Test Bank for Kozier and Erbs Fundamentals of Nursing 11th Edition Berman Chapter 1 51| Updated Guide 2022. READY FOR DOWNLOAD
Kozier and Erbs Fundamentals of Nursing 11th Edition Berman Test Bank Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 1 Historical and Contemporary Nursing Practice 1) The nurse is reviewing historic events in nursing for a presentation to be provided to new nursing students. In which chronological order should the nurse present these events? Begin with the earliest (1) and end with the most recent (5). 1. The Order of Deaconesses opens a small hospital in Kaiserswerth, Germany 2. The Knights of St. Lazarus dedicate themselves to the care of people with leprosy, syphilis, and chronic skin conditions. 3. During the American Civil War (1861-1865), Harriet Tubman administered to the care of slaves and injured soldiers. 4. World War II casualties created an acute shortage of care, and the Cadet Nurse Corps was established in response to the shortage of nurses. 5. During the Crimean War (1854-1856), Ms. Nightingale transformed the military hospitals by setting up sanitation practices., Answer: 2, 1, 5, 3, 4 Explanation: 1. In 1836, Theodore Fliedner reinstituted the Order of Deaconesses and opened a small hospital and training school in Kaiserswerth, Germany, where Florence Nightingale received her training. 2. Religion played a significant role in the development of nursing. The crusades saw the formation of several orders of knights who provided care to the sick and injured, including the Knights of St. Lazarus. 3. During the American Civil War (1861-1865), Harriet Tubman administered to the care of slaves and injured soldiers. 4. World War II casualties created an acute shortage of care, and the Cadet Nurse Corps was established in response to the shortage of nurses. 5. During the Crimean War (1854-1856), Ms. Nightingale transformed the military hospitals by setting up sanitation practices. Page Ref: 4-6 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. C. 3. Value the perspectives and expertise of all health team members | AACN Essential Competencies: I. 9. Value the ideal of lifelong learning to support excellence in nursing practice | NLN Competencies: Knowledge and Science; Knowledge; Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1. Discuss historical factors and nursing leaders, female and male, who influenced the development of nursing. MNL Learning Outcome: 1. Recognize how historical factors and leaders influenced the development of contemporary nursing practice.
2) The nurse is caring for a nurse who provided care to soldiers during the Vietnam War. What information in this patient's history should the nurse use to understand the patient's nursing career? 1. The patient was still a student when serving in the war. 2. The patient decided to leave the profession after serving in the war. 3. The patient's first patient care experiences were during a time of war. 4. The patient contracted long-term illnesses from being overseas in a war. Answer: 3 Explanation: During the Vietnam War, approximately 11,000 American military women stationed in Vietnam were nurses. Most of them volunteered to go to Vietnam right after they graduated from nursing school, making them the youngest group of medical personnel ever to serve in wartime. The patient was not a student when serving in the war. There is no evidence that the patient left the profession after the war or contracted long-term illnesses from being overseas during a wary. Page Ref: 6 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. C. 3. Value the perspectives and expertise of all health team members | AACN Essential Competencies: I. 9. Value the ideal of lifelong learning to support excellence in nursing practice | NLN Competencies: Knowledge and Science; Knowledge; Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Discuss historical factors and nursing leaders, female and male, who influenced the development of nursing. MNL Learning Outcome: 1. Recognize how historical factors and leaders influenced the development of contemporary nursing practice.
3) The nurse is reviewing public health and health promotion roles available for nurses. To which leader should the nurse attribute the development of these roles? 1. Clara Barton 2. Lillian Wald 3. Mary Brewster 4. Florence Nightingale Answer: 4 Explanation: Florence Nightingale's vision of nursing included public health and health promotion roles for nurses, but it was only partly addressed in the early days of nursing. Her focus tended to be on developing the profession within the hospitals. Clara Barton is noted for establishing the American Red Cross. She persuaded Congress to ratify the Treaty of Geneva in 1882 so that the Red Cross could perform humanitarian efforts in times of peace. Lillian Wald is considered the founder of public health nursing. She and Mary Brewster were the first to offer trained nursing services to the poor in the New York slums and developed the Visiting Nurse Service, along with the Henry Street Settlement. Page Ref: 7-8 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. C. 3. Value the perspectives and expertise of all health team members | AACN Essential Competencies: I. 9. Value the ideal of lifelong learning to support excellence in nursing practice | NLN Competencies: Knowledge and Science; Knowledge; Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Discuss historical factors and nursing leaders, female and male, who influenced the development of nursing. MNL Learning Outcome: 1. Recognize how historical factors and leaders influenced the development of contemporary nursing practice.
4) The nurse has been asked to participate on the hospital's Shared Governance Committee. To which nurse leader should the nurse attribute the ability for nurses to control the profession? 1. Mary Breckinridge 2. Lavinia Dock 3. Virginia Henderson 4. Margaret Higgins Sanger Answer: 2 Explanation: Lavinia Dock was a feminist, writer, and activist. She participated in protest movements for women's rights that resulted in passage of the 19th Amendment, which allowed women the right to vote. In addition, Dock campaigned for legislation to allow nurses, rather than physicians, to control their profession. Mary Breckinridge established the Frontier Nursing Service. Margaret Higgins Sanger is considered the founder of Planned Parenthood. Page Ref: 9 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. C. 3. Value the perspectives and expertise of all health team members | AACN Essential Competencies: I. 9. Value the ideal of lifelong learning to support excellence in nursing practice | NLN Competencies: Knowledge and Science; Knowledge; Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 1. Discuss historical factors and nursing leaders, female and male, who influenced the development of nursing. MNL Learning Outcome: 1. Recognize how historical factors and leaders influenced the development of contemporary nursing practice.
5) While conducting a health assessment, the individual asks why the term patient is being used. What should the nurse explain about the implication of the term patient? 1. The person is seeking assistance because of illness. 2. The individual is proactive in his or her healthcare needs. 3. The person is a collaborator in his or her care. 4. The individual is using a service or commodity. Answer: 1 Explanation: The word patient comes from a Latin word meaning "to suffer" or "to bear." Usually, people become patients when they seek assistance because of illness or for surgery. Some nurses believe that the word patient implies passive acceptance of the decisions and care of health professionals, which would be opposite of being proactive in one's healthcare needs. The term client presents the recipient of healthcare as a collaborator in that care, along with the people who are providing service. A consumer is an individual, a group of people, or a community that uses a service or commodity. Page Ref: 15 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. C. 3. Value the perspectives and expertise of all health team members | AACN Essential Competencies: I. 9. Value the ideal of lifelong learning to support excellence in nursing practice | NLN Competencies: Relationship Centered Care; PracticeKnow-How; Learn continuously, learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Describe how the definition of nursing has evolved since Florence Nightingale. MNL Learning Outcome: 3. Recognize the components that make up professional nursing practice.
6) The nurse is creating a community education program on health promotion and wellness. Which topic should the nurse use for this program? 1. Prenatal and infant care 2. Prevention of sexually transmitted infections 3. Exercise class for clients who have had a stroke 4. Home accident prevention Answer: 4 Explanation: Wellness is a process that engages in activities and behaviors that enhance quality of life and maximize personal potential. This involves individual and community activities to enhance healthy lifestyles, such as improving nutrition and physical fitness, preventing drug and alcohol misuse, restricting smoking, and preventing accidents in the home and workplace. The goal of illness prevention is to maintain optimal health by preventing disease, which would include immunization, prenatal and infant care, and prevention of sexually transmitted infections. Teaching clients about recovery activities, such as exercises that accelerate recovery after a stroke, would focus on health restoration. Page Ref: 15 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice; Apply health promotion/disease prevention strategies; Apply health policy | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Identify the four major areas of nursing practice. MNL Learning Outcome: 3. Recognize the components that make up professional nursing practice.
7) The nurse is measuring stool for occult blood during a community health fair. Which level of practice is the nurse providing? 1. Promoting health and wellness 2. Illness prevention 3. Restoring health 4. Rehabilitation Answer: 3 Explanation: Restoring health focuses on the ill client, and it extends from early detection (such as checking for occult blood in feces) through helping the client during the recovery period. Health promotion and wellness activities enhance the quality of life and maximize personal potential. Rehabilitation is an activity of health restoration. Page Ref: 15 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice; Apply health promotion/disease prevention strategies; Apply health policy | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Identify the four major areas of nursing practice. MNL Learning Outcome: 3. Recognize the components that make up professional nursing practice.
8) The nurse has started working in a state other than the one in which the nursing education program was located. Which should the nurse consult in order to understand the implications of this change of venue? 1. American Nurses Association (ANA) 2. National League for Nursing (NLN) 3. National Council of State Boards of Nursing (NCSBN) 4. Nurse State Practice Act Answer: 4 Explanation: Nurse practice acts regulate the practice of nursing in the United States and Canada. Each state and each province have its own act. Nurses are responsible for knowing their state's nurse practice act, as it governs their practice. The ANA is the professional organization of nursing, the NLN is responsible for accrediting schools of nursing, and the NCSBN handles licensure of professional nurses. Page Ref: 16 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. A. 2. Describe scopes of practice and roles of healthcare team members | AACN Essential Competencies: V. 5. Describe state and national statues, rules, and regulations that authorize and define professional nursing practice | NLN Competencies: Context and Environment; Knowledge; Scope of practice considerations | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Identify the purposes of nurse practice acts and standards of professional nursing practice. MNL Learning Outcome: 3. Recognize the components that make up professional nursing practice. 9) The nurse is orienting a graduate nurse to the care area. When should the nurse expect the graduate nurse's professional identity to be established? 1. During nursing school 2. Upon graduation from school 3. After passing the NCLEX examination 4. After practicing nursing for several years Answer: 1 Explanation: The development of professional identity begins during nursing education. It is not established after graduation from school, after passing the NCLEX examination, or after practicing nursing for several years. Page Ref: 20 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. A. 2. Describe scopes of practice and roles of healthcare team members | AACN Essential Competencies: V. 5. Describe state and national statues, rules, and regulations that authorize and define professional nursing practice | NLN Competencies: Knowledge; Code of Ethics; Regulatory and professional standards | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13. Discuss the criteria of a profession and professional identity formation. MNL Learning Outcome: 3. Recognize the components that make up professional nursing practice.
10) The nurse ensures that a patient is covered during a bath. In which role is the nurse functioning? 1. Caregiver 2. Communicator 3. Teacher 4. Client advocate Answer: 1 Explanation: The caregiver role includes those activities that assist the client physically and psychologically while preserving the client's dignity. As a communicator, the nurse identifies client problems, then communicates these verbally or in writing to other members of the health team. As a teacher, the nurse helps clients learn about their health and the healthcare procedures they need to perform to maintain or restore their health. A client advocate acts to protect clients and represents their needs and wishes to other health professionals. Page Ref: 17 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. A. 2. Describe scopes of practice and roles of healthcare team members | AACN Essential Competencies: V. 5. Describe state and national statues, rules, and regulations that authorize and define professional nursing practice | NLN Competencies: Context and Environment; Knowledge; Code of Ethics; Regulatory and professional standards | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11. Describe the roles of nurses. MNL Learning Outcome: 3. Recognize the components that make up professional nursing practice.
11) A client wishes to discontinue cancer treatment. If acting as the client advocate, which statement should the nurse make to the client's physician? 1. "The client is making his own decision." 2. "The client would benefit from additional information about treatment options." 3. "The family must be involved in this decision." 4. "Let's educate the family about the consequences of this decision." Answer: 1 Explanation: A client advocate acts to protect the client and may represent the client's needs and wishes to other health professionals, such as relaying the client's wishes for information to the physician. Providing additional information to the client about treatment options and bringing the family into the decision-making process would be examples of the nurse acting as teacher or counselor. Page Ref: 17 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: II. A. 2. Describe scopes of practice and roles of healthcare team members | AACN Essential Competencies: VI. 2. Use inter- and intra-professional communication and collaborative skills to deliver evidence-based, patient-centered care | NLN Competencies: Context and Environment; Knowledge; Principles of informed consent, confidentiality, patient self-determination | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11. Describe the roles of nurses. MNL Learning Outcome: 3. Recognize the components that make up professional nursing practice.
12) The nurse has accepted a position as a case manager. What should the nurse expect to perform when functioning in this role? 1. Managing a client's hospital stay 2. Delegating activities to other nurses 3. Evaluating the performance of ancillary workers 4. Identifying areas of client concern or problems Answer: 1 Explanation: The case manager oversees the care of a specific caseload or may act as the primary nurse to provide some level of direct care to the client and family. Responsibilities may vary from managing acute hospitalizations to managing high-cost clients or case types. Delegating activities to other nurses and evaluating the performance of ancillary workers are responsibilities of the nurse manager. Identifying areas of researchable problems would fall to the research consumer. Page Ref: 18 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. A. 2. Describe scopes of practice and roles of healthcare team members | AACN Essential Competencies: VII. 4. Use behavioral change techniques to promote health and manage illness | NLN Competencies: Context and Environment; Knowledge; Health promotion/disease prevention | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11. Describe the roles of nurses. MNL Learning Outcome: 3. Recognize the components that make up professional nursing practice.
13) The manager identifies that a nurse is practicing a professional identity. What did the manager observe to come to this conclusion? 1. Recognizing characteristics considered to be professional 2. Maintaining specific character and spirit 3. Learning about the influences of Florence Nightingale 4. Promising to uphold the standards of the profession Answer: 2 Explanation: Professional identity is a "sense of oneself that is influenced by characteristics, norms, and values of the nursing discipline, resulting in an individual thinking, acting, and feeling like a nurse." Florence Nightingale influenced nursing professionalism a great deal, but simply learning about her influence does not constitute a professional identity because a professional identity refers to a way of life. Professionalization is the process of becoming professional, which is acquiring characteristics considered to be professional and upholding the standards of a profession. Page Ref: 20 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. C. 5. Respect the unique attributes that members bring to a team, including variations in professional orientations and accountabilities | AACN Essential Competencies: VIII. 4. Demonstrate professionalism, including attention to appearance, demeanor, respect for self and others, and attention to professional boundaries with patients and families as well as among caregivers | NLN Competencies: Context and Environment; Practice; Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 13. Discuss the criteria of a profession and professional identity formation. MNL Learning Outcome: 3. Recognize the components that make up professional nursing practice.
14) The nurse is caring for several acutely ill patients. What nursing action demonstrates professional autonomy? 1. Delivering medications and prescribed treatments in a timely manner 2. Prioritizing client according to client needs 3. Communicating with peers when help is needed 4. Informing the supervisor about high acuity level and staff-to-client ratio Answer: 2 Explanation: Autonomy in nursing means independence at work, responsibility, and accountability for one's actions. Making decisions about which client requires care according to needs is an example of autonomy. Carrying out physician orders would be an example of nursing care, but not independence. Communication is important in any profession, as is making concerns known to supervisors, but these are not examples of controlling activity–a hallmark of autonomy. Page Ref: 19 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. C. 5. Respect the unique attributes that members bring to a team, including variations in professional orientations and accountabilities | AACN Essential Competencies: VIII. 4. Demonstrate professionalism, including attention to appearance, demeanor, respect for self and others, and attention to professional boundaries with patients and families as well as among caregivers | NLN Competencies: Context and Environment; Practice; Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 13. Discuss the criteria of a profession and professional identity formation. MNL Learning Outcome: 3. Recognize the components that make up professional nursing practice.
15) The student nurse contacts a number of other students to create a study group. What behavior is the student nurse demonstrating? 1. Governance 2. Professional identity 3. Service orientation 4. Specialized education Answer: 2 Explanation: The formation of a professional identity involves learning to behave, feel, and see the world in a manner similar to other persons occupying the same role. The goal is to instill in others the norms, values, attitudes, and behaviors deemed essential. One of the most powerful mechanisms of professional identity is interacting with fellow students and becoming bound together by feelings of mutual cooperation, support, and solidarity. Page Ref: 20 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. C. 5. Respect the unique attributes that members bring to a team, including variations in professional orientations and accountabilities | AACN Essential Competencies: VIII. 4. Demonstrate professionalism, including attention to appearance, demeanor, respect for self and others, and attention to professional boundaries with patients and families as well as among caregivers | NLN Competencies: Context and Environment; Practice; Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13. Discuss the criteria of a profession and professional identity formation. MNL Learning Outcome: 3. Recognize the components that make up professional nursing practice.
16) The nursing instructor is explaining the present economic challenges in healthcare to students in a community health course. What should the instructor emphasize as being important for the students to be aware of? 1. Continuation of the Affordable Care Act (ACA) 2. Consumer presence on the boards of nursing associations and regulatory agencies 3. Diagnostic-related groups (DRGs) 4. Advances in science and technology Answer: 1 Explanation: There have been many attempts to repeal the ACA, however, it is still in place. Other forces include consumer demands, family structure, and science and technology. DRGs are a classification system that categorically establishes pretreatment billing based on diagnosis. Although advances in science and technology affect nursing, it is not the underlying cause of more personnel being employed in community-based settings. Consumer presence on nursing associations and regulatory agencies does not cause an economic challenge to the healthcare industry. Page Ref: 21 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. A. 4. Recognize contributions of other individuals and groups in helping patient/family achieve health goals | AACN Essential Competencies: V. 6. Explore the impact of socio-cultural, economic, legal, and political factors influencing healthcare delivery and practice | NLN Competencies: Context and Environment; Knowledge; Health care systems | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15. Describe factors influencing contemporary nursing practice. MNL Learning Outcome: 4. Examine the factors that influence contemporary nursing practice.
17) The community health nurse is caring for adolescent mothers and their children. For what should the nurse assess these patients when determining their degree of vulnerability? 1. Distance separation from their nuclear families 2. Increased levels of poverty 3. Raising children without the support of family 4. The normal difficulties of adolescence Answer: 4 Explanation: Adolescent mothers have the normal needs of teenagers as well as those of new mothers, with motherhood compounding the difficulties of adolescence. Although many adolescent mothers are raising children alone, without the support of the baby's father or perhaps their own families, and many live in poverty, all are vulnerable because of their age. Page Ref: 22 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; Family dynamics | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12. Describe the expanded career roles of nurses and their functions. MNL Learning Outcome: 4. Examine the factors that influence contemporary nursing practice. 18) A client tells the nurse about research information on the Internet to learn more about a new health problem. What should the nurse respond to this client? 1. "Information from the Internet isn't always accurate." 2. "It's best to check this information with your physician." 3. "Bring your information to the clinic so we can go through it together." 4. "I'd prefer you rely on information you haven't received from our office." Answer: 3 Explanation: Nurses may need to interpret Internet sources of information to clients and their families. Although not all Internet-based information is accurate, some may be high quality and valid. Nurses need to become information brokers so they, not just the physician, can help clients access and evaluate information to determine its usefulness. Page Ref: 22 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: VI. A. 4. Describe examples of how technology and information management are related to the quality and safety of patient care | AACN Essential Competencies: IV. 6. Evaluate data from all relevant sources, including technology, to inform the delivery of care | NLN Competencies: Knowledge and Science; Knowledge; Electronic databases; literature retrieval; evaluating data for validity and reliability; evidence and best practices for nursing | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12. Describe the expanded career roles of nurses and their functions. MNL Learning Outcome: 4. Examine the factors that influence contemporary nursing practice.
19) The nurse practitioner is working with a staff nurse to change the plan of care for a client with a terminal illness. In which areas of nursing practice are these nurses functioning? 1. Promoting health and wellness 2. Preventing illness 3. Restoring health 4. Caring for the dying Answer: 4 Explanation: Caring for the dying involves comforting and caring for people of all ages who are dying. It includes helping clients be as comfortable as possible until death and helping support persons cope with death. Page Ref: 16 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs | AACN Essential Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Context and Environment; Ethical Comportment; Examine personal beliefs, values, and biases with regard to respect for persons, human dignity, equality, and justice; explore ideas of nurse caring and compassion | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9. Identify the four major areas of nursing practice. MNL Learning Outcome: 3. Recognize the components that make up professional nursing practice.
20) The nurse is scheduled to attend a continuing education program to learn about the latest urinary catheterization care. Which type of credential should the nurse expect to earn after attending this program? 1. None because this program is designed to enhance a skill 2. Advanced degree 3. Certification as a renal nurse 4. Credit hours toward an advanced degree Answer: 1 Explanation: The term continuing education (CE) refers to formalized experiences designed to enhance the knowledge or skills of practicing professionals. Compared to advanced educational programs, which result in an academic degree, CE courses tend to be more specific and shorter. Participants may receive certificates of completion or specialization. Page Ref: 14-15 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VIII. 13. Articulate the value of pursuing practice excellence, lifelong learning, and professional engagement to foster professional growth and development | NLN Competencies: Relationship Centered Care; Practice-Know-How; Learn continuously, learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7. Explain the importance of continuing nursing education. MNL Learning Outcome: 2. Differentiate between the types and purposes of programs involving nursing education. 21) The nurse is planning to apply to graduate school to earn a master's degree in nursing. On what should the nurse expect the program's curriculum to focus? 1. Case manager 2. Wound care specialist 3. An advanced leadership role 4. Intravenous therapy specialist Answer: 3 Explanation: The emphasis of master's degree programs is on preparing nurses for advanced leadership roles in administration, clinical, or teaching. This program would not focus on case management, wound care, or intravenous care. Page Ref: 13 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. B. 2. Initiate plan for self-development as a team member | AACN Essential Competencies: VIII. 13. Articulate the value of pursuing practice excellence, lifelong learning, and professional engagement to foster professional growth and development | NLN Competencies: Relationship Centered Care; Practice-Know-How; Learn continuously, learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3. Describe the different types of educational programs for nurses. MNL Learning Outcome: 2. Differentiate between the types and purposes of programs involving nursing education.
22) The staff nurse is considering membership in the National League for Nurses. What should the nurse expect as a member of this organization? 1. Members that are non-nurses 2. Assistance with getting into graduate school 3. Opportunities to be awarded scholarships 4. Assistance with finding employment Answer: 1 Explanation: The NLN is an organization of both individuals and agencies. Its objective is to foster the development and improvement of all nursing services and nursing education. People who are not nurses but have an interest in nursing services can be members of the league. Page Ref: 24 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. B. 2. Initiate plan for self-development as a team member | AACN Essential Competencies: VIII. 13. Articulate the value of pursuing practice excellence, lifelong learning, and professional engagement to foster professional growth and development | NLN Competencies: Relationship Centered Care; Practice-Know-How; Learn continuously, learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 16. Explain the functions of national and international nurses' associations. MNL Learning Outcome: 4. Examine the factors that influence contemporary nursing practice.
23) The nurse is consulting other professionals as well as educating, supporting, and managing a client's chemotherapy regimen. In which role is this nurse functioning? 1. Nurse educator 2. Nurse practitioner 3. Nurse entrepreneur 4. Clinical nurse specialist Answer: 4 Explanation: A clinical nurse specialist has an advanced degree or expertise and is considered to be an expert in a specialized area of practice (oncology in this case). The nurse provides direct client care, educates others, consults, conducts research, and manages care. A nurse practitioner has advanced education, is a graduate of a nurse practitioner program, and usually focuses on nonemergency acute or chronic illness and provides primary ambulatory care. The nurse educator is responsible for classroom and clinical teaching. A nurse entrepreneur usually has an advanced degree, manages a health-related business, and may be involved in education, consultation, or research. Page Ref: 18 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. B. 2. Initiate plan for self-development as a team member | AACN Essential Competencies: VIII. 13. Articulate the value of pursuing practice excellence, lifelong learning, and professional engagement to foster professional growth and development | NLN Competencies: Relationship Centered Care; Practice-Know-How; Learn continuously, learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Discuss the evolution of nursing education and entry into professional nursing practice. MNL Learning Outcome: 2. Differentiate between the types and purposes of programs involving nursing education.
24) A staff nurse is serving as a preceptor for nursing students. In which level of Benner's proficiency is this nurse practicing? 1. Stage II 2. Stage III 3. Stage IV 4. Stage V Answer: 3 Explanation: Stage IV is a proficiency stage. The person has 3 to 5 years of experience and has a holistic understanding of the client, which improves decision making and focuses on long-term goals. Stage II is advanced beginner. The person demonstrates marginally acceptable performance. Stage III is competent. The nurse has 2 or 3 years of experience and demonstrates organizational/planning abilities. Stage V is considered expert. Performance is fluid, flexible, and highly proficient. The expert nurse no longer requires rules, guidelines, or maxims to connect an understanding of the situation to appropriate action. This person has highly intuitive and analytic abilities in new situations. Page Ref: 20 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. B. 2. Initiate plan for self-development as a team member | AACN Essential Competencies: VIII. 13. Articulate the value of pursuing practice excellence, lifelong learning, and professional engagement to foster professional growth and development | NLN Competencies: Relationship Centered Care; Practice-Know-How; Learn continuously, learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 14. Discuss Benner's levels of nursing proficiency. MNL Learning Outcome: 3. Recognize the components that make up professional nursing practice.
25) The nurse is asked to define nursing. Which term should the nurse include in the response? (Select all that apply.) 1. Protection 2. Promotion 3. Prevention of illness 4. Advocacy 5. Physician focused Answer: 1, 2, 3, 4 Explanation: One term to define nursing is protection. One term to define nursing is promotion. Nursing focuses on the prevention of illness. One term to define nursing is advocacy. Page Ref: 15 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. C. 2. Appreciate importance of intra- and inter-professional collaboration | AACN Essential Competencies: VIII. 3. Promote the image of nursing by modeling the values and articulating the knowledge, skills, and attitudes of the nursing profession | NLN Competencies: Relationship Centered Care; Practice-Know-How; Learn continuously, learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Describe how the definition of nursing has evolved since Florence Nightingale. MNL Learning Outcome: 3. Recognize the components that make up professional nursing practice.
26) A faculty member is speaking to prospective students interested in enrolling in the BSN program at the university. What should the faculty member emphasize as a major incentive for students to select a BSN program over an ADN program? 1. Liberal arts education 2. Easier transition to graduate school 3. Ability to work in critical care areas 4. Better opportunity for career advancement Answer: 4 Explanation: The nurse who holds a baccalaureate degree enjoys greater autonomy, responsibility, participation in institutional decision making, and career advancement. A BSN program is not a liberal arts education, although liberal arts courses are a part of the program. This type of degree does not guarantee an easier transition into graduate school. The ability to work in a critical care area requires specialized training. Page Ref: 12 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. A. 2. Describe scopes of practice and roles of healthcare team members | AACN Essential Competencies: VIII. 3. Promote the image of nursing by modeling the values and articulating the knowledge, skills, and attitudes of the nursing profession | NLN Competencies: Relationship Centered Care; Practice-Know-How; Learn continuously, learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Discuss the evolution of nursing education and entry into professional nursing practice. MNL Learning Outcome: 2. Differentiate between the types and purposes of programs involving nursing education.
27) A high school graduate is considering entering a nursing program that offers a baccalaureate degree. What organization accreditation should the nurse use to help select a nursing program? 1. NLN (National League for Nursing) 2. NCLEX® (National Council Licensure Examination) 3. CCNE (Commission on Collegiate Nursing Education) 4. NCSBN (National Council of State Boards of Nursing) Answer: 3 Explanation: The CCNE accredits baccalaureate- and graduate-degree nursing programs. The NLN accredits nursing programs at all levels, including LVN and LPN. Both of these offer voluntary accreditation. The NCLEX® is the licensure examination administered by each state, and the NCSBN is the council to which all state boards of nursing belong. Page Ref: 11 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. B. 2. Initiate plan for self-development as a team member | AACN Essential Competencies: VIII. 13. Articulate the value of pursuing practice excellence, lifelong learning, and professional engagement to foster professional growth and development | NLN Competencies: Relationship Centered Care; Practice-Know-How; Learn continuously, learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Discuss the evolution of nursing education and entry into professional nursing practice. MNL Learning Outcome: 2. Differentiate between the types and purposes of programs involving nursing education.
28) The student nurse is reviewing the code of academic and clinical conduct prior to beginning a clinical assignment. On what area should the nurse focus when providing client care? (Select all that apply.) 1. Support lifelong learning. 2. Ensure the safety of all clients. 3. Maintain client confidentiality. 4. Provide care in a professional manner. 5. Collaborate with students and faculty. Answer: 2, 3, 4 Explanation: When providing care, the student nurse should focus on client safety. When providing care, the student nurse should focus on client confidentiality. When providing care, the student nurse should ensure professionalism. Page Ref: 20 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essential Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct | NLN Competencies: Context and Environment; Knowledge; Code of Ethics; Regulatory and professional standards | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Identify the purposes of nurse practice acts and standards of professional nursing practice. MNL Learning Outcome: 3. Recognize the components that make up professional nursing practice. 29) The nurse is interested in specializing in forensics. What should the nurse expect to learn prior to assuming the role of a forensics nurse? (Select all that apply.) 1. Knowledge about the legal system 2. Approaches to collecting evidence 3. Budgeting, staffing, and planning programs 4. Information necessary when providing testimony in court 5. Training in identification, evaluation, and documentation of injuries Answer: 1, 2, 4, 5 Page Ref: 18 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. B. 2. Initiate plan for self-development as a team member | AACN Essential Competencies: VIII. 13. Articulate the value of pursuing practice excellence, lifelong learning, and professional engagement to foster professional growth and development | NLN Competencies: Quality and Safety; Ethical Comportment; Engage in lifelong learning to keep professional knowledge current | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 12. Describe the expanded career roles of nurses and their functions. MNL Learning Outcome: 4. Examine the factors that influence contemporary nursing practice.
