General measures that bring about behavioral changes include accepting responsibility for self, defining realistic goals, using resources to enact change, and rewarding positive outcomes. Goals must be realistic and achievable.
8. A nursing instructor has just finished discussing therapeutic communication with a group of students. Which statement by a student indicates a need for further education? Select all that apply.
A)
A nurse must possess self-awareness to develop therapeutic relationships with her patients.
B)
Developing trust is essential in therapeutic relationships.
C)
Showing sympathy to your patients helps in developing therapeutic relationships.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Effective communication is the key to therapeutic communication.
E)
Establishing rapport is not needed in a therapeutic relationship.
Ans:
C, E
700
Feedback: To develop therapeutic relationships, nurses must demonstrate great selfawareness and effective communication. Conveying a sense of friendship and trust helps establish rapport with patients. When empathy, not sympathy, is shown, patients believe that nurses understand their feelings and will care for their needs.
9. A student nurse has recently started a new job in a long-term care facility. In the interview, the student was told that she would receive two weeks of orientation prior to working on her own. After the first night of work, the student was told she was now allowed to work on her own. This situation may lead to which of the following?
A)
Role conflict
B)
Role ambiguity
C)
Role strain
D)
Role transition
Ans:
A
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Feedback: Role ambiguity occurs when the person lacks knowledge of role expectations, which fosters anxiety and confusion. Role conflict is related to expectations concerning the role. Role conflict can be described as intrapersonal, interpersonal, or interrole. Role strain occurs when the person perceives himself or herself as inadequate or unsuited for a role. This can occur in any role or because of having to fill too many roles. People make multiple role transitions in a lifetime.
10. A newly married patient is attempting to fulfill the role of wife, professional, and lover. She tells the nurse that she does not feel that she is fulfilling any of the roles well. The nurse will document this as which of the following?
A)
Role strain
B)
Role ambiguity
C)
Role conflict
D)
Role transition
Ans:
A Feedback: Role strain occurs when the person perceives himself or herself as inadequate or unsuited for a role. This can occur in any role or because of numerous roles. People make multiple role transitions in a lifetime. Role ambiguity occurs when the person lacks knowledge of role expectations, which fosters anxiety and confusion. Role conflict is related to
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expectations concerning the role. Role conflict can be described as intrapersonal, interpersonal, or interrole.
11. Which patient is at greatest risk of developing a damaged self-concept during a period of increased stress?
A)
A single mother with a supportive family
B)
A married female with a large network of friends
C)
An elderly female who is newly widowed
D)
A teenager who is active in his church
Ans:
C Feedback: Coping and stress tolerance influence self-concept. People who are able to adapt to stress and resolve conflicts through coping tend to develop healthy self-concepts. Internal resources, such as a sense of humor and productivity under pressure, and external resources, such as strong support groups, enhance coping.
12. A group of nursing students is attending a seminar on self-concept. Which statement by a student concerning self-esteem indicates a need for further education?
A)
Children whose parents set limitations on their behavior have higher selfesteem.
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B)
Parental acceptance helps to increase a childs self-esteem.
C)
Clear expectations set by parents help to increase a childs self-esteem.
D)
Children who agree with their parents opinions have higher selfesteem.
Ans:
D Feedback: Parental acceptance, clear expectations, limitations, and freedom to express opinions are all associated with higher self-esteem in children.
13. A patient is describing how he thinks others see him. This is a description of the patients
A)
self-awareness
B)
social self
C)
self-concept
D)
self-perception
Ans:
B Feedback:
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704
Self-concept is the mental image a person has of him- or herself. It is the persons meaning when stated as I or me. Self-perception is how a person explains behavior based on self-observation. Self-knowledge or selfawareness involves a basic understanding of him- or herself, a cognitive perception. It is consciousness of ones abilities: cognitive, affective, and physical. Social self is how a person sees himself or herself in relation to social situations, including behavior and interaction with others.
14.Asking a patient to describe himself is one way to assess their:
A)
self-concept.
B)
self-knowledge.
C)
self-expectation.
D)
social self.
Ans:
A
Feedback: Self-concept is the mental image a person has of him- or herself. It is the persons meaning when stated as I or me. Self-perception is how a person explains behavior based on self-observation. Self-knowledge or selfawareness involves a basic understanding of him- or herself, a cognitive perception. It is consciousness of ones abilities: cognitive, affective, and physical. Social self is how a person sees himself or herself in relation to social situations, including behavior and interaction with others.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
705
15. A female patient, prominent in the local media, has had surgery for a colostomy. The patient avoids looking at the colostomy and refuses visitors. Identify the most appropriate nursing diagnosis.
A)
Altered self-esteem related to colostomy and poor self-image
B)
Disturbed body image related to colostomy as evidenced by avoidance of colostomy
C)
Fear of rejection by others related to colostomy and altered self-image
D)
Altered role performance related to inability to cope with visitors
Ans:
B Feedback: Disturbed body image possesses the clinical cues of behaviors of avoidance, monitoring, or acknowledgement of ones body.
16. To obtain subjective data about a burn patients self-concept, the nurse should
A)
Ask the patient how she would describe herself
B)
Observe the patients interactions with others
C)
Document the patients lack of eye contact
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Note how the patient conceals her wound
Ans:
A
706
Feedback: Gordon (1997) suggests asking patients how they would describe themselves in the assessment of self-concept.
17. The nurse promotes the self-concept of the parents of a 6-month-old infant admitted to the hospital with a fever and dehydration by
A)
Telling the parents that the infants condition was not their fault
B)
Allowing the parents to participate in the infants care
C)
Encouraging the parents to visit the infant every other day
D)
Teaching the parents health-maintenance behaviors
Ans:
B
Feedback: When a person suffers from an illness or exhibits a self-concept dysfunction, family members may also be affected. Family members may need to assist the individual to perform activities of daily living or have to change the living situation with the use of adaptive equipment or other assistive devices.
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707
18. A newlywed couple has moved to another city due to a job opportunity. The couple would be at risk for alteration in self-concept related to
A)
Inadequate coping
B)
Role strain
C)
Anxiety
D)
Stress
Ans:
A Feedback: Lack of support systems and inability to prioritize and problem solve contribute to inadequate self-esteem.
19. A nurse student states, I feel good that I put an indwelling catheter in my patient without any problem. This demonstrates which factor affecting selfconcept?
A)
Culture
B)
Inadequate coping
C)
Stress tolerance
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Values
Ans:
C
708
Feedback: Coping and stress tolerance influence self-concept. People who are able to adapt to stress and resolve conflicts through coping tend to develop healthy self-concepts. 20. A nurse visits a 60-year-old diabetic patient in his home after the patients above-theknee amputation of his left leg. The patient appears disheveled and with poor hygiene. He also avoids making eye contact with the nurse. Which of the following is likely to occur as a result of the patients reduced self-esteem?
A)
Lethargy
B)
Withdrawal
C)
Self-care deficit
D)
Lack of interest
Ans:
C Feedback:
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
709
Physical changes such as decreased strength, skin turgor, and sensory acuity affect body image in later life. Because of the valuation of youth in the media and popular culture, some older people experience lowered self-esteem with the changed body image.
21.Preschoolers exhibit sexual curiosity. This builds the preschoolers
A)
Self-concept
B)
Ideal self
C)
Body image
D)
Diminished self
Ans:
A Feedback: Self-concept continues to develop actively during preschool years. Preschoolers sense of self becomes more defined as they realize that they are separate and unique. During this stage of development, children exhibit great sexual curiosity.
22.In regards to development of self-concept, an infant
A)
Plays independently with toys
B)
Has no separate existence
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Is not affected by self-concept
D)
Develops new roles daily
Ans:
B
710
Feedback: Newborns have undifferentiated selves; they do not experience separate existence from others.
23.What role does the son play in your patients life?
A)
Hereditary
B)
Ascribed
C)
Designated
D)
Assumed
Ans:
B Feedback: An ascribed role is one in which the person has no choice.
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711
24. When the paraplegic patient demonstrates the ability to cope with his personal deficiencies and to maximize his strengths, the nurse determines that the patient has developed
A)
Self-determination
B)
Self-evaluation
C)
Self-esteem
D)
Self-image
Ans:
C Feedback: The person with adequate self-esteem has learned to cope with personal deficiencies and to maximize strengths.
25.A soldier has lost his right leg in a roadside bomb. This accident will affect his
A)
Body image
B)
Self-evaluation
C)
Self-perception
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Ideal self
Ans:
A
712
Feedback: The human body is the selfs physical manifestation. How a person pictures and feels about his or her body describes body image.
26. An adolescent states, I want to go to college and learn to be a chef. This is an example of
A)
Self-perception
B)
Self-knowledge
C)
Self-expectation
D)
Social self
Ans:
C Feedback: Self-expectation involves the ideal selfthe self a person wants to be.
27. A patient states to you, I am not smart enough to learn how to take of my mother, and I just dont think I can do it. This is an example of
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Self-perception
B)
Self-knowledge
C)
Self-expectation
D)
Social self
Ans:
B
713
Feedback: Self-knowledge or self-awareness involves the basic understanding of oneself, a cognitive perception. It is consciousness of ones abilities: cognitive, affective, and physical. Self-concept is the way a person thinks about himself or herself whereas self-perception is how a person explains behavior based on self-observation.
28. A nurse wants to know about the patients self-perception. Which of the following questions will assess for the patients self-perception?
A)
How do you view yourself in regards to your importance both in your job and in your life?
B)
Do you feel people appreciate your accomplishments in your career? Do you like your life?
C)
Can I ask you a question about your life? Are you aware of any failings you have experienced?
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D)
People with disabilities often feel threatened in their self-concept. Do you feel threatened?
Ans:
A Feedback: This represents a broad question that will provide a wide range of information regarding self-perception. Self-perception is how a person explains behavior based on self-observation.
29. The function of self-concept in human beings is to serve as a frame of reference that
A)
Identifies areas of strength and weakness
B)
Processes external stimuli from the environment
C)
Evaluates events as they are occurring in life
D)
Influences how one handles life situations
Ans:
D Feedback: Self-concept is the mental image a person has of oneself. Self-concept is the frame of reference that influences how a person handles situations and relationships.
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715
30. What term best describes a persons sense of his or her own adequacy and worth?
A)
Esteem
B)
Self-esteem
C)
Love
D)
Self-actualization
Ans:
B Feedback: Self-esteem is a persons sense of his or her own adequacy and worth.
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716
Chapter 38- Families and Their Relationships
1.
The nurse is assessing a family for potential sources of conflict.
Which of the following assessment findings would not be a potential source of conflict? A) The mother and father both work outside the home
B)
The fathers parents live next door.
C)
Lower socioeconomic status
D)
Recent relocation for new jobs for both parents
Ans:
D Feedback: Potential sources of conflict include both parents working outside the home and sharing child rearing roles, inlaws, lower socioeconomic status, and relocation for the benefit of only one family member.
2.
A)
The nursing instructor has just finished a lecture on family function. Which statement by a student indicates a need for further education?
Previous life experiences can affect the way a family functions.
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B)
Chronic illness does not affect the way a family functions, only acute illnesses do.
C)
A familys culture may affect the way a family functions.
D)
A change in a persons lifestyle may affect the way their family functions.
Ans:
B Feedback: Factors that affect family function include culture, values and beliefs, economics, lifestyle, previous life experience, stress, and illness.
3. The nurse is providing assistance to a family experiencing altered family function. Which of the following interventions should the nurse utilize? Select all that apply.
A)
Assist the family to clarify the conflict
B)
Correct misconceptions
C)
Focus on facts, not feelings
D)
Stress effective communication practices
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
E)
Provide concrete feedback
Ans:
A, B, D, E
718
Feedback: Aim interventions at resolving family conflicts by first identifying the participants willingness to acknowledge a problem and to work on their ability to communicate. Stress effective communication practices. Allow each member to speak, listen, and express feelings as well as facts. Clarify the conflict with participants, help participants identify contributing factors, correct misconceptions, provide concrete feedback based on nursing observations, assist participants to develop solutions, and support decision making among participants.
4. A patient states, I cant go to therapy everyday. I cant miss that much work. They will fire me and then how will I provide for my family? Which is the most appropriate nursing diagnosis?
A)
Ineffective Role Performance
B)
Caregiver Role Strain
C)
Denial
D)
Interrupted Family Process
Ans:
A
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
719
Feedback: The patient is concerned about his ability to provide for his family. Ineffective Role Performance would be the most appropriate diagnosis. Caregiver Role Strain focuses on the caregiver. Denial is not a NANDAI approved nursing diagnosis. Interrupted Family Process would be applicable if the patient did lose his job and was not able to provide for his family.
5. The hospice nurse has completed a family function assessment on a patient who is dying. Which of the following behavioral signs would suggest family dysfunction?
A)
The patient states, I cant live like this anymore.
B)
The patients mother is laughing one minute and crying the next.
C)
The patients daughter states, I havent slept in 3 days.
D)
The patient makes good eye contact during the assessment.
Ans:
B Feedback: Objective data for assessing family function includes observation of family interactions and the behavior of members, as well as physical examination. Behavioral signs of family dysfunction include labile emotions, withdrawal, irritability, poor sleeping and eating, inability to concentrate, and dependency. Direct quotes are subjective data.
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6. The nurse has completed an altered family function risk assessment and has identified several potential risk factors for the family. Which of the following would not be considered a risk factor for altered family function?
A)
Father has a history of drug abuse
B)
Grandparents live next door
C)
Child has a diagnosis of ADHD
D)
Mother lost her job 2 weeks ago
Ans:
B Feedback: Characteristic risk factors for potential alterations in family processes include unrealistic expectations of self or others; lack of appropriate role models; history of abuse; inability to bond with others; inadequate support systems; presence of stress; skill or knowledge deficit; acute or chronic illness; and unmet psychosocial needs of children or adults
7.
The nurse is preparing to do an altered family function risk assessment on a patient. Which question should the nurse ask first?
A)
What are the potential sources of stress in your family?
B)
Are you able to cope with family health problems?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Tell me about your familys eating habits?
D)
What is the general sleep pattern in your family?
E)
How would each member describe this family?
Ans:
A
721
Feedback: History taking to identify areas of risk or potential problems requires both openended and focused questioning. Questions related to potential sources of stress in the areas of roles, finances, lifestyle, previous experience, and general health are crucial. Follow a general question, such as What are the potential sources of stress in your family? with more specific questions. 8.
The nurse is caring for a patient who is an alcoholic. The patients daughter states, I dont understand why my mother keeps buying beer for my dad. She wont admit that hes an alcoholic. Which of the following is the best response by the nurse?
A)
Your father would still be an alcoholic even if your mother didnt buy his beer.
B)
Your mother is trying to keep your family functioning.
C)
Your father is an enabler.
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D)
If your mother stopped buying beer for your father he would most likely stop drinking.
Ans:
B Feedback: A spouse or child usually becomes the alcoholics enabler, the person who keeps the family functioning even at an altered level. The enabler assumes tasks that the alcoholic cannot accomplish and cares and makes excuses for the alcoholic. These behaviors enable the alcoholic to continue drinking, which contributes to the deterioration of the family unit.
9.
The nurse is concerned that a child may have been neglected or abused at home. Which of the following assessment findings would not support this concern?
A)
Diagnosis of failure to thrive
B)
A strong attachment to the parental figure
C)
Multiple bruises to the childs back
D)
Underweight for age and height
Ans:
B Feedback:
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A lack of attachment (bonding) may be evidenced by an adults failure to care for the childs physical or emotional needs or by verbalized resentment or indifference toward the parenting role. Evidence of neglect or physical abuse may be noted, as well as failure to thrive.
10. A nursing instructor has been discussing abuse with a group of students. Which statement by a student indicates a need for further education?
A)
Factors that contribute to abuse in families include unemployment, substance abuse, and chronic illness.
B)
Many abused children grow up and abuse their own children.
C)
Changing abusive patterns is easy once they are detected.
D)
Abuse can happen in any socioeconomic status.
Ans:
C Feedback: Factors that contribute to abuse in families include unemployment, substance abuse, chronic illness, inadequate housing, and lack of education and other resources (Chartier, Hesselbrock, & Hesselbrock, 2009; Moracco, Runyan, Bowling & Earp, 2007). Abuse is not limited to any one socioeconomic level and frequently is passed down through the generations. Many abused children grow up to abuse family members. Changing abusive patterns of behavior is difficult.
11. A student nurse is preparing a presentation on the functions of a family. What information should the student include? Select all that apply.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Family functions do not change over time
B)
Economic provisions of care
C)
Socialization
D)
Provide nurturing
E)
Provide support and security for family members
Ans:
B, C, D, E
724
Feedback: The usual functions of families involve physical and economic provisions of care, sexual intimacy, reproduction, education, socialization (including communication), and nurturing and support for problem solving and goal setting. Besides the physical bonds of family relationships, members experience emotional bonds that provide support and security for members, thereby fostering growth and development. Like family structures, family functions evolve over time within individual families. 12. A patient states that she has just moved in with her boyfriend. They are going to try living together prior to getting married. The nurse would document this as what type of family?
A)
Blended
B)
Cohabitated
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Extended
D)
Nuclear
Ans:
B
725
Feedback: Cohabitated family structure means people living together without the formal or legal bond of marriage. Blended families or stepfamilies include children who live with one birth parent and one non-birth parent, as well as any offspring of the nonbirth parent. Extended families include grandparents, aunt/uncles, and/or cousins.
13. A child states that she lives with her parents, sister, and grandmother. The nurse would document this as what type of family?
A)
Extended
B)
Cohabitated
C)
Nuclear
D)
Blended
Ans:
A Feedback:
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
726
The extended family structure expands the previously listed family types by adding grandparents, aunts, uncles, and cousins. Cohabitated family structure means people living together without the formal or legal bond of marriage. Members of a blended family (stepfamily) include children who live with one birth parent and one nonbirth parent, as well as any offspring of the non-birth parent. The nuclear family traditionally includes a married adult man and woman and their children.
14. During a home visit in the postpartum period, the nurse notes the patient is having difficulty with breastfeeding. The nurse should refer the patient to
A)
A nurse practitioner
B)
LaLeche League International
C)
Parent effectiveness training
D)
Nurses for Newborns
Ans:
B Feedback: Professional referrals and peer support groups may be sources of help to those experiencing difficulty with parenting roles. LaLeche League International focuses on issues with breastfeeding.
15. The spouse of a terminally ill woman states, I cannot do this anymore. It is so hard to go to work every day and leave her. I know she is dying and
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
727
we have such limited time, but my company will not give me any more time off. The most appropriate nursing diagnosis is
A)
Caregiver role strain related to difficulty with specific caregiving activities as evidenced by situational factors with other responsibilities
B)
Ineffective family coping related to terminal illness and impending death
C)
Ineffective family coping related to cancer as evidenced by statements of anxiety
D)
Altered family processes related to age of caregiver and employment responsibilities
Ans:
A Feedback: The most appropriate nursing diagnosis is caregiver role strain since the caregivercare receiver relationship is changed.
16. The daughter of an ill patient states, I feel so guilty that I have to go to work and cannot be with my mother. The nurse realizes this statement reflects
A)
Caregiver role conflict
B)
Separation anxiety
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Coping with change
D)
Fear of the unknown
Ans:
A
728
Feedback: As an ill family member experiences change, the caregivers role changes as well. This may be evidenced by verbalization of feelings of inadequacy, guilt, anxiety, failure, helplessness, and powerlessness.
17. Using an interactional approach, the nurse focuses the assessment of a family on the familys
A)
Cultural practices
B)
Developmental stages
C)
Communication patterns
D)
Potential sources of stress
Ans:
C Feedback: Communication patterns are considered key to an interactional approach.
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729
18. When a member of the family is diagnosed with malignant cancer, the family functioning may be affected primarily by the
A)
Economic impact of the illness
B)
Absence of role models
C)
Family strengths
D)
Maintenance of roles
Ans:
A Feedback:
Common stressors in chronic illness include exhaustion, anxiety, needing help from relatives and friends, alterations in social contacts or travel abilities, concern about sibling needs, and financial concerns. Family roles, responsibilities, and social relationships change to meet the needs of the family system as well as the ill child or adult.
19. Research has shown that children of employed mothers are able to develop well and have their needs met as long as
A)
The parent has sufficient support
B)
Adequate childcare is provided
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
The parent is well educated
D)
No crisis occurs in the family
Ans:
B
730
Feedback: Research has shown that children of employed mothers are able to develop well and have their needs met as long as adequate childcare is available.
20. A couple with two children are also caring for an aging parent who has become physically disabled. The couple may experience
A)
Frustration
B)
Substance abuse
C)
Illness
D)
Economic stability
Ans:
A Feedback: Relationships with aging parents may result in conflict, frustration, and/or anger as older adults become more dependent.
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731
21. A teenage girl does not physically develop as quickly as her peers. This can impair her
A)
Future development
B)
Physically
C)
Hygiene
D)
Psychosocially
Ans:
D Feedback: Psychosocial development is closely related to changes in physical development.
22. You are working on the oncology division at a local hospital. An elderly patient has just passed away. He was very close to his grandchildren. To address care of the family, the nurse should
A)
Assist with funeral arrangements at the mortuary
B)
Assure preschoolers it is not their fault
C)
Tell toddlers grandpa died and is not coming back
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Only allow immediate family with the deceased
Ans:
B
732
Feedback: Family members should assure preschool children that changes such as death are not their fault.
23. The nurse instructs the parents of two preschool-aged children that children learn about relationships early in life primarily from
A)
Parents
B)
Peers
C)
Teachers
D)
Siblings
Ans:
A Feedback: Preschoolers identify with the role of man or woman as they interact differently with parents or primary caregivers. The caregiver of the opposite sex becomes the focus of the childs love, whereas the child may direct aggression toward adults of the same sex.
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733
24. A nurse working in a daycare setting understands that a common issue with toddlers is
A)
Neglect
B)
Separation anxiety
C)
Depression
D)
Sibling rivalry
Ans:
B Feedback: Despite power struggles, toddlers remain attached to their caregivers, and severe separation anxiety may be noted when primary caregivers leave these children from 18 to 24 months of age.
25. Which of the following terms describes a support function of the family structure?
A)
Formal education
B)
Economic stability
C)
Problem solving
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Reproduction and unity
Ans:
C
734
Feedback: The usual functions of families involve physical and economic provisions of care, sexual intimacy, reproduction, education, socialization, and nurturing and support for problem solving and goal setting.