30) The nurse is considering a Doctor of Nursing Practice (DNP) degree. Which should the nurse expect to be a focus of this program? (Select all that apply.) 1. Research 2. Teaching 3. Systems leadership 4. Quality improvement 5. Evidence-based practice (EBP) Answer: 3, 4, 5 Explanation: The nurse who earns a DNP receives additional education in systems leadership. The nurse who earns a DNP receives additional education in quality improvement. The nurse who earns a DNP receives additional education in EBP. Page Ref: 13 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. B. 2. Initiate plan for self-development as a team member | AACN Essential Competencies: VIII. 13. Articulate the value of pursuing practice excellence, lifelong learning, and professional engagement to foster professional growth and development | NLN Competencies: Relationship Centered Care; Practice-Know-How; Learn continuously, learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3. Describe the different types of educational programs for nurses. MNL Learning Outcome: 2. Differentiate between the types and purposes of programs involving nursing education. 31) The nurse is enrolled in a course that is based upon scientific theory. Which should the nurse expect to be the purpose of research in this course? 1. Theory development 2. Perform a professional role 3. New possibilities for practice 4. Understand the impact of the role Answer: 1 Explanation: A course that focuses on scientific theory will have research and theory development as the central focus. A course on practice will focus on professional role development, new possibilities for practice, and understanding the impact of the role. Page Ref: 13 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. B. 2. Initiate plan for self-development as a team member | AACN Essential Competencies: VIII. 13. Articulate the value of pursuing practice excellence, lifelong learning, and professional engagement to foster professional growth and development | NLN Competencies: Relationship Centered Care; Practice-Know-How; Learn continuously, learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4. Describe the major purpose of theory in the sciences and practice disciplines. MNL Learning Outcome: 2. Differentiate between the types and purposes of programs involving nursing education.
32) The nurse enrolled in a Doctor of Nursing Practice (DNP) program is designing a research study as an expectation for graduation. Which should the nurse identify as a topic for this study? 1. Validity of a systems theory of health care 2. Application of a humanistic theory of nursing 3. Advantages of using a caring theory in nursing 4. Implementation of the role of DNP in community healthcare clinics Answer: 4 Explanation: In a practice discipline the practice disciplines, the main function of theory and research is to provide new possibilities for understanding the discipline's practice such as implementing the role of DNP into community clinics. Applying a theory, using a theory in practice, or validating a theory would promote theory development and not application to practice. Page Ref: 13 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. B. 2. Initiate plan for self-development as a team member | AACN Essential Competencies: VIII. 13. Articulate the value of pursuing practice excellence, lifelong learning, and professional engagement to foster professional growth and development | NLN Competencies: Relationship Centered Care; Practice-Know-How; Learn continuously, learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4. Describe the major purpose of theory in the sciences and practice disciplines. MNL Learning Outcome: 2. Differentiate between the types and purposes of programs involving nursing education.
33) The nurse is asked to explain the metaparadigm for nursing. Which characteristic should the nurse include in response? (Select all that apply.) 1. Health 2. Person 3. Nursing 4. Education 5. Environment Answer: 1, 2, 3, 5 Explanation: Health is the degree of wellness or well-being that the patient experiences. Person is the recipient of nursing care to include individuals, families, groups, or the community. Nursing is the attributes, characteristics, and actions of the nurse providing care on behalf of, or in conjunction with, the patient. Environment is the internal and external surroundings that affect the patient. Page Ref: 14 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: III. A. 2. Describe EBP to include the components of research evidence, clinical expertise, and patient/family values | AACN Essential Competencies: III. 1. Explain the interrelationships among theory, practice, and research | NLN Competencies: Knowledge and Science; Knowledge; 1. Retrieve research findings and other sources of information | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Identify the components of the metaparadigm for nursing. MNL Learning Outcome: 3. Recognize the components that make up professional nursing practice.
34) The research committee is planning a study that focuses on nursing activities. On which theme should the study focus? (Select all that apply.) 1. Art 2. Caring 3. Holism 4. Science 5. Curative Answer: 1, 2, 3, 4 Explanation: A common theme in theoretical definitions of nursing include nursing is an art. A common theme in theoretical definitions of nursing include nursing is caring. A common theme in theoretical definitions of nursing include nursing is holism. A common theme in theoretical definitions of nursing include nursing is science. Page Ref: 14 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: III. A. 2. Describe EBP to include the components of research evidence, clinical expertise, and patient/family values | AACN Essential Competencies: III. 1. Explain the interrelationships among theory, practice, and research | NLN Competencies: Knowledge and Science; Knowledge; 1. Retrieve research findings and other sources of information | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Identify the components of the metaparadigm for nursing. MNL Learning Outcome: 3. Recognize the components that make up professional nursing practice. 35) The department of nursing is redesigning the approach used for patient care. For which reason should a nursing theory be identified to base this care? 1. Reduces the need to create care plans 2. Enhances the nurse-patient relationship 3. Eliminates the need to validate interventions 4. Guides knowledge development and directs practice Answer: 4 Explanation: There is a direct link between nursing theory, education, research, and clinical practice. Nursing theory guides knowledge development and directs practice. Nursing theory is not used to reduce the need to create care plans, enhance the nurse—patient relationship, or eliminate the need to validate interventions. Page Ref: 14 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: III. A. 2. Describe EBP to include the components of research evidence, clinical expertise, and patient/family values | AACN Essential Competencies: III. 1. Explain the interrelationships among theory, practice, and research | NLN Competencies: Knowledge and Science; Knowledge; 1. Retrieve research findings and other sources of information | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6. Identify the role of nursing theory in nursing education, research, and clinical practice. MNL Learning Outcome: 3. Recognize the components that make up professional nursing practice.
36) The nurse educator is preparing a tool on the different types of nursing theories. Which theorist should be included in this tool? (Select all that apply.) 1. Roy 2. Orem 3. Erikson 4. Neuman 5. Leininger Answer: 1, 2, 4, 5 Explanation: Roy's adaptation model is an example of a nursing theory. Orem's general theory of nursing is an example of a nursing theory. Neuman's systems model is an example of a nursing theory. Leininger's cultural care diversity and universality theory is an example of a nursing theory. Page Ref: 14 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: III. A. 2. Describe EBP to include the components of research evidence, clinical expertise, and patient/family values | AACN Essential Competencies: III. 1. Explain the interrelationships among theory, practice, and research | NLN Competencies: Knowledge and Science; Knowledge; 1. Retrieve research findings and other sources of information | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6. Identify the role of nursing theory in nursing education, research, and clinical practice. MNL Learning Outcome: 3. Recognize the components that make up professional nursing practice.
37) The nurse wants to complete a continuing education program before renewing state licensure. Which topic should the nurse select for this program? (Select all that apply.) 1. Medication administration 2. Advances in hemodialysis care 3. Update on weaning procedures 4. Actions to prevent pressure injuries 5. New laws affecting advance directives Answer: 2, 3, 5 Explanation: Advances in hemodialysis care would inform about a new technology and would be appropriate for continuing education. Update on weaning procedures would help attain expertise in a specialized area of practice. New laws affecting advance directives would provide information about a legal aspect of nursing. Page Ref: 14-15 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VIII. 13. Articulate the value of pursuing practice excellence, lifelong learning, and professional engagement to foster professional growth and development | NLN Competencies: Relationship Centered Care; Practice-Know-How; Learn continuously, learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7. Explain the importance of continuing nursing education. MNL Learning Outcome: 2. Differentiate between the types and purposes of programs involving nursing education.
38) The nurse provides care to clients in the community clinic. Which should the nurse provide to help the clients prevent the development of disease? (Select all that apply.) 1. Infant care 2. Medications 3. Prenatal care 4. Immunizations 5. Prevention of sexually transmitted infections (STIs) Answer: 1, 3, 4, 5 Explanation: Infant care is one activity to prevent illness. Prenatal care is one activity to prevent illness. Immunizations are used to prevent illness. Preventing STIs will maintain optimal health and prevent disease. Page Ref: 15 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs | AACN Essential Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Context and Environment; Ethical Comportment; Examine personal beliefs, values, and biases with regard to respect for persons, human dignity, equality, and justice; explore ideas of nurse caring and compassion | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Identify the four major areas of nursing practice. MNL Learning Outcome: 3. Recognize the components that make up professional nursing practice.
39) A nurse has been caring for patients on the same care area for 10 years. Which behavior demonstrates that the nurse is performing at the expert level? (Select all that apply.) 1. Follows regulations 2. Focuses on long-term goals 3. Acts when it feels right to do so 4. Coordinates multiple complex care demands 5. Does not refer to guides when providing care Answer: 3, 5 Explanation: The expert nurse acts when it feels right to do so. The expert nurse does not refer to guides when providing care. Page Ref: 20 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. B. 2. Initiate plan for self-development as a team member | AACN Essential Competencies: VIII. 13. Articulate the value of pursuing practice excellence, lifelong learning, and professional engagement to foster professional growth and development | NLN Competencies: Relationship Centered Care; Practice-Know-How; Learn continuously, learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 14. Discuss Benner's levels of nursing proficiency. MNL Learning Outcome: 3. Recognize the components that make up professional nursing practice. 40) The nurse is employed in a company that provides telenursing services. Which type of care should the nurse expect to provide to patients? (Select all that apply.) 1. Home visits 2. Internet -based 3. Telephone contact 4. Video conferencing 5. Telemonitoring equipment Answer: 2, 3, 4, 5 Explanation: Telenursing is Internet-based. Telephone contact is a part of telenursing. Telenursing can include video conferencing. Telenursing can include telemonitoring equipment. Page Ref: 23 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. A. 4. Recognize contributions of other individuals and groups in helping patient/family achieve health goals | AACN Essential Competencies: VII. 6. Use information and communication technologies in preventive care | NLN Competencies: Context and Environment; Knowledge; Health care systems | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15. Describe factors influencing contemporary nursing practice. MNL Learning Outcome: 4. Examine the factors that influence contemporary nursing practice.
41) The nurse receives notification of being selected as a member Sigma Theta Tau. What should the nurse expect as a member of this organization? (Select all that apply.) 1. Nursing students are members 2. It is a professional organization 3. It represents nursing worldwide 4. The organization has various chapters 5. Academic achievement is used to identify members Answer: 2, 4, 5 Explanation: Sigma Theta Tau is a professional organization. Sigma Theta Tau has various chapters. Academic achievement is used to identify members in Sigma Theta Tau. Page Ref: 24 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. B. 2. Initiate plan for self-development as a team member | AACN Essential Competencies: VIII. 13. Articulate the value of pursuing practice excellence, lifelong learning, and professional engagement to foster professional growth and development | NLN Competencies: Relationship Centered Care; Practice-Know-How; Learn continuously, learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 16. Explain the functions of national and international nurses' associations. MNL Learning Outcome: 4. Examine the factors that influence contemporary nursing practice.
Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 2 Evidence-Based Practice and Research in Nursing 1) The nurse is reviewing the history of research in nursing care for a school project. In which chronological order should the nurse place the events that occurred in nursing research? Start with the earliest (1) to the most recent (4): 1. The National Center for Nursing Research was created. 2. The National Institute for Nursing Research was created. 3. The journal Nursing Research was established. 4. End-of-life/palliative care research was conducted. Answer: 3, 1, 2, 4 Explanation: The journal Nursing Research was established in 1952. The National Center for Nursing Research was created in 1985 at the National Institutes of Health (NIH). In 1993, it was promoted to the National Institute for Nursing Research (NINR). End-of-life/palliative care was identified at NINR as an area of research for 2000-2004. Page Ref: 2-3 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: III. A. 1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: III. 1. Explain the interrelationships among theory, practice, and research | NLN Competencies: Knowledge and Science; Knowledge; Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Apply the steps of change used in implementing evidence-based practice. MNL Learning Outcome: 1. Examine the relationship of research and evidence-based practice in nursing.
2) A nursing student is assigned to develop a research question for a quantitative study. Which question should the student write? 1. How do siblings react to a new baby of a second marriage after divorce of their parents? 2. What dressing selections work best for a wound dehiscence? 3. What support do terminal cancer clients find least beneficial in hospice care? 4. Does expression of client spirituality affect recovery time? Answer: 2 Explanation: Quantitative research is often viewed as "hard" science. It progresses through systematic, logical steps to collect information under controlled conditions. The information is analyzed using statistical procedures. The questions about siblings reactions, hospice care, and spirituality would be appropriate for a qualitative research study. Page Ref: 4 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: III. A. 1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: III. 1. Explain the interrelationships among theory, practice, and research | NLN Competencies: Knowledge and Science; Knowledge; Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 4. Differentiate the quantitative approach from the qualitative approach in nursing research. MNL Learning Outcome: 2. Recognize the components and activities involved in the research process.
3) A client has agreed to participate in a research study. Which action would constitute risk of harm to this client? 1. Withholding information about the study 2. Suggesting that participation would greatly benefit the client's financial situation 3. Giving false information about the client's participation 4. Providing the client's name as a participant in the study Answer: 4 Explanation: Risk of harm to a research subject is exposure to the possibility of injury, which could involve physical or psychological injury such as loss of confidentiality or loss of privacy. Withholding information or giving false information would be a violation of full disclosure. Participants should feel free from coercion or undue influence to participate in a study or this would be a violation against the right of self-determination. Page Ref: 10 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: III. C. 2. Value the need for ethical conduct of research and quality improvement | AACN Essential Competencies: III. 3. Advocate for the protection of human subjects in the conduct of research | NLN Competencies: Knowledge and Science; Ethical Comportment; Value evidence-based approaches to yield best practices for nursing | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Describe the nurse's role in protecting the rights of human participants in research. MNL Learning Outcome: 4. Recognize the legal and ethical responsibilities of nurses in research.
4) A nursing instructor is researching the implementation of assigning study guides for homework points and the effect this has on the students' test grades. The instructor reports group data for published research. Which research right did the instructor implement? 1. Right of full disclosure 2. Right of privacy 3. Right of self-determination 4. Risk of harm Answer: 2 Explanation: Within the right to privacy, confidentiality is to be maintained, which means that any information a participant relates will not be made public, and investigators must inform research participants about the measures to provide for these rights. Such measures may include the use of code numbers or reporting only group or aggregate data in published research. The right of full disclosure means that deception, by either withholding information about a client's participation in a study or giving the client false or misleading information about what participating in the study will involve, must not occur. The right to self-determination means that participants should feel free from constraints, coercion, or any undue influence to participate in a study. The risk of harm to a research subject is exposure to the possibility of injury going beyond everyday situations. Page Ref: 10 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: III. C. 2. Value the need for ethical conduct of research and quality improvement | AACN Essential Competencies: III. 3. Advocate for the protection of human subjects in the conduct of research | NLN Competencies: Knowledge and Science; Ethical Comportment; Value evidence-based approaches to yield best practices for nursing | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 7. Describe the nurse's role in protecting the rights of human participants in research. MNL Learning Outcome: 4. Recognize the legal and ethical responsibilities of nurses in research.
5) The nurse is considering whether the findings of a project may present uncertain results in the clinical area. Upon which criteria is the nurse reflecting? 1. Significance 2. Researchability 3. Confidentiality 4. Variables Answer: 2 Explanation: Researchability means that the problem can be subjected to scientific investigation. If a significant problem produces ambiguity or uncertainty in clinical situations, it may not be appropriate to research. Significance means that a finding did not occur by chance. Confidentiality means that any information a participant relates will not be made public or available to others without the participant's consent. Variable refers to anything that would influence the results of a study. Page Ref: 5 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: III. A. 1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: III. 1. Explain the interrelationships among theory, practice, and research | NLN Competencies: Knowledge and Science; Knowledge; 2. Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2. Apply the steps of change used in implementing evidence-based practice. MNL Learning Outcome: 1. Examine the relationship of research and evidence-based practice in nursing.
6) The nurse researcher is considering the use of various nonpharmacological distraction techniques that have shown success for behavior control in troubled adolescents. Which criteria is this researcher considering using? 1. Significance 2. Researchability 3. Feasibility 4. Interest Answer: 1 Explanation: The research problem has significance if it has the potential to contribute to nursing science by enhancing client care, testing or generating a theory, or resolving a day-to-day clinical problem. If the adolescents are showing improved behavior, then these techniques have significance in enhancing client care. Researchability means that the problem can be subjected to scientific investigation. Feasibility determines if the results of the study can be applied to practice. Interest refers to a broad area of study. Page Ref: 6 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: III. A. 1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: III. 1. Explain the interrelationships among theory, practice, and research | NLN Competencies: Knowledge and Science; Knowledge; Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Outline the steps of the research process. MNL Learning Outcome: 2. Recognize the components and activities involved in the research process.
7) The nurse develops the research question "Do students who study in groups score better on the NCLEX® exam when compared to students who study independently?" Which phrase should the nurse identify as the dependent variable? 1. Number of students in a study group 2. NCLEX scores of both groups 3. Students' college GPAs 4. Time between graduation and sitting for the NCLEX Answer: 2 Explanation: The dependent variable is the behavior, characteristic, or outcome that the researcher wishes to explain or predict. The independent variable is the presumed cause of or influence on the dependent variable. In this situation, the prediction is the success on NCLEX. Independent variables would be the number of students in the study group, college GPAs, and time between graduation and sitting for the examination. Page Ref: 5 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: III. A. 1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: III. 1. Explain the interrelationships among theory, practice, and research | NLN Competencies: Knowledge and Science; Knowledge; Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Outline the steps of the research process. MNL Learning Outcome: 2. Recognize the components and activities involved in the research process. 8) The nurse has defined a research problem. What action should the nurse take next? 1. Formulate a hypothesis. 2. Define variables. 3. Review the literature. 4. Select a design. Answer: 3 Explanation: Before progressing with the research design, the researcher determines what is known and not known about the problem. A thorough review of the literature provides the foundation on which to build new knowledge. Next, a hypothesis is formulated, variables are defined, and the research design is selected. Page Ref: 5 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: III. A. 1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: III. 1. Explain the interrelationships among theory, practice, and research | NLN Competencies: Knowledge and Science; Knowledge; Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Outline the steps of the research process. MNL Learning Outcome: 2. Recognize the components and activities involved in the research process.
9) The nurse researcher is testing the effects of a new dressing preparation on certain participants, while continuing to use older but more familiar products on others. Which type of research design is the nurse using? 1. Quasi-experimental 2. Experimental 3. Nonexperimental 4. Pilot study Answer: 2 Explanation: Experimental design is one in which the investigator manipulates the independent variable by administering an experimental treatment to some participants while withholding it from others. This would be the situation if some of the participants were exposed to new products while others were not. Quasi-experimental is not identified as a type of research design. With a nonexperimental design, there is no manipulation of the independent variable and there may be no identifiable independent and dependent variables in the study. A pilot is used to do a preliminary estimate of reliability and validity. Page Ref: 6 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: III. A. 1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: III. 1. Explain the interrelationships among theory, practice, and research | NLN Competencies: Knowledge and Science; Knowledge; Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Differentiate the quantitative approach from the qualitative approach in nursing research. MNL Learning Outcome: 2. Recognize the components and activities involved in the research process.
10) A researcher is conducting a study with single-parent families within a school system. What sample is the researcher using? 1. The school system 2. Children 3. Parents 4. Single-parent families Answer: 4 Explanation: The sample is the segment of the population from which the data will actually be collected–in this case, single-parent families. The sample is not the school system, individual children, or individual parents. Page Ref: 6 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: III. A. 1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: III. 1. Explain the interrelationships among theory, practice, and research | NLN Competencies: Knowledge and Science; Knowledge; Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Outline the steps of the research process. MNL Learning Outcome: 2. Recognize the components and activities involved in the research process. 11) The nurse researcher is using an instrument that provides similar results each time it is implemented. Which term should the researcher use to describe the quality of this instrument? 1. Validity 2. Reliability 3. Consistency 4. Variability Answer: 2 Explanation: Reliability is the degree of consistency with which an instrument measures a concept or variable. If it is reliable, repeated measurement of the same variable should yield similar or nearly similar results. Validity refers to the completeness and conceptual accuracy of measures. Consistency and variability are not terms used to describe the quality of research instruments. Page Ref: 6 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: III. A. 1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: III. 1. Explain the interrelationships among theory, practice, and research | NLN Competencies: Knowledge and Science; Knowledge; Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5. Outline the steps of the research process. MNL Learning Outcome: 2. Recognize the components and activities involved in the research process.
12) The nurse is examining the dispersion of data in a research study. Which measurements should the nurse expect to review? 1. Mean, median, and mode 2. Range, variance, and standard deviation 3. Mean, range, and standard deviation 4. Measures of central tendency Answer: 2 Explanation: Measures of variability indicate the degree of dispersion or spread of the data. They include the range, variance, and standard deviation. Measures of central tendency describe the center of distribution of the data, denoting where most of the subjects lie. They include the mean, median, and mode. Page Ref: 6 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: III. A. 1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: III. 1. Explain the interrelationships among theory, practice, and research | NLN Competencies: Knowledge and Science; Knowledge; Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5. Outline the steps of the research process. MNL Learning Outcome: 2. Recognize the components and activities involved in the research process. 13) After the data have been analyzed, the nurse realizes that the probability has a value of less than .05. What should this finding indicate to the nurse? 1. Statistically significant 2. Statistically insignificant 3. Chance occurrences 4. Generalized Answer: 1 Explanation: If findings in a research study are statistically significant–which means they did not occur by chance–the probability value is less than .05, the acceptable level of significance. A finding of less than 0.5 would not be statistically insignificant, caused by a change occurrence, or generalized. Page Ref: 6 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: III. A. 1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: III. 1. Explain the interrelationships among theory, practice, and research | NLN Competencies: Knowledge and Science; Knowledge; Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5. Outline the steps of the research process. MNL Learning Outcome: 2. Recognize the components and activities involved in the research process.
14) The nurse completes a literature review on evidence-based practice (EBP). Which action indicates that the nurse understands EBP? 1. Presenting information about EBP during a staff meeting 2. Repositioning a client at risk for skin breakdown every 2 hours 3. Explaining EBP to fellow nurses 4. Trying to find other problems to implement EBP Answer: 2 Explanation: In evidence-based practice, the nurse integrates research findings with clinical experience, the client's preferences, and available resources in planning and implementing care. Evidence-based practice would support frequent repositioning to prevent skin breakdown in an at-risk client, demonstrating that this nurse is able to incorporate research into practice. Presenting information about EBP, explaining EBP to others, or locating other problems to implement EBP does not indicate understanding about EBP. Page Ref: 1 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: III. A. 1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: III. 1. Explain the interrelationships among theory, practice, and research | NLN Competencies: Knowledge and Science; Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Describe research-related roles and responsibilities for nurses. MNL Learning Outcome: 3. Examine the various research-related roles and responsibilities for nurses.
15) The nurse is researching how care providers of Stage I/II Alzheimer's clients use prior coping skills in dealing with their current situation. Which qualitative research tradition is the nurse using? 1. Grounded theory 2. Ethnography 3. Phenomenology 4. Substantive dimension Answer: 3 Explanation: Phenomenology is research that investigates people's life experiences and how they interpret those experiences. Using prior coping skills (life experiences) and applying them to current situations in order to interpret the process of Alzheimer's disease is an example of phenomenology. Grounded theory focuses on social processes. Ethnography focuses on cultural patterns of thoughts and behaviors. Substantive dimension is not identified as an element of research. Page Ref: 4 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: III. A. 1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: III. 1. Explain the interrelationships among theory, practice, and research | NLN Competencies: Knowledge and Science; Knowledge; Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Differentiate the quantitative approach from the qualitative approach in nursing research. MNL Learning Outcome: 2. Recognize the components and activities involved in the research process.
16) The nurse is evaluating the results of a study prior to implementing its findings into practice. Which action should the nurse take when scientifically validating the research results? 1. Scrutinizing how the study was conceptualized, designed, and conducted in order to make a judgment about the overall quality of its findings 2. Assessing how the study's findings compare to findings from other studies about the problem 3. Determining how the study's findings will transfer from the research conditions to the clinical practice conditions in which they will be used 4. Identifying practical or feasibility considerations that need to be addressed when applying the findings in practice Answer: 1 Explanation: Scientific validation is a thorough critique of a study for its conceptual and methodological integrity. This means scrutinizing how the study was conceptualized, designed, and conducted in order to make a judgment about the overall quality of its findings. Comparing the findings to other studies, determining how to transfer the findings to clinical practice, and identifying considerations when applying the findings to practice are actions to take when completing a comparative analysis. Page Ref: 7 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: III. A. 1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: III. 1. Explain the interrelationships among theory, practice, and research | NLN Competencies: Knowledge and Science; Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Describe research-related roles and responsibilities for nurses. MNL Learning Outcome: 3. Examine the various research-related roles and responsibilities for nurses.
17) A nurse practitioner feels it is important to participate in nursing research. Which activity is most appropriate for this nurse's level of education and position? 1. Helping to identify clinical problems in direct client care 2. Using research findings to develop policies and procedures 3. Critically analyzing and interpreting research for application to practice 4. Participating in data collection Answer: 3 Explanation: The nurse practitioner, having a graduate-level education as well as prior nursing experience, would most likely be analyzing and interpreting research for application. The nurse with a baccalaureate degree will help identify clinical problems in direct client care and participate in data collection. The nurse with a practice-focused doctorate will help develop policies and procedures. The nurse who focuses on research would participate in data collection. Page Ref: 3 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: III. A. 1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: III. 1. Explain the interrelationships among theory, practice, and research | NLN Competencies: Knowledge and Science; Practice-KnowHow; Translate research into practice in order to promote quality and improve practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Describe research-related roles and responsibilities for nurses. MNL Learning Outcome: 3. Examine the various research-related roles and responsibilities for nurses.
18) A nurse researcher is exploring and formulating research problems. Which criteria should the nurse researcher consider in this process? (Select all that apply.) 1. Significance 2. Confidentiality 3. Researchability 4. Design 5. Feasibility 6. Interest to the researcher Answer: 1, 3, 5, 6 Explanation: When formulating a research problem, significance (the potential to contribute to nursing science by enhancing client care) should be considered, along with researchability (the problem can be subjected to scientific investigation) and feasibility (the availability of time as well as material and human resources, space, money, etc.). Because researchers spend much time and energy while conducting a research project, it would also be important that they have genuine interest in the project. When formulating a research problem, researchability (the problem can be subjected to scientific investigation) should be considered. When formulating a research problem, feasibility (the availability of time as well as material and human resources, space, money, etc.) should be considered. Because researchers spend much time and energy while conducting a research project, it would also be important that they have genuine interest in the project. Page Ref: 5 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: III. A. 1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: III. 1. Explain the interrelationships among theory, practice, and research | NLN Competencies: Knowledge and Science; Knowledge; Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Outline the steps of the research process. MNL Learning Outcome: 2. Recognize the components and activities involved in the research process.
19) The nurse is planning to use evidence-based practice to help guide the care of a client. In which order should the nurse implement the steps of EBP? 1. Design practice change. 2. Assess the need for a change in practice. 3. Integrate and maintain change in practice. 4. Implement and evaluate the change. 5. Critically analyze the evidence. 6. Locate the best evidence. Answer: 2, 6, 5, 1, 4, 3 Explanation: The nurse should first assess the need for a change in practice. Then the best evidence should be located. The evidence should then be analyzed prior to designing a change in practice. The change should be implemented and then evaluated. Finally, the change in practice should be integrated and maintained. Page Ref: 1 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: III. A. 1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: III. 1. Explain the interrelationships among theory, practice, and research | NLN Competencies: Knowledge and Science; Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Outline the steps of the research process. MNL Learning Outcome: 3. Examine the various research-related roles and responsibilities for nurses.