26. When a patient tells the nurse that she is divorced and remarried with one son from her first marriage, the nurse documents the patients family structure as
A)
Extended
B)
Blended
C)
Cohabitated
D)
Divided
Ans:
B Feedback:
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
735
Members of a blended family include children who live with one birth parent and one non-birth parent, as well as any offspring of the non-birth parent.
27. Because of high divorce rates and separations in recent years, there has been a significant increase in the family structure termed
A)
Single-parent
B)
Communal
C)
Extended
D)
Foster child
Ans:
A Feedback: Single-parent families, composed of one parent and one or more children, more than doubled from 11% in 1970 to 24% in 2000, because of increasing rates of separation and divorce.
28. Which of the following statements is accurate related to the nuclear family structure in the United States?
A)
The number of traditional families is stable.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
It includes single-parent families.
C)
There are 17.3 million nuclear families in the United States.
D)
It included blended families.
Ans:
A
736
Feedback: The number of traditional families remained stable over the last 30 years, ranging from 23.5 million to 26 million.
29. When providing care to an elderly patient living with her son and daughterin-law, the nurse assesses the patient and family. This is an aspect of
A)
Patient-centered nursing interventions
B)
Outcome criteria for care
C)
Family-centered care
D)
Age-related nursing care
Ans:
C Feedback:
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
Nurses who practice family-centered care, which means caring for the patient and family as a unit, recognize the positive aspects of diversity and facilitate patient/caregiver/professional collaboration.
737
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738
Chapter 39- Cognitive Processes
1.
The nurse is caring for a client who is difficult to arouse and when aroused is confused. The nurse would document the clients condition as:
A)
lethargic.
B)
obtunded.
C)
somnolent.
D)
depressed.
Ans:
B Feedback: Obtunded describes the patient who is difficult to arouse and when aroused is confused. Lethargic describes the patient who is not fully awake and tends to drift off to sleep when not actively stimulated. Somnolent describes a client who is sleepy. Depressed is an emotional feeling.
2. A nurse is caring for a client with schizophrenia. The nurse understands that patients suffering from schizophrenia have problems in which of the following areas? Select all that apply.
A)
Processing information
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Inappropriate social behavior
C)
Communication
D)
Memory
E)
Decision making
Ans:
A, B, C, D, E
739
Feedback: People with schizophrenia experience problems with thinking, memory, attention, communication, decision making, emotions, social behavior, and ability to perceive reality accurately.
3. The nurse is caring for a patient with altered cognitive function who has recently been admitted to the hospital from a long-term care facility. Which of the following interventions would address the clients safety? Select all that apply. A) Place the client in a room close to the nurses station.
B)
Keep the bed in the lowest position possible.
C)
Use a night light in the patients room.
D)
Keep the patients door closed to reduce noise.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
E)
Leave the television on at all times.
Ans:
A, B, C
740
Feedback: Safety measures such as orienting patients to the room and the nurse call system, using lights at night to help orient patients to their environment, keeping beds in the lowest possible position, and placing patients in rooms closest to the nursing station for closer observation help to prevent accidents and injuries. Keeping the door closed and leaving the television on may lead to perception issues, which could increase the clients risk of falling.
4.
The nurse is working with a patient experiencing minimal memory
problems. The nurse is teaching the patient about memory training programs. Which statement by the patient would indicate a need for further education? A)
I will do a crossword puzzle every day.
B)
I will start making lists of things I need to remember.
C)
I will not try to learn any new hobbies.
D)
I will take a nap every day.
Ans:
C Feedback:
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
741
For people with minimal memory problems, memory training programs and devices may be beneficial. Making lists, using mnemonic devices (formulas or patterns of letters to aid in remembering), putting things on a calendar/planner, repeating what you want to remember, and developing other association techniques can assist with remembering tasks or information. The regular practice or rehearsal of retrieving information from the memory helps maintain the skill.
5. The nurse is caring for a client who has had a stroke. Since the stroke, the client has trouble saying words correctly and his speech seems slurred. The nurse documents this speech pattern as:
A)
dysarthria.
B)
anomic aphasia.
C)
dysphasia.
D)
expressive aphasia.
Ans:
A Feedback: Patients with dysarthria usually have normal auditory comprehension and can select and order words correctly. They have a motor speech disorder that causes them difficulty in saying words and sounds precisely using appropriate stress, loudness, pitch, and control. The result is speech described as slurred, heavy, or unclear. Expressive aphasia (also called Brocas, motor, or nonfluent aphasia) is characterized by limited speech that is slow and halting with great effort, reduced grammar, and poor
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
742
articulation. Anomic or amnesic aphasia is characterized predominantly by word-finding problems of a milder nature than expressive aphasia. The speech is fluent and grammatically correct. 6.
The nursing instructor has completed a presentation regarding ways to help clients with cognitive deficits to remain oriented. What statement by a student would indicate a need for further education?
A)
I will place clocks and calendars in the clients rooms.
B)
I will change the activity schedule on a daily basis.
C)
I will be consistent when making nursing care assignments.
D)
I will provide frequent orientation reminders for the clients.
Ans:
B Feedback: Maintaining a structured environment assists patients in adapting to cognitive alteration and in reestablishing communication. Structured routines minimize the number of factors on which patients must focus. Sequenced events, consistent daily schedules and care providers, calendars, and frequent reminders contribute to structure.
7.
The nurse is caring for a client who has suffered a stroke. The client is now unable to speak, read, or write. She is also unable to understand spoken language. The nurse would document this as:
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
anomic aphasia.
B)
expressive aphasia.
C)
receptive aphasia.
D)
global aphasia.
Ans:
D
743
Feedback: Anomic or amnesic aphasia is characterized predominantly by wordfinding problems of a milder nature than expressive aphasia. Expressive aphasia (also called Brocas, motor, or nonfluent aphasia) is characterized by limited speech that is slow and halting with great effort, reduced grammar, and poor articulation. Receptive aphasia (also called Wernickes, sensory, or fluent aphasia) is characterized by speech that is well articulated and has good melody and normal or slightly faster rate. The major manifestations are impaired auditory comprehension and feedback. Global aphasia results from severe and extensive damage to all language areas (Brocas and Wernickes). These patients have no consistent functional skills in any language modality.
8.
A nurse is caring for a client who had difficulty finding the correct names for particular objects. The nurse would document this as:
A)
anomic aphasia.
B)
receptive aphasia.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
expressive aphasia.
D)
global aphasia.
Ans:
A
744
Feedback: Anomic or amnesic aphasia is characterized predominantly by wordfinding problems of a milder nature than expressive aphasia. Expressive aphasia (also called Brocas, motor, or nonfluent aphasia) is characterized by limited speech that is slow and halting with great effort, reduced grammar, and poor articulation. Receptive aphasia (also called Wernickes, sensory, or fluent aphasia) is characterized by speech that is well articulated and has good melody and normal or slightly faster rate. The major manifestations are impaired auditory comprehension and feedback. Global aphasia results from severe and extensive damage to all language areas (Brocas and Wernickes). These patients have no consistent functional skills in any language modality.
9.
The nurse is caring for a client recently diagnosed with Alzheimers dementia. Which assessment finding would cause the client to question this diagnosis?
A)
Sudden onset of confusion
B)
Short term memory loss
C)
Increased agitation at sundown
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Inattention to ADLs
Ans:
A
745
Feedback: People with Alzheimers dementia experience a gradual decline in all cognitive processes. A sudden onset of confusion would not be suggestive of Alzheimers. Increased agitation at sundown and inattention to ADLs are both symptoms of Alzheimers dementia.
10. The most appropriate diagnosis for the elderly client with Alzheimers disease who requires bathing is
A)
Chronic confusion related to disease process as evidenced by the inability to manage activities of daily living
B)
Chronic confusion related to dementia and biochemical imbalances as evidenced by hallucination
C)
Altered thought processes related to confusion, biochemical imbalances, and Alzheimers disease
D)
Confusion as evidenced by inability to remain oriented to place and time resulting from Alzheimers disease
Ans:
A Feedback:
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
746
The priority nursing diagnosis is chronic confusion related to disease process as evidenced by the inability to manage daily activities.
11. To assess a newly admitted adult clients perception of reality, the nurse asks the client about
A)
Person, place, and time
B)
Family history
C)
Memory ability
D)
Confusional state
Ans:
A Feedback: Assessing perception of reality includes determining the persons orientation to time, place, and person.
12.The nurse recognizes that the client diagnosed with global aphasia will
A)
Have difficulty with grammar and articulation
B)
Demonstrate unintelligible speech
C)
Express comments that do not make sense
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Be unable to speak, read, or write
Ans:
D
747
Feedback: Global aphasia results from severe extensive damage to all language areas (Brocas and Wernickes).
13. Which of the following types of aphasia occurs in the brain-injured person and results in limited speech that is slow and halting, is completed with great effort, and is poorly articulated?
A)
Brocas
B)
Receptive
C)
Global
D)
Anomic
Ans:
A Feedback: Expressive aphasia (Brocas) is characterized by limited speech that is slow and halting, with great effort, reduced grammar, and poor articulation.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
748
14. When an elderly client is alert and calm during the day but becomes confused and agitated every night, the nurse recognizes that the client is experiencing
A)
Hallucinations
B)
Delirium
C)
Sundown syndrome
D)
Delusions
Ans:
C Feedback: Sundown syndrome is defined as an increase in confusion and agitation that occurs at the end of the day.
15. Which of the following statements accurately characterizes dementia? The disease is
A)
Equivalent to organic brain syndrome
B)
A result of the normal aging process
C)
Reversible with early diagnosis and treatment
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Irreversible with gradual cognitive decline
Ans:
D
749
Feedback: People with dementia experience a gradual decline in all cognitive processes which is irreversible, as contrasted to acute confusion ordelirium , in which dysfunction may be reversible.
16. The most common form of dementia is
A)
Organic brain syndrome
B)
Senile dementia
C)
Delirium tremens
D)
Alzheimers type
Ans:
D Feedback: The most common form of dementia is Alzheimers type, which is primary neuronal degeneration of unknown cause.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
750
17. When a nurse makes a home visit and finds that a previously alert and oriented elderly client is demonstrating early signs of confusion, the nurse suspects that the client may be experiencing the onset of
A)
Infection
B)
Hyperglycemia
C)
Hepatic encephalopathy
D)
Hyperkalemia
Ans:
A Feedback: Altered cognitive function in an older adult may be the earliest indication of an infectious process anywhere in the body.
18. Which of the following problems is the most likely physical cause of an elderly clients altered cognition?
A)
Hypothyroidism
B)
Hyperthyroidism
C)
Hypopituitarism
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Hyperparathyroidism
Ans:
A
751
Feedback: Disorders that impair metabolic processes and oxygen use, such as hypothermia and hypothyroidism, can also alter cognition. The bodys inadequate intake or impaired use of glucose will limit the quantity available for the brains metabolic demands.
19.For optimal functioning, the brain requires a large amount of
A)
Sodium
B)
Magnesium
C)
Glucose
D)
Vitamin A
Ans:
C Feedback: The brain cells need glucose for metabolic energy and other nutrients for optimal functioning. The brain consumes 25% of the glucose the body uses.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
752
20. A 78-year-old client has suffered a cerebrovascular accident. The family inquires about the clients speech. The client has expressive aphasia. The nurse explains the client will require a(n)
A)
Speech pathologist
B)
Physical therapist
C)
Occupational therapist
D)
Physiatrist
Ans:
A Feedback: Approximately 20% of all stroke survivors require the specialized services of a speech pathologist to help them regain communication skills.