20) The nurse reviews concerns about the use of research for evidence-based practice (EBP). What particular concern should the nurse highlight? (Select all that apply.) 1. When EBP is done appropriately, the process often becomes cost-prohibitive. 2. The research environment results in strictly constructed and controlled circumstances. 3. There is a "best" solution or practice for any specific research question. 4. EBP is most applicable to physiological problems. 5. Research evidence can be flawed when applied to various cultures and ethnic groups. Answer: 2, 3, 4, 5 Explanation: Research is often done under very controlled circumstances, which is very different from the real world of healthcare delivery. Research evidence suggests that there is one best solution to a problem for all clients. This limited perspective stifles creativity. EBP appears to have greater relevance for physiological problems than for psychological, social, or spiritual ones. Implementing EBP may not take into consideration organizational culture and ethnic characteristics. Page Ref: 2 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: III. A. 1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: III. 1. Explain the interrelationships among theory, practice, and research | NLN Competencies: Knowledge and Science; Knowledge; Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Describe limitations in relying on research as the primary source of evidence for practice. MNL Learning Outcome: 1. Examine the relationship of research and evidence-based practice in nursing.
21) The nurse using evidence-based practice to guide care has identified a study in which the findings would be appropriate to address a client's healthcare need. What action should the nurse take before implementing these findings? (Select all that apply.) 1. Ask the client if the findings can be used. 2. Immediately apply the findings to client care. 3. Examine how the findings fit with the client's health needs. 4. Determine if resources are available to implement the findings. 5. Identify organization policies to support or address the findings. Answer: 1, 3, 4, 5 Page Ref: 3 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: III. A. 1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: III. 1. Explain the interrelationships among theory, practice, and research | NLN Competencies: Knowledge and Science; Practice-KnowHow; Translate research into practice in order to promote quality and improve practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Explain the relationship between research and evidence-based nursing practice. MNL Learning Outcome: 3. Examine the various research-related roles and responsibilities for nurses. 22) The nurse researcher is determining the best way to formulate a research problem. What should the nurse identify if implementing the PICO format? (Select all that apply.) 1. Intervention to use 2. Problem of interest 3. Comparison of treatments 4. Outcome of the treatments 5. Individuals to perform actions Answer: 1, 2, 3, 4 Page Ref: 5 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: III. A. 1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: III. 1. Explain the interrelationships among theory, practice, and research | NLN Competencies: Knowledge and Science; Knowledge; Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Outline the steps of the research process. MNL Learning Outcome: 2. Recognize the components and activities involved in the research process.
23) The nurse is reviewing a variety of articles about a clinical problem. Which article should the nurse select as being the most accurate and dependable? 1. Theory 2. Research based 3. Opinion of experts 4. Clinical assessment findings Answer: 2 Explanation: Because research entails using formal and systematic processes to solve problems and answer questions, the disciplined thinking and the careful planning and execution that characterize research means that the resulting findings should be accurate, dependable, and free from bias. Evidence includes theories, opinions of experts, and clinical assessment findings that are not always the most accurate and dependable. Page Ref: 2 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: III. A. 1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: III. 1. Explain the interrelationships among theory, practice, and research | NLN Competencies: Knowledge and Science; Practice-KnowHow; Translate research into practice in order to promote quality and improve practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Explain the relationship between research and evidence-based nursing practice. MNL Learning Outcome: 1. Examine the relationship of research and evidence-based practice in nursing.
24) The nurse manager decides to forgo implementing a new approach to care delivery after reviewing research studies completed on the approach. Which characteristic of research did the manager most likely use to make this decision? (Select all that apply.) 1. The cost to redesign the care area is prohibitive 2. Was not feasible because of the size of the care area 3. The approach proved to be meaningful to the clients and nursing staff 4. Approach did not take into consideration different levels of care providers 5. Approach neglected to specify the type of client population used in the study Answer: 1, 2, 4, 5 Explanation: Reasons for relying on research for best practices include cost because this variable is not often included in traditional research studies. Research may ignore the feasibility of an intervention or plan. Research may ignore the real world of care delivery and appropriateness of interventions. Research is often done under controlled circumstances and may have flaws such as not identifying the type of client population used in the study. Page Ref: 2 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: III. A. 1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: III. 1. Explain the interrelationships among theory, practice, and research | NLN Competencies: Knowledge and Science; Knowledge; Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 3. Describe limitations in relying on research as the primary source of evidence for practice. MNL Learning Outcome: 1. Examine the relationship of research and evidence-based practice in nursing.
Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 3 Legal Aspects of Nursing 1) A client received the wrong dose of medication and died. The case is being tried in court and similar cases are used by the court in comparison to arrive at a decision. Which doctrine should the nurse's attorney explain is applied to this situation? 1. Common law 2. Public law 3. Administrative law 4. Stare decisis Answer: 4 Explanation: Stare decisis, "to stand by things decided," is a doctrine courts adhere to when arriving at a ruling in a particular case. The courts apply the same rules and principles applied in previous, similar cases. Common, public, and administrative law do not apply to this situation. Page Ref: 40 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essential Competencies: V. 6. Explore the impact of socio-cultural, economic, legal, and political factors influencing healthcare delivery and practice | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. List sources of law and types of laws. MNL Learning Outcome: 3. Recognize areas of potential legal liability in nursing.
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2) The nurse is notified about new state practice act regulations. Which type of law should the nurse expect to implement to enforce the nurse practice act regulations? 1. Statutory law 2. Administrative law 3. Common law 4. Public law Answer: 2 Explanation: Administrative agencies are given authority to create rules and regulations to enforce statutory law when the state legislature passes a statute. State boards of nursing write rules and regulations to implement and enforce a nurse practice act, which was created through statutory law but is enforced by administrative law. Statutory, common, and public law are not used to implement or enforce nurse practice act regulations. Page Ref: 40 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essential Competencies: V. 6. Explore the impact of socio-cultural, economic, legal, and political factors influencing healthcare delivery and practice | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1. List sources of law and types of laws. MNL Learning Outcome: 2. Consider the legal aspects that affect nursing practice. 3) During the admission process, a client is informed that even though forms are signed for the client's insurance company to be billed for services, the client is still responsible for payment if the insurance company fails to pay. Which type of law was explained to the client? 1. Contract law 2. Tort law 3. Statutory law 4. Administrative law Answer: 1 Explanation: Contract law involves the enforcement of agreements among private individuals or the payment of compensation for failure to fulfill the agreements. Signing a form prior to receipt of healthcare services makes the client responsible for cost, regardless of insurance payment. Tort, statutory, and administrative law to do apply to this situation. Page Ref: 40-41 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essential Competencies: V. 6. Explore the impact of socio-cultural, economic, legal, and political factors influencing healthcare delivery and practice | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1. List sources of law and types of laws. MNL Learning Outcome: 2. Consider the legal aspects that affect nursing practice. 2
4) A client falls out of bed when reaching for the call light that the nurse was to place within the patient's reach. With what should the nurse expect to be charged? 1. Assault 2. Battery 3. Negligence 4. Criminal intent Answer: 3 Explanation: Negligence is an example of a tort law. Negligence occurs when something is accidental and harm results, as in this case. This is not a situation of assault, battery, or criminal intent. Page Ref: 57 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essential Competencies: VIII. 12. Act to prevent unsafe, illegal, or unethical care practices | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 10. Compare and contrast intentional torts (assault and battery, false imprisonment, invasion of privacy, defamation) and unintentional torts (professional negligence). MNL Learning Outcome: 3. Recognize areas of potential legal liability in nursing. 5) The attorney of a client who is suing the hospital for malpractice meets with staff and reads the medical record. Which activity is the attorney completing? 1. Burden of proof 2. Complaint 3. Discovery 4. Civil action Answer: 3 Explanation: Discovery is an effort by both parties to obtain all the facts of the situation. It occurs before the trial. During a trial, a plaintiff must offer evidence of the defendant's wrongdoing. This duty to prove an assertion of wrongdoing is called the burden of proof. The issue is written in the form of a complaint. Civil actions deal with the relationships among individuals in society. Page Ref: 41 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essential Competencies: V. 6. Explore the impact of socio-cultural, economic, legal, and political factors influencing healthcare delivery and practice | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1. List sources of law and types of laws. MNL Learning Outcome: 2. Consider the legal aspects that affect nursing practice. 3
6) Before applying for relicensure, the nurse attends continuing education programs. Which action is the nurse performing to adhere to the state board of nursing expectation? 1. Licensure 2. Competency 3. Credentialing 4. Certification Answer: 3 Explanation: Credentialing is the process of determining and maintaining competence in general nursing practice. It is one way to maintain the professional standards of practice and accountability for the members' educational preparation. Page Ref: 43 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essential Competencies: V. 6. Explore the impact of socio-cultural, economic, legal, and political factors influencing healthcare delivery and practice | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe ways nurse practice acts, credentialing, standards of care, and agency policies and procedures affect the scope of nursing practice. MNL Learning Outcome: 1. Recognize how nursing practice is regulated. 7) The high school graduate desiring to attend nursing school reviews the schools for accreditation. Which regulatory body's actions is the student analyzing? 1. State board of nursing 2. Nurse Licensure Compact (NLC) 3. Commission on Collegiate Nursing Education (CCNE) 4. American Nurses Association (ANA) Answer: 1 Explanation: All states require that all schools of nursing in the state are approved/accredited by the state board of nursing. An interstate compact called the NLC is the mechanism used to create mutual recognition among states. The CCNE is a private organization that schools of nursing can use to obtain voluntary accreditation. The ANA does not accredit schools of nursing. Page Ref: 44 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essential Competencies: V. 6. Explore the impact of socio-cultural, economic, legal, and political factors influencing healthcare delivery and practice | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Describe ways nurse practice acts, credentialing, standards of care, and agency policies and procedures affect the scope of nursing practice. MNL Learning Outcome: 1. Recognize how nursing practice is regulated. 4
8) The nurse carries out a medication order, incorrectly written by the physician and subsequently filled by the pharmacist. Who, in this situation, is legally liable for the action? 1. Physician 2. Pharmacist 3. Hospital 4. Nurse Answer: 4 Explanation: The responsibility for the nursing activity–in this case, giving the medication– belongs to the nurse. Liability is legal responsibility for one's action. Even though the physician wrote the order incorrectly and the pharmacist filled it, it was the nurse who carried it out, making that person ultimately responsible for the action. Page Ref: 45 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essential Competencies: V. 6. Explore the impact of socio-cultural, economic, legal, and political factors influencing healthcare delivery and practice | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Recognize the nurse's legal responsibilities with selected aspects of nursing practice. MNL Learning Outcome: 3. Recognize areas of potential legal liability in nursing. 9) A hospital receives notice of being sued for an action performed by a nurse. Which doctrine should be implemented in this case? 1. Contractual relationship 2. Stare decisis 3. Respondeat superior 4. Res ipsa loquitur Answer: 3 Explanation: "Let the master answer," or respondeat superior, means that the master (in this case the hospital/employer) assumes responsibility for the conduct of the servant (the nurse) and can be held responsible for the nurse's failure to act in a competent way. This situation should not be treated as a contractual relationship, stare decisis, or res ipsa loquitur. Page Ref: 45 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essential Competencies: V. 6. Explore the impact of socio-cultural, economic, legal, and political factors influencing healthcare delivery and practice | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Recognize the nurse's legal responsibilities with selected aspects of nursing practice. MNL Learning Outcome: 3. Recognize areas of potential legal liability in nursing. 5
10) A client being prepared for an invasive procedure questions some of the terminology in the consent form. Which response should the nurse make? 1. "I'll explain whatever you don't understand." 2. "You should have asked your physician when he was in here." 3. "I'll call your physician back in the room to answer your questions." 4. "Just sign the form, and I'll make sure your physician talks to you before he begins the procedure." Answer: 3 Explanation: Obtaining informed consent for specific medical treatment is the responsibility of the person who is going to perform the procedure, in this case the physician. Informed consent suggests that the client has been given complete information, including benefits, risks, and alternatives if the treatment is not given. An element of informed consent is that the client must be given enough information to be the ultimate decision maker. If not, it is the physician's responsibility to make sure the client's understanding is clear. It is important that the person obtaining the consent (the physician in this case) answer the client's questions. Page Ref: 47 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essential Competencies: VIII. 12. Act to prevent unsafe, illegal, or unethical care practices | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4. Describe the purpose and essential elements of informed consent. MNL Learning Outcome: 4. Recognize legal protections in nursing practice.
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11) A client moves the arm to the edge of the bed when the nurse states that an intravenous catheter is needed for antibiotics. Which behavior did the client demonstrate? 1. Informed consent 2. Express consent 3. Implied consent 4. Compliance Answer: 3 Explanation: Implied consent is when the individual's nonverbal behavior indicates agreement. In this case, presenting the hand for IV initiation would be a nonverbal behavior indicating agreement with the treatment. Express consent is a verbal or written agreement. Informed consent suggests that the client has been given complete information, including benefits, risks, and alternatives if the treatment is not given. The client's behavior does not indicate compliance. Page Ref: 47 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essential Competencies: VIII. 12. Act to prevent unsafe, illegal, or unethical care practices | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4. Describe the purpose and essential elements of informed consent. MNL Learning Outcome: 4. Recognize legal protections in nursing practice. 12) An adult client who cannot read needs surgery but is competent to make personal decisions. What is the best action that the nurse should take? 1. Tell the client in the nurse's own words what the surgical procedure involves. 2. Read the consent form to the client and have the client state understanding. 3. Make sure the physician explains the procedure to the client. 4. Have a family member who can read sign the consent form. Answer: 2 Explanation: If a client cannot read, the consent form must be read to the client and the client must state understanding before the form is signed. The nurse should not paraphrase the surgical procedure. The physician should explain the procedure to the client, however, this does not obtain informed consent from the client. Family should not sign the consent form since the client is competent to make personal decisions. Page Ref: 48 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essential Competencies: VIII. 12. Act to prevent unsafe, illegal, or unethical care practices | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Describe the purpose and essential elements of informed consent. MNL Learning Outcome: 4. Recognize legal protections in nursing practice.
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13) An older adult fell at home and fractured a hip, which requires surgical repair. After admittance to the emergency department, the client was given sedation for pain before a surgical permit was signed. What should be done to obtain consent? 1. The physician should have the spouse sign the consent form. 2. The physician should wait until the effects of the medication wear off and have the client sign the form. 3. Because the client has been medicated, the nurse should thoroughly explain the consent form to the client. 4. This would be considered an emergency situation and consent would be implied. Answer: 1 Explanation: A client who is confused, disoriented, or sedated is not considered functionally competent and a legal guardian or representative can provide or refuse consent for the client. In this case, because the client was given medication for sedation, the spouse would be appropriate for giving consent for the surgical procedure. The procedure should not be delayed. The client is sedated and would not be competent to understand an explanation of the consent form. Since the client has a spouse, consent would not be implied. Page Ref: 49 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essential Competencies: VIII. 12. Act to prevent unsafe, illegal, or unethical care practices | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Describe the purpose and essential elements of informed consent. MNL Learning Outcome: 4. Recognize legal protections in nursing practice.
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14) A client who does not speak English needs emergency surgery for traumatic injuries. Which action should the nurse take to obtain consent from this client? 1. Read the consent form and have the client sign it anyway. 2. Explain the form to the best of the nurse's ability using pictures and gestures. 3. Have the hospital interpreter explain the procedure. 4. Proceed with surgery, as implied consent would be the case in this situation. Answer: 3 Explanation: If the client does not speak the same language as the health professional who is providing the information, an interpreter must be present. The client should not be expected to sign a form if it is not communicated in the client's language. Pictures and gestures would not be appropriate. Implied consent would not be appropriate for this situation. Page Ref: 48-49 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essential Competencies: VIII. 12. Act to prevent unsafe, illegal, or unethical care practices | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Describe the purpose and essential elements of informed consent. MNL Learning Outcome: 4. Recognize legal protections in nursing practice. 15) The nurse manager learns that vital signs delegated to unlicensed assistive personnel (UAP) were not recorded accurately. With which care provider should the manager discuss this finding? 1. The UAP 2. The nurse 3. Both the UAP and the nurse 4. The team leader Answer: 2 Explanation: Although taking vital signs was an appropriate task to delegate to the UAP, the responsibility of the action–in this case, the inaction, as the vitals were recorded inaccurately– remains with the nurse. Page Ref: 50 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essential Competencies: VIII. 12. Act to prevent unsafe, illegal, or unethical care practices | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Recognize the nurse's legal responsibilities with selected aspects of nursing practice. MNL Learning Outcome: 3. Recognize areas of potential legal liability in nursing.
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16) During an assessment, the nurse notes that an older client has bruises on the back and arms and vaguely explains how they occurred. Which action should the nurse take? 1. Report the situation to law enforcement. 2. Report the situation to social services. 3. Question the person who brought the client to the hospital. 4. Document the finding in the medical record. Answer: 2 Explanation: Nurses are considered mandated reporters. As a result, they must report any situation when an injury is present and appears to be the result of abuse, neglect, or exploitation. The situation described may or may not be one of abuse or neglect, but the nurse is required to report it to the proper authorities. In this case, social services should be notified. There is no reason to report the situation to law enforcement or to question the person who brought the client to the hospital. The nurse needs to do more than document the finding in the medical record. Page Ref: 51 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essential Competencies: VIII. 12. Act to prevent unsafe, illegal, or unethical care practices | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Recognize the nurse's legal responsibilities with selected aspects of nursing practice. MNL Learning Outcome: 3. Recognize areas of potential legal liability in nursing.
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17) A nurse who is currently employed in an organization is injured and is now paralyzed from the shoulders down. What should the organization do when the nurse expects to continue working as a nurse? 1. Accommodate the nurse. 2. Find another job for the nurse. 3. Claim undue hardship to accommodate this nurse. 4. Terminate the nurse's employment. Answer: 3 Explanation: According to the ADA, it is the employer's responsibility to provide reasonable accommodations that would allow the person with a disability to perform the job satisfactorily. With limited use of the upper arms, this nurse would not be able to perform the tasks required of a nurse working at the bedside. There would be minimal jobs for the nurse to do. Terminating the nurse's employment would be a violation of the Americans with Disabilities Act (ADA). Page Ref: 51 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essential Competencies: VIII. 12. Act to prevent unsafe, illegal, or unethical care practices | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Describe the purpose of the Americans with Disabilities Act. MNL Learning Outcome: 4. Recognize legal protections in nursing practice.
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18) The nurse notices that a coworker exhibits a pattern of behavior suggestive of drug abuse. What should the nurse do? 1. Report the situation to the unit charge nurse. 2. Send an anonymous letter to the director of nursing. 3. Let other coworkers know about the situation. 4. Let management take care of it. Answer: 1 Explanation: As a mandatory reporter, the nurse is required to report situations where coworkers are suspected of impairment, which includes alcohol/drug abuse as well as mental illness. The nurse should report the matter starting at the lowest possible level in the agency hierarchy. In this case, the charge nurse would be appropriate. An anonymous letter should not be sent to the director of nursing. Other co-workers should not be informed of the situation. Management needs to be informed of the situation for it to be handled. Page Ref: 52 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essential Competencies: VIII. 12. Act to prevent unsafe, illegal, or unethical care practices | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Discuss substance use disorder in nursing and available alternative-todiscipline or peer assistance programs. MNL Learning Outcome: 3. Recognize areas of potential legal liability in nursing.
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19) A coworker makes a practice of telling offensive jokes or stories with a sexual undertone during the shift. Which action should the nurse take first? 1. Ignore the coworker and walk away. 2. Report the incident to the nurse manager. 3. Tell the coworker to stop the activity because the conduct is offensive. 4. Ask to be scheduled opposite this coworker. Answer: 3 Explanation: Nurses must develop skills of assertiveness to deter sexual harassment in the workplace. Telling the coworker to stop, and why, is the first step in putting an end to the situation. The co-worker should not be ignored. The incident should be reported but only after asking the co-worker to stop making the comments. Changing a work schedule would not be appropriate since the co-worker's behavior may continue. Page Ref: 52-53 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essential Competencies: VIII. 12. Act to prevent unsafe, illegal, or unethical care practices | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Recognize the nurse's legal responsibilities with selected aspects of nursing practice. MNL Learning Outcome: 3. Recognize areas of potential legal liability in nursing.
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20) The nurse who is opposed to abortion works in a hospital where abortions are performed. Which action should the nurse take? 1. Take no action because the nurse cannot interfere with a woman's constitutional right to privacy. 2. Voluntarily terminate employment. 3. Counsel clients before they have an abortion. 4. Refuse to participate in abortions. Answer: 4 Explanation: In Roe v. Wade and Doe v. Bolton, the Supreme Court upheld that a woman's right to privacy includes control over her own body to the extent that she can abort her fetus. Although the nurse cannot interfere with this, the conscience clause states that nurses, as well as other healthcare personnel, have a right to refuse to participate in abortions and hospitals have the right to deny admission to abortion clients. There is no reason for the nurse to terminate employment. The nurse should not counsel clients before having an abortion. Page Ref: 53 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essential Competencies: VIII. 12. Act to prevent unsafe, illegal, or unethical care practices | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Recognize the nurse's legal responsibilities with selected aspects of nursing practice. MNL Learning Outcome: 2. Consider the legal aspects that affect nursing practice.
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21) A client who woke in the middle of the night confused got out of bed unassisted and fell even though the call light was within reach. Which element of malpractice should the client's attorney realize is missing in this case? 1. Foreseeability 2. Damages 3. Injury 4. Duty Answer: 1 Explanation: Foreseeability is the link between the nurse's act and the injury suffered. The call light was within reach, but the client did not use it and got out of bed unassisted. Nighttime confusion occurs with some clients, but unless the nurse had knowledge or awareness that this would happen, there was no link between the nurse's action and the client's fall. Page Ref: 57 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essential Competencies: VIII. 12. Act to prevent unsafe, illegal, or unethical care practices | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Discriminate between negligence and professional negligence or malpractice. MNL Learning Outcome: 3. Recognize areas of potential legal liability in nursing. 22) A client scheduled for surgery has signed the consent form but refuses to have an indwelling urinary catheter inserted because it is not a part of the surgery. What should the nurse do? 1. Explain that this is part of the surgical preparation and continue with the procedure. 2. Explain that the client has already signed the consent and insert the catheter. 3. Respect the client's wishes and document accordingly. 4. Offer to call the physician. Answer: 3 Explanation: Consent is required before procedures are performed. Depending on the invasiveness of the procedure, a written consent may be required. The client signed a consent form for surgery, and the refusal for insertion of a catheter should be respected. The nurse should document the incident and not continue with the procedure. Page Ref: 50 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essential Competencies: VIII. 12. Act to prevent unsafe, illegal, or unethical care practices | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Describe the purpose and essential elements of informed consent. MNL Learning Outcome: 4. Recognize legal protections in nursing practice.
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23) The nurse documents in a medical record: "The client is a drug addict and is always asking for more medication than what is necessary." With what might the nurse be charged? 1. Defamation 2. Slander 3. Libel 4. Incompetence Answer: 3 Explanation: Libel is defamation of character by means of print, writing, or pictures. Putting a statement such as this in the client's medical record is, first, making a diagnosis, which the nurse is not qualified to do, and, second, making an assumption about the client's need for medication, which is a personal attitude about how the client responds. This statement does not indicated defamation, slander, or incompetence. Page Ref: 59 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essential Competencies: VIII. 12. Act to prevent unsafe, illegal, or unethical care practices | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Discriminate between negligence and professional negligence or malpractice. MNL Learning Outcome: 3. Recognize areas of potential legal liability in nursing.
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24) The nurse is reviewing the Good Samaritan acts. For which situation should the nurse realize that these laws apply? 1. Giving CPR to a client brought to the emergency department, when the client later is found to have a "Do Not Resuscitate" order 2. Permitting a nursing student to try to insert an airway in an unconscious client 3. Leaving the scene of an emergency to call for help 4. Helping deliver the baby of a neighbor during a snowstorm Answer: 4 Explanation: The Good Samaritan acts are laws designed to protect healthcare providers against claims of malpractice in cases of emergency, unless it can be shown that there was a gross departure from the normal standard of care. Assisting with the delivery of a baby during a snowstorm would be an appropriate use of the Good Samaritan Act. Giving CPR would be considered a level of care provided by any other reasonable person under similar circumstances. The fact that the client had a DNR order was not apparent at the time of care rendered by the nurse. A nursing student trying to insert an airway is not appropriate, as it would be above the level of care a student is able to do. A nurse should not leave the scene of an emergency until another qualified person takes over. The nurse should have someone else call or go for additional help. Page Ref: 62-63 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essential Competencies: VIII. 12. Act to prevent unsafe, illegal, or unethical care practices | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13. Describe the laws and strategies that protect the nurse from litigation. MNL Learning Outcome: 3. Recognize areas of potential legal liability in nursing.
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25) The nurse is preparing to provide care to a client. Which actions should the nurse take to ensure legal protection from liability? (Select all that apply.) 1. Checking the client's name band prior to the administration of a preoperative medication 2. Asking for help when moving a comatose client because the client cannot be safely handled by one nurse 3. Attending an in-service on the appropriate use of a new piece of equipment used in the facility 4. Delegating only those tasks that he or she cannot personally perform 5. Reviewing the five rights of medication administration when the client questions one pill Answer: 1, 2, 3, 5 Explanation: Legal protection for nurses is best assured by always checking the identity of the client to make sure it is the right client. Legal protection for nurses is best assured by asking for assistance and/or supervision in situations in which the nurse feels inadequately prepared. Legal protection for nurses is best assured by maintaining clinical competence. Legal protection for nurses is best assured by checking any order that a client questions. Page Ref: 64 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essential Competencies: VIII. 12. Act to prevent unsafe, illegal, or unethical care practices | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13. Describe the laws and strategies that protect the nurse from litigation. MNL Learning Outcome: 3. Recognize areas of potential legal liability in nursing.
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26) The instructor determines that a nursing student understands the legal responsibilities to clients when providing care. What did the instructor observe to come to this conclusion? (Select all that apply.) 1. Prepared to discuss the client's medical diagnosis in preconference 2. Overheard stating, "My care is held to the same standards as that of the unit nurses" 3. Offers to stay with the client who is about to experience a painful diagnostic procedure 4. Addresses the staff and clients respectfully and by their full names 5. Asks for help with a dressing change involving techniques he or she has not yet performed alone Answer: 1, 2, 4 Explanation: Nursing students are held to the same standards as licensed nurses, and therefore need to make sure that they are prepared to provide the necessary care to assigned clients. Nursing students are held to the same standards as licensed nurses, and therefore need to make sure that they are prepared to provide the necessary care to assigned clients. Addressing the staff and clients respectfully and by full names is not a legal responsibility, however, it does demonstrate respect. Page Ref: 65-66 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essential Competencies: VIII. 12. Act to prevent unsafe, illegal, or unethical care practices | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14. Discuss the legal responsibilities of nursing students. MNL Learning Outcome: 3. Recognize areas of potential legal liability in nursing.
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27) While working a scheduled shift the nurse focuses on actions to protect the privacy of a client with local notoriety. What actions should the nurse take at this time? (Select all that apply.) 1. Secure the client's medical record. 2. Review the client's care with the media. 3. Remove the client's name from the door. 4. Permit family to view the client's record. 5. Fax the client's lab values with a cover sheet. Answer: 1, 3, 5 Explanation: Actions to ensure the client's privacy include securing the medical record. Actions to ensure the client's privacy include removing the client's name from the door. Actions to ensure the client's privacy include faxing information with a cover sheet. Page Ref: 61 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essential Competencies: VIII. 12. Act to prevent unsafe, illegal, or unethical care practices | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11. Describe the four specific areas of the Health Insurance Portability and Accountability Act and their impact on nursing practice. MNL Learning Outcome: 2. Consider the legal aspects that affect nursing practice. 28) The nurse manager is concerned that a staff nurse's care demonstrates gross negligence. What actions did the manager use to make this determination? (Select all that apply.) 1. Removed a client's central line 2. Reconnected contaminated intravenous tubing to a client 3. Accessed the computerized documentation system with a password 4. Walked a client with a blood pressure of 70/58 mm Hg to the bathroom 5. Delegated nasotracheal suctioning for a client to unlicensed assistive personnel Answer: 1, 2, 4, 5 Page Ref: 57 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essential Competencies: VIII. 12. Act to prevent unsafe, illegal, or unethical care practices | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 9. Delineate the elements of professional negligence. MNL Learning Outcome: 3. Recognize areas of potential legal liability in nursing.
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29) The nurse works in a state that follows the Enhanced Nurse Licensure Compact (eNLC). Which requirement does the nurse need to obtain this type of license? (Select all that apply.) 1. No felony offenses 2. Proficiency in English 3. Acceptable credit score 4. Five years' work experience 5. Valid U.S. Social Security number Answer: 1, 2, 4 Explanation: The major difference between the NLC and the eNLC is the addition of the Uniform Licensure Requirements, which includes no misdemeanor or felony offenses, proficiency in English, and a valid U.S. Social Security number. Credit score and work experience are not a part of the Uniform Licensure Requirements. Proficiency in English is a Uniform Licensure Requirement. Work experience is not a Uniform Licensure Requirement. Page Ref: 43 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essential Competencies: V. 6. Explore the impact of socio-cultural, economic, legal, and political factors influencing healthcare delivery and practice | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3. Compare and contrast the state-based licensure model and the enhanced nurse licensure compact for multistate licensure. MNL Learning Outcome: 1. Recognize how nursing practice is regulated.
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30) The nurse lives in a state that has adopted the Enhanced Nurse Licensure Compact (eNLC). In which way does the eNLC affect the nurse's practice? (Select all that apply.) 1. Able to practice in the state of residence 2. Retake the NCLEX-RN examination every 5 years 3. Prove ability to communicate in a non-English language 4. No longer needs continuing education hours for relicensure 5. Able to practice in any other state that has adopted the eNLC Answer: 1, 5 Explanation: The eNLC allows all RNs and LPNs to have one multistate license, with the ability to practice in both their home state and all other compact states. There is an ability to practice in all other compact states. Page Ref: 43 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essential Competencies: V. 6. Explore the impact of socio-cultural, economic, legal, and political factors influencing healthcare delivery and practice | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Compare and contrast the state-based licensure model and the enhanced nurse licensure compact for multistate licensure. MNL Learning Outcome: 1. Recognize how nursing practice is regulated.
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31) The manager receives a request from a staff member to be regarded as having a disability. For which health problem should the staff member's request be denied? (Select all that apply.) 1. Anxiety 2. Depression 3. Pregnancy 4. Limb paralysis 5. Migraine headaches Answer: 1, 2, 3, 5 Explanation: Court cases have held that a variety of conditions do not constitute a disability under ADA. These health conditions include depression and anxiety, migraine headaches, and pregnancy. Limb paralysis would not be denied a request as a disability. Court cases have held that a variety of conditions do not constitute a disability under ADA. These health conditions include depression and anxiety, migraine headaches, and pregnancy. Limb paralysis would not be denied a request as a disability. Court cases have held that a variety of conditions do not constitute a disability under ADA. These health conditions include depression and anxiety, migraine headaches, and pregnancy. Limb paralysis would not be denied a request as a disability. Court cases have held that a variety of conditions do not constitute a disability under ADA. These health conditions include depression and anxiety, migraine headaches, and pregnancy. Limb paralysis would not be denied a request as a disability. Page Ref: 51 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essential Competencies: VIII. 12. Act to prevent unsafe, illegal, or unethical care practices | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Describe the purpose of the Americans with Disabilities Act. MNL Learning Outcome: 4. Recognize legal protections in nursing practice.
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32) The nurse voluntarily enters a peer assistance program to help with addiction to opioids. Which change in practice should the nurse expect while participating in this program? (Select all that apply.) 1. No overtime 2. Work only the day shift 3. Random drug screening 4. Licensure revoked for 6 months 5. No access to controlled substances Answer: 1, 2, 3, 5 Explanation: A nurse in a peer assistance program cannot work overtime. A nurse in a peer assistance program is permitted to work only the day shift. A nurse in a peer assistance program may have random drug screening. A nurse in a peer assistance program is to have no access to controlled substances. Page Ref: 52 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essential Competencies: VIII. 12. Act to prevent unsafe, illegal, or unethical care practices | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6. Discuss substance use disorder in nursing and available alternative-todiscipline or peer assistance programs. MNL Learning Outcome: 3. Recognize areas of potential legal liability in nursing.
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33) A client's whose intravenous chemotherapy medication infiltrated a month ago has filed a lawsuit against the nurse providing care. What needs to be proven before the nurse is found negligent? (Select all that apply.) 1. Harm 2. Libel 3. Damages 4. Causation 5. Breach of duty Answer: 1, 3, 4, 5 Explanation: Elements that must be present for a case of nursing professional negligence to be proven include harm, damages, causation, and breach of duty. Damages must be present for a case of nursing professional negligence to be proven. Causation must be present for a case of nursing professional negligence to be proven. Breach of duty must be present for a case of nursing professional negligence to be proven. Page Ref: 57 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essential Competencies: VIII. 12. Act to prevent unsafe, illegal, or unethical care practices | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 9. Delineate the elements of professional negligence. MNL Learning Outcome: 3. Recognize areas of potential legal liability in nursing.
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34) The nurse comments on a Facebook page that a client who is well -known in the community was having cosmetic surgery performed the next day. With which violation should this nurse be charged? 1. Libel 2. Slander 3. False imprisonment 4. Invasion of privacy Answer: 4 Explanation: The client's privacy was violated when the nurse documented on a social media site that the client was having cosmetic surgery. Invasion of privacy injures the feelings of the individual and does not take into account the effect of revealed information on the reputation of the individual in the community. This comment does not represent libel, slander, or false imprisonment. Page Ref: 60 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essential Competencies: VIII. 12. Act to prevent unsafe, illegal or unethical care practices | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 10. Compare and contrast intentional torts (assault and battery, false imprisonment, invasion of privacy, defamation) and unintentional torts (professional negligence). MNL Learning Outcome: 3. Recognize areas of potential legal liability in nursing.
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35) A healthcare organization is cited for a Health Insurance Portability and Accountability Act (HIPAA) violation. Which action should the nurse manager take to ensure this act is being followed? (Select all that apply.) 1. Place a paper shredder next to the fax machine 2. Write client last names on the white board in the hallway 3. Post a notice in each client room informing of the right to privacy 4. Schedule staff to attend an inservice on current HIPAA regulations 5. Assign each staff member a password to access the clinical documentation system Answer: 1, 3, 4, 5 Explanation: To adhere to HIPAA regulations, printed copies of protected health information should not be left unattended. Placing a paper shredder next to the fax machine ensures that this information will be destroyed. Information about the clients' rights to privacy should be posted. Staff should be current with HIPAA regulations. All healthcare providers should have a personal password to access the clinical documentation system. Page Ref: 61 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essential Competencies: VIII. 12. Act to prevent unsafe, illegal, or unethical care practices | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11. Describe the four specific areas of the Health Insurance Portability and Accountability Act and their impact on nursing practice. MNL Learning Outcome: 2. Consider the legal aspects that affect nursing practice.
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36) A healthcare organization is updating its policy on the use of social media for all staff members. Which information should be included in this policy? (Select all that apply.) 1. Do not take or post pictures of any clients 2. Identify as a healthcare professional for all comments 3. All staff are forbidden to participate in social media sites 4. Report any breach of confidentiality posted on a social media site 5. Use only last names when referring to clients on a social media site Answer: 1, 4 Explanation: Posting of pictures of clients on social media sites should never occur since this would be a breach of confidentiality. Any breach of confidentiality on a social media site should be reported. Page Ref: 61-62 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essential Competencies: VIII. 12. Act to prevent unsafe, illegal, or unethical care practices | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12. Discuss the benefits and consequences of participating in social media. MNL Learning Outcome: 4. Recognize legal protections in nursing practice. 37) The nurse receives an electronic notice on a personal smart phone that shows a posting made of a client's foot wound after surgery. Which action should the nurse take? 1. "Like" the posting 2. Report the posting 3. Delete the notice and posting 4. Make a comment on the posting Answer: 2 Explanation: To maintain client confidentiality, no photos or videos should be posted on a social media site. A posting of a client's foot wound is a breach of client confidentiality and should be reported. Liking the posting is unacceptable. Deleting the notice and posting is not sufficient since the person who posted the information should be reported. Comments made on social media are considered public information. Identifying oneself as a nurse carries serious responsibility. Public communication by nurses needs to meet professional standards by being accurate and respectful and following ethical practice. Page Ref: 61-62 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essential Competencies: VIII. 12. Act to prevent unsafe, illegal, or unethical care practices | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12. Discuss the benefits and consequences of participating in social media. MNL Learning Outcome: 4. Recognize legal protections in nursing practice. 28
38) A student nurse graduating from school in a few weeks works part -time as unlicensed assistive personnel (UAP) and is asked to suction the tracheostomy of an assigned client. Which response should the student nurse make? 1. "Is there any particular time I should do this?" 2. "Should I complete tracheostomy care also?" 3. "Is all of the equipment already in the client's room?" 4. "That is beyond my scope of practice as an assistant." Answer: 4 Explanation: Students who work as part-time or temporary UAP must also remember that legally they can perform only those tasks that appear in the job description of the UAP. Even though a student may have received instruction and acquired competence in suctioning a tracheostomy tube, the student cannot legally perform this task while employed as a UAP. While acting as a paid employee, the student is covered for negligent acts by the employer, not the school of nursing. Asking when the task should be completed, if tracheostomy care is needed, and if equipment is available are inappropriate responses. Page Ref: 65-66 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essential Competencies: VIII. 12. Act to prevent unsafe, illegal, or unethical care practices | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14. Discuss the legal responsibilities of nursing students. MNL Learning Outcome: 3. Recognize areas of potential legal liability in nursing.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 4 Values, Ethics, and Advocacy 1) A student is attending a school with a high first-time pass rate on the NCLEX®. Which student statement articulates a belief that the student has about faculty in the program? 1. Expect high academic standards from their students 2. Are concerned with job placement of their graduates 3. Are most concerned with the successful licensure of each student 4. Work hard to make sure students are successful Answer: 3 Explanation: Beliefs are interpretations or conclusions that people accept as true. They are based more on faith than fact and may or may not be true. Stating that faculty is more concerned with licensure would be a belief that the student has. It may or may not be true and it may be something that the student believes only for a short time–for example, until the student has had experiences with more of the faculty than just a few. Page Ref: 70 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. C. 3. Value the perspectives and expertise of all health team members | AACN Essentials Competencies: VIII. 3. Promote the image of nursing by modeling the values and articulating the knowledge, skills, and attitudes of the nursing profession | NLN Competencies: Teamwork; Ethical Comportment; Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Explain how values, moral frameworks, and codes of ethics affect moral decisions. MNL Learning Outcome: 1. Recognize how values, principles of ethical decision making, codes of ethics, and strategies are used to support decisions in nursing practice.
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2) The nurse manager tries to make sure staff are able to observe certain religious holidays. Which value is the manager practicing? 1. Human dignity 2. Social justice 3. Autonomy 4. Altruism Answer: 4 Explanation: Altruism is a concern for the welfare and well-being of others. A professional behavior of this value is demonstrating understanding of the cultures, beliefs, and perspectives of others. This action does not demonstrate human dignity, social justice, or autonomy. Page Ref: 71 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: II. C. 3. Value the perspectives and expertise of all health team members | AACN Essentials Competencies: VIII. 3. Promote the image of nursing by modeling the values and articulating the knowledge, skills, and attitudes of the nursing profession | NLN Competencies: Teamwork; Ethical Comportment; Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Explain how values, moral frameworks, and codes of ethics affect moral decisions. MNL Learning Outcome: 1. Recognize how values, principles of ethical decision making, codes of ethics, and strategies are used to support decisions in nursing practice.
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3) Parents of a terminally ill child have decided to remove their child from life support, a decision that has met with little positive support. Which nursing action demonstrates autonomy regarding the parents' decision? 1. Showing respect for the family 2. Respecting the parents' decision 3. Referring the parents to social services 4. Asking to be assigned to a different client Answer: 2 Explanation: Autonomy is the right to self-determination, and professional practice reflects autonomy when the nurse respects patients' rights to make decisions about their healthcare. Autonomy is more than showing respect for the family. Referring the parents to social services and asking for a reassignment does not demonstrate autonomy regarding the parents' decision. Page Ref: 72 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: II. C. 3. Value the perspectives and expertise of all health team members | AACN Essentials Competencies: VIII. 3. Promote the image of nursing by modeling the values and articulating the knowledge, skills, and attitudes of the nursing profession | NLN Competencies: Teamwork; Ethical Comportment; Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Explain how values, moral frameworks, and codes of ethics affect moral decisions. MNL Learning Outcome: 1. Recognize how values, principles of ethical decision making, codes of ethics, and strategies are used to support decisions in nursing practice.
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4) The nurse is working with a local agency to provide care to the inadequately insured by helping to staff an after-hours clinic. Which professional value is the nurse demonstrating? 1. Human dignity 2. Altruism 3. Social justice 4. Integrity Answer: 3 Explanation: Social justice is upholding moral, legal, and humanistic principles. This value is demonstrated in professional practice when the nurse works to ensure equal treatment under the law and equal access to quality healthcare. The nurse is not demonstrating human dignity, altruism, or integrity. Page Ref: 71 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: II. C. 3. Value the perspectives and expertise of all health team members | AACN Essentials Competencies: VIII. 3. Promote the image of nursing by modeling the values and articulating the knowledge, skills, and attitudes of the nursing profession | NLN Competencies: Teamwork; Ethical Comportment; Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Explain how values, moral frameworks, and codes of ethics affect moral decisions. MNL Learning Outcome: 1. Recognize how values, principles of ethical decision making, codes of ethics, and strategies are used to support decisions in nursing practice.
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5) The nurse gives a client who was to be NPO for a procedure a breakfast tray. What is demonstrated when the nurse apologizes to the client, informs the physician of the error, and documents the reason for the procedure delay in the medical record? 1. Altruism 2. Integrity 3. Social justice 4. Human dignity Answer: 2 Explanation: Integrity is acting in accordance with an appropriate code of ethics and accepted standards of practice. The nurse's actions do not demonstrate altruism, social justice, or human dignity. Page Ref: 71 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct | NLN Competencies: Context and Environment; PracticeKnow-How; Apply ethical decision-making models | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Explain how nurses use knowledge of values to make ethical decisions and to assist clients in clarifying their values. MNL Learning Outcome: 1. Recognize how values, principles of ethical decision making, codes of ethics, and strategies are used to support decisions in nursing practice. 6) A pregnant client wants the baby to be born healthy, even though the client admits to drinking alcohol on a regular basis. With what should the nurse realize this client is struggling? 1. Values transmission 2. Values clarification 3. Morals 4. Ethics Answer: 2 Explanation: Behavior that indicates unclear values includes ignoring a health professional's advice, such as using alcohol during pregnancy. The client is not having difficulty with values transmission, morals, or ethics. Page Ref: 71 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. C. 1. Value seeing healthcare situations "through patients' eyes" | AACN Essentials Competencies: VII. 3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations | NLN Competencies: Teamwork; Ethical Comportment; Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Explain how nurses use knowledge of values to make ethical decisions and to assist clients in clarifying their values. MNL Learning Outcome: 2. Recognize how moral development and moral principles impact client care. 5
7) A client who has been blinded as result of an injury informs plans to return to work full -time. Which aspect of values clarification is this client demonstrating? 1. Choosing 2. Prizing 3. Acting 4. Clarifying Answer: 3 Explanation: The "acting" component of values clarification is a behavioral action in which chosen beliefs are affirmed to others, incorporated into one's behavior, and repeated consistently in one's life. Stating the intention to return to prior employment on a full-time basis would be an affirmation of the client's plan. The client is not demonstrating choosing, prizing, or clarifying. Page Ref: 71 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: III. C. 1. Value seeing healthcare situations "through patients' eyes" | AACN Essentials Competencies: VII. 3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations | NLN Competencies: Teamwork; Ethical Comportment; Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Explain how nurses use knowledge of values to make ethical decisions and to assist clients in clarifying their values. MNL Learning Outcome: 2. Recognize how moral development and moral principles impact client care.
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8) A client continues to experience pain after receiving the maximum amount of medication prescribed by the physician. Which action demonstrates the nurse's respect for the client's autonomy? 1. Telling the client that he will have to "tough it out" 2. Calling the physician for further orders 3. Telling coworkers that this client has no pain tolerance 4. Believing the client is drug seeking Answer: 2 Explanation: Honoring the principle of autonomy means that the nurse respects the client's right to make decisions, treating others with consideration and not as impersonal sources of knowledge or training. Believing the client continues to have pain would be an example of treating with consideration. For whatever reason, this particular client is not responding to the medication ordered by the physician, and other medications or treatment should be initiated. Telling the client to tough it out, stating the client has no pain tolerance, and believing the client is drug seeking does not respect the client's autonomy. Page Ref: 74 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: III. C. 1. Value seeing healthcare situations "through patients' eyes" | AACN Essentials Competencies: VII. 3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations | NLN Competencies: Teamwork; Ethical Comportment; Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2. Explain how nurses use knowledge of values to make ethical decisions and to assist clients in clarifying their values. MNL Learning Outcome: 2. Recognize how moral development and moral principles impact client care.
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9) A client has chosen to discontinue hemodialysis even though the family is not supportive of the decision. Which statement should the nurse make that demonstrates the theory of principlesbased reasoning? 1. "This client is of sound mind and is capable of making his own decisions regarding healthcare. It really is his decision to make." 2. "I need to try and help the family understand the client's decision so they can work through this situation together." 3. "This client's health is so deteriorated that the treatment is not saving his life. It is prolonging the ultimate outcome, which is his death." 4. "The client understands his decision and the advanced stage of his disease. If he quits treatment, he will die." Answer: 1 Explanation: Principles-based theories stress individual rights, such as autonomy. The client has the ability to make the decision and has the right to do that. The other statements do not demonstrate the theory of principles-based reasoning. Page Ref: 73 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct | NLN Competencies: Context and Environment; PracticeKnow-How; Apply ethical decision-making models | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. When presented with an ethical situation, identify the moral issues and principles involved. MNL Learning Outcome: 3. Consider the ethical issues encountered in nursing practice and the nurse's role in managing client care.
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10) Hospital administration is relocating a clinic into the infrastructure to support the staff and client needs despite causing a transportation issue for some clinic users. Which moral framework did the hospital leadership use to make this decision? 1. Teleological theory 2. Deontological theory 3. Utilitarianism 4. Caring theory Answer: 3 Explanation: Utilitarianism views a good act as one that brings the most good and the least harm for the greatest number of people. Continuing to provide a service, even though it has to be relocated, is better than discontinuing something that clients continue to use and employees depend on. This decision is not based upon teleological theory, deontological theory, or the caring theory. Page Ref: 73 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct | NLN Competencies: Context and Environment; PracticeKnow-How; Apply ethical decision-making models | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Explain how values, moral frameworks, and codes of ethics affect moral decisions. MNL Learning Outcome: 1. Recognize how values, principles of ethical decision making, codes of ethics, and strategies are used to support decisions in nursing practice.
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11) A decision has been made for an older client to receive aggressive cancer therapy despite knowing that the therapy will actually be more harmful than the disease and subject the client to harmful chemicals. With which ethical principle is this nurse caring for this client struggling? 1. Autonomy 2. Justice 3. Beneficence 4. Nonmaleficence Answer: 4 Explanation: Nonmaleficence is the duty to "do no harm." Doing intentional harm is never acceptable in nursing. Placing a client at risk of harm is what is depicted in this scenario, and it occurs as a known consequence of a nursing intervention or some other type of treatment. It is unknown how much therapy will be of benefit to the client or whether it will actually do more harm. The nurse is not struggling with autonomy, justice, or beneficence. Page Ref: 74 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct | NLN Competencies: Context and Environment; PracticeKnow-How; Apply ethical decision-making models | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Discuss common ethical issues currently facing healthcare professionals. MNL Learning Outcome: 3. Consider the ethical issues encountered in nursing practice and the nurse's role in managing client care.
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12) The parent of a toddler who is scared and crying asks if inserting an intravenous access device is painful. When practicing veracity, what should the nurse respond to the parent? 1. "I won't lie to you. It may be easier for you if you step out until we get the line in." 2. "We'll take every care not to hurt your child." 3. "It shouldn't be too bad and I'll be quick." 4. "We do this all the time, so don't worry." Answer: 1 Explanation: Veracity refers to telling the truth. Even though telling the truth may frighten the parent, starting an IV on a frightened, scared, ill child is a difficult task. Because of the child's developmental stage, any explanation given by the nurse won't be understood. Being honest with the parent will help the nurse gain trust and will outweigh any benefits that may be gained by downplaying the situation. Page Ref: 74 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct | NLN Competencies: Context and Environment; PracticeKnow-How; Apply ethical decision-making models | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Explain how values, moral frameworks, and codes of ethics affect moral decisions. MNL Learning Outcome: 1. Recognize how values, principles of ethical decision making, codes of ethics, and strategies are used to support decisions in nursing practice.
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13) A student nurse is informed of accidentally leaving the call light outside the reach of an older client, apologizes, and states the need to double-check for call light placement before leaving a client's room. What behavior did the student demonstrate? 1. Justice 2. Fidelity 3. Responsibility 4. Accountability Answer: 4 Explanation: Accountability means "answering to oneself and others for one's own actions." By admitting that double-checking should be done, the student showed accountability. The student did not demonstrate justice, fidelity, or responsibility. Page Ref: 74 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct | NLN Competencies: Context and Environment; PracticeKnow-How; Apply ethical decision-making models | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 3. When presented with an ethical situation, identify the moral issues and principles involved. MNL Learning Outcome: 2. Recognize how moral development and moral principles impact client care. 14) The nurse is reviewing the Code of Ethics for Nurses. What should the nurse identify as a characteristic of this code? (Select all that apply.) 1. It is a formal statement. 2. It contains the same standards as legal standards. 3. It is shared by group members. 4. It reflects legal judgments. 5. It serves as a standard for professional actions. Answer: 1, 3, 5 Explanation: A code of ethics is a formal statement. Codes of ethics are shared by members of the group. Codes of ethics serve as a standard for professional actions. Page Ref: 75-76 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct | NLN Competencies: Context and Environment; PracticeKnow-How; Apply ethical decision-making models | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Explain how nurses use knowledge of values to make ethical decisions and to assist clients in clarifying their values. MNL Learning Outcome: 1. Recognize how values, principles of ethical decision making, codes of ethics, and strategies are used to support decisions in nursing practice. 12
15) A young adult client with Down syndrome who is able to live and work independently wants a treatment for an illness even though the client's parents do not want the treatment to be given. According to the nursing code of ethics, to whom is the nurse's first loyalty? 1. The client 2. The parent 3. The physician 4. The nurse Answer: 1 Explanation: The nurse's first loyalty is to the client. Conflicts among obligations to families, physicians, employing institutions, and clients may arise because of the nurse's unique position. It is not always easy to determine which action best serves the client's needs. Page Ref: 77 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct | NLN Competencies: Context and Environment; PracticeKnow-How; Apply ethical decision-making models | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Discuss the advocacy role of the nurse. MNL Learning Outcome: 4. Determine appropriate nursing responses to protect, support, and advocate for clients. 16) A client with terminal cancer asks for guidance and support to end life. What information should the nurse use when making an ethical and moral decision about this client's request? 1. Passive euthanasia is an easy decision to arrive at. 2. Legal issues are not the same as moral or ethical ones. 3. Active euthanasia is supported in the Code for Nurses. 4. Assisted suicide is illegal in all states. Answer: 2 Explanation: Determining whether an action is legal is only one aspect of deciding whether it is ethical. Legality and morality are not one and the same. The nurse must know and follow the legal statutes of the profession and boundaries within the state before making any decision. Passive euthanasia is not an easy decision to make. Active euthanasia is not supported in the Code for Nurses. Assisted suicide is legal in five states. Page Ref: 80 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct | NLN Competencies: Context and Environment; PracticeKnow-How; Apply ethical decision-making models | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Discuss common ethical issues currently facing healthcare professionals. MNL Learning Outcome: 3. Consider the ethical issues encountered in nursing practice and the nurse's role in managing client care. 13
17) The family of a client with terminal cancer wants a gastrostomy tube placed since the client is refusing all food and fluids. What should the nurse do? 1. Honor the family's wishes and have them sign a consent form. 2. Talk to the physician so he or she can move forward with the family's wishes. 3. Honor the client's refusal and help the family come to terms with the situation. 4. Take the case to the hospital's ethics committee. Answer: 3 Explanation: The nurse is morally obligated to withhold food and fluids if it is determined to be more harmful to administer them than to withhold them. The nurse must also honor competent clients' refusal of food and fluids. This position is supported by the ANA's Code of Ethics for Nurses, through the nurse's role as a client advocate, and through the moral principle of autonomy. Clients, not their families, should make decisions about their own healthcare and treatment. In this case, the client has made a decision and it should be honored. The issue does not need to be discussed with the physician or the hospital ethics committee. Page Ref: 81 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct | NLN Competencies: Context and Environment; PracticeKnow-How; Apply ethical decision-making models | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. When presented with an ethical situation, identify the moral issues and principles involved. MNL Learning Outcome: 3. Consider the ethical issues encountered in nursing practice and the nurse's role in managing client care.
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18) A client with a sexually transmitted infection (STI) does not want anyone to know about the diagnosis. According to the Health Insurance Portability and Accountability Act (HIPAA), what must the nurse do? 1. Honor the client's wishes. 2. Not disclose any information to anyone. 3. Respect the client's privacy and confidentiality. 4. Communicate only necessary information. Answer: 4 Explanation: HIPAA includes standards that protect the confidentiality, integrity, and availability of data as well as standards that define appropriate disclosures of identifiable health information and patient rights protection. Nurses are entrusted with sensitive information that, at times, must be revealed to other healthcare personnel in order to provide appropriate healthcare. In this case, the nurse may be required to report information to the state health department. Honoring the client's wishes might not be able to be done. The nurse may need to share the information despite wanting to respect the client's privacy and confidentiality. Page Ref: 81 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Discuss common ethical issues currently facing healthcare professionals. MNL Learning Outcome: 3. Consider the ethical issues encountered in nursing practice and the nurse's role in managing client care.
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19) The nurse learns that a home care client is diluting prescribed nutritional supplements because of the cost. What should the nurse do to advocate for this client? 1. Help the client look for available community resources that may be of assistance. 2. Tell the client that the prescribed amount needs to be taken. 3. Report the situation to the physician. 4. Weigh the client on a weekly basis to monitor weight gain or loss. Answer: 1 Explanation: Resource allocation and financial considerations are major issues in home healthcare. When clients are in their own home, they operate from their own values and client autonomy must be respected. Community resources may be of benefit for this client to be able to afford the proper supplement at the correct dose or to provide assistance in other financial areas so the client has treatment needs met. Page Ref: 82 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct | NLN Competencies: Context and Environment; PracticeKnow-How; Apply ethical decision-making models | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Discuss the advocacy role of the nurse. MNL Learning Outcome: 4. Determine appropriate nursing responses to protect, support, and advocate for clients.
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20) The nurse is reviewing the preamble of the International Council of Nurses Code of Ethics. On which responsibilities should the nurse focus when reviewing this preamble? (Select all that apply.) 1. Promote health. 2. Restore health. 3. Inform the public about minimum standards of nursing conduct. 4. Provide self-regulation in the profession. 5. Prevent illness. 6. Alleviate suffering. Answer: 1, 2, 5, 6 Explanation: Promotion of health is one of the fundamental responsibilities of nurses according to the International Council of Nurses Code of Ethics. Restoration of health is one of the fundamental responsibilities of nurses according to the International Council of Nurses Code of Ethics. Preventing illness is one of the fundamental responsibilities of nurses according to the International Council of Nurses Code of Ethics. The alleviation of suffering is one of the fundamental responsibilities of nurses according to the International Council of Nurses Code of Ethics. Page Ref: 76 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct | NLN Competencies: Context and Environment; PracticeKnow-How; Apply ethical decision-making models | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Explain how values, moral frameworks, and codes of ethics affect moral decisions. MNL Learning Outcome: 1. Recognize how values, principles of ethical decision making, codes of ethics, and strategies are used to support decisions in nursing practice.
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21) The nurse manager determines that a staff nurse demonstrates understanding of the professional responsibility to advocate for a client's health, safety, and rights. What did the manager observe to come to this conclusion about the staff nurse? (Select all that apply.) 1. Reporting a medication error that the nurse made 2. Notifying the unit manager that a nurse is showing signs of being under the influence of alcohol 3. Being sure the computer screen is not visible to visitors when charting 4. Asking the client to explain in her own words the purpose of the research project she asked to act in as a participant 5. Calling the healthcare provider to clarify a confusing prescription for a client's pain Answer: 2, 3, 4, 5 Explanation: The nurse advocates for client health and safety when reporting the impaired nurse. The nurse advocates for client rights when protecting confidentiality. The nurse advocates for client health and safety when protecting the participants in a research project. The nurse advocates for client health and safety when clarifying confusing orders or questionable medical practices. Page Ref: 81-82 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct | NLN Competencies: Context and Environment; PracticeKnow-How; Apply ethical decision-making models | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5. Discuss the advocacy role of the nurse. MNL Learning Outcome: 4. Determine appropriate nursing responses to protect, support, and advocate for clients.