21. An elderly male client who has been smoking a pipe and cigar for more than 30 years develops chronic hoarseness. The nurse understands that the client is a risk for which alteration in cognitive function?
A)
Memory
B)
Thinking
C)
Communication
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Muscular dysfunction
Ans:
C
753
Feedback: Communication may be altered by the functional impairment of speech apparatus of the larynx, the ability to move air, the use of the tongue and oral pharynx, and/or the innervation to each of these structures.
22. When the elderly client seems very forgetful and often fails to dress appropriately, the nurse determines that the client is demonstrating
A)
Normal aging
B)
Confusion
C)
Cognitive impairment
D)
Chronic senile dementia
Ans:
C Feedback: Although the brain undergoes some degenerative changes as the ventricles enlarge slightly and brain weight decreases, significant cognitive impairment in older persons is never normal but is indicative of a disorder.
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754
23. An adolescent client states, I am tired of everything and I am very bored. The nurse should encourage
A)
Peer relationships
B)
Time for prayer
C)
Ability to think
D)
Activity therapy
Ans:
A Feedback:
During illness, peer relationships provide support and companionship for adolescents.
24.The thinking patterns of a 4-year-old will typically demonstrate
A)
Categorization
B)
Abstract thought
C)
Conservatism
D)
Egocentrism
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
Ans:
755
D Feedback: Preschoolers have concrete thinking patterns and demonstrate pronounced egocentrism, or self-concern.
25. The toddler begins to label familiar items such as the stove is hot, and the ball bounces at age
A)
Less than one
B)
1 to 3 years
C)
3 to 5 years
D)
5 to 7 years
Ans:
B Feedback: During the toddler years, the toddler develops the concept of object permanence, and begins to label familiar items.
26. The nurse instructs the newly delivered, first-time mother that to enhance the newborns cognitive development, the mother should
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Teach the infant to hold the bottle
B)
Frequently stimulate and interact with him
C)
Reinforce the newborns environment with symbols
D)
Encourage the neonate to coo and babble
Ans:
B
756
Feedback: Providing stimulation through varied objects, different sounds, and faceto-face communication and interaction enhances cognitive development.
27. The process of receiving and interpreting the sensory stimuli that functions as a basis for understanding, knowing, and learning is termed
A)
Perception
B)
Attending
C)
Thinking
D)
Memory
Ans:
A
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
757
Feedback: Perception is the process of receiving and interpreting sensory stimuli that functions as a basis for understanding, knowing, and learning.
28. Sensory receptors that respond to stimuli from deeper tissues such as bone are termed
A)
Neuroreceptors
B)
Interoceptors
C)
Proprioceptors
D)
Exteroceptors
Ans:
B Feedback: Interoceptors are located in and respond to stimuli from the bodys viscera and deeper tissues such as bone.
29. Sensory receptors that are located in the ear, muscles, tendons, and joints that relate to the bodys physical state are termed
A)
Neuroreceptors
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Interoceptors
C)
Proprioceptors
D)
Exteroceptors
Ans:
C
758
Feedback: Proprioceptors are located in the inner ear, muscles, tendons, and joints.
Chapter 40- Sexuality
1.
The nurse is assisting during a physical exam of a patient. In regards to the genital exam, what steps does the nurse need to complete? Select all that apply.
A)
Provide privacy.
B)
Instruments should be kept cold.
C)
Use careful draping of the patient.
D)
Use gloves during the exam.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
E)
Observe breasts for deviations from normal.
Ans:
A, C, D
759
Feedback: Provide privacy and use careful draping. Instruments should be warm. Be sure to wear gloves during a physical examination of a patients genitals.
2.
A female patient presents with a complaint of pain and burning in the area of the vulva during intercourse. The nurse documents this complaint as:
A)
vulvodynia
B)
vaginismus
C)
dyspareunia
D)
orgasmic dysfunction
Ans:
A Feedback: Vulvodynia produces symptoms of burning and pain in areas of the vulva. Vaginismus is involuntary contraction of the muscles surrounding the vaginal orifice so that penetration may be impossible and very painful. Dyspareunia is painful at the vaginal opening during intercourse or deep thrusting.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
760
3. The nurse is speaking to a patient regarding his sexual history. The patient states, I was born with a penis but I should have had a vagina. The nurse would document the patients gender identity as which of the following?
A)
Transsexual
B)
Homosexual
C)
Bisexual
D)
Transvestite
Ans:
A Feedback: A transsexual man views himself as a woman trapped in a mans body; the reverse is true for a female transsexual. Transvestite is an outdated term used to describe a person who dresses like someone of the opposite sex but views themselves according to their biological gender. Bisexuals are attracted to both males and females. Homosexuals are attracted to those of the same gender.
4.
The nurse is providing education about barrier contraceptives. Which statement by the patient indicates a need for further education?
A)
I have to wash my cervical caps after each use.
B)
I can leave my diaphragm in for up to 48 hours.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
761
C)
I can insert my female condoms up to 8 hours before intercourse.
D)
Male latex condoms when used correctly are an effective means of contraceptive and very effective at preventing transmission of STDs.
Ans:
B Feedback: The diaphragm stays in for 8 hours after intercourse. The FemCap can stay for 48 hours. Diaphragms and cervical caps are washable and reusable. Female condoms can be inserted up to 8 hours before intercourse to avoid interrupting sexual activity. Missing part of sentence control is the condom. Male condoms can be made of latex, polyurethane or natural membranes. Male latex condoms when used correctly are an effective means of contraceptive and very effective at preventing transmission of STDs.
5.
The nurse has provided information to a patient about oral contraceptives. Which statement by the patient would indicate a need for further education?
A)
Some oral contraceptives protect against STDs.
B)
Hormonal oral contraceptives reduce the risk of ovarian cancer.
C)
Oral contraceptives need to be taken on a daily basis.
D)
Some hormonal contraceptives do not contain estrogen and rely instead on a progestin only.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
Ans:
762
A Feedback: Oral contraceptives need to be taken on a daily basis to prevent breakthrough ovulation. Oral contraceptives do not protect against STDs and patients still need to use STD protection such as condoms. In addition to preventing pregnancy, hormonal contraceptives have many health benefits including reduction in risk of ovarian cancer and endometrial cancer, reducing symptoms of premenstrual discomforts, decreasing blood loss and anemia, reducing symptoms of endometriosis, and many other benefits.
6.
The nurse is preparing a presentation on contraceptive methods. Which methods are designated highly effective? Select all that apply.
A)
Vaginal ring
B)
Injectable depoprovera
C)
Subdermal implants
D)
IUDs
E)
Transdermal patch
Ans: B, C, D Feedback:
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
763
Highly effective methods include sterilization, subdermal implants, IUDs and injectable depoprovera. Moderately effective methods include oral contraceptives, the vaginal ring, and the transdermal patch.
7. The nurse is caring for a patient diagnosed with vaginismus. When reviewing the patients history, what would the nurse expect to find?
A)
Past history of a rape
B)
Past history of an STD
C)
Multiple vaginal deliveries
D)
The patient is in the first trimester of pregnancy
Ans:
A Feedback: Vaginismus usually results from psychological problems, namely fear of penetration due to a negative association such as rape, sexual abuse, or fear of sexual intercourse.
8.
The nurse is using the PLISSIT model when discussing sexual health
with a patient. Which of the following would be an appropriate comment for the SS portion? A) $5.00 per month.
If you were to use the pill, the cost of the pill will be
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
764
B)
The typical signs and symptoms include nausea and vomiting.
C)
Keeping sexual secrets can hurt a healthy relationship.
D)
Some people practice birth control, while others choose not to. It is an individual choice.
Ans:
A Feedback: The acronym stands for the following: P = permission giving, LI = limited information, SS = specific suggestions, and IT = intensive therapy
9.
After instructing the male patient on the performance of a testicular examination, the nurse instructs the patient to perform the examination
A)
Monthly
B)
Weekly
C)
Bi-monthly
D)
Bi-yearly
Ans:
A Feedback:
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
765
The patient should perform a testicular examination monthly.
10. The nurse determines that the patient needs further instruction regarding Kegel exercises when the patient tells the nurse that one of the benefits of the exercises is
A)
More frequent orgasms
B)
Rapid postpartum recovery C) Increased vaginal
lubrication
D)
Relief of constipation.
Ans:
A Feedback: Benefits of Kegel exercises are increased vaginal lubrication during sexual arousal, enhanced sexual excitement, stronger gripping of the base of the penis, more rapid postpartum recovery of the pelvic floor muscles, increased flexibility of episiotomy scars, and relief of constipation.
11. The nurse determines that a female patient understands how to perform breast selfexamination when the patient states A)
The best time to perform the exam is 1 week after my period.
B)
I should use my whole hand to feel for lumps and only at the nipple.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
I should palpate the breast in a random manner with my thumb.
D)
Dimples around the nipple are normal and increase with age.
Ans:
A
766
Feedback: The patient understands breast self-examination when she describes performing the examination approximately 1 week after her period.
12. A woman complains of pain with intercourse. What patient medications should the nurse check for that contribute to dyspareunia?
A)
Antihistamines
B)
Calcium supplements
C)
Antibiotics
D)
Antihypertensives
Ans:
A Feedback: Common causes of dyspareunia are organic problems, including inadequate lubrication at the vaginal opening or within the vaginal walls.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
767
Medications that cause dyspareunia include antihistamines, certain tranquilizers, marijuana, and alcohol.
13. When a 19-year-old male patient tells the nurse that he has never been able to achieve an erection, the nurse recognizes that the patient is experiencing
A)
Sexual identity problems
B)
Primary impotence
C)
Psychological impotence
D)
Ejaculatory dysfunction
Ans:
B Feedback: Primary impotence refers to a man who has never been able to achieve an erection necessary for intercourse; secondary impotence refers to a man who was once successful in attaining and maintaining erections but who has subsequently experienced difficulty. Causes of impotence, whether primary or secondary, can be physiologic, psychological, or both. Certain manifestations may indicate the probability that the problem is secondary to a physiologic or a psychological factor.
14. The nurse should instruct an Islamic female patient who is reluctant to undergo a pelvic examination because her assigned healthcare provider is a man to
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Ask her husband to be present during the examination
B)
Seek a female healthcare provider to perform the examination
C)
Tell her to refuse to have the examination based on beliefs
D)
Have a pelvic examination with another woman present
Ans:
B
768
Feedback: The woman is from a culture or ethnic group whose values influence her feelings about a pelvic examination, particularly one done by a male healthcare provider.
15. The term used to describe sexual changes that occur in the transition of a female from middle age to old age is
A)
Plateau
B)
Menopause
C)
Menarche
D)
Climacteric
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
Ans:
769
D Feedback: The term climacteric refers to the period during which significant sexual changes occur in the transition from middle to old age.
16. When the mother of a 2-year-old tells the pediatric nurse that the child masturbates, the nurse informs the mother that the child
A)
May have an identity crisis
B)
Should have a physical examination
C)
Needs family counseling
D)
Is exhibiting normal behavior
Ans:
D Feedback: Toddlers may engage in masturbation, and parents should be assured that this behavior is normal and healthy for development.
17. During the orgasmic phase of the sexual response, the woman may experience
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Vaginal relaxation
B)
Bradycardia
C)
Hypoventilation
D)
Hypertension
Ans:
D
770
Feedback: The orgasm in the woman produces contractions, and the woman experiences an increased respiratory rate, heart rate, and blood pressure.
18.During the plateau phase of the sexual response, the man may experience
A)
Nipple erection
B)
Bradycardia
C)
Hypoventilation
D)
Hypotension
Ans:
A
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
771
Feedback: In the plateau phase, the man may experience nippleerection , and a sex flush, characterized by a maculopapular rash over the epigastric area, may appear during the latter part of this phase.
19. When a man cannot achieve an erection, the phase of the sexual response in which the man is experiencing difficulty is the
A)
Refractory phase
B)
Obligatory phase
C)
Excitement phase
D)
Orgasmic phase
Ans:
C Feedback: The excitement phase is characterized by rapid erection of the penis with tensing and thickening of the scrotal skin and elevation of the scrotal sac.
20. A child is born and is identified as intersexed. The nurse should inform the parents that
A)
The baby will not get married or have intimate relationships.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
The infant may eventually undergo surgery to determine gender.
C)
The infant will never lead a normal life emotionally or sexually.
D)
The baby will be intersexed for the remainder of his or her life.
Ans:
B
772
Feedback: Some people are intersexed, meaning they were born with what is referred to as ambiguous genitalia, in which it is difficult to determine sex. These people may eventually undergo surgery to differentiate and determine their gender.
21. The term that is used to describe the female patient who states that shes a man trapped in a womans body is
A)
Bisexual
B)
Homosexual
C)
Heterosexual
D)
Transsexual
Ans:
D
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
773
Feedback: A transsexual woman views herself as a man trapped in womans body. Some people are heterosexual, attracted sexually to members of the opposite gender. Others are bisexual, attracted to both men and women sexually. Others are homosexual, attracted sexually to members of the same gender.
22. A pregnant teenager did not understand the process of fertilization. The school nurses best explanation of fertilization is that
A)
The fertilization process occurs in the outer third of the fallopian tube.
B)
Fertilization is a process that occurs in the lower portion of the cervix.
C)
An ovum can be fertilized during a period of 1 week after intercourse.
D)
The first 2 months after fertilization is critical for the embryo.
Ans:
A Feedback: Fertilization of one ovum with one spermatozoon normally occurs in the outer third of the fallopian tube. The time period in which the woman can be impregnated is only a few days.
23. Which of the following statements should be incorporated into the teaching plan developed to present instruction about the female menstrual cycle to nursing students?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Menses ensues when the levels of estrogen and progesterone fall.
B)
The follicular phase is dominated by progesterone and testosterone.
C)
Progesterone influences the growth of endometrial lining.
D)
Estrogen is the dominant hormone during the luteal phase.
Ans:
A
774
Feedback: Menstruation depends on the interplay of various hormones. The hypothalamus secretes gonadotropin-releasing hormone, which stimulates the pituitary gland to secrete follicle-stimulating hormone and luteinizing hormone. These hormones stimulate the ovaries to produce estrogen and progesterone, which are necessary for stimulation of the target organs (vagina, breast, uterus) in preparing for pregnancy.
24. In the female reproductive system, the hormones estrogen and progesterone are produced by the
A)
Vagina
B)
Bartholins glands
C)
Skenes glands
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Ovaries
Ans:
D
775
Feedback: The ovaries are two almond-shaped bodies lying on either side of the pelvic cavity. They contain ova and female hormones, specifically estrogen and progesterone.
25. In the male reproductive system, the glands that produce and store most of the seminal fluid include the seminal vesicle and the
A)
Prostate
B)
Glans penis
C)
Gonads
D)
Scrotum
Ans:
A Feedback: The internal organs include the prostate gland and seminal vesicles. These glands produce and store most of the seminal fluid. The combination of seminal fluid and spermatozoa forms semen, the secretion discharged from the urethra during orgasm.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
776
26.In the female reproductive system, what corresponds with the male penis?
A)
Clitoris
B)
Mons pubis
C)
Skenes glands
D)
Urethral meatus
Ans:
A Feedback: The clitoris corresponds to the penis in the male in that both organs respond to stimulation that can result in orgasm.
27.The combination of seminal fluid and spermatozoa forms
A)
Ovum
B)
Orgasm
C)
Blood
D)
Semen
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
Ans:
777
D Feedback: The combination of seminal fluid and spermatozoa forms semen, the secretion discharged from the male urethra during orgasm.
28. What hormones do the testes produce?
A)
Estrogen and testosterone
B)
Testosterone and spermatozoa
C)
Progesterone and ovum
D)
Thyroxin and cortisol
Ans:
B Feedback: The testes are the male gonad, which are the reproductive glands that produce male cells (spermatozoa) and testosterone (male hormone).
The Surgeon Generals Call To Action To Promote Sexual Health and 29. Responsible Sexual Behavior was released in 2001. The goal of this document is to
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Decrease fear of sexual expression
B)
Enhance prevention with free care
C)
Promote general health and wellness
D)
To stop sexual promiscuity in the country
Ans:
C
778
Feedback: The Surgeon Generals Call to Action To Promote Sexual Health and Responsible Sexual Behavior was released by the U.S. Office of the Surgeon General. Approaching sexuality issues from a public health perspective, this document emphasizes the challenges to promoting responsible sexual behavior with the goal of promoting general health and wellness in our society.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
779
Chapter 41- Stress, Coping, and Adaptation
1. The patient tells the nurse she has never gotten over the loss of her husband two years ago. The patient states she is drinking alcohol to excess every day and has started smoking, saying both help her cope. The best response by the nurse would be
A)
You need to decrease your alcohol consumption and stop smoking for your overall health.
B)
It may be time for you to consider a comprehensive treatment program.
C)
Many people develop these habits in response to severe stress. As you learn to better cope, you will see a decrease in your need for these substances.
D)
This is the way you are coping with the stress. Everyone copes in their own way.
Ans:
B Feedback: People exhibiting stress and altered coping through substance abuse or overeating require a comprehensive treatment program to address their coping and adaptation problems.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
2.
780
A woman has just suffered the loss of her husband. The woman tells
the nurse she cannot eat. The nurse understands this form of coping is: A) part of the normal sympathetic stress response.
B)
maladaptive coping.
C)
the womans coping style.
D)
resolution of loss.
Ans:
A Feedback: Some individuals lose their appetite during stressful situations. This is actually part of the normal sympathetic stress response that diminishes appetite and digestive function. Sympathetic Nervous System activity, however, should be short-term and a persons appetite should return.
3.
A teenaged boy describes a dysfunctional home life to the nurse. The boy states he is running 10 miles or more a day to keep his mind off of his home life. The nurse identifies this form of coping as:
A)
beneficial
B)
maladaptive
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
generational
D)
cultural
Ans:
B
781
Feedback: Substance abuse, beginning or increasing smoking, oversleeping, overor undereating, oversleeping, overexercising, excessive daydreaming, and fantasizing are various ways individuals with the inability to cope with stress successfully deal with stress.
4. A 7-year-old boy has been the victim of abuse. He appears stoic and disconnected while being interviewed by the nurse. Although he currently has a painful injury, he does not cry or flinch when the area is touched. The nurse understands that: A) The child has learned to cope by shutting off his feelings.
B)
The child is mentally ill.
C)
The child is refusing to cooperate with the interview.
D)
The abuse is likely short-lived.
Ans:
A Feedback:
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
782
Children in an abusive home may find ways to protect themselves through forms of escape such as talking to imaginary friends or learning to shut off feelings. 5.
The nurse is caring for a post-operative Asian patient who speaks minimal English. The nurse notes the patient has not requested medication for pain. Considering the patients culture, the nurse would:
A)
Understand that, culturally, Asians often do not take medicine.
B)
Understand that, culturally, Asians may see pain as weakness.
C)
Understand that the patient is not in pain.
D)
Understand that the patient is being difficult.
Ans:
B Feedback: Some cultural beliefs, for example, discourage admitting feeling pain, as it may be thought of as a sign of weakness. A patient experiencing pain may hesitate to ask for pain medication so as not to break the cultural norm.
6.
A teenaged girl is discussing her recent breakup with her boyfriend. She tells the nurse she just stays in bed all day and cannot seem to feel any better. She says she is only relieved of the pain while sleeping. The nurse identifies this coping strategy as:
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
avoidance coping
B)
buffering
C)
chronic stress
D)
adaptation
Ans:
A
783
Feedback: Temporary mechanisms called avoidance coping may alleviate the feelings of anxiety brought on by the stress for a short period of time, but the stressor still needs to be dealt with.
7.
The patient asks the nurse what she should do about a skin lesion she is very worried about. The nurse suggests the patient should notify her physician for a diagnosis. The patient is relieved and states she will make an appointment. This type of activity is considered:
A)
coping
B)
buffering
C)
appraisal
D)
secondary appraisal
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
Ans:
784
B Feedback: Social buffering is the act of soliciting other individuals to help resolve or provide comfort during a stressful event and can be quite effective.
8.
The nurse is discussing an event with a patient. The patient has perceived the event as stress and states she feels better when she takes a brisk walk. The development of coping mechanisms is an example of:
A)
appraisal
B)
secondary appraisal
C)
buffering
D)
adaptation
Ans:
B Feedback: This is called secondary appraisal and is associated with engaging in coping mechanisms to deal with the stress.
9.
A young woman, who has recently suffered acute stress, asks the nurse why she seems to be more sensitive to stress than her husband. The nurse explains that which of the following contribute to this phenomenon?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Thyroid production
B)
Adrenal function
C)
Estrogen levels
D)
Cortisol
Ans:
C
785
Feedback: Women have higher levels of estrogen, which are associated with greater sensitivity to stress and a tendency towards being emotionally supportive and building meaningful relationships.
10. A dancer has suffered a fall injury, which will prevent participation in a much anticipated event. The fall is classified as which of the following?
A)
Stressor
B)
Adaptation
C)
Chronic stress
D)
Resolution
Ans:
A
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
786
Feedback: A stressor can be a number of things, including environmental changes, alterations in routine activities of daily living, unexpected traumas, or tragedies.
11.The grief and angst following a stressful event is sometimes described as:
A)
chaos
B)
coping
C)
distress
D)
adaptation
Ans:
C Feedback: Stress is also unavoidable. The resulting feelings of angst and grief are sometimes labeled distress.
12. The nurse is explaining the bodys response to a stressful situation. The nurse includes which of the following manifestations? Select all that apply.
A)
Hypoglycemia
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Dilated pupils
C)
Increased pulse
D)
Inhibition of urination
E)
Increased digestive function
Ans:
B, C, D
787
Feedback: During a stressful situation, the excitatory actions will cause pupil dilation, increased heart rate and force of contraction, bronchial dilation, and stimulation of converting glycogen to glucose. These inhibitory effects include decreasing digestive function, inhibiting insulin secretion from the pancreas, and preventing urination.
13. During acute stress, the body secretes cortisol, which has which of the following effects on mood?
A)
Depression
B)
Mood protection
C)
Anxiety
D)
Chronic worry
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
Ans:
788
B Feedback: Under acute stress, cortisol is protective of mood, whereas under chronic stress, it is associated with depression and anxiety.