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22) The nurse is addressing an ethical issue. In which order should the nurse implement the steps of this decision-making process? 1. Interviewing the client regarding details of the problem 2. Discussing the various results of the identified possible actions to resolve the problem 3. Determining what, if any, ethical issues exist 4. Determining whether affected parties are in ethical conflict 5. Assessing all involved parties concerning their ethical beliefs regarding the problem Answer: 1, 3, 5, 4, 2 Explanation: 1. Gathering additional information to clarify the situation is the first step in this model. 2. Identifying the range of actions with anticipated outcomes is the final step in this process among the available options. 3. Identifying the ethical issues in the situation occurs immediately after the information concerning the problem is obtained. 4. Identifying value conflicts occurs after information has been gathered, after it is determined that an ethical problem exists, and after affected individuals are assessed for their ethical beliefs. 5. Identifying moral positions of key individuals involved occurs after information has been gathered and it is determined that an ethical problem exists. Page Ref: 78-79 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct | NLN Competencies: Context and Environment; PracticeKnow-How; Apply ethical decision-making models | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Explain how nurses use knowledge of values to make ethical decisions and to assist clients in clarifying their values. MNL Learning Outcome: 1. Recognize how values, principles of ethical decision making, codes of ethics, and strategies are used to support decisions in nursing practice.
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23) A client with lung disease is strongly urged to stop smoking but likes to smoke and does not know what to do. In what order should the nurse take the following actions to help this client clarify values? 1. Choose freely. 2. List alternatives. 3. Affirm the choice. 4. Act with a pattern. 5. Examine consequences of choices. 6. Examine feelings about the choice. Answer: 2, 5, 1, 6, 3, 4 Explanation: 1. The nurse should ask if the client has a say in the decision in the third step of the process. 2. In the first step of the process, the nurse should help the client list alternatives so that the client is aware of all alternative actions. 3. The nurse needs to ask how the client affirmed the choice by asking if the choice was discussed with others in the fifth step of the process. 4. The final step is to find out if the client has acted with a pattern or consistently performs an action in a certain way. 5. In the second step of the process, consequences of all choices need to be examined so that the client has thought about possible results of each action. 6. In the fourth step of the process, the nurse needs to examine the client's feelings about the choice. Some clients may not feel satisfied with their decision. Page Ref: 71 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct | NLN Competencies: Context and Environment; PracticeKnow-How; Apply ethical decision-making models | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Explain how nurses use knowledge of values to make ethical decisions and to assist clients in clarifying their values. MNL Learning Outcome: 1. Recognize how values, principles of ethical decision making, codes of ethics, and strategies are used to support decisions in nursing practice.
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24) The school of nursing professor is preparing a classroom activity to assist the students in acquiring professional values. Which actions should the professor select for this assignment? (Select all that apply.) 1. Discuss codes of ethics with the students. 2. Recommend that the students avoid ethical issues. 3. Encourage the students to discuss experiences. 4. Invite other professors to participate in a discussion. 5. Have the students interview each other about experiences. Answer: 1, 3, 4, 5 Explanation: Nurses' professional values are acquired during socialization into nursing from codes of ethics, nursing experiences, teachers, and peers. Nurses' professional values are acquired during socialization into nursing from codes of ethics, nursing experiences, teachers, and peers. Nurses' professional values are acquired during socialization into nursing from codes of ethics, nursing experiences, teachers, and peers. Nurses' professional values are acquired during socialization into nursing from codes of ethics, nursing experiences, teachers, and peers. Page Ref: 71-72 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct | NLN Competencies: Context and Environment; PracticeKnow-How; Apply ethical decision-making models | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1. Explain how values, moral frameworks, and codes of ethics affect moral decisions. MNL Learning Outcome: 1. Recognize how values, principles of ethical decision making, codes of ethics, and strategies are used to support decisions in nursing practice.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 5 Healthcare Delivery Systems 1) The nurse is reviewing the Healthy People 2030 primary goals. Which plan should the nurse realize is in alignment with one of the goals? 1. Providing free screening to schoolchildren 2. Opening a wellness clinic 3. Developing better insurance controls 4. Developing new pharmacological treatments Answer: 2 Explanation: Healthy People 2030 has five overarching goals: (1) Attain healthy, thriving lives and well-being, free of preventable disease, disability, injury, and premature death. (2) Eliminate health disparities, achieve health equity, and attain health literacy to improve the health and wellbeing of all. (3) Create social, physical, and economic environments that promote attaining full potential for health and well-being for all. (4) Promote healthy development, healthy behaviors, and well-being across all life stages., and (5) Engage leadership, key constituents, and the public across multiple sectors to take action and design policies that improve the health and well-being of all. Opening a wellness clinic focuses on bettering health, which would be in line with goal 1. Page Ref: 87 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 10. Collaborate with others to develop an intervention plan that takes into account determinants of health, available resources, and the range of activities that contribute to health and prevention of illness, injury, disability, and premature death | NLN Competencies: Teamwork; Practice-KnowHow; Clarify roles and integrate the contributions of others who play a role in helping the patient/family achieve health goals | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Differentiate healthcare services based on primary, secondary, and tertiary disease prevention categories. MNL Learning Outcome: 1. Recognize the three levels of preventative healthcare services, types of healthcare agencies and services, and roles of healthcare providers.
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2) Several nurses are working to open a clinic that focuses on health promotion. Which activity should the nurses expect to perform once this clinic opens? 1. Teaching biofeedback techniques for stress reduction 2. Providing immunization clinics 3. Evaluating regional industrial centers for environmental pollution 4. Teaching smoking-cessation classes to adolescents Answer: 1 Explanation: Health promotion programs address nutrition, weight control, exercise, and stress reduction. Health promotion activities emphasize the role of clients in maintaining their own health and provide encouragement in maintaining the highest level of wellness they can achieve. Immunization clinics, evaluating for environment pollution, and smoking cessation focus on illness prevention. Page Ref: 87-88 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 10. Collaborate with others to develop an intervention plan that takes into account determinants of health, available resources, and the range of activities that contribute to health and prevention of illness, injury, disability, and premature death | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1. Differentiate healthcare services based on primary, secondary, and tertiary disease prevention categories. MNL Learning Outcome: 1. Recognize the three levels of preventative healthcare services, types of healthcare agencies and services, and roles of healthcare providers.
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3) A client is in the end stages of cancer. Which type of service should the nurse consider as being the best for this client? 1. Rehabilitation 2. Health restoration 3. Acute care 4. Palliative care Answer: 4 Explanation: Palliative care is service that provides comfort and treatment of symptoms. This type of care is for clients who cannot be returned to health. It may be conducted in many settings, including the home. Rehabilitation, health restoration, and acute care would not be the best for this client. Page Ref: 88 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 10. Collaborate with others to develop an intervention plan that takes into account determinants of health, available resources, and the range of activities that contribute to health and prevention of illness, injury, disability, and premature death | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Describe the functions and purposes of the healthcare agencies outlined in this chapter. MNL Learning Outcome: 1. Recognize the three levels of preventative healthcare services, types of healthcare agencies and services, and roles of healthcare providers.
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4) Several nurses are looking for an agency to sponsor a program that would meet the needs of a community group lacking in health promotion education. Which agency should the nurse approach to fill this need? 1. State health department 2. Local health department 3. Local hospital 4. Federal government Answer: 2 Explanation: The local health department has the responsibility for developing programs to meet the health needs of the people, providing the necessary staff and facilities to carry out those programs, evaluating their effectiveness, and monitoring changing needs. The state health department, local hospital, or federal government would not be appropriate to meet the needs of the community. Page Ref: 88 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 10. Collaborate with others to develop an intervention plan that takes into account determinants of health, available resources, and the range of activities that contribute to health and prevention of illness, injury, disability, and premature death | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe the functions and purposes of the healthcare agencies outlined in this chapter. MNL Learning Outcome: 1. Recognize the three levels of preventative healthcare services, types of healthcare agencies and services, and roles of healthcare providers.
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5) The nurse is hired to provide care in a hospital that offers services in all specialty areas. How should the nurse categorize this type of healthcare facility? 1. General hospital 2. Specialty hospital 3. Long-term care hospital 4. Short-term care hospital Answer: 1 Explanation: Hospitals are classified by the services they provide as well as by their ownership. General hospitals admit clients requiring a variety of services, such as medical, surgical, obstetric, pediatric, and psychiatric services. A specialty, long-term care, or short-term care hospital would not provide services in all specialty areas. Page Ref: 90 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 10. Collaborate with others to develop an intervention plan that takes into account determinants of health, available resources, and the range of activities that contribute to health and prevention of illness, injury, disability, and premature death | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Describe the functions and purposes of the healthcare agencies outlined in this chapter. MNL Learning Outcome: 1. Recognize the three levels of preventative healthcare services, types of healthcare agencies and services, and roles of healthcare providers.
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6) A client being discharged from an acute care hospital requires IV antibiotics, is not able to complete activities of daily living without assistance, and has no family available to assist in the recovery phase. Which type of recommendation should the nurse make for this client? 1. Stay in the hospital until the client is fully capable of self-care. 2. Remain in the hospital until the antibiotic course is completed. 3. Be discharged to an extended care facility. 4. Go to an assisted living facility. Answer: 3 Explanation: Extended care facilities provide care for clients who require rehabilitation and custodial care after discharge from an acute care hospital. Because this client still receives antibiotic therapy and requires some custodial care, this type of facility can provide the best care until the client is ready for discharge home. It is inappropriate for the client to remain hospitalized until able to provide self-care or until the antibiotic course is completed. The client needs more can what would be provided in an assisted living facility. Page Ref: 90-91 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 10. Collaborate with others to develop an intervention plan that takes into account determinants of health, available resources, and the range of activities that contribute to health and prevention of illness, injury, disability, and premature death | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe the functions and purposes of the healthcare agencies outlined in this chapter. MNL Learning Outcome: 1. Recognize the three levels of preventative healthcare services, types of healthcare agencies and services, and roles of healthcare providers.
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7) An older client with osteoarthritis lives alone, does not want to cook, and has been losing weight. What should the nurse recommend for this client? 1. See a psychiatrist because the client is depressed. 2. Check out joint replacement options for the osteoarthritis. 3. Start thinking about long-term care. 4. Consider moving to an assisted living facility. Answer: 4 Explanation: Assisted living facilities offer meals, laundry services, nursing care, transportation, and social activities to residents who are able to live relatively independently. They are intended to meet the needs of people who are unable to remain at home but do not require hospital or nursing home care. The client in this scenario has some physical limitations but could benefit from socialization and interaction with peers as well as having staff available to provide limited care and health promotion activities. There is no evidence that the client is depressed. Investigating joint replacement surgery would be a client decision. The client does not need long-term care. Page Ref: 91 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 10. Collaborate with others to develop an intervention plan that takes into account determinants of health, available resources, and the range of activities that contribute to health and prevention of illness, injury, disability, and premature death | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe the functions and purposes of the healthcare agencies outlined in this chapter. MNL Learning Outcome: 1. Recognize the three levels of preventative healthcare services, types of healthcare agencies and services, and roles of healthcare providers.
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8) The spouse of a client with Stage I/II Alzheimer's disease must continue to work full time; however, the client has started to wander outside the house, forgets to turn off the stove after preparing food, and tries to drive the car if the keys are available. What should the nurse recommend for this family? 1. The client should be placed in long-term care. 2. The spouse should consider early retirement. 3. The client should be placed in an adult day-care environment. 4. An increase in the client's medications should be considered to slow the progress of the disease. Answer: 3 Explanation: Day-care centers provide care and nutrition for adults who cannot be left at home alone but do not need to be in an institution. These centers often provide care involving socializing, exercise programs, and stimulation. Some provide counseling and physical therapy. Nurses who are employed in day-care centers may provide medications, treatment, and counseling. The client does not need long-term care. It is inappropriate for the spouse to consider early retirement. There is no medication to treat this disease process. Page Ref: 92 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 10. Collaborate with others to develop an intervention plan that takes into account determinants of health, available resources, and the range of activities that contribute to health and prevention of illness, injury, disability, and premature death | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe the functions and purposes of the healthcare agencies outlined in this chapter. MNL Learning Outcome: 1. Recognize the three levels of preventative healthcare services, types of healthcare agencies and services, and roles of healthcare providers.
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9) The spouse of a client referred to hospice care asks why the client needs the change in services. How should the nurse respond to this question? 1. "So we can see if there's any way to improve your spouse's life." 2. "There is no need for acute care any longer." 3. "It's best for your spouse to be cared for at home." 4. "Hospice care is cheaper than acute care." Answer: 1 Explanation: The central concept of the hospice movement is not saving life but improving or maintaining the quality of life until death. Hospice care provides a variety of services given to the terminally ill, their families, and support persons. The place of care varies, but includes home, hospital, or skilled nursing facilities. The other responses are inaccurate and inappropriate for the nurse to make. Page Ref: 92 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 10. Collaborate with others to develop an intervention plan that takes into account determinants of health, available resources, and the range of activities that contribute to health and prevention of illness, injury, disability, and premature death | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe the functions and purposes of the healthcare agencies outlined in this chapter. MNL Learning Outcome: 1. Recognize the three levels of preventative healthcare services, types of healthcare agencies and services, and roles of healthcare providers.
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10) A young adult client recovering from an injury that resulted in partial paralysis plans to live independently as before the injury. Which referral should the nurse identify as being the best for this client? 1. Paramedical technologist 2. Physical therapist 3. Occupational therapist 4. Case manager Answer: 3 Explanation: An occupational therapist assists clients with impaired function to gain the skills necessary for activities of daily living. The therapist teaches skills that are therapeutic but at the same time provide fulfillment. Helping a client with paralysis learn to use equipment or different methods of doing daily tasks will enable the client to be as independent as possible. The client does not need a referral for a paramedical technologist, physical therapist, or case manager. Page Ref: 93-94 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 10. Collaborate with others to develop an intervention plan that takes into account determinants of health, available resources, and the range of activities that contribute to health and prevention of illness, injury, disability, and premature death | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe the functions and purposes of the healthcare agencies outlined in this chapter. MNL Learning Outcome: 1. Recognize the three levels of preventative healthcare services, types of healthcare agencies and services, and roles of healthcare providers.
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11) The nurse is interviewing a client at a clinic near a shelter for the homeless. Understanding the increased risk a poor physical environment creates for this client, on what should the nurse focus during the intake phase of the interview? 1. Lack of social support 2. Recent history of chills and body aches 3. Improper nutrition 4. Few personal resources Answer: 2 Explanation: A poor physical environment results in increased susceptibility to infections. The client's recent history of chills and body aches should alert the nurse that this client may have an infection. Lack of social support, improper nutrition, and few personal resources are all important but will not be impacted by a poor physical environment as much as a recent history of chills and body aches. Page Ref: 97-98 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 10. Collaborate with others to develop an intervention plan that takes into account determinants of health, available resources, and the range of activities that contribute to health and prevention of illness, injury, disability, and premature death | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify the roles of various healthcare professionals. MNL Learning Outcome: 1. Recognize the three levels of preventative healthcare services, types of healthcare agencies and services, and roles of healthcare providers.
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12) The nurse is working in a clinic that emphasizes cost control, customer satisfaction, health promotion, and preventive services. In which type of health system is this nurse providing care? 1. Managed care 2. Case management 3. Differentiated practice 4. Patient-focused care Answer: 1 Explanation: Managed care describes a healthcare system whose goals are to provide costeffective, quality care that focuses on decreased costs and improved outcomes for groups of clients. Cost control, customer satisfaction, health promotion, and preventive services does not describe case management, differentiated practice, or patient-focused care. Page Ref: 98 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 10. Collaborate with others to develop an intervention plan that takes into account determinants of health, available resources, and the range of activities that contribute to health and prevention of illness, injury, disability, and premature death | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Describe the factors that affect healthcare delivery. MNL Learning Outcome: 1. Recognize the three levels of preventative healthcare services, types of healthcare agencies and services, and roles of healthcare providers.
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13) A new graduate nurse is looking for employment and is hoping to find a facility that utilizes nursing personnel based on their educational preparation and skill set. In which type of facility should the new graduate apply for a position? 1. Patient-focused care 2. Functional method 3. Differentiated practice 4. Managed care Answer: 3 Explanation: Differentiated practice is a system in which the best possible use of nursing personnel is based on their educational preparation and resultant skill sets. This model consists of specific job descriptions for nurses according to their education or training. The best use of nursing personnel is not a criteria for patient-focused care, functional method, or managed care. Page Ref: 99 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 10. Collaborate with others to develop an intervention plan that takes into account determinants of health, available resources, and the range of activities that contribute to health and prevention of illness, injury, disability, and premature death | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify the roles of various healthcare professionals. MNL Learning Outcome: 1. Recognize the three levels of preventative healthcare services, types of healthcare agencies and services, and roles of healthcare providers.
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14) The nurse is considering leaving a position in an organization that utilized differentiated practice. Which type of delivery system should the nurse consider as being the most similar to differentiated practice? 1. Case method 2. Case management 3. Functional method 4. Team nursing Answer: 4 Explanation: Team nursing is the delivery of individualized nursing care to clients by a team led by a professional nurse. The nursing team consists of registered nurses, licensed practical nurses, and unlicensed assistive personnel. The registered nurse retains responsibility and authority for client care but delegates appropriate tasks to the other team members. This enables nurses to progress and assume roles and responsibilities appropriate for their level of experience, capability, and education–much like the differentiated practice system. The case method, case management, and the functional method are not the most similar to differentiated practice. Page Ref: 100 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 10. Collaborate with others to develop an intervention plan that takes into account determinants of health, available resources, and the range of activities that contribute to health and prevention of illness, injury, disability, and premature death | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify the roles of various healthcare professionals. MNL Learning Outcome: 1. Recognize the three levels of preventative healthcare services, types of healthcare agencies and services, and roles of healthcare providers.
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15) A nurse is especially competent in knowledge of the computerized charting system in a facility and is able to assume the team leader role on a regular basis. In which type of care delivery system is this nurse most likely providing care? 1. Primary nursing 2. Team nursing 3. Differentiated practice 4. Case method Answer: 1 Explanation: Primary nursing is a system in which one nurse is responsible for total care of a number of clients, 24 hours a day, 7 days a week. It is a method of providing comprehensive, individualized, and consistent care. Primary nursing uses the nurse's technical knowledge and management skills in assessing and prioritizing each client's needs, implementing the plan of care, and evaluating the plan's effectiveness. The nurse's activities do not describe team nursing, differentiated practice, or the case method. Page Ref: 100 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 10. Collaborate with others to develop an intervention plan that takes into account determinants of health, available resources, and the range of activities that contribute to health and prevention of illness, injury, disability, and premature death | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify the roles of various healthcare professionals. MNL Learning Outcome: 1. Recognize the three levels of preventative healthcare services, types of healthcare agencies and services, and roles of healthcare providers.
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16) A 68-year-old client is concerned about paying for extended hospitalization and expensive medications to treat his health problem. What should the nurse respond to this client? 1. "Don't worry. I'm sure everything will work out OK." 2. "You need to focus on recovering, not worrying about finances." 3. "Much of your care will be covered by Medicare." 4. "I'll have someone from the business office come and talk to you about your bill." Answer: 3 Explanation: The Medicare amendment to the Social Security Act provided a national and state health insurance program for older adults. By the mid-1970s, virtually everyone over 65 years of age was protected by hospital insurance under Part A. In 1988, Congress expanded Medicare to include extremely expensive hospital care, "catastrophic care," and expensive drugs. The nurse should not minimize the client's concerns. The client is not asking for assisting understanding the bill. Page Ref: 100-101 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 10. Collaborate with others to develop an intervention plan that takes into account determinants of health, available resources, and the range of activities that contribute to health and prevention of illness, injury, disability, and premature death | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Compare various systems of payment for healthcare services. MNL Learning Outcome: 4. Recognize the various systems of payment for healthcare services.
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17) A clinic in a rural area depends primarily on the services of a nurse practitioner. Which legislation provided the opportunity for the nurse practitioner to have this position? 1. Medicare 2. Medicaid 3. Rural Health Clinics Act 4. National Health Planning and Resources Development Act Answer: 3 Explanation: In 1978, the Rural Health Clinics Act provided for the development of healthcare in medically underserved rural areas. This act opened the door for nurse practitioners to provide primary care. The role of the nurse practitioner is not legislated by Medicare, Medicaid, or the National Health Planning and Resources Development Act. Page Ref: 101 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 10. Collaborate with others to develop an intervention plan that takes into account determinants of health, available resources, and the range of activities that contribute to health and prevention of illness, injury, disability, and premature death | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5. Describe frameworks for the delivery of nursing care. MNL Learning Outcome: 3. Examine the frameworks for care and how they impact patients and nursing.
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18) The nurse is reviewing the principles of the Affordable Care Act with a client. What information should the nurse include when discussing the act with the client? (Select all that apply.) 1. Individuals will be fined if they do not have health insurance. 2. Employers must offer health insurance if they meet identified requirements. 3. Insurance can be purchased through exchanges. 4. Individuals with preexisting health conditions cannot be denied health insurance coverage. 5. Health insurance is free. Answer: 3, 4 Explanation: A provision within the Affordable Care Act is that insurance can be purchased through exchanges. A provision within the Affordable Care Act is that individuals with preexisting health conditions cannot be denied health insurance coverage. Page Ref: 96-97 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 10. Collaborate with others to develop an intervention plan that takes into account determinants of health, available resources, and the range of activities that contribute to health and prevention of illness, injury, disability, and premature death | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Describe frameworks for the delivery of nursing care. MNL Learning Outcome: 3. Examine the frameworks for care and how they impact patients and nursing.
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19) A client asks the nurse to explain the difference between an HMO and a PPO. What should the nurse include when responding to the client? 1. "You'll have good healthcare benefits, so don't worry." 2. "Both the HMO and PPO are covered by your employer, so it's really not your concern." 3. "Your PPO offered you a choice in your healthcare provider as well as services. Now, you will choose a primary care provider who will evaluate your health and will coordinate all of your care." 4. "You really should be happy about the HMO. You'll pay little, if any, out-of-pocket expenses." Answer: 3 Explanation: HMO plans emphasize wellness, and members choose a primary care provider who evaluates their health status and coordinates their care. Clients are limited in their ability to select healthcare providers and services, but available services are at minimal and predetermined cost to the client. PPOs consist of a group of physicians that provide an insurance company or employer with health services at a discounted rate. One advantage of the PPO is that it provides clients with a choice of healthcare providers and services. Page Ref: 102-103 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 10. Collaborate with others to develop an intervention plan that takes into account determinants of health, available resources, and the range of activities that contribute to health and prevention of illness, injury, disability, and premature death | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Describe frameworks for the delivery of nursing care. MNL Learning Outcome: 3. Examine the frameworks for care and how they impact patients and nursing.
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20) The nurse is reviewing changes occurring within the healthcare industry. What should the nurse identify as factors that have an effect on healthcare delivery? (Select all that apply.) 1. Increased use of complementary and alternative medicine 2. More knowledgeable consumers 3. Increase in the number of older adults 4. Decrease in chronic disease 5. Technological advances 6. Economics Answer: 2, 3, 5, 6 Explanation: With the improved availability of health-related information, consumers are more knowledgeable and play an active role in their healthcare. People over age 85 are projected to be the fastest-growing population in the United States. Technology related to healthcare is rapidly increasing and includes improved diagnostic procedures and equipment that permits early recognition of diseases. Inflation increases all costs and paying for healthcare services is becoming a greater problem. Page Ref: 95-98 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 10. Collaborate with others to develop an intervention plan that takes into account determinants of health, available resources, and the range of activities that contribute to health and prevention of illness, injury, disability, and premature death | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Describe the factors that affect healthcare delivery. MNL Learning Outcome: 2. Examine the factors that affect healthcare delivery.
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21) A client in the hospital is concerned about the cost of receiving hospitalized care. What should the nurse realize is causing the increase in the client's medical expenses? (Select all that apply.) 1. Healthcare of the older adult 2. Number of uninsured population 3. Changes in birth rate over last 20 years 4. Cost of prescription drugs 5. State of inflation 6. Amount of diagnosed chronic illnesses Answer: 1, 2, 4, 5, 6 Explanation: The total population is growing, especially the older adult segment that tends to have greater healthcare needs compared to younger persons. The uninsured numbers are on the rise: 17% of persons under age 65. The cost of prescription drugs is increasing and represents 19% of total healthcare expenditures in the United States. Inflation increases all costs. The total population is growing, especially the older adult segment that tends to have diagnosed chronic illnesses. Page Ref: 96-98 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 10. Collaborate with others to develop an intervention plan that takes into account determinants of health, available resources, and the range of activities that contribute to health and prevention of illness, injury, disability, and premature death | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Describe the factors that affect healthcare delivery. MNL Learning Outcome: 2. Examine the factors that affect healthcare delivery.
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22) In order to comply with the U.S. Department of Health and Human Services' most current healthcare goals as stated in Healthy People 2030, what should the nurse do? (Select all that apply.) 1. Plan a depression screening for senior citizens who regularly have lunch at the senior center. 2. Attend an educational in-service on the use of a new automated blood pressure monitor. 3. Advocate for psychiatric healthcare for those with no private insurance coverage. 4. Organize a park "cleanup day" to ensure the community's children have a safe place to play. 5. Counsel older clients regarding programs available to assist them to live in their homes independently. Answer: 1, 3, 4, 5 Page Ref: 87 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 10. Collaborate with others to develop an intervention plan that takes into account determinants of health, available resources, and the range of activities that contribute to health and prevention of illness, injury, disability, and premature death | NLN Competencies: Teamwork; Practice-KnowHow; Clarify roles and integrate the contributions of others who play a role in helping the patient/family achieve health goals | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Differentiate healthcare services based on primary, secondary, and tertiary disease prevention categories. MNL Learning Outcome: 1. Recognize the three levels of preventative healthcare services, types of healthcare agencies and services, and roles of healthcare providers.
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23) The nurse is reviewing sources of federal funding for healthcare services provided to clients. For which clients should the nurse recognize as most likely having healthcare paid through a federal funding source? (Select all that apply.) 1. 35-year-old self-employed house painter 2. 72-year-old retired schoolteacher 3. 52-year-old nurse who runs the family farm 4. 29-year-old mentally challenged sheltered workshop employee 5. 40-year-old factory worker Answer: 2, 4 Explanation: This client would be on a federally funded insurance plan like Medicare. This client would be on a federally funded insurance plan like Medicaid. Page Ref: 100-101 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 10. Collaborate with others to develop an intervention plan that takes into account determinants of health, available resources, and the range of activities that contribute to health and prevention of illness, injury, disability, and premature death | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Describe frameworks for the delivery of nursing care. MNL Learning Outcome: 3. Examine the frameworks for care and how they impact patients and nursing. 24) The nurse is concerned that the hospital will not receive payment for care provided to a client. Which client health problems are causing the nurse this concern? (Select all that apply.) 1. Intravenous fluids were prescribed for 4 days. 2. X-rays of the left leg and left arm were prescribed. 3. A stage II pressure ulcer developed on the client's heels. 4. A urinary tract infection occurred because of an indwelling urinary catheter. 5. Physical therapy treatments were prescribed for 7 days for crutch walking. Answer: 3, 4 Page Ref: 101-102 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 10. Collaborate with others to develop an intervention plan that takes into account determinants of health, available resources, and the range of activities that contribute to health and prevention of illness, injury, disability, and premature death | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 6. Compare various systems of payment for healthcare services. MNL Learning Outcome: 4. Recognize the various systems of payment for healthcare services.
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25) The nurse is considering a position with a home health agency. What type of care should the nurse realize will be provided when working for this type of agency? (Select all that apply.) 1. Providing ventilatory support 2. Completing a health and wellness visit 3. Instructing about care of a surgical wound 4. Providing intravenous antibiotics once a day 5. Teaching about medications for self-management of diabetes Answer: 3, 4, 5 Page Ref: 92 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 10. Collaborate with others to develop an intervention plan that takes into account determinants of health, available resources, and the range of activities that contribute to health and prevention of illness, injury, disability, and premature death | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Describe the functions and purposes of the healthcare agencies outlined in this chapter. MNL Learning Outcome: 1. Recognize the three levels of preventative healthcare services, types of healthcare agencies and services, and roles of healthcare providers.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 6 Community Nursing and Care Continuity 1) The nurse is explaining primary healthcare (PHC) and the extension of its boundaries beyond traditional healthcare services to a group of community members. What issues related to PHC should the nurse include in this discussion? 1. Distribution and participation 2. Environment, agriculture, and housing 3. Consumerism and governmental subsidies 4. Low life expectancies and high mortality rates among children Answer: 2 Explanation: PHC involves issues of the environment, agriculture, and housing. It also involves other social, economic, and political issues such as poverty, transportation, unemployment, and economic development to sustain the population. Distribution and participation are two of the five principles incorporated in PHC. Consumerism and governmental subsidies are not part of the PHC makeup. Low life expectancies and high mortality rates among children are two concerns about healthcare that led to the global health strategy of primary healthcare. Page Ref: 107 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Discuss factors influencing healthcare reform. MNL Learning Outcome: 1. Recognize the impact of the movement of healthcare to the community and the various community-based healthcare frameworks.