14. A young mother has accidentally locked her keys in her car with her baby strapped in the car seat. In a panic, the mother summons help from a lockout service. This action would be considered:
A)
stressor
B)
adaptation
C)
coping
D)
appraisal
Ans:
C Feedback: Coping can be problem-focused through taking actions to directly work with the event or situation causing the stress, or emotion-focused through finding ways to lessen the feelings of anxiety and angst triggered by the stressful event.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
789
15. An adult receives a call from her bank stating her account is overdrawn and a significant fee has been assessed. The adult would have an initial reaction of which of the following?
A)
appraisal
B)
coping
C)
adaptation
D)
intervention
Ans:
A Feedback: The initial reaction to a potentially stressful situation is appraisal. Appraisal is the process of interpreting a situation and determining if it is stress.
16. The patient asks the patient to explain stress and its effect on the body. Which of the following will the nurse include? Select all that apply. A) Stress begins in children at about age two.
B)
All stress has a negative effect on the human body in some form.
C)
Stress begins in utero.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Stress is ever-present.
E)
Some forms of stress are positive events.
Ans:
C, D, E
790
Feedback: Stress is part of our lives from the time we are developing in utero through death. Stress is an ever-present component of our physical and social environments. Although stress predominately has a negative overtone, it can be a positive experience as well. Good stress, or eustress, is when a sense of accomplishment or even exhilaration is felt with overcoming a challenge or obstacle.
17. During an interview, the patient states, When my stress is really high, I have diarrhea. The physiologic response affects
A)
Adequacy of sleep
B)
Nutritional status
C)
Gastrointestinal status
D)
Heart rate
Ans:
C
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
791
Feedback: Because the physiologic response to stress is an activation or arousal response, the nurse should ask about fatigue, adequacy of sleep, level of physical activity, and bowel elimination patterns.
18. Which of the following statements, made by a senior citizen who has taken a class on stress reduction, would indicate to the nurse the need for further instruction? A) Adults draw on coping skills learned throughout life.
B)
Family members can be supportive during stress.
C)
Stress may be positive or negative.
D)
As one grows older, their stress decreases.
Ans:
D Feedback: As a person ages, stress does not decrease; in fact, some people experience increased stressors associated with commonly encountered circumstances, such as experiencing empty-nest syndrome or dealing with the death of family and friends.
19. An example of long-term coping strategy is
A)
Crying to release tension after a stressful event
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Indulging in a rich desert after a stressful day
C)
Walking briskly three times a week for 20 minutes
D)
Taking a stick and banging it on a tree
Ans:
C
792
Feedback: Long-term coping mechanisms are positive, constructive ways of dealing with stress, and can be effective over long periods. 20. Which of the following actions demonstrates a coping mechanism to deal with anxiety produced by a very demanding, yet well-paying job?
A)
Accepting understanding and sympathy from others
B)
Expressing an opinion to the manager about the job
C)
Taking a daily walk in the neighborhood park
D)
Applying for a less demanding job
Ans:
D Feedback:
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
793
The person may respond by limiting his or her emotional response, taking direct action to solve a problem, or using defense mechanisms. 21. A young woman who has just started college is 6 weeks into the semester and has several tests and assignments due in approximately 3 days. She has developed a sore throat and fever. The development of illness is related to
A)
Immunosuppression with stress
B)
Exposure to streptococcus
C)
Decreased energy
D)
Sleep deprivation
Ans:
A Feedback: Chronic stress is associated with immunosuppression.
22. To assess the coping abilities of a first-time mother who expresses concern to the nurse about feeling overwhelmed by the needs of her newborn, the nurse should ask the patient about her
A)
Past experiences with childcare
B)
Interpretation of events
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Nutritional patterns
D)
Exercise patterns
Ans:
B
794
Feedback: Knowing the nature of potential stressors provides the means of anticipating problems and their related psychological reactions. The extent of activation of physiologic responses and subsequent recovery to daily hassles is important to a persons health because accumulated allostatic responses may adversely affect the body.
23. A middle-aged womans father has passed away, and her mother requires physical and emotional help due to disabilities. The woman is married and raising two children, along with working full time. All of the factors described are
A)
Stressors
B)
Stimuli
C)
Illnesses
D)
Demands
Ans:
A Feedback:
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
795
Stress is defined as any event or set of events, a stressor, that causes a response. Everyday triggers associated with work or social relationships, and uncommon events such as natural disasters, physical trauma, injuries, illnesses, divorce, death of a loved one, or loss of a job are commonly recognized stressors.
24. During the stress response in human beings, the primary hormone secreted by the adrenal cortex is
A)
Cortisol
B)
Insulin
C)
Epinephrine
D)
Thyroxin
Ans:
A Feedback: Cortisol is the main glucocorticoid hormone from the adrenal cortex. Cortisol affects glucose metabolism, which is necessary for increased energy expenditure.
25.In human beings, the physiologic response to a stressor includes the
A)
Sympathetic nervous system slowing the heart rate
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Hypothalamus secreting adrenocorticotropic hormone
C)
Hypothalamus secreting thyroid-stimulating hormone
D)
Epinephrine increasing the blood-glucose level
Ans:
D
796
Feedback: Homeostasis in physiologic systems is maintained within a narrow range around a set point through continual changes in internal processes. Adjustments in heart rate, blood pressure, body temperature, fluid and electrolyte balance, blood glucose concentration, and blood oxygen level occur automatically to maintain proper system functioning and survival.
26. A high school student comes to the nurses office to discuss her anxiety regarding an upcoming test. Her test-taking anxiety is a(an)
A)
Concern
B)
Stressor
C)
Threat
D)
Adjustment
Ans:
B
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
797
Feedback: Stress, coping, and adaptation are interrelated. Survival depends upon successful coping responses to ordinary and sometimes extraordinary circumstances and challenges.
27. An adolescent entering high school voices anxiety over changing schools. Stating anxiety is an act of
A)
Adaptation
B)
Evaluation
C)
Reaction
D)
Valuation
Ans:
A Feedback: Adaptation is generally considered a persons capacity to flourish and survive, even with diversity.
28. A patient is using prayer to assist in relieving stress. The use of prayer allows the patient to A)
Cope
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Understand
C)
Plan
D)
Recover
Ans:
A
798
Feedback: The ability to cope is a crucial element that influences well-being.
Chapter 42- Loss and Grieving
1.
The nurse is caring for a patient who is dying. She overhears the patient saying, God, if you will only let me live to see my daughter get married, I promise I will start going to church again. The nurse understands that the patient is in which stage of grief according to Kubler-Ross?
A)
Denial
B)
Bargaining
C)
Depression D) Anger
E)
Acceptance
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
Ans:
799
B Feedback:
Kubler-Ross proposed five stages of grief: (a) denial, (b) anger, (c) bargaining, (d) depression, and (e) acceptance. Denial may range from complete denial of the illness and impending death to denial of the effect that dying will have on self and others. In the second stage, anger may be directed toward fate, God, family members, healthcare providers, or others. Bargaining occurs as the patient seeks to delay the dreaded event; the patient bargains with God for more time and, in return, promises to do something to repay God for this favor. Depression occurs when the patient acknowledges the reality and inevitability of the impending death. In the final stage, acceptance, the patient comes to terms with the loss, begins to detach from supportive people, and loses interest in worldly activities.
2. The nurse is preparing a presentation on preparing children for death. What information should the nurse include? Select all that apply.
A)
Encourage forgetting of the deceased
B)
Encourage expression of feelings
C)
Provide for stability and safety
D)
Praise stoicism
E)
Talk openly about death and the feelings associated with it
Ans:
B, C, E
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
800
Feedback: In preparing children for death, encourage expression of feelings, provide for stability and safety, and talk openly about death.. Dont praise stoicism, encourage forgetting of the deceased, or force the child to participate in mourning rituals. 3.
A nurse is caring for a patient whose husband died over four years ago. The nurse suspects that the patient has abnormal grief. Which of the assessment findings would support this?
A)
Talking about her husband as if he were still alive
B)
Keeping photos of her husband on her bedside table
C)
Talking and laughing about the time when he forgot their anniversary
D)
Crying on the anniversary of his death
Ans:
A Feedback: Abnormal grief responses if present beyond 3 years include leaving the deceaseds room and belongings intact, reporting physical symptoms similar to those the deceased had before death, and talking about the deceased as if they were still alive.
4.
My father has been dead for over a year and my mother still cant talk about him without crying. Is that normal? What is the best response by the nurse?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
801
A)
The inability to talk about your dad without crying, even after a year, is still considered normal.
B)
It is not normal. Your mother needs to see a therapist about her grief.
C)
Everyone deals with loss differently. You just need to be patient with your mother.
D)
Did your mother cry a lot before your father died?
Ans:
A Feedback: Normal responses to bereavement after 1 year include the inability to speak of the deceased without intense emotion, clinical signs of depression, and feelings of meaningless.
5. When reviewing a patients chart, the nurse notes that the patient is in the disorganization stage of grief. Which assessment finding would support this diagnosis?
A)
It doesnt matter what I look like.
B)
I havent let my children out of my sight. I am afraid something will happen to them.
C)
I had a good time at my class reunion. It was nice to be out with other people again.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
Im sick all of the time. I just cant get rid of this cold.
Ans:
D
802
Feedback: In the protest stage of grief the patient may exhibit preoccupation with thoughts of the deceased, searching for the deceased, dreams/nightmares, hallucinations, and concerns about others health and safety. In the shock stage the patient may exhibit slowed and disorganized thinking, blocking of thoughts, neglect of appearance, and wishes to join the deceased. In the disorganization stage of grief the patient may exhibit difficulty making decisions, aimlessness, decreased resistance to illness, and loss of interest in people, work, and usual activities. In the reorganization stage of grief the patient may exhibit a realistic memory of the deceased, be comfortable when remembering the deceased and return to previous level of ability. 6.
The hospice nurse is visiting the wife of a patient who died 10 months ago. The wife states, My life is meaningless since my husband died. The nurse recognizes that the patient is in which stage of grief?
A)
Shock
B)
Protest
C)
Disorganization
D)
Reorganization
Ans:
C
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
803
Feedback: In the protest stage of grief the patient may exhibit preoccupation with thoughts of the deceased, searching for the deceased, dreams/nightmares, hallucinations, and concerns about others health and safety. In the shock stage the patient may exhibit slowed and disorganized thinking, blocking of thoughts, and wishes to join the deceased. In the disorganization stage of grief the patient may exhibit difficulty making decisions, aimlessness, and loss of interest in people, work, and usual activities. In the reorganization stage of grief, the patient may exhibit a realistic memory of the deceased, be comfortable when remembering the deceased and return to previous level of ability. 7.
The wife of a recently deceased patient states that she cant think of anything other than her husband. She wakes up at night and goes to look for him before realizing that he is dead. The nurse understands that the wife is in which stage of grief?
A)
Shock
B)
Protest
C)
Disorganization
D)
Reorganization
Ans:
B Feedback:
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
804
In the protest stage of grief, the patient may exhibit preoccupation with thoughts of the deceased, searching for the deceased, dreams/nightmares, hallucinations, and concerns about others health and safety. In the shock stage, the patient may exhibit slowed and disorganized thinking, blocking of thoughts, and wishes to join the deceased. In the disorganization stage of grief the patient may exhibit difficulty making decisions, aimlessness, and loss of interest in people, work, and usual activities. In the reorganization stage of grief the patient may exhibit a realistic memory of the deceased, be comfortable when remembering the deceased, and return to previous level of ability.