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2) After a community was hit by a tornado, the nurses in the community helped to make sure people had adequate food and clothing. Which function of community were these nurses focused on restoring? 1. Social control 2. Social interparticipation 3. Mutual support 4. Distribution of goods and services Answer: 4 Explanation: Production, distribution, and consumption of goods and services are the means by which the community provides for the economic needs of its members. It includes supplying food and clothing as well as providing water, electricity, police and fire protection, and the disposal of refuse. Social control refers to the way in which order is maintained in a community. Social interparticipation refers to community activities that are designed to meet individuals' needs for companionship. Mutual support refers to the community's ability to provide resources at a time of illness or disaster. Page Ref: 108 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values | AACN Essentials Competencies: VII. 13. Use evaluation results to influence the delivery of care, deployment of resources, and to provide input into the development of policies to promote health and prevent disease | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe various community-based healthcare frameworks, including integrated healthcare systems, community initiatives and conditions, and case management. MNL Learning Outcome: 1. Recognize the impact of the movement of healthcare to the community and the various community-based healthcare frameworks.
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3) A nurse is helping to set up an elder social group at a local senior center where residents can come to play cards or participate in structured activities three times a week. In which community function is this nurse working? 1. Socialization 2. Social control 3. Social interparticipation 4. Mutual support Answer: 3 Explanation: Social interparticipation refers to community activities that are designed to meet people's needs for companionship. Socialization refers to the process of transmitting values, knowledge, culture, and skills to others. Social control refers to the way in which order is maintained in a community. Mutual support refers to the community's ability to provide resources at a time of illness or disaster. Page Ref: 108 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values | AACN Essentials Competencies: VII. 13. Use evaluation results to influence the delivery of care, deployment of resources, and to provide input into the development of policies to promote health and prevent disease | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Differentiate community-based nursing from traditional institutionalbased nursing. MNL Learning Outcome: 1. Recognize the impact of the movement of healthcare to the community and the various community-based healthcare frameworks.
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4) The nurse is explaining the difference between community and population to a group of community members. What should the nurse use as an example for population? 1. Commuters on the subway 2. A grade school class 3. Graduating nursing students 4. A group of employees at a local plant Answer: 1 Explanation: A population is composed of people who share some common characteristic, but who do not necessarily interact with each other–as people on a subway might behave. They are all riding, but not really interacting. A grade school class, graduating nursing students, and a group of employees would all be members of a community. Page Ref: 108 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values | AACN Essentials Competencies: VII. 13. Use evaluation results to influence the delivery of care, deployment of resources, and to provide input into the development of policies to promote health and prevent disease | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Explain essential aspects of collaborative healthcare: definitions, objectives, benefits, and the nurse's role. MNL Learning Outcome: 2. Examine the differences between community-based healthcare settings/nursing practice and traditional settings/institutional-based nursing practice.
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5) When completing a community assessment, the community health nurse will take several aspects into account. What is the first stage of this assessment that the nurse will complete? 1. Learn about the people in the community. 2. Understand the major illnesses present in the community. 3. Identify the boundaries of the community. 4. Make sure resources are available in the community. Answer: 1 Explanation: The first stage in assessment is to learn about the people in the community. When completing a community assessment, the nurse needs to focus on a much larger "client"–which is the whole community. Understanding the major illnesses, identifying the boundaries, and ensuring resources are available occur later in the process. Page Ref: 108 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Describe various community-based healthcare frameworks, including integrated healthcare systems, community initiatives and conditions, and case management. MNL Learning Outcome: 1. Recognize the impact of the movement of healthcare to the community and the various community-based healthcare frameworks.
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6) While completing a community assessment, the nurse needs to learn the location of main health facilities and the number of community members who receive welfare. Where should the nurse access this information? 1. Police department 2. City health planning board 3. County health department 4. State census data Answer: 3 Explanation: The county health department would be able to supply information about location of health facilities, occupational health programs, numbers of health professionals, numbers of welfare recipients, and so on. This information would not be available in the police department, city health planning board, or from state census data. Page Ref: 109 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Explain essential aspects of collaborative healthcare: definitions, objectives, benefits, and the nurse's role. MNL Learning Outcome: 2. Examine the differences between community-based healthcare settings/nursing practice and traditional settings/institutional-based nursing practice.
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7) The new community health nurse is compiling information about the community and wants to understand more about services to maintain and promote health. What entity should the nurse access to learn this information? 1. Chamber of commerce 2. Public and university libraries 3. Recreational directors 4. Teachers and school nurses Answer: 4 Explanation: Teachers and school nurses provide information about the incidence of children's health problems and information on facilities and services to maintain and promote health. This information would not be available from the chamber of commerce, libraries, or recreational directors. Page Ref: 109 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Explain essential aspects of collaborative healthcare: definitions, objectives, benefits, and the nurse's role. MNL Learning Outcome: 3. Examine the competencies that community-based nurses need for practice and the essential aspects of collaborative healthcare.
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8) A client in the ambulatory clinic asks if there are any community programs to help with health and wellness issues. What should the nurse access to locate these types of activities? 1. Online computer services 2. Recreational directors 3. Local newspapers 4. Telephone book Answer: 3 Explanation: Local newspapers contain information–including date and time–about community activities related to health and wellness, such as health lectures or health fairs. This information may not be available through online computer searches, recreational directors, or the telephone book. Page Ref: 109 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Describe the role of the nurse in providing continuity of care. MNL Learning Outcome: 4. Consider the role of the nurse in discharge planning and ensuring continuity of care.
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9) Several nurses at the county health department are involved in planning a community health program. In order to create a plan that will be acceptable to members of the community, who else should be involved in this venture? 1. As many people from the community as possible 2. Physicians and other nurses 3. Members of the chamber of commerce and governing board of the community 4. Just the nurses at the county health department Answer: 1 Explanation: A broadly based planning group is most likely to create a plan that is acceptable to members of the community. People who are involved in planning become educated about problems, resources, and interrelationships within the system. Responsibility for planning at the community level is usually broadly based and needs to include as many of the community partners as possible. Physicians, nurses, governing body members, and community health members would not be sufficient when planning community health. Page Ref: 109 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values | AACN Essentials Competencies: VII. 10. Collaborate with others to develop an intervention plan that takes into account determinants of health, available resources, and the range of activities that contribute to health and prevention of illness, injury, disability, and premature death | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Describe various community-based healthcare frameworks, including integrated healthcare systems, community initiatives and conditions, and case management. MNL Learning Outcome: 2. Examine the differences between community-based healthcare settings/nursing practice and traditional settings/institutional-based nursing practice.
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10) After implementing health promotion activities and plans to prioritize health problems, the community must evaluate the effectiveness of the interventions. Which groups should be involved in this process? 1. Healthcare providers at the community level 2. Hospital and clinic personnel who administered healthcare needs 3. Healthcare providers, consumers, community leaders, and politicians 4. Those consumers who were directly affected by the services provided Answer: 3 Explanation: Because community health is usually a collaborative process between health providers, community leaders, politicians, and consumers, all may be involved in the evaluation process. Often, the community health nurse is the agent of evaluation, collecting and assessing data that determine the effectiveness of implemented programs. Page Ref: 109 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values | AACN Essentials Competencies: VII. 13. Use evaluation results to influence the delivery of care, deployment of resources, and to provide input into the development of policies to promote health and prevent disease | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 6. Explain essential aspects of collaborative healthcare: definitions, objectives, benefits, and the nurse's role. MNL Learning Outcome: 2. Examine the differences between community-based healthcare settings/nursing practice and traditional settings/institutional-based nursing practice.
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11) A large community clinic provides health education, illness prevention, acute care, screening, and rehabilitation and health promotion services for the chronically ill. What should the community health nurse identify this approach to healthcare as being? 1. Community-based setting 2. Integrated healthcare system 3. Wellness center 4. Community outreach center Answer: 2 Explanation: An integrated healthcare system makes all levels of care available in an integrated form, including primary care (education and illness prevention), secondary care (acute care and screening), and tertiary care (rehabilitation and services for the chronically ill). This extent of healthcare services may not occur in a community-based setting, a wellness center, or a community outreach center. Page Ref: 109 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values | AACN Essentials Competencies: VII. 13. Use evaluation results to influence the delivery of care, deployment of resources, and to provide input into the development of policies to promote health and prevent disease | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2. Describe various community-based healthcare frameworks, including integrated healthcare systems, community initiatives and conditions, and case management. MNL Learning Outcome: 2. Examine the differences between community-based healthcare settings/nursing practice and traditional settings/institutional-based nursing practice.
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12) A parish health nurse is working with a particular congregation in setting up a support program for shut-ins within the congregation who are not able to come to regular prayer services. In which role is this nurse functioning? 1. Counselor 2. Educator 3. Referral source 4. Facilitator Answer: 4 Explanation: A facilitator recruits and coordinates volunteers within the congregation and develops support groups. A counselor discusses health issues and problems. An educator supports individuals through health education activities. A referral source serves as a liaison to other community resources, Page Ref: 111 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. B. 4. Function competently within own scope of practice as a member of the healthcare team | AACN Essentials Competencies: VI. 1. Compare/contrast the roles and perspectives of the nursing profession with other care professionals on the healthcare team (i.e., scope of discipline, education and licensure requirements) | NLN Competencies: Teamwork; Knowledge; Scope of practice, roles, and responsibilities of healthcare team members, including overlaps | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Describe the role of the nurse in providing continuity of care. MNL Learning Outcome: 4. Consider the role of the nurse in discharge planning and ensuring continuity of care.
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13) A parish nurse is helping a group of new parents within the congregation find appropriate healthcare providers within the community who specialize in infant/child and family healthcare needs. In which role is the nurse functioning? 1. Health educator 2. Referral source 3. Facilitator 4. Integrator Answer: 2 Explanation: A referral source acts as a liaison to other congregational and community resources. Helping new parents find appropriate sources for healthcare would be an example of a referral source. An educator supports individuals through health education activities. A facilitator recruits and coordinates volunteers within the congregation and develops support groups. An integrator integrates faith with health. Page Ref: 111 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. B. 4. Function competently within own scope of practice as a member of the healthcare team | AACN Essentials Competencies: VI. 1. Compare/contrast the roles and perspectives of the nursing profession with other care professionals on the healthcare team (i.e., scope of discipline, education and licensure requirements) | NLN Competencies: Teamwork; Knowledge; Scope of practice, roles, and responsibilities of healthcare team members, including overlaps | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Describe the role of the nurse in providing continuity of care. MNL Learning Outcome: 4. Consider the role of the nurse in discharge planning and ensuring continuity of care.
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14) A public health nurse in a remote area sets up video conferencing and video clinics for home health nurses to support client teaching and health promotion activities. What activity did the public health nurse perform? 1. Community-based nursing 2. Parish nursing 3. Telenursing 4. Collaborative healthcare Answer: 3 Explanation: Telehealth projects use communication and information technology to provide health information and healthcare services to people in rural, remote, or underserviced areas. Video conferences and video clinics enable healthcare workers to provide distant consultation to assess and treat ambulatory clients who have a variety of healthcare needs. Telenursing enables nurses to provide client teaching and health promotion to distant clients. The public health's actions would not be considered community-based nursing, parish nursing, or collaborative healthcare. Page Ref: 111 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: VI. B. 5. Employ communication technologies to coordinate care for patients | AACN Essentials Competencies: IV. 2. Use telecommunication technologies to assist in effective communication in a variety of healthcare settings | NLN Competencies: Quality and Safety; Practice-Know-How; Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2. Describe various community-based healthcare frameworks, including integrated healthcare systems, community initiatives and conditions, and case management. MNL Learning Outcome: 2. Examine the differences between community-based healthcare settings/nursing practice and traditional settings/institutional-based nursing practice.
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15) Several nurses are working with other healthcare providers to provide care for a group of community members who have complications of diabetes mellitus and require extensive dressing changes and comprehensive education. In what capacity are the nurses and care providers working? 1. Collaboration 2. Case management 3. Health promotion 4. Health education Answer: 1 Explanation: Collaboration means a collegial working relationship with other healthcare providers to supply patient care. Collaborative practice requires the discussion of diagnoses and management in the delivery of care. The actions of the nurses and care providers does not characterize case management, health promotion, or health education. Page Ref: 112 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: II. B. 4. Function competently within own scope of practice as a member of the healthcare team | AACN Essentials Competencies: VI. 2. Use inter- and intraprofessional communication and collaborative skills to deliver evidence-based, patientcentered care | NLN Competencies: Quality and Safety; Practice; Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Explain essential aspects of collaborative healthcare: definitions, objectives, benefits, and the nurse's role. MNL Learning Outcome: 3. Examine the competencies that community-based nurses need for practice and the essential aspects of collaborative healthcare.
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16) The nurse and a group of healthcare providers in a community clinic setting define a problem and now are focusing on objectives and considering various viewpoints presented by the group. Which collaboration competency is this nurse demonstrating? 1. Mutual respect 2. Trust 3. Communication 4. Decision making Answer: 4 Explanation: Decision making involves shared responsibility for the outcome. The team must follow specific steps of the decision-making process, beginning with a clear definition of the problem. Team decision making must be directed at the objectives of the effort and requires full consideration and respect for various and diverse viewpoints. The group's actions do not demonstrate mutual respect, trust, or communication. Page Ref: 113 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. B. 4. Function competently within own scope of practice as a member of the healthcare team | AACN Essentials Competencies: VI. 2. Use inter- and intraprofessional communication and collaborative skills to deliver evidence-based, patientcentered care | NLN Competencies: Quality and Safety; Practice; Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Discuss competencies community-based nurses need for practice, including the Pew Health Professions Commission recommendations for health competencies for future health practitioners. MNL Learning Outcome: 3. Examine the competencies that community-based nurses need for practice and the essential aspects of collaborative healthcare.
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17) The nurse case manager's office is in a cluster of offices that share a fax machine. Which action by the nurse ensures that HIPAA requirements are met? 1. Have the client sign a consent form for information to be released. 2. Have sending agencies call ahead before any information is sent. 3. Do not utilize the fax machine; depend on the mail system. 4. Take relevant information over the phone. Answer: 2 Explanation: Case manager nurses need to maintain vigilance to protect the privacy of client healthcare information when sending and receiving messages. In this case, having the sending agency call prior to faxing information would alert the nurse to collect the information from the fax machine at the time it is received, securing that information so others do not have access to it. The client does not need to sign a consent form. The fax machine can be used. Relaying information over the telephone may cause an in increases in errors and violate confidentiality depending upon the environment in which the conversation is taking place. Page Ref: 114 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: VI. B. 5. Employ communication technologies to coordinate care for patients | AACN Essentials Competencies: IV. 8. Uphold ethical standards related to data security, regulatory requirements, confidentiality, and clients' right to privacy | NLN Competencies: Context and Environment; Knowledge; Principles of informed consent, confidentiality, patient self-determination | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Explain essential aspects of collaborative healthcare: definitions, objectives, benefits, and the nurse's role. MNL Learning Outcome: 4. Consider the role of the nurse in discharge planning and ensuring continuity of care.
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18) The nurse is helping in discharge planning of a client who needs extensive rehabilitation and is on a complicated medication schedule. Which individual should the nurse include in this client's plan? 1. Client's spouse 2. Physician 3. Pharmacist 4. Social worker Answer: 1 Explanation: Effective discharge planning necessitates health team conferences and family conferences and gives the client, family, and healthcare professionals the opportunity to plan care and set goals. Involving the client's spouse would be important in this situation because of the complexity of the client's situation. The physician, pharmacist, and social worker would not be required when planning for this client's discharge. Page Ref: 114-115 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Describe the role of the nurse in providing continuity of care. MNL Learning Outcome: 4. Consider the role of the nurse in discharge planning and ensuring continuity of care.
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19) A client is getting ready to go home from an intermediate care facility following surgery and a lengthy recovery period. On which item should the home health nurse focus to determine effectiveness of discharge teaching? 1. Activity restrictions 2. Follow-up appointment dates 3. Return demonstration of dressing change 4. Signs of complications Answer: 3 Explanation: Clients need teaching before discharge that includes information about medications, dietary and activity restrictions, signs of complications that need to be reported to the physician, follow-up appointments, and where supplies can be obtained. Clients, and perhaps caregivers, also need to demonstrate safe performance of any necessary treatments. Clients need help to understand their situation, to make healthcare decisions, and to learn new health behaviors. All the options would be important for the client to retain, but to determine whether the task of changing the dressing was learned, the client would have to demonstrate the skill back to the nurse. Activity restrictions, follow-up appointment dates, and the signs of complications would be topics to include in the teaching. Page Ref: 115 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 7. Describe the role of the nurse in providing continuity of care. MNL Learning Outcome: 4. Consider the role of the nurse in discharge planning and ensuring continuity of care.
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20) A multiorganization medical system is designing a community-based facility to support the healthcare needs of members who live in an urban area. What should the medical system keep in mind when designing the new facility? (Select all that apply.) 1. Affordability 2. Easy to travel to the facility 3. A focus on the needs of mothers and children 4. Many services available to meet community members' needs 5. Communication of care needs to the community members' other healthcare providers Answer: 1, 2, 3, 4, 5 Explanation: To be effective, a community-based health care system needs to address the care needs of families, be flexible in responding to the care needs of individuals and families, and promote care between and among healthcare agencies through improved communication mechanisms. To be effective, a community-based health care system needs to address the care needs of families, be flexible in responding to the care needs of individuals and families, and promote care between and among healthcare agencies through improved communication mechanisms. To be effective, a community-based health care system needs to address the care needs of families, be flexible in responding to the care needs of individuals and families, and promote care between and among healthcare agencies through improved communication mechanisms. To be effective, a community-based health care system needs to address the care needs of families, be flexible in responding to the care needs of individuals and families, and promote care between and among healthcare agencies through improved communication mechanisms. To be effective, a community-based health care system needs to address the care needs of families, be flexible in responding to the care needs of individuals and families, and promote care between and among healthcare agencies through improved communication mechanisms. Page Ref: 108 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3. Differentiate community healthcare settings from traditional settings. MNL Learning Outcome: 2. Examine the differences between community-based healthcare settings/nursing practice and traditional settings/institutional-based nursing practice.
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21) The community health nurse is identifying approaches to support a community's healthcare needs. Which programs should the nurse select to support community-based healthcare? (Select all that apply.) 1. Smoking-cessation classes 2. Personal safety classes for women 3. Blood pressure measurement clinic 4. Outpatient clinic for minor ailments 5. Allergy injection clinic on weekends Answer: 1, 2, 3 Page Ref: 108 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3. Differentiate community healthcare settings from traditional settings. MNL Learning Outcome: 2. Examine the differences between community-based healthcare settings/nursing practice and traditional settings/institutional-based nursing practice.
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22) The nurse is preparing a teaching brochure that outlines the changes in healthcare delivery systems. What information about consumer health-related values should the nurse include in this brochure? (Select all that apply.) 1. Disease prevention is important. 2. Health disparities need to be addressed. 3. Quality of life includes a healthy environment. 4. Health encompasses well-being and quality of life. 5. Individuals can maintain their health through lifestyle changes. Answer: 1, 3, 4, 5 Explanation: Consumers are adopting health-related values that include the importance of disease prevention, a healthy environment, health encompassing well-being and quality of life, and lifestyle changes to maintain health. Consumers are adopting health-related values that include a healthy environment. Consumers are adopting health-related values that include health encompassing well-being and quality of life. Consumers are adopting health-related values that include lifestyle changes to maintain health. Page Ref: 106 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching and Learning Learning Outcome: 1. Discuss factors influencing healthcare reform. MNL Learning Outcome: 1. Recognize the impact of the movement of healthcare to the community and the various community-based healthcare frameworks.
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23) A nurse is desired to work in a community health organization. Which type of agency should the nurse consider for employment? (Select all that apply.) 1. Home care 2. Senior center 3. Wellness center 4. Day- care center 5. Physician practice Answer: 1, 2, 3, 4 Explanation: Home care, senior centers, wellness centers, and day-care centers are considered a community health agencies. Senior centers are considered community health agencies Wellness centers are considered community health agencies. Day care centers are considered community health agencies. Page Ref: 111 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values | AACN Essentials Competencies: VII. 13. Use evaluation results to influence the delivery of care, deployment of resources, and to provide input into the development of policies to promote health and prevent disease | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Differentiate community-based nursing from traditional institutionalbased nursing. MNL Learning Outcome: 1. Recognize the impact of the movement of healthcare to the community and the various community-based healthcare frameworks.
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24) A healthcare organization is creating a position description for nurses hired to provide care in their outpatient ambulatory clinics. Which competencies should be included in the position description? (Select all that apply.) 1. Practice leadership 2. Work in interdisciplinary teams 3. Obtain an advanced degree in nursing 4. Provide culturally sensitive care to a diverse population 5. Use information technology effectively and appropriately Answer: 1, 2, 4, 5 Explanation: Competencies for nurses include the practice of leadership, Competencies for nurses include working in interdisciplinary teams, providing culturally sensitive care to a diverse population, and using information technology effectively and appropriately. Competencies for nurses include providing culturally sensitive care to a diverse population. Competencies for nurses include using information technology effectively and appropriately. Page Ref: 112 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. B. 4. Function competently within own scope of practice as a member of the healthcare team | AACN Essentials Competencies: VI. 2. Use inter- and intraprofessional communication and collaborative skills to deliver evidence-based, patientcentered care | NLN Competencies: Quality and Safety; Practice; Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Discuss competencies community-based nurses need for practice, including the Pew Health Professions Commission recommendations for health competencies for future health practitioners. MNL Learning Outcome: 3. Examine the competencies that community-based nurses need for practice and the essential aspects of collaborative healthcare.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 7 Home Health Nursing Care 1) The nurse learns that two new home care agencies are opening in a community. What should the nurse consider as reasons why home care agencies are increasing in numbers? (Select all that apply.) 1. The need for custodial care 2. Third-party payers who support cost control measures 3. The increase in the older adult population 4. The decreasing need for acute care 5. The focus on the needs of the community Answer: 2, 3 Page Ref: 120 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Define home healthcare. MNL Learning Outcome: 1. Recognize the scope, unique aspects, and system of home care. 2) During orientation with a home care agency, the nurse is learning the difference in care delivery between home health nursing and community nursing. What should the nurse understand as being the focus of home healthcare nursing? 1. Individuals, families, and groups 2. The individual and his or her family 3. The terminally ill client and his or her family 4. The client in a home setting Answer: 2 Explanation: The focus of home healthcare nursing is individuals and their families. The focus of home health nursing care is not the terminally ill. Page Ref: 119 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Define home healthcare. MNL Learning Outcome: 1. Recognize the scope, unique aspects, and system of home care. 1
3) To help a home health client with a difficult medication regimen, the nurse contacts the pharmacist for ideas to facilitate the process. Which behavior did the nurse demonstrate when caring for this client? 1. Hands-on care 2. Direct care 3. Advocacy 4. Indirect care Answer: 4 Explanation: Indirect care is provided by the home health nurse to the client each time the nurse consults with other healthcare providers about ways to improve nursing care for the client. Contacting the pharmacist does not demonstrate hands-on care, advocacy, or direct care. Page Ref: 122 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Describe the roles of the home healthcare nurse. MNL Learning Outcome: 2. Examine the roles of the home health nurse and the perspectives of home care clients.
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4) A client being discharged needs physical therapy for progressive ambulation, wound care to treat a postoperative wound, and assistance with the payment of hospital bills. Before the nurse contacts a home care agency, who should prescribed home care for this client? 1. Physician 2. Nurse 3. Social worker 4. Physical therapist Answer: 1 Explanation: A client may be referred to home healthcare by providers, nurses, social workers, and therapists, but home care cannot begin without a physician's order and a physician-approved treatment plan. This is a legal reimbursement requirement. Page Ref: 120 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Describe the types of home health agencies, including referral and reimbursement sources. MNL Learning Outcome: 1. Recognize the scope, unique aspects, and system of home care.
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5) During the first home care visit, the nurse determines that the client needs speech therapy, physical therapy, and custodial care several times a week. When should the nurse schedule the client's care to begin? 1. As soon as the nurse completes the initial assessment 2. As soon as the client agrees to the care 3. When the physician signs the plan of care the nurse develops 4. Within 48 hours of the nurse's visit Answer: 3 Explanation: At the initial visit, the nurse develops a plan of care that identifies the client's needs. This plan must by reviewed, approved, authorized, and signed by the attending physician before the home health agency providers can continue with services. Care does not begin after the initial assessment is completed, when the client agrees to care, or within 48 hours of the nurse's visit. Page Ref: 121 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Compare the characteristics of home healthcare nursing to those of institutional nursing care. MNL Learning Outcome: 1. Recognize the scope, unique aspects, and system of home care.
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6) A home health client has a complicated case involving occupational therapy, respiratory therapy, a dietitian, the nurse, and a nurse's aide who provides assistance with bathing, housekeeping, and grocery shopping. Which care provider should be prepared to coordinate this client's care? 1. Physician 2. Nurse 3. Social worker 4. Home health agency Answer: 2 Explanation: Because clients often require the services of several professionals, case coordination is essential and generally rests with the registered nurse. The physician, social worker, or home health agency will not coordinate the client's care. Page Ref: 121 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4. Describe the roles of the home healthcare nurse. MNL Learning Outcome: 2. Examine the roles of the home health nurse and the perspectives of home care clients.
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7) The nurse is hired to provide home care through a community agency that is operated by the state health department and financed by taxes. In which type of agency is this nurse employed? 1. Institution based 2. Private 3. Not-for-profit 4. Official Answer: 4 Explanation: Official or public agencies are operated by state or local governments and financed primarily by tax funds. An agency that is operated by the state health department and financed by taxes is not institution based, private, or not-for-profit. Page Ref: 121 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Describe the types of home health agencies, including referral and reimbursement sources. MNL Learning Outcome: 1. Recognize the scope, unique aspects, and system of home care.
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8) While reviewing a health insurance plan, the nurse learns that a client has coverage for durable medical equipment (DME). What care need should the nurse identify as being covered by the client's health plan? 1. Dressings and bandages 2. Medications 3. A hospital bed 4. Visits by the home health nurse Answer: 3 Explanation: Durable medical equipment (DME) ranges from hospital beds to bedside commodes to ventilators and apnea monitors. Equipment that will not be "used up" is considered DME. Page Ref: 121 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Describe the types of home health agencies, including referral and reimbursement sources. MNL Learning Outcome: 1. Recognize the scope, unique aspects, and system of home care.
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9) The nurse would like to admit a client to home health care but is worried about insurance reimbursement. What client action is causing the nurse to question if home care can be prescribed for this client? 1. Lives with a spouse 2. Needs skilled care 3. Needs intermittent care 4. Drives a car for trips to the barber Answer: 4 Explanation: Clients must meet certain criteria, including homebound status, except for occasional outings. Barber trips are included as "occasional outings," but the client is not the driver. Page Ref: 122 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Describe the types of home health agencies, including referral and reimbursement sources. MNL Learning Outcome: 1. Recognize the scope, unique aspects, and system of home care.
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10) A client receiving home care decides to discontinue hemodialysis. In which role is the nurse functioning when helping the family accept the client's decision? 1. Caregiver 2. Advocate 3. Educator 4. Counselor Answer: 2 Explanation: As a client advocate, the nurse explores and supports the client's choices in healthcare. Advocacy includes having discussions about the client's rights, advance medical directives, living wills, and durable power of attorney for healthcare. At times, the client's views may vary from those of other family members. In the event of conflict, the nurse ensures that the client's rights and desires are upheld. The nurse is not functioning in the role of caregiver, educator, or counselor in this situation. Page Ref: 122 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Describe the roles of the home healthcare nurse. MNL Learning Outcome: 2. Examine the roles of the home health nurse and the perspectives of home care clients. 11) During a home visit, the client with terminal cancer undergoes respiratory arrest; however, the client has a DNR (do not resuscitate) order. What should the nurse do when the spouse wants to call 911? 1. Assess vital signs. 2. Call 911. 3. Start CPR. 4. Remind the spouse of the client's desires. Answer: 4 Explanation: In the event of conflict between the client's desires and the family's wishes, the nurse, being the client's primary advocate, ensures that the client's rights and desires are upheld. This is a difficult situation, but the nurse is bound to the client's desires. Page Ref: 122 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Describe the roles of the home healthcare nurse. MNL Learning Outcome: 2. Examine the roles of the home health nurse and the perspectives of home care clients. 9
12) During a home visit, the nurse explains the procedures for preventing infection in a central venous access device to the spouse who watches while the nurse attaches the client to the medication infusion. Which role is the nurse performing at this time? 1. Caregiver 2. Advocate 3. Educator 4. Coordinator Answer: 3 Explanation: Education can be the most essential aspect of home care practice, the goal of which is to help clients learn to manage as independently as possible. Involving the spouse in care and educating the spouse along with the client promotes wellness and helps prevent problems. The nurse is not functioning in the role of caregiver, advocate, or coordinator. Page Ref: 122-123 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching and Learning Learning Outcome: 4. Describe the roles of the home healthcare nurse. MNL Learning Outcome: 2. Examine the roles of the home health nurse and the perspectives of home care clients.