8. The nurse is preparing the body of a patient who was killed in a car accident for the family to view. Which of the following steps would be contraindicated ? A) Removal of all IVs and other medical tubing.
B)
Clean, position, and cover the patient with a sheet, exposing only the head and a hand.
C)
Inform the family that they can have as much time alone with the patient as they wish.
D)
Respect all religious and cultural practices of the family.
Ans:
A Feedback: In an effort to limit exposure to the disturbing sight of equipment and medical supplies, the nurse should, if possible, remove unneeded items and clean, position, and cover the patient. However, under some circumstances (such as an unexpected death), intravenous and other lines
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
805
and tubes should not be removed, as the body may need to be examined by a medical examiner. Having time alone with the patient is an important step for some families, whereas others appreciate the presence of a nurse, a spiritual leader, or friends. Religious and cultural beliefs and customs should be observed as much as possible.
9. A nurse has just finished a presentation on hospice and palliative care. Which statement by a participant would indicate a need for further education?
A)
Palliative care provides pain relief and other distressing symptoms.
B)
Hospice care programs focus on quality rather than length of life.
C)
In hospice care, the nurses make most of the care decisions for the patients.
D)
Hospice focuses on treatments and care aimed only at relieving symptoms in the last few months of life
E)
Palliative care affirms life and regards dying as a normal process.
Ans:
C
Feedback: The philosophy of hospice is that patients and families are empowered to achieve as much control over their lives as possible. Hospice focuses on relieving symptoms and supporting patients with a life expectancy of six months or less, rather than years, and their families. However, palliative care may be given at any time during a patients illness, from diagnosis to end of life.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
806
10. The nurse is preparing a care plan for a patient with the nursing diagnosis of Dysfunctional Grieving. Which of the following nursing interventions should the nurse include? Select all that apply.
A)
Provide the patient with information regarding a grief support group.
B)
Encourage the patient to have regular check-ups with their healthcare provider.
C)
Avoid talking about the loss if it upsets the patient.
D)
Refer the patient to a grief specialist.
E)
Encourage the patient to talk about only the positives of the deceased person.
Ans:
A, B, D Feedback: Encourage the mourner to remember and talk about both negative and positive memories of the deceased. Encourage patients to continue contact with their primary healthcare provider (physician or nurse) as well, because the grief process often decreases resistance to disease and exacerbates existing illnesses. Support groups and grief specialists can offer additional support to the patient.
11. The hospice nurse is assessing the wife of a patient who died 14 months ago. The nurse is concerned that the wife is still grieving the death of her husband. Which of the following objective assessment findings would suggest that the wife is NOT still grieving?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Stating, I think about him all of the time.
B)
Weight loss of 40 pounds in the last 14 months
C)
Stating, I cant go on living like this.
D)
Hair is clean and styled.
Ans:
D
807
Feedback: Many of the subjective manifestations of grief have concomitant objective manifestations: Dejected physical appearance, slowed motor function, weeping, outbursts of anger, emotional blunting, unkempt appearance, sleep, appetite disturbance (excessive weight loss or gain). Direct quotes are subjective data.
12. A nursing instructor has finished presenting information to a group of nursing students on the factors that influence the grieving process. Which statement by a student would indicate a need for further education?
A)
The age of the person who died can dramatically affect the grieving process.
B)
A death that occurs as a result of homicide or suicide is just as stressful as a death from natural causes.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
808
C)
Some people find strength in dealing with loss through their religious beliefs, whereas others experience greater distress due to their beliefs.
D)
Absence of social supports can create additional stressors for the grieving person.
Ans:
B Feedback: Many factors influence the grieving process, including the meaning of the loss to the individual, the circumstances of the loss, personal resources and stressors, and sociocultural resources and stressors.
13. The hospice nurse is caring for a patient with lung cancer. The patients daughter states, My mom isnt happy with anything I do for her. She is constantly yelling at me. The nurse understands that the patient is in which stage of grief according to Kbler-Ross?
A)
Depression
B)
Anger
C)
Acceptance
D)
Bargaining
E)
Denial
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
Ans:
809
B
Feedback: Kbler-Ross proposed five stages of grief: (a) denial, (b) anger, (c) bargaining, (d) depression, and (e) acceptance. Denial may range from complete denial of the illness and impending death to denial of the effect that dying will have on self and others. In the second stage, anger may be directed toward fate, God, family members, healthcare providers, or others. Bargaining occurs as the patient seeks to delay the dreaded event; the patient bargains with God for more time and, in return, promises to do something to repay God for this favor. Depression occurs when the patient acknowledges the reality and inevitability of the impending death. In the final stage, acceptance, the patient comes to terms with the loss, begins to detach from supportive people, and loses interest in worldly activities.
14. An appropriate nursing diagnosis for the family of a patient dying of cancer whose members have expressed sorrow over the forthcoming loss would be
A)
Anticipatory grieving related to the loss of family member as evidenced by sorrow
B)
Dysfunctional grieving related to the loss of family member as manifested by behaviors indicating anxiety
C)
Potential for grieving related to the loss of family member and sorrow
D)
Dysfunctional grieving related to the future loss of family member manifested by the familys developmental regression
Ans:
A
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
810
Feedback: Anticipatory grieving comprises the intellectual and emotional responses and behaviors by which individuals, families, and communities work through the process of modifying self-concept based on the perception of loss.
15. A widow develops cancer within 6 months of her husbands death. This may be a result of
A)
Social isolation
B)
Alcohol intake
C)
Bereavement
D)
Multiple losses
Ans:
C Feedback: Physical health and psychosocial adjustment are intricately intertwined. The bereaved are known to be at greater risk for mortality and morbidity than are comparable nonbereaved people.
16. Which of the following manifestations of grief by the patient who lost his wife 3 years earlier is considered abnormal?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Showing a photograph of the decedent
B)
Talking about his wifes absent-mindedness
C)
Telling the nurse how his life has changed
D)
Leaving the wifes room and belongings intact
Ans:
D
811
Feedback: Bereavement experts reported that they considered almost all bereavement manifestations to be normal during the early stages of grief but considered most of the manifestations to be abnormal if they continue beyond 3 years.
17. To adequately assist a patient and family from a different culture with the death and dying process, the nurse must
A)
Understand the patients cultural beliefs
B)
Progress through the stages of grief
C)
Experience death in his own life
D)
Have felt distress and anger
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
Ans:
812
A Feedback: Nurses should gain knowledge of the specific cultural and religious beliefs of the patients they are serving and help their patients deal with loss in a manner that is congruent with their cultural and religious beliefs and practices.
18. Which of the following statements about grief should the nurse include in the teaching plan developed to address a group of young adults?
A)
Individuals from lower socioeconomic classes tend to have a better outcome about loss.
B)
Nutrition and wellness have little effect on the outcome of grief.
C)
A familys developmental state does not affect the grief process.
D)
Multiple losses may strain the individuals ability to cope effectively.
Ans:
D Feedback: Young adults often experience many losses within a short period of time, which places them particularly at risk for poor outcomes. These multiple losses, coupled with their inexperience with loss and grief, make them particularly at risk.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
813
19. Which of the following statements regarding perceptions of death by children is accurate?
A)
Toddlers perceive death as irreversible and unnatural.
B)
Preschool-age children view death as a spiritual release.
C)
At age 9, the child perceives death as irreversible.
D)
Adolescents tend to respond better than adults with death.
Ans:
C Feedback: At about 9 years of age, the childs concept of death matures, and the child perceives death realistically as irreversible, universal, inevitable, and natural.
20.A pediatric nurse recognizes that preschoolers think of death as
A)
A long sleep
B)
Irreversible
C)
Inevitable
D)
Natural
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
Ans:
814
A Feedback: Preschoolers think of death as a long sleep.
21. A widower who continues to improve his level of functioning higher than before the loss is best described at which stage of the Grief Cycle Model?
A)
Shock
B)
Protest
C)
Disorganization
D)
Reorganization
Ans:
D Feedback: People who have sufficient resources during this period are likely to continue to improve their level of functioning and often emerge from the grief cycle at a higher level of functioning than before the loss.
22. Which of the following stages of grieving is displayed by a woman who appears depressed and withdrawn?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Shock
B)
Protest
C)
Disorganization
D)
Reorganization
Ans:
C
815
Feedback: The disorganization stage is characterized by severe depression, social withdrawal, and lack of interest in people and activities.
23. In the Parkes Model, a person uses denial as a psychological defense in the stage of
A)
Numbness
B)
Yearning
C)
Disorganization
D)
Reorganization
Ans:
A
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
816
Feedback: In the numbness stage, which is usually brief, trauma so overwhelms the bereaved survivor that he or she must use denial as a psychological defense. 24. A widow has just returned home from the funeral of her husband. She feels alone in her home. Her family has left to go back to their home in another area of the country. What stage of Engels model does this represent?
A)
Shock and disbelief
B)
Developing awareness
C)
Restitution
D)
Resolving the grief
Ans:
B Feedback: Developing awareness occurs as the reality and meaning of the loss penetrate the persons consciousness.
25. Which of the following stages of grieving is exhibited by the husband of a victim of sudden death who refuses to accept that she is dead?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Shock
B)
Protest
C)
Depression
D)
Doubt
Ans:
A
817
Feedback: In the shock and disbelief stage, the survivor either refuses to accept the loss or shows intellectual acceptance of the loss but denies the emotional impact.
26. The term bereavement is best defined as a
A)
Psychological response to a loss
B)
Socially conventional behavior after a loss
C)
Period of time after a loss of a loved one
D)
State of desolation that occurs after a loss
Ans:
D
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
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Feedback: Bereavement is a state of desolation that occurs as the result of a loss, particularly the death of a significant other.
27. A middle-age woman is mentally preparing for the death of her mother. This is termed
A)
Grieving
B)
Anticipatory grieving
C)
Bereavement
D)
Loss
Ans:
B Feedback: Anticipatory grief is the characteristic pattern of psychological and physiologic responses a person makes to the impending loss (real or imagined) of a significant person, object, belief, or relationship.
28. The experience of parting with an object, person, belief, or relationship that one values is
A)
Loss
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Bereavement
C)
Grief
D)
Death
Ans:
A
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Feedback: Loss is defined as the experience of parting with an object, person, belief, or relationship that one values; the loss requires a reorganization of one or more aspects of the persons life.
Chapter 43- Spiritual Health
1.
The nurse is caring for a patient who states, No one can understand God. The nurse would document the patients spiritual belief as which of the following?
A)
Atheist
B)
Agnostic
C)
Theist
D)
Holistic
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
Ans:
820
B Feedback: Beliefs may range from atheism (denial of Gods existence) to agnosticism (belief that Gods reality is unknown and unknowable) to theism (belief that Gods reality is personal, without a body, perfect in all things, and creator and sustainer of the universe).
2.
The nurse is caring for a patient diagnosed with HIV 10 years ago. The patient states that her relationship with God has helped her survive this long. The nurse understands that spiritual well-being is a condition in which a person is at peace with which of the following? Select all that apply.
A)
God
B)
Self
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Community
D)
Environment
Ans:
A, B, C, D Feedback: Spiritual well-being is the condition in which a person is at peace with God, self, community, and environment.
3.