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13) During a home visit the nurse sees that most of the rooms in the house have only one outlet with various cords plugged in to the outlet. What should the nurse do when the client and spouse say, "This is the way we've lived for years"? 1. Provide telephone numbers for local electricians. 2. Continue to persuade the client to have the home rewired. 3. Not bring the subject up again. 4. Document the findings and the client and spouse's response to the concern. Answer: 4 Explanation: Home health nurses cannot expect to change a family's living space and lifestyle. However, they can express concern when a situation suggests the possibility for injury. Nurses must document information they provide and the family's response to instruction as well as make ongoing assessments about the family's use of safety precautions. Page Ref: 123 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essentials Competencies: II. 7. Promote factors that create a culture of safety and caring | NLN Competencies: Quality and Safety; Practice-Know-How; Encourage patients and families to communicate their observations and concerns regarding safety | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Discuss the safety and infection control dimensions applicable to the home care setting. MNL Learning Outcome: 4. Examine the practice of nursing in the home and its future.
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14) A home health client lives alone in a small apartment and has only one phone, which is a land line. What safety recommendation should the visiting home health nurse make for this particular client? 1. Suggest that the client move to a nursing home or assisted living dwelling. 2. Recommend that the client be enrolled in an emergency response system. 3. Enroll the client in a program that places all of the client's vital medical information in one place for emergency personnel. 4. Have the client post a list of emergency numbers (fire, police, ambulance) near the phone. Answer: 2 Explanation: An emergency response system provides a small device with a help button that attaches to the client's wrist or is worn around the neck. The client can send a signal to a home base that would indicate if the client is in trouble (i.e., has fallen or become ill) and can't get to the phone. This system is particularly useful for clients who live alone. Page Ref: 124 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essentials Competencies: II. 7. Promote factors that create a culture of safety and caring | NLN Competencies: Quality and Safety; Practice-Know-How; Encourage patients and families to communicate their observations and concerns regarding safety | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Discuss the safety and infection control dimensions applicable to the home care setting. MNL Learning Outcome: 4. Examine the practice of nursing in the home and its future.
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15) The home health nurse has scheduled a visit to a client who lives in a neighborhood that is known to be unsafe because of gang activity. Before going to the client's home, what should the nurse do? 1. Call for an escort. 2. Call the client to let the client know the nurse is on the way. 3. Ask if the client could meet the nurse at the agency. 4. Take a second nurse along on the visit. Answer: 1 Explanation: Some less desirable living locations pose safety concerns for the nurse. Many home health agencies have contracts with security firms to escort nurses needing to see clients in potentially unsafe neighborhoods. If there is no such firm for escort, the police can also provide security for the nurse. Page Ref: 124 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essentials Competencies: II. 7. Promote factors that create a culture of safety and caring | NLN Competencies: Quality and Safety; Practice-Know-How; Encourage patients and families to communicate their observations and concerns regarding safety | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Discuss the safety and infection control dimensions applicable to the home care setting. MNL Learning Outcome: 4. Examine the practice of nursing in the home and its future. 16) The nurse visits the home of a client with a central venous access device; however, the home lacks cleanliness. What is the best way for the nurse to protect the client against infection? 1. Have the client wash her hands before the infusion begins. 2. Practice strict aseptic technique during the infusion process. 3. Help the client clean the room before starting the infusion. 4. Suggest that the client have a housekeeper come on the morning of the infusion. Answer: 2 Explanation: Infection control can present a challenge to the home health nurse, especially if the home care facilities are not conducive to basic aseptic requirements. The most important ways to prevent infection are making sure the site is clean, accessing the port following sterile procedure, and following standard precautions while accessing the line. Page Ref: 125 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essentials Competencies: II. 7. Promote factors that create a culture of safety and caring | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Discuss the safety and infection control dimensions applicable to the home care setting. MNL Learning Outcome: 4. Examine the practice of nursing in the home and its future. 13
17) The nurse is concerned that the spouse of a home care client with multiple sclerosis is experiencing caregiver role strain. What did the nurse observe to come to this conclusion? (Select all that apply.) 1. The home appears cluttered. 2. The spouse expresses feelings of anger. 3. The spouse reports decreased energy and insufficient time for caregiving. 4. The spouse reports that she is learning how to manage finances. 5. The client asks when the nurse will return for the next visit. Answer: 2, 3 Page Ref: 125 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essentials Competencies: II. 7. Promote factors that create a culture of safety and caring | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 7. Identify ways the home healthcare nurse can recognize and minimize caregiver role strain. MNL Learning Outcome: 4. Examine the practice of nursing in the home and its future. 18) After completing an initial assessment, the nurse identifies teaching that the client will need. Why did the nurse identify learning needs for this client? 1. Lack of knowledge related to health conditions and self-care 2. The fact that there is little time to complete education in the acute care setting 3. The fact that teaching someone who is willing to learn is easier in the home 4. The need for reimbursement for education by Medicare Answer: 1 Explanation: One of the most common health issues that nurses address with clients in home care settings is lack of knowledge related to health conditions and self-care. Client education is considered a skill reimbursed by Medicare. Page Ref: 126-127 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Identify the essential aspects of the home visit. MNL Learning Outcome: 3. Relate the dimensions of home health nursing to patient care.
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19) An older client being discharged from an acute care facility is prescribed home care. When should the home care nurse see the client to understand needs for safety and mobility? 1. At the initial home visit, in order to see the client in the home environment 2. While the client is still a patient in the acute care hospital 3. After the client has been home for a few days and can help the nurse decide what is needed 4. When the spouse is available to assist in the assessment Answer: 2 Explanation: Assessment for the older client being discharged to home health should be initiated while the client is in the hospital to determine the need for assistive devices or environmental changes before the client returns home. Page Ref: 129 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Identify the essential aspects of the home visit. MNL Learning Outcome: 4. Examine the practice of nursing in the home and its future. 20) A client has been receiving home care for several weeks. Which individual should the nurse realize is responsible for ensuring that the client is receiving care at the appropriate times and in the appropriate amounts? 1. Client 2. Nurse 3. Physician 4. Client's spouse Answer: 2 Explanation: Even though the client and family may become independent in self-care skills, the home health nurse still has the ultimate responsibility to ensure that the client is receiving the prescribed therapy at the appropriate timed intervals. On subsequent home visits, the nurse observes the same parameters assessed on the initial visit. Page Ref: 127 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5. Identify the essential aspects of the home visit. MNL Learning Outcome: 3. Relate the dimensions of home health nursing to patient care. 15
21) The nurse is attending a seminar that focuses on the changes within the home healthcare industry. Which statements that the nurse makes indicate an understanding of home care as a primary health service delivery system? (Select all that apply.) 1. "It's unfortunate that clients can be screened for illnesses in the privacy of their own home." 2. "With people living well into their 70s and 80s, the healthcare system is being stressed immensely." 3. "The cost of acute hospital-based healthcare has become an economic burden to most people." 4. "A client's chronic cardiac problems can be monitored well with in-home health services." 5. "It relieves so much stress when care can come to them instead of their going to the health provider." Answer: 2, 3, 4, 5 Page Ref: 119 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2. Compare the characteristics of home healthcare nursing to those of institutional nursing care. MNL Learning Outcome: 1. Recognize the scope, unique aspects, and system of home care. 22) The nurse is taking a tour of a home care agency as part of the interview process. Which services should the nurse recognize as being provided through this health agency? (Select all that apply.) 1. A case manager arranging services to meet the client's need for physical therapy after a fall 2. A nurse educating the pregnant adolescent on the signs of premature labor 3. A durable supply company delivering a wheelchair to a client with spina bifida 4. A nurse assessing the feet of a home-bound diabetic client 5. A grocery store delivering groceries to a client recovering from cancer surgery Answer: 1, 3, 4 Page Ref: 119 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Define home healthcare. MNL Learning Outcome: 1. Recognize the scope, unique aspects, and system of home care. 16
23) The nurse has two older parents who were recently hospitalized at the same time and are being discharged home on the same day. What should the nurse do to ensure these family members receive the highest quality of care in the home? (Select all that apply.) 1. Call off from work to provide care to both parents. 2. Adjust personal schedule to provide care to the parents. 3. Move in with the parents until conditions are stabilized. 4. Determine if custodial support is needed for the parents. 5. Find out when the home care nurse is scheduled to arrive. Answer: 4, 5 Page Ref: 126 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Identify ways the home healthcare nurse can recognize and minimize caregiver role strain. MNL Learning Outcome: 3. Relate the dimensions of home health nursing to patient care. 24) During a home visit, the nurse is concerned that a client recovering from hip replacement surgery is at risk for falling in the home. What information from the home assessment did the nurse use to come to this conclusion? (Select all that apply.) 1. Laminated floors that are highly polished 2. Scatter rugs in the kitchen and bathroom 3. Smoke detector battery low in the bedroom 4. Cleaning solution placed in an unlabeled jar 5. Expired medication in the bathroom cabinet Answer: 1, 2 Page Ref: 123 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essentials Competencies: II. 7. Promote factors that create a culture of safety and caring | NLN Competencies: Quality and Safety; Practice-Know-How; Encourage patients and families to communicate their observations and concerns regarding safety | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 6. Discuss the safety and infection control dimensions applicable to the home care setting. MNL Learning Outcome: 3. Relate the dimensions of home health nursing to patient care.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 8 Electronic Health Records and Information Technology 1) The nurse needs to complete mandatory continuing education on client safety as part of a regulatory requirement for the hospital. Which computerized approach should the nurse consider to complete this required education? 1. Complete a computerized tutorial on client safety 2. Read information on safety from a website 3. Review the online hospital policies about client safety 4. Complete a literature review on client safety Answer: 1 Explanation: Nursing has benefited from the computer revolution in the form of computerassisted instruction (CAI). Programs cover a variety of topics, which allow almost instant access to any content. Completion of CAI programs may also be an acceptable means of demonstrating continuing education activities. Reading information on a website or online hospital policies does not demonstrate a computerized approach. A literature review does not demonstrate a computerized approach. Page Ref: 134 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: VI. B. 2. Apply technology and information management tools to support safe processes of care | AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice | NLN Competencies: Knowledge and Science; Practice-Know-How; Document via electronic health records; Use software applications related to nursing practice | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching and Learning Learning Outcome: 1. Describe the uses of computers and technology in nursing. MNL Learning Outcome: 1. Relate the use of informatics to nursing and healthcare.
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2) The nurse manager is responsible for scheduling the staff of all units in a critical care hospital. Which program should the manager use for computerized scheduling? 1. Database 2. Word processing 3. Graphics program 4. Spreadsheet Answer: 4 Explanation: Spreadsheets are programs that can manipulate numbers. Data are arranged in columns and rows. Spreadsheets are used for budgets and are useful for working with staffing, scheduling, invoicing, research, and other analyses. Word processing, graphics, or a database would not be appropriate for scheduling staff. Page Ref: 143 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: VI. B. 2. Apply technology and information management tools to support safe processes of care | AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice | NLN Competencies: Knowledge and Science; Practice-Know-How; Document via electronic health records; Use software applications related to nursing practice | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. List ways technology may be used by nurse administrators in the areas of human resources, facilities management, finance, quality assurance, and accreditation. MNL Learning Outcome: 4. Examine the use of technology in education, administration, human resources, facilities management, finance, quality assurance, accreditation, and research.
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3) A client tells the nurse about researching on the Internet for information about a newly prescribed medication. What should the nurse respond to the client? 1. "I'm glad you're interested in your therapy." 2. "Information on the Internet cannot be trusted. You should check with your pharmacist." 3. "Your physician is the one you should be asking these kinds of questions." 4. "Let's look at some of the sites you've been visiting." Answer: 4 Explanation: Thousands of health-related sites exist on the Internet, with new ones occurring daily. There are no controls to ensure that information provided on these sites is accurate. Therefore, the nurse should help the client find reliable and accurate information. Clients are involved consumers. Wanting more information about their medications, disease processes, and treatment options is taking a proactive approach to their own care. It is appropriate to ask questions and seek information from a variety of sources. However, nurses must assist clients in making sure the information they gather is credible and accurate. Page Ref: 132 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: VI. B. 2. Apply technology and information management tools to support safe processes of care | AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice | NLN Competencies: Knowledge and Science; Practice-Know-How; Document via electronic health records; Use software applications related to nursing practice | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 3. Identify computer applications used in client assessment and care. MNL Learning Outcome: 2. Recognize the functionality and components of computerized patient documentation systems.
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4) The nurse wants to search for articles having to do with a client care problem. Which database should the nurse use to find this information? 1. CINAHL 2. Google 3. ERIC 4. PsychINFO Answer: 1 Explanation: The Cumulative Index to Nursing and Allied Health Literature (CINAHL) focuses on nursing and allied health articles, including research. In this database, the user can search systematically for articles that are related to nursing research, peer reviewed, published, and so on. Google, ERIC, and PsychInfo will not necessarily provide articles that focus on client care problems. Page Ref: 134 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: VI. B. 2. Apply technology and information management tools to support safe processes of care | AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice | NLN Competencies: Knowledge and Science; Practice-Know-How; Document via electronic health records; Use software applications related to nursing practice | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Identify the role of technology in each step of the research process. MNL Learning Outcome: 4. Examine the use of technology in education, administration, human resources, facilities management, finance, quality assurance, accreditation, and research.
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5) A small nursing program has limited access to clinical sites, especially those with specialty areas. What should the nurse educators consider as an option to allow students "hands-on" simulated clinical experience in these areas? 1. A field trip to a larger nursing institution 2. Videos 3. CAI 4. Workbook with written study guides Answer: 3 Explanation: Computer-assisted instruction (CAI) helps students as well as nurses learn and demonstrate learning. Programs cover topics from drug dosage calculations to ethical decision making, drill and practice, simulation, and testing. CAI simulations can provide a virtual experience for the student through a computer program. Hands-on experience would not be obtained through a field trip, videos, or with written study guides. Page Ref: 134 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: VI. B. 2. Apply technology and information management tools to support safe processes of care | AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice | NLN Competencies: Knowledge and Science; Practice-Know-How; Document via electronic health records; Use software applications related to nursing practice | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching and Learning Learning Outcome: 1. Describe the uses of computers and technology in nursing. MNL Learning Outcome: 4. Examine the use of technology in education, administration, human resources, facilities management, finance, quality assurance, accreditation, and research.
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6) The nurse enrolled in graduate courses is able to continue studies while visiting abroad. What has this nurse's nursing school implemented to make this possible? 1. Classroom technology 2. Distance learning 3. CAI 4. Informatics Answer: 2 Explanation: Distance learning is a model to deliver information and class sessions via audio or video transmission. The use of computers is required to offer this type of delivery in education. This type of learning does not demonstrate classroom technology, CAI, or informatics. Page Ref: 134 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: VI. B. 2. Apply technology and information management tools to support safe processes of care | AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice | NLN Competencies: Knowledge and Science; Practice-Know-How; Document via electronic health records; Use software applications related to nursing practice | Nursing/Integrated Concepts: Nursing Process: Assessment/Teaching and Learning Learning Outcome: 1. Describe the uses of computers and technology in nursing. MNL Learning Outcome: 4. Examine the use of technology in education, administration, human resources, facilities management, finance, quality assurance, accreditation, and research.
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7) The nurse educator stores grade data, including homework and assignment scores, in order to track trends. What is the educator using to maintain this information? 1. Informatics 2. Student record management 3. Data warehousing 4. Management information system (MIS) Answer: 3 Explanation: Data warehousing is the accumulation of large amounts of data that are stored over time and can be examined for output in different types of reports (charts and tables). This information is not being compiled through the use of informatics, student record management, or a MIS. Page Ref: 135 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: VI. B. 2. Apply technology and information management tools to support safe processes of care | AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice | NLN Competencies: Knowledge and Science; Practice-Know-How; Document via electronic health records; Use software applications related to nursing practice | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. List ways technology may be used by nurse administrators in the areas of human resources, facilities management, finance, quality assurance, and accreditation. MNL Learning Outcome: 4. Examine the use of technology in education, administration, human resources, facilities management, finance, quality assurance, accreditation, and research.
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8) The nurse accesses previous hospitalization information to learn more about a client's previous health history. In what way is the availability of the client's health information assisting with the planning to address new care needs? 1. Ability to monitor quality 2. Access warehoused data (stored data) 3. Client sharing of knowledge that influences health 4. Constant availability of client health information Answer: 4 Explanation: There are at least four ways the EHR can improve healthcare. Accessing previous hospitalization information is being done to review the client's information to aid with planning for this current hospitalization. The client's health information is not being used to monitor quality, access stored data, or have the client share knowledge to influence health. Page Ref: 137 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: VI. B. 2. Apply technology and information management tools to support safe processes of care | AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice | NLN Competencies: Knowledge and Science; Practice-Know-How; Document via electronic health records; Use software applications related to nursing practice | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Discuss the advantages of and concerns about computerized client documentation systems. MNL Learning Outcome: 2. Recognize the functionality and components of computerized patient documentation systems.
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9) A client asks what is done to keep computerized personal health information confidential. How should the nurse respond? 1. "Don't worry; your information is always safe." 2. "Information in our system requires a password to retrieve." 3. "Our system was designed with a lot of input from nursing staff." 4. "I can see why you're worried, with all the computer hackers out there these days." Answer: 2 Explanation: Maintaining privacy and security of data is a significant issue. One way that computers can protect data is by the use of passwords–only those persons who have a legitimate need to access the data receive the password. Saying that the information is always safe is not necessarily true. The client is not asking about the design of the system. Mentioning hackers would cause the client to have more fears about confidentiality. Page Ref: 137 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: VI. B. 2. Apply technology and information management tools to support safe processes of care | AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice | NLN Competencies: Knowledge and Science; Practice-Know-How; Document via electronic health records; Use software applications related to nursing practice | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Discuss the advantages of and concerns about computerized client documentation systems. MNL Learning Outcome: 2. Recognize the functionality and components of computerized patient documentation systems.
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10) The nurse is accessing information about standard classification of terms prior to documenting in a client's computerized clinical record. Which systems should the nurse consider using for this documentation? (Select all that apply.) 1. ANA 2. HIPAA 3. NANDA 4. The Omaha System 5. HHCC 6. NOC Answer: 3, 4, 5, 6 Page Ref: 139 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: VI. B. 2. Apply technology and information management tools to support safe processes of care | AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice | NLN Competencies: Knowledge and Science; Practice-Know-How; Document via electronic health records; Use software applications related to nursing practice | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. List ways technology may be used by nurse administrators in the areas of human resources, facilities management, finance, quality assurance, and accreditation. MNL Learning Outcome: 4. Examine the use of technology in education, administration, human resources, facilities management, finance, quality assurance, accreditation, and research. 11) The nurse educator is considering ways to impact the learning of students through the use of computer technology. Which actions should the educator take to achieve this goal? (Select all that apply.) 1. Assign distance learners to conduct a research study of current evidence-based articles on caring for the diabetic client. 2. Expect that notification of clinical absences be provided by e-mail. 3. Require a clinical group to make daily reflective entries in an online journal. 4. Provide extra credit for academic work that is created on a computer as an electronic file. 5. Encourage the learners to access online NCLEX review questions as a way to assess their classroom learning. Answer: 1, 3, 5 Page Ref: 134-135 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: VI. B. 2. Apply technology and information management tools to support safe processes of care | AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice | NLN Competencies: Knowledge and Science; Practice-Know-How; Document via electronic health records; Use software applications related to nursing practice | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Identify the role of technology in each step of the research process. MNL Learning Outcome: 4. Examine the use of technology in education, administration, human resources, facilities management, finance, quality assurance, accreditation, and research. 10
12) A nurse educator believes computers can enhance student learning. Which actions should the instructor take to demonstrate this belief? (Select all that apply.) 1. Allow students to research a nursing topic either by going to the library or via an online literature search. 2. Require a student to remediate after a failed test by completing appropriate computer-assisted instruction modules. 3. Use PowerPoint slides to reinforce complex concepts during classroom lectures. 4. Assign a collaborative group project to students enrolled in an online course. 5. Use computer-generated graphics to make written material less monotonous. Answer: 1, 2, 3, 4 Page Ref: 134 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: VI. B. 2. Apply technology and information management tools to support safe processes of care | AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice | NLN Competencies: Knowledge and Science; Practice-Know-How; Document via electronic health records; Use software applications related to nursing practice | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching and Learning Learning Outcome: 1. Describe the uses of computers and technology in nursing. MNL Learning Outcome: 4. Examine the use of technology in education, administration, human resources, facilities management, finance, quality assurance, accreditation, and research. 13) The nurse is beginning a physical assessment of a client who is a freelance computer information technologist. On which areas should the nurse place particular emphasis during this assessment? (Select all that apply.) 1. Vision 2. Hearing 3. Back flexibility 4. Hand range of motion 5. Range of motion of arms Answer: 1, 3, 4, 5 Page Ref: 145 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify computer applications used in client assessment and care. MNL Learning Outcome: 4. Examine the use of technology in education, administration, human resources, facilities management, finance, quality assurance, accreditation, and research. 14) The nurse is participating in the development of a research study. What elements of the 11
computer should the nurse ensure are in place before the study begins? (Select all that apply.) 1. Computer speed adequate 2. Printer drivers installed 3. Word processing program 4. Computer storage capacity adequate 5. Appropriate software programs Answer: 1, 3, 4, 5 Page Ref: 144 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: VI. B. 2. Apply technology and information management tools to support safe processes of care | AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice | NLN Competencies: Knowledge and Science; Practice-Know-How; Document via electronic health records; Use software applications related to nursing practice | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Identify the role of technology in each step of the research process. MNL Learning Outcome: 4. Examine the use of technology in education, administration, human resources, facilities management, finance, quality assurance, accreditation, and research.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 9 Critical Thinking and Clinical Reasoning 1) The nurse is providing care to a group of clients. For which situation would the nurse's use of critical thinking be a priority? 1. Administering IV push meds to critically ill clients 2. Educating a home health client about treatment options 3. Teaching new parents car seat safety 4. Assisting an orthopedic client with the proper use of crutches Answer: 2 Explanation: Nurses who utilize good critical thinking skills are able to think and act in areas where there are neither clear answers nor standard procedures. Treatment options, especially for the home health client, can be extensive. There are many points to consider (good and bad) and choosing between treatment options can cause conflict among family members. The nurse in this case must use creativity, analysis based on science, and problem-solving skills–all of which contribute to critical thinking skills. Page Ref: 151-152 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1. Describe the significance of developing critical thinking abilities in order to practice safe, effective, and professional nursing care. MNL Learning Outcome: 1. Recognize the importance of developing critical thinking in nursing practice.
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2) A client recovering from a stroke does not want to perform prescribed shoulder exercises. What should the nurse say to the client that demonstrates critical thinking with creativity? 1. "You'll only get worse if you don't do these exercises." 2. "As soon as you get these into your routine, you'll feel better." 3. "Your physician wouldn't have ordered these if they weren't important." 4. "Here's a marker. See how many circles you can make on this board in 10 minutes." Answer: 4 Explanation: Making the exercise routine into something more fun–such as a game, drawing a picture, or even "decorating the walls," for example–would raise a challenge to the client, take the focus off the "why," and still achieve the end result. Page Ref: 152 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe the actions of clinical reasoning in the implementation of the nursing process. MNL Learning Outcome: 2. Apply techniques of critical thinking to nursing care.
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3) A student nurse resists when encouraged to be creative when providing client care. What should the nurse educator say to encourage this student to be creative? 1. "Creativity allows unique solutions to unique problems." 2. "Not all your answers are going to be from your textbook." 3. "Creativity makes nursing more fun." 4. "You'll get bored if you don't learn to be creative." Answer: 1 Explanation: Creativity is thinking that results in the development of new ideas and products and is the ability to develop and implement new and better solutions. When nurses incorporate creativity into thinking, they are able to find unique solutions to unique problems. Creativity does make the nurse look beyond the answers found in the text, but it also brings originality and individuality to nursing. Page Ref: 152 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Describe the significance of developing critical thinking abilities in order to practice safe, effective, and professional nursing care. MNL Learning Outcome: 1. Recognize the importance of developing critical thinking in nursing practice.
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4) The nurse educator assigns students an activity to implement Socratic questioning in their daily lives. Which question provided by a student demonstrates this reasoning technique? 1. "What makes you think cramming for a test is an ineffective way to study?" 2. "What other ways of studying could you implement?" 3. "If you didn't study for your test, what is the probability you will fail?" 4. "If you study all the unit outcomes, what effect will that have?" Answer: 1 Explanation: Socratic questioning is a technique one can use to look beneath the surface, recognize and examine assumptions, search for inconsistencies, examine multiple points of view, and differentiate what one knows from what one merely believes. Questions about evidence and reason focus on just that (e.g., what evidence is there, how you know, what would change your mind). Page Ref: 154 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 3. Discuss the attitudes and skills needed to develop critical thinking and clinical reasoning. MNL Learning Outcome: 3. Recognize the effect of attitudes and the components of critical thinking.
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5) A client is experiencing a productive cough, audible coarse crackles, elevated temperature of 102.3°F, chills, and body aches. What did the nurse use to determine that this patient is experiencing respiratory compromise? 1. Deductive reasoning 2. Inductive reasoning 3. Socratic questioning 4. Critical analysis Answer: 1 Explanation: Deductive reasoning is reasoning from the general to the specific. The nurse starts with a framework and makes descriptive interpretations of the client's condition in relation to the framework. Productive cough, crackles, fever, and chills all point to problems with respiratory status. Page Ref: 147 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2. Describe the actions of clinical reasoning in the implementation of the nursing process. MNL Learning Outcome: 2. Apply techniques of critical thinking to nursing care.
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6) A client with a PhD in epidemiology has been to numerous physicians and has had numerous laboratory tests, all of which were abnormal, and exploratory surgery, but no one is able to explain the etiology of his problem. Which statement should the nurse make that demonstrates critical thinking? 1. "Why don't you just tell your physician what you think you have?" 2. "Did you bring your prior tests and results with you, so we don't repeat anything?" 3. "If you know what you have, what do you want from us?" 4. "Describe what tests you've had and explain the symptoms of this disorder." Answer: 4 Explanation: In critical thinking, the nurse also differentiates statements of fact, inference, judgment, and opinion. The nurse will have to ascertain the accuracy of information and evaluate the credibility of the information sources. Page Ref: 153 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe the actions of clinical reasoning in the implementation of the nursing process. MNL Learning Outcome: 2. Apply techniques of critical thinking to nursing care.
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7) A nurse educator observes a colleague's approach to instruct a class and rethinks current strategies being used. What behavior is the educator demonstrating? 1. Integrity 2. Perseverance 3. Fair-mindedness 4. Humility Answer: 1 Explanation: Intellectual integrity requires that individuals apply the same rigorous standards of proof to their own knowledge and beliefs as they apply to the knowledge and beliefs of others. Trying new teaching techniques in the hope that students might respond positively shows that the first educator is willing to question her own practices, just as she would question those of another. Page Ref: 156 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3. Discuss the attitudes and skills needed to develop critical thinking and clinical reasoning. MNL Learning Outcome: 3. Recognize the effect of attitudes and the components of critical thinking.
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8) The nurse who just moved from an urban area to a sparsely populated rural area understands that certain customs and practices the nurse follows may be quite foreign to the people in the new area. Which attitude of critical thinking is the nurse demonstrating? 1. Fair-mindedness 2. Insight into egocentricity 3. Intellectual humility 4. Intellectual courage to challenge the status quo and rituals Answer: 2 Explanation: Critical thinkers are open to the possibility that their personal biases or social pressures and customs could unduly affect their thinking. They actively try to examine their own biases and bring them to awareness each time they make a decision. Understanding that how things were done and what practices were common may be completely different in the new surroundings is an example of the nurse implementing this attitude. Page Ref: 156 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 3. Discuss the attitudes and skills needed to develop critical thinking and clinical reasoning. MNL Learning Outcome: 3. Recognize the effect of attitudes and the components of critical thinking.