The nurse is assisting a patient with his meal selection for the next day. The patient states, I cant have meat tomorrow, its a Holy Day. The nurse recognizes that the patient is a member of which religious organization?
A)
Orthodox Jewish
B)
Reform Jewish
C)
Roman Catholic
D)
Islamic
Ans:
C Feedback:
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C) Roman Catholics observe fasting and abstinence from meat on certain Holy Days.
4.
The nurse is caring for a dying male patient who is Islamic. What
is the most appropriate action for the nurse after the patients death? A) Ensure that a male washes the patients body.
B)
Place the body on the floor to facilitate the souls journey.
C)
Ensure that no one is in the room when the patient dies.
D)
Ensure that someone performs the anointing of the sick sacrament prior to the patients death.
Ans:
A Feedback: Islamic beliefs about death are that the family should be with the dying person so they can read the Koran and pray. There are also special procedures for care of the body after death; men wash male bodies and women wash female bodies and perform a variety of other rituals. Hinduism beliefs include placing the body on the floor to facilitate the souls journey. The anointing of the sick sacrament is part of the Roman Catholic faith.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
823
5.
The nurse is caring for a Roman Catholic patient who is dying. Which of the following would be an appropriate action of the nurse?
A)
Contact a local priest to complete the anointing of the sick ritual.
B)
Contact a local priest to provide special care to the body after death.
After death, place the patients body on the floor to facilitate the souls
journey. D) Ensure that a person of the same sex as the deceased clean the body.
Ans:
A Feedback: Roman Catholics believe that people should have the anointing of the sick as well as the Eucharist and penance by a priest before death. There are no special care rituals for the body after death.
6. Using the FICA spiritual assessment tool, which would be an appropriate question for the C?
A)
Do you consider yourself a spiritual person?
B)
Do you attend a specific church?
C)
How do these concerns effect your health?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C) D)
Can I discuss your concerns with your family?
Ans:
B
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Feedback: In the FICA model, C is for community. Topics to ask about in this area would include whether the patient is actively involved with a church community and if she uses that community as support.
7.
Which of the following questions would be appropriate for the F in the FICA spiritual assessment tool?
A)
Do you consider yourself a spiritual person?
B)
Are you actively involved with a church community?
C)
Do you use your church family for support?
D)
How would you like me to address this issue in your healthcare?
Ans:
A Feedback: F is for questions of faith. Some examples of questions to ask would include the following: Do you consider yourself a spiritual person?
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
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What gives your life meaning? I represents the importance of this resource in the patients life. Assessment questions might include asking how often the patient attends worship services. Do your beliefs strongly influence your decisions with regards to your medical practices? C is for community. Are you actively involved with a church community, and do you use this as support? A is for the practitioner to address these concerns with the patient, such as to ask, how would you like me to address these issues in your healthcare?
8.
The nurse is preparing to complete a spiritual assessment of a patient. What step should the nurse complete first?
A)
Perform a self-assessment of their own spiritual beliefs
B)
Provide for privacy during the assessment
Determine if the patient would like any family members present during the assessment
D)
Ans:
Gather the needed paperwork for the assessment
A Feedback: Prior to assessment, nurses should be aware of their own spiritual condition. Acknowledging and recognizing select spiritual beliefs as personal will allow the nurse to discern and focus on the specific needs of the patient.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
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C) 9. The nurse is caring for a patient with a nursing diagnosis of Spiritual Distress. Which assessment finding would support this nursing diagnosis?
A)
Views illness as punishment
B)
Offers to forgive others
C)
Is nonjudgemental of others
D)
Accepts help from others
Ans:
A Feedback: Adaptive expressions of spiritual needs include offers to forgive others, is nonjudgemental, and accepts help from others. Maladaptive expressions include viewing illness as a punishment and not trusting others.
10. The nursing instructor has been discussing spirituality with a group of nursing students. Which statement by a student would indicate a need for further education? A) Spiritual beliefs and practices do not give strength when a person is in crisis.
B)
Spiritual beliefs and practices give healing strength and support.
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C)
A persons daily living habits can be guided by their spiritual beliefs.
D)
Spiritual beliefs can help give a person meaning in their life.
Ans:
A Feedback: Spiritual beliefs and habits can give meaning to life, illness, other crises, and death, contribute a sense of security for present and future, guide daily living habits, provide strength in meeting lifes crises, and give healing strength and support.
11. The nurse is caring for a patient who states, Why are you asking me all these questions about religion? There is no God. The nurse would document this belief as_______?
A)
Atheism
B)
Agnostic
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
C)
Theism
D)
Faith
Ans:
A
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Feedback: Atheism is the denial of Gods existence. Agnosticism is the belief that Gods reality is unknown and unknowable and theism is the belief that Gods reality is personal, without a body, perfect in all things, and creator and sustainer of the universe. Faith is the way that a person acts out beliefs in his or her life.
12. A question that would be appropriate for the E in the HOPE spiritual assessment tool would be?
A)
Do you have a living will?
B)
Do you want to experience a Catholic mass?
C)
Do you expect to go to heaven when you die?
D)
Do you want to end your drug addiction?
Ans:
A Feedback:
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
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In the HOPE spiritual assessment, the H addresses spiritual resources, such as hope, with direct focus on religion or spirituality. The O represents importance of organized religion in their lives. The P represents inquiry with regards to personal practices. The E is to remind the practitioner to work with the patient to discuss end-of-life issues, such as living wills.
13.
The nurse is caring for a patient who is recovering from a suicide
attempt. Which of the following nursing interventions would be inappropriate for this patient? A)
Utilize active listening techniques.
B)
Allow for expression of negative feelings.
C)
Implement all-new coping mechanisms.
D)
Include the patients family and friends.
Ans:
C Feedback: Active listening, expression of both positive and negative feelings and inclusion of family and friends builds trust, safety, and a sense of acceptance, love, and belonging. Building on past positive coping mechanisms enhances a sense of selfcontrol and self-esteem.
14. When a 76-year-old patient diagnosed with terminal cancer expresses hopelessness and despair to the nurse, the nurse should
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Notify the physician
B)
Contact the religious leader at his church
C)
Encourage him to think positively
D)
Listen empathetically and attentively
Ans:
D
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Feedback: As with other age groups, listening and support are essential as patients deal with healthillness.
15.Children who are hospitalized may view hospitalization as
A)
The work of the devil
B)
Punishment for wrongdoing
C)
A lack of faith in God
D)
Poor parental bonding
Ans:
B
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
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Feedback: Young children are very sensitive to goodbad issues. Do not tell them that painful or scary treatments are in any way a punishment.
16. Which of the following food groups would be appropriate to suggest to a patient who practices tenets of the Islamic faith?
A)
Salad with crumbled bacon and cheese with a cup of tea
B)
Barbecued pork sandwich with a milkshake
C)
Sliced ham and cheese sandwich and 2% milk
D)
Broiled chicken sandwich with skimmed milk
Ans:
D Feedback: Members of the Islamic faith are forbidden to eat pork or drink alcohol.
17. An appropriate goal for the patient with a nursing diagnosis of spiritual distress related to intense pain and suffering as verbalized by the patient would be that the patient will
A)
Express feelings of anger and despair to God
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
B)
Have a minister meet with the patient daily
C)
Reflect on past accomplishments in life
D)
Participate in supportive spiritual practices
Ans:
D
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Feedback: The goal for the patient should focus on supporting the patients strengths.
18. To obtain subjective data related to a 16-year-old patients spirituality, the nurse should
A)
Ask the patients parents if the patient attends services
B)
Observe whether the patient reads religious material
C)
Ask the patient if religion or a higher being is significant
D)
Document the number of times a minister visits
Ans:
C Feedback:
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
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In a spiritual assessment, the nurse may ask if religion or God is significant to the patient.
19. An appropriate nursing diagnosis for a bedridden hospitalized patient who tells the nurse that he has not missed a Methodist church service in 50 years would be
A)
Spiritual distress related to inability to attend church services evidenced by verbal states of guilt
B)
Spiritual need as evidenced by verbalizations and distress at missing Methodist church services
C)
Dysfunctional grieving related to inability to attend church services as a result of his medical condition
D)
Potential for enhanced spiritual well-being related to distress at missing Methodist church services
Ans:
A Feedback: Persons suffering spiritual dysfunction or distress may verbalize such distress or express a need for help.
20.Individuals who are Christian Scientists may not approve of
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Expensive treatments
B)
Circumcisions
C)
Contraception
D)
Immunizations
Ans:
D
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Feedback: Some groups, such as Christian Scientists and the Amish, have been legally exempted from immunizations; however, many medical decisions are reviewed on a case-by-case basis depending on the patients age and imminence of death.
21. An 80-year-old woman does not believe certain religions should allow gay marriage. However, her grandchildren support this view. The grandmother is experiencing
A)
Moral dilemma
B)
Conjunctive faith
C)
Value clarification
D)
Unethical behavior.
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
Ans:
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B Feedback: Older adults notice the polarities or extremes in life such as young and old, rich and poor, masculine and feminine, constructive and destructive, and self-awareness and self-denial. These tensions, enhanced or precipitated by personal and environmental situations, demand integration and resolution. This is referred to as conjunctive faith.
22. When discussing spirituality with the mother of an 8-year-old child, the nurse instructs the mother that children of this age A)
Enjoy lore and legends of religious groups
B)
Are influenced by their peer groups
C)
Are moved deeply by spirituality
D)
May question religious authority
Ans:
A Feedback: Childhood is the period when lore, legends, language, and symbols of a particular religious group are best presented.
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23. When providing care to the Native American culture, it is important to elicit help from the
A)
Spiritual healer
B)
Priestess
C)
Rabbi
D)
Preacher
Ans:
A Feedback: Shamans and spiritual healers are found among Native Americans and many Southeast Asian groups.
24. When the patient tells the nurse that she believes Gods reality is personal, and that God is the creator of all beings, the nurse determines the patient is expressing
A)
Faith
B)
Agnosticism
C)
Atheism
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
D)
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Theism Ans: D
Feedback: Theism is the belief that Gods reality is personal, without a body, perfect in all things, and creator and sustainer of the universe.
25.The best definition of a spiritual need is
A)
Universal belief in truth, justice, and compassion
B)
Expression of a persons inner being and meaning
C)
A quest to discover lifes meaning
D)
An affirmation of life, peace, and harmony
Ans:
B Feedback: A spiritual need represents a normal expression of a persons inner being that seeks meaning in all experiences and a dynamic relationship with self, others, and to the supreme other as the person defines it.
26. When a nurse asks himself or herself questions such as Why am I here?, the nurse is attempting to
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
A)
Develop the concepts of holism and integration
B)
Become a more spiritual being for other people
C)
Develop a philosophical base for clearer thinking
D)
Strive toward unity with the higher power
Ans:
C
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Feedback: In terms of spiritual care, your own background, family, culture, and religion are integral parts of interactions with patients. For this reason, taking a step back and examining your own spirituality, values, and beliefs is essential.
27. When a patient informs the nurse that he is a Jehovahs Witness, the nurse must recognize and validate that the patient will not accept
A)
Blood transfusions
B)
Traditional health practices
C)
Pain medication
D)
Disease causation from germs
Test Bank - Fundamentals of Nursing (9th Edition by Craven)
Ans:
A Feedback: Jehovahs Witnesses do not accept blood transfusions.
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