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9) The nurse implements a quicker way to set up and initiate an intravenous infusion while still following safe practice. Which attitude of critical thinking is this nurse practicing? 1. Independence 2. Intellectual courage to challenge the status quo or rituals 3. Integrity 4. Confidence Answer: 1 Explanation: Nurses who can think for themselves and consider different methods of performing technical skills–not just the way they may have been taught in school–develop an attitude of independence. Page Ref: 155 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Discuss the attitudes and skills needed to develop critical thinking and clinical reasoning. MNL Learning Outcome: 3. Recognize the effect of attitudes and the components of critical thinking.
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10) The nurse questions the practice of administering rectal suppositories to residents in a longterm care facility at bedtime, rather than earlier in the day. Which critical thinking attitude is this nurse demonstrating? 1. Confidence 2. Perseverance 3. Curiosity 4. Integrity Answer: 3 Explanation: The internal conversation going on within the mind of a critical thinker is filled with questions. The curious nurse may value tradition but is not afraid to examine traditions to be sure they are still valid, as in this case. This nurse is asking valid questions. Page Ref: 157 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Discuss the attitudes and skills needed to develop critical thinking and clinical reasoning. MNL Learning Outcome: 3. Recognize the effect of attitudes and the components of critical thinking.
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11) A seasoned nurse uses past experiences and knowledge gained from previous care situations to care for a client with complex health issues. Which attribute of critical thinking is this nurse practicing? 1. Reflection 2. Context 3. Dialogue 4. Time Answer: 1 Explanation: Reflection involves being able to determine what data are relevant and to make connections between that data and the decisions reached. The nurse reflects on previous clinical experiences similar to this one and determines if the outcomes of care improved the clients' conditions. Page Ref: 159 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Integrate strategies to enhance critical thinking and clinical reasoning as the provider of nursing care. MNL Learning Outcome: 4. Examine the components and strategies that enhance and implement clinical reasoning and clinical critical thinking in patient care.
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12) While listening to a client describe current symptoms, the nurse considers the client's entire situation. Which attribute of critical thinking is the nurse practicing? 1. Reflection 2. Context 3. Dialogue 4. Time Answer: 2 Explanation: Context is being considerate of the whole situation–including relationships, background, and environment–and its relevant to the current situation. Page Ref: 153 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Discuss the attitudes and skills needed to develop critical thinking and clinical reasoning. MNL Learning Outcome: 3. Recognize the effect of attitudes and the components of critical thinking.
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13) The nurse assesses findings that are different from those a client reports. Which standard of critical thinking does the nurse use to analyze this conflict? 1. Clarity 2. Accuracy 3. Logical reasoning 4. Significance Answer: 3 Explanation: Logicalness would ask if the report follows from the evidence. In this case, it does not. However, the nurse is still questioning, which shows she is engaged in critically thinking through the situation. Page Ref: 159 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Integrate strategies to enhance critical thinking and clinical reasoning as the provider of nursing care. MNL Learning Outcome: 4. Examine the components and strategies that enhance and implement clinical reasoning and clinical critical thinking in patient care.
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14) The nurse enters the room of a critically ill child after sensing that "something" isn't right and finds that the last IV solution hung by the previous nurse was not the correct solution. Which problem-solving method did this nurse use? 1. Trial and error 2. Intuition 3. Judgment 4. Scientific method Answer: 2 Explanation: Intuition is the understanding or learning of things without the conscious use of reasoning. It is also known as sixth sense, hunch, instinct, feeling, or suspicion. Clinical experience allows the nurse to recognize cues and patterns and begin to reach correct conclusions using intuition. Finding no cause for concern in the physical assessment of the client, the nurse is not satisfied and continues to assess the client's surroundings, finding the error. Page Ref: 155 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Integrate strategies to enhance critical thinking and clinical reasoning as the provider of nursing care. MNL Learning Outcome: 4. Examine the components and strategies that enhance and implement clinical reasoning and clinical critical thinking in patient care.
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15) The nurse systematically tries a variety of products to help with healing of a client's wound. Which problem-solving method is the nurse using? 1. Intuition 2. Scientific method 3. Research process 4. Trial and error Answer: 4 Explanation: Trial and error is solving problems by utilizing a number of approaches. Trial-anderror methods can be dangerous in nursing because the client might suffer harm if an approach is inappropriate. In this case, the client may not suffer harm, but there will be no way to know if one product used is effective because the nurse is changing them on a daily basis. Page Ref: 155 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Integrate strategies to implement clinical reasoning while caring for clients during clinical. MNL Learning Outcome: 2. Apply techniques of critical thinking to nursing care.
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16) A client is prescribed a medication to be given either through the oral or intravenous route; however, the nurse does not know if the client will experience adverse effects. Which part of the decision-making process is the nurse using? 1. Identify the purpose 2. Seek alternatives 3. Project 4. Implement Answer: 2 Explanation: In this step, the decision maker (nurse) identifies possible ways to meet the criteria. Alternatives considered are which route to give a certain medication: IV versus oral. The nurse is utilizing experience, taking into consideration the client's problems and pharmacology, and will make a selection based on that information. Page Ref: 153 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4. Describe the components of clinical reasoning. MNL Learning Outcome: 4. Examine the components and strategies that enhance and implement clinical reasoning and clinical critical thinking in patient care.
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17) Prior to providing client care, the nurse reviews previous shift charting and the responses to nursing interventions. Which decision-making action is the nurse using? 1. Set the criteria 2. Examine alternatives 3. Implement 4. Evaluate the outcome Answer: 4 Explanation: In evaluating, the nurse determines the effectiveness of the plan and whether the initial purpose was achieved. In this situation, the nurse wants to determine what worked on the previous shift and what didn't. This will help with deciding on interventions for the client during the shift. Page Ref: 157 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4. Describe the components of clinical reasoning. MNL Learning Outcome: 4. Examine the components and strategies that enhance and implement clinical reasoning and clinical critical thinking in patient care.
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18) Parents ask why invasive diagnostic tests were prescribed for their ill child. H however, the nurse has just received handoff communication and has not had a chance to review the data. What should the nurse respond to the parents? 1. "I'm not sure I can answer your question just now." 2. "It's a good idea to listen to what your physician wants." 3. "Your child's doctor is the best there is. I don't see why you wouldn't follow his advice." 4. "Maybe you should get another opinion if you're not comfortable with your doctor." Answer: 1 Explanation: Suspending judgment means tolerating ambiguity for a time. If an issue is complex, it may not be resolved quickly and judgment should be postponed. In this case, the nurse just doesn't have enough information to give a good answer to the parents. For a while, the nurse will need to say, "I don't know" and be comfortable with that answer. Page Ref: 153 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Describe the components of clinical reasoning. MNL Learning Outcome: 4. Examine the components and strategies that enhance and implement clinical reasoning and clinical critical thinking in patient care.
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19) The nurse suspects that a client with "extreme" low back pain will have elevated blood pressure and heart rate. What thought process did the nurse use to come to this conclusion? 1. Fact 2. Inference 3. Judgment 4. Opinion Answer: 2 Explanation: Inferences are conclusions drawn from facts, going beyond facts to make a statement about something that is not currently known. In this case, acute, severe pain will most likely cause the blood pressure as well as pulse rate to be elevated as the body's response to the painful experience. Page Ref: 154 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 3. Discuss the attitudes and skills needed to develop critical thinking and clinical reasoning. MNL Learning Outcome: 3. Recognize the effect of attitudes and the components of critical thinking.
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20) The nurse completes collecting data from a client and determines a list of problems. Which step in the nursing process should the nurse perform next? 1. Assess 2. Diagnose 3. Plan 4. Evaluate Answer: 3 Explanation: The planning portion of the nursing process involves setting criteria, weighting the criteria, and seeking/examining alternatives when compared to the decision-making process. Page Ref: 154 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Integrate strategies to implement clinical reasoning while caring for clients during clinical. MNL Learning Outcome: 2. Apply techniques of critical thinking to nursing care.
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21) While caring for a client of a different culture, the nurse becomes disturbed when the client's spouse makes all the decisions about care and treatments. What behavior is this nurse demonstrating? 1. Inference 2. Judgment 3. Opinion 4. Evaluation Answer: 3 Explanation: Opinions are beliefs formed over time and include judgments that may fit facts or be in error. In this case, the nurse may not understand that, culturally, this may be very appropriate and fitting for this client. If this is the case, the nurse should not become disturbed by the spouse's attention. Page Ref: 154 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Discuss the attitudes and skills needed to develop critical thinking and clinical reasoning. MNL Learning Outcome: 3. Recognize the effect of attitudes and the components of critical thinking.
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22) The staff nurse asks why unlicensed assistive personnel are responsible for stocking the unit refrigerator with refreshments when dietary personnel place the items on the shelf in the kitchen. What characteristic of critical reasoning is this nurse demonstrating? 1. Curiosity 2. Clinical reasoning 3. Setting priorities 4. Developing rationales Answer: 4 Explanation: Developing rationales is when the nurse transfers nursing knowledge to the clinical situation to justify the plan of care. Page Ref: 157 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Integrate strategies to implement clinical reasoning while caring for clients during clinical. MNL Learning Outcome: 4. Examine the components and strategies that enhance and implement clinical reasoning and clinical critical thinking in patient care.
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23) A clinical instructor senses that a student has been struggling with clinical skills learned in lab. To combat this, the educator pairs the student with a staff nurse who has clients with a variety of treatments and cares. Which type of problem solving is the instructor using? 1. Trial and error 2. Intuition 3. Research process 4. Experience Answer: 2 Explanation: Intuition is the understanding or learning of things without the conscious use of reasoning. It is also known as the sixth sense, hunch, instinct, feeling, or suspicion. In this case, the educator has a sense that the student is struggling, although there are no real facts to support it. Page Ref: 155 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Integrate strategies to implement clinical reasoning while caring for clients during clinical. MNL Learning Outcome: 4. Examine the components and strategies that enhance and implement clinical reasoning and clinical critical thinking in patient care.
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24) The nurse desires to improve critical thinking skills when providing client care. On which attributes should the nurse focus when developing these skills? (Select all that apply.) 1. Independence 2. Egocentricity 3. Intellectual humility 4. Fair-mindedness 5. Confidence 6. Perseverance Answer: 1, 3, 4, 5, 6 Page Ref: 155 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3. Discuss the attitudes and skills needed to develop critical thinking and clinical reasoning. MNL Learning Outcome: 3. Recognize the effect of attitudes and the components of critical thinking.
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25) During a clinical conference, a staff nurse states that critical thinking is essential when providing client care. What additional statements should this nurse make to support the use of critical thinking? (Select all that apply.) 1. "Patient acuity is so much greater than it was even 10 years ago." 2. "Care delivery systems are only as good as the nurses delivering care." 3. "Nurses have always relied on common-sense thinking to provide quality, appropriate nursing care." 4. "With healthcare being so expensive, nursing has to take on responsibility to keep the costs controlled." 5. "My practice involves caring for clients who require care that didn't even exist when I went to school." Answer: 1, 2, 4, 5 Explanation: Patients are sicker, with multiple problems, and so nursing care requires a more critical form of thinking in order to meet their nursing needs. Redesigning care delivery is useless if nurses don't have the thinking skills required to deal with today's world. Consumers and payers demand to see evidence of benefits, efficiency, and results. Today's progress often creates new problems that can't be solved by old ways of thinking. Page Ref: 151-152 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Describe the significance of developing critical thinking abilities in order to practice safe, effective, and professional nursing care. MNL Learning Outcome: 1. Recognize the importance of developing critical thinking in nursing practice.
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26) The nurse manager determines that a new staff nurse is demonstrating characteristics of a critical thinker. What did the manager observe the nurse perform? (Select all that apply.) 1. Listening with empathy to a client who recently has been diagnosed. 2. Waiting for the medical team to determine the focus of the client's supportive care. 3. Questioning a medication order that does not appear to meet the client's needs for pain management. 4. Exhibiting a willingness to try alternate methods of addressing a client's care needs. 5. Practicing nursing in a culturally competent fashion. Answer: 1, 3, 4, 5 Page Ref: 153 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 3. Discuss the attitudes and skills needed to develop critical thinking and clinical reasoning. MNL Learning Outcome: 3. Recognize the effect of attitudes and the components of critical thinking.
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27) The staff nurse is helping a new graduate understand the relationship between care concepts and planned interventions. What value would it be for the staff nurse to encourage the new graduate to use a concept map? (Select all that apply.) 1. Used to highlight key areas 2. Provides a visual representation 3. Can be quicker than taking notes 4. Takes years to study how to create 5. Aids in developing critical thinking Answer: 1, 2, 3, 5 Explanation: Concept mapping is a technique that uses a graphic depiction of nonlinear and linear relationships to represent critical thinking. A general benefit is that it highlights key areas. Concept maps provide an opportunity to visualize things. A general benefit of these maps is that they are quicker than note taking. Also known as mind maps, concept maps are context dependent and can be used to develop analytical skills. The attributes of the concept are linked, making meaning of the concept they represent. Page Ref: 160 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7. Describe the process of concept mapping to enhance critical thinking and clinical reasoning for the provision of nursing care. MNL Learning Outcome: 4. Examine the components and strategies that enhance and implement clinical reasoning and clinical critical thinking in patient care.
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28) The nurse is planning to create a concept map to explain relationships between concepts and associated attributes. Which types of concept maps should the nurse consider creating? (Select all that apply.) 1. Spider 2. Systems 3. Flowchart 4. Definitions 5. Hierarchical Answer: 1, 2, 3, 5 Explanation: Spider maps depict the interrelatedness of the concept and its attributes in the map. Systems maps identify inputs and outputs that illustrate relationships among the concept and its attributes. Flowchart maps are linear diagrams demonstrating sequence or cause-and-effect relations. In a hierarchical map, the concept and attributes are arranged in a hierarchical pattern and are typically constructed in descending order of importance. Relationships are identified between and among a concept and its attributes. Page Ref: 160 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7. Describe the process of concept mapping to enhance critical thinking and clinical reasoning for the provision of nursing care. MNL Learning Outcome: 4. Examine the components and strategies that enhance and implement clinical reasoning and clinical critical thinking in patient care.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 10 Assessing 1) The student is learning the steps of the nursing process. What is the first thing that the student should realize about the purpose of this process? 1. Deliver care to a client in an organized way. 2. Implement a plan that is close to the medical model. 3. Identify client needs and deliver care to meet those needs. 4. Make sure that standardized care is available to clients. Answer: 3 Explanation: The purpose of the nursing process is to identify a client's health status and actual or potential healthcare problems or needs, to establish plans to meet the identified needs, and to deliver specific nursing interventions to meet those needs. Page Ref: 164 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1. Describe the phases of the nursing process. MNL Learning Outcome: 1. Consider the phases and characteristics of the nursing process as applied to patient care.
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2) While conducting a dressing change, the nurse notes a new area of skin breakdown that was caused from the tape used to secure the dressing. In which phase of the nursing process is the nurse working? 1. Assessment 2. Diagnosis 3. Implementation 4. Evaluation Answer: 1 Explanation: Assessment is the collection, organization, validation, and documentation of data. Assessment is carried throughout the nursing process, as in this case. Even though performing the dressing change is implementation, noticing the new skin breakdown is assessment. Page Ref: 167 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Identify the four major activities associated with the assessing phase. MNL Learning Outcome: 2. Recognize types of assessment, types of data, sources of data, and methods of collecting data. 3) During an assessment, a client who is not very talkative appears pale, diaphoretic, and restless in the bed and says, "Leave me alone." Which subjective data should the nurse document? 1. Restlessness 2. "Leave me alone" 3. Not talkative 4. Pale and diaphoretic Answer: 2 Explanation: Subjective data can be described or verified only by that person and are apparent only to the person affected. Subjective data include the client's sensations, feelings, beliefs, attitudes, and perceptions of personal health status and life situations. Page Ref: 172 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Differentiate objective and subjective data and primary and secondary data. MNL Learning Outcome: 2. Recognize types of assessment, types of data, sources of data, and methods of collecting data. 2
4) Family of a client demonstrating confusion state that this is not the client's usual behavior. How should the nurse document this data? 1. Inference 2. Subjective data 3. Objective data 4. Secondary subjective data Answer: 3 Explanation: Information supplied by family members, significant others, or other health professionals are considered subjective if it is not based on fact. Because this information is factual, in that the spouse is able to provide the nurse with information about the client's routine behavior and patterns, this is objective data. Page Ref: 172 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Differentiate objective and subjective data and primary and secondary data. MNL Learning Outcome: 2. Recognize types of assessment, types of data, sources of data, and methods of collecting data.
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5) The nurse provides a back rub to a client after administering a pain medication with the hope that these two actions will help decrease the client's pain. Which phase of the nursing process is this nurse implementing? 1. Assessment 2. Diagnosis 3. Implementation 4. Evaluation Answer: 3 Explanation: Implementation is that part of the nursing process in which the nurse applies knowledge to perform interventions. Page Ref: 167 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Describe the phases of the nursing process. MNL Learning Outcome: 1. Consider the phases and characteristics of the nursing process as applied to patient care. 6) A new client has been admitted to the care area. How soon should the nurse plan to complete a physical assessment on this patient? 1. 1 hour 2. 12 hours 3. 48 hours 4. 24 hours Answer: 4 Explanation: The Joint Commission requires that each client have an initial assessment consisting of a history and physical performed and documented within 24 hours of admission as an inpatient. Page Ref: 169 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 10. Contrast various frameworks used for nursing assessment. MNL Learning Outcome: 3. Utilize techniques to collect data for a nursing assessment.
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7) The nurse is admitting an infant to the care area. The parents and grandmother are present. What should the nurse use as the best source of data for this client? 1. Medical record from the child's birth 2. Grandmother 3. Parents 4. Admitting physician Answer: 3 Explanation: The best source of data is usually the client, unless the client is too ill, young, or confused to communicate clearly. The parents would be able to provide the nurse with the most accurate, current information regarding the baby (diet, schedule, symptoms, etc.). Page Ref: 178 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Identify three methods of data collection and give examples of how each is useful. MNL Learning Outcome: 2. Recognize types of assessment, types of data, sources of data, and methods of collecting data.
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8) A newly admitted client is angry because nursing staff continue to ask the same questions. What should the nurse respond to this client? 1. "In order to make sure all of your information is complete, I need to ask these questions." 2. "You're right. Let me know if there's anything you need right now." 3. "I'll be done shortly, just give me a few more minutes." 4. "You shouldn't be upset. We're only doing our jobs." Answer: 2 Explanation: Repeated questioning can be stressful and annoying, especially for hospitalized clients, and cause concern about the lack of communication among health professionals. The nurse should review previous records that contain data about the client's occupation, religion, and marital status, as well as take time to review all the information the previous nurse collected. Validating the client's feelings is always a good idea and helps to build rapport between the nurse and client. Page Ref: 173 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Describe important aspects of the interview setting. MNL Learning Outcome: 4. Recognize methods used to organize, validate, and document data.
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9) The nurse documents: "Client avoids eye contact and gives only vague, nonspecific answers to direct questioning by the professional staff. Is quite animated (laughs aloud, smiles, uses hand gestures) in conversation with spouse." Which method of data collection does this documentation demonstrate? 1. Examining 2. Interviewing 3. Listening 4. Observing Answer: 4 Explanation: Observation is a conscious, deliberate skill that is developed through effort and with an organized approach. Observation occurs whenever the nurse is in contact with the client or support persons. Page Ref: 174 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Identify three methods of data collection and give examples of how each is useful. MNL Learning Outcome: 3. Utilize techniques to collect data for a nursing assessment. 10) The nurse has worked in the trauma critical care area for several years. Which noise may become indiscriminate for this particular nurse? 1. A client with audible breathing 2. Moaning of a client in pain 3. Whirring of ventilators 4. Coworkers discussing their clients' conditions Answer: 3 Explanation: The noises of machines and other equipment noises–except alarms–would be easy to ignore, as these are the usual, normal sounds of the unit. Page Ref: 176 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10. Contrast various frameworks used for nursing assessment. MNL Learning Outcome: 3. Utilize techniques to collect data for a nursing assessment.
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11) A client has been using the call light routinely throughout the evening. Upon entering the room, the nurse observes the following details. Organize them according to priority sequencing (1 is first priority; 5 is least priority). 1. The family is at the bedside. 2. The IV pump is running on battery. 3. The ECG monitor shows tachycardia. 4. The client reports being restless. 5. O2 tubing is not attached to wall regulator. Answer: 3, 4, 5, 2, 1 Explanation: 1. Has no apparent bearing on client's symptoms 2. Indicates an issue worth observing 3. Indicates an objective cardiac symptom 4. Indicates a subjective symptom 5. Indicates a possible cause of the client's symptoms Page Ref: 170 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify the purpose of assessing. MNL Learning Outcome: 2. Recognize types of assessment, types of data, sources of data, and methods of collecting data.
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12) During an initial interview, the client says, "I don't understand why I have to have surgery; I'm really not that sick or in pain right now." How should the nurse respond to the client? 1. "It's OK to be worried. Surgery is a big step." 2. "What kind of questions do you have about your surgery?" 3. "I think these are things you should be asking your doctor." 4. "Have you had surgery before?" Answer: 2 Explanation: The nurse should use a combination of directive and nondirective approaches during the interview to determine areas of concern for the client. Page Ref: 174 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 8. Compare closed and open-ended questions, providing examples and listing advantages and disadvantages of each. MNL Learning Outcome: 3. Utilize techniques to collect data for a nursing assessment. 13) The nurse is completing a health history with a client who has complications from chronic asthma. Which open-ended question should the nurse use? 1. "How would you describe your sleep pattern?" 2. "Can you describe your coughing pattern?" 3. "Is there anything that makes your breathing worse?" 4. "What medications are you on?" Answer: 1 Explanation: Open-ended questions invite clients to discover and explore, elaborate, clarify, or illustrate their thoughts or feelings. They specify only the broad topic to be discussed. Openended questions invite long answers–longer than one or two words. Page Ref: 175 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment/Communication and Documentation Learning Outcome: 8. Compare closed and open-ended questions, providing examples and listing advantages and disadvantages of each. MNL Learning Outcome: 3. Utilize techniques to collect data for a nursing assessment. 9
14) The nurse is assessing a client's level of pain. Which open-ended question should the nurse use for this situation? 1. "Is your pain worse at night?" 2. "What brought you to the clinic?" 3. "How has the pain impacted your life?" 4. "You're feeling down about having pain, aren't you?" Answer: 3 Explanation: An open-ended question would be beneficial to explore more about the client's experience and should be asked with a "how" or "what." Page Ref: 175 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment/Communication and Documentation Learning Outcome: 8. Compare closed and open-ended questions, providing examples and listing advantages and disadvantages of each. MNL Learning Outcome: 3. Utilize techniques to collect data for a nursing assessment. 15) A client is coming into the clinic for the first time. In order for the nurse to allow the client the most comfort during the interview, what should the nurse do? 1. Sit next to the client, a few feet apart. 2. Sit behind a desk. 3. Stand at the side of the client's chair. 4. Stand at the counter to take notes during the interview. Answer: 1 Explanation: A seating arrangement in which the client and nurse are seated in chairs, a few feet apart, at right angles to each other and with no table between, creates a less formal atmosphere, with the nurse and client feeling on equal terms. This would allow for more comfort and relaxation during the interview phase. Page Ref: 176 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Describe important aspects of the interview setting. MNL Learning Outcome: 3. Utilize techniques to collect data for a nursing assessment. 10
16) A client in the emergency department has a non-life-threatening wound. The unit is busy with other clients, families, and people in the waiting room. How should the nurse conduct an interview with this client? 1. Have the client wait until the department quiets down, as the wound is not too serious. 2. Tell the client to wait in the waiting room and fill out the paperwork. 3. Draw curtains around the client and nurse to provide as much privacy as possible. 4. Make sure the client's back is to the rest of the room so as not to be heard by passersby. Answer: 3 Explanation: The interview setting should be in a well-lighted, well-ventilated room that is relatively free of noise, movements, and distractions in order to encourage communication. The interview should also take place in an area where others cannot overhear or see the client, if possible. In this situation, at least pulling a privacy curtain will help keep the client from view of others in the department. Page Ref: 176 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Compare directive and nondirective approaches to interviewing. MNL Learning Outcome: 3. Utilize techniques to collect data for a nursing assessment. 17) A client has been admitted for acute dehydration, secondary to nausea and diarrhea. When is the best time for the nurse to conduct this client's interview? 1. As soon as the client gets to the floor 2. After the client has settled in and been oriented to the room 3. When the family is available to help 4. After the client has been medicated Answer: 2 Explanation: After the client has been oriented to the bathroom and nurse call light, the nurse should start the interview process. In this situation, the nurse may have to pace the interview according to the client's comfort level. Page Ref: 176 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9. Describe important aspects of the interview setting. MNL Learning Outcome: 3. Utilize techniques to collect data for a nursing assessment. 11
18) A nurse has been assigned a new client who cannot speak English. How should the nurse facilitate communication with this client? 1. Have a member of the housekeeping staff who speaks the same language translate. 2. Use the translation services supplied by the hospital. 3. Make sure a family member who does speak English is available. 4. Conduct the interview using hand gestures. Answer: 2 Explanation: Live translation is preferred because the client can then ask questions for clarification. Many large facilities are establishing their own translator services for the languages commonly spoken in their geographical regions. Page Ref: 176 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Identify three methods of data collection and give examples of how each is useful. MNL Learning Outcome: 3. Utilize techniques to collect data for a nursing assessment.
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19) The nurse is greeting a newly admitted client. What statement should the nurse make to establish rapport with this client? 1. "Hello, I'm your nurse and I'll be taking care of you today." 2. "You're lucky–there are no students on the unit today." 3. "Good morning, is there anything you need right now?" 4. "Hi. If you need anything, put on your call light." Answer: 1 Explanation: Establishing rapport is a process of creating goodwill and trust and usually begins with a greeting and self-introduction, accompanied by nonverbal gestures such as a smile, a handshake, and a friendly manner. Making introductions, especially offering the use of your name, is especially good in establishing rapport. Page Ref: 177 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 6. Identify three methods of data collection and give examples of how each is useful. MNL Learning Outcome: 3. Utilize techniques to collect data for a nursing assessment.
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20) The nurse has just completed an admission interview with a new client. Which nursing statement indicates that the interview is in the closing phase? 1. "I'm going to set up your physical assessment now. Do you have any questions?" 2. "Tell me more about how you feel." 3. "Could you give examples of what types of other treatments you've had?" 4. "Is there anything you're worried about?" Answer: 1 Explanation: Closing the interview is important for maintaining the rapport and trust between the client and nurse as well as to facilitate future interactions. The closing should contain an offer for questions, conclusions, plans for the next meeting, and a summary to verify accuracy. Page Ref: 177 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 6. Identify three methods of data collection and give examples of how each is useful. MNL Learning Outcome: 3. Utilize techniques to collect data for a nursing assessment. 21) During an assessment interview, the client states that an elective surgical procedure will not be done because it does not fit into the client's life goals. Into which of Gordon's functional health patterns should the nurse identify this client's comment? 1. Cognitive/perceptual pattern 2. Coping/stress-tolerance pattern 3. Health-perception/health-management pattern 4. Value/belief pattern Answer: 4 Explanation: The value/belief pattern describes the patterns of values, beliefs (including spiritual), and goals that guide the client's choices or decisions. The client in this situation has decided against a surgical procedure because it doesn't coincide with the client's beliefs and goals. Page Ref: 178 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 10. Contrast various frameworks used for nursing assessment. MNL Learning Outcome: 4. Recognize methods used to organize, validate, and document data. 14
22) The nurse suspects that a client with a history of injuries is a victim of abuse. What did the nurse use to come to this conclusion? 1. Observation of cues 2. Validation 3. Inference 4. Judgment Answer: 3 Explanation: Inferences are the nurse's interpretations of conclusions made based on the cues, which in this case would be the frequent visits to the emergency department and the client's injuries. Data must be based on cues, and the nurse must be careful not to jump to conclusions. Page Ref: 182 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 7. Compare directive and nondirective approaches to interviewing. MNL Learning Outcome: 3. Utilize techniques to collect data for a nursing assessment. 23) The nurse is reviewing the nursing process with a first-year nursing student. What should the nurse explain as being the purpose of the diagnosis phase? (Select all that apply.) 1. Develop a list of problems. 2. Identify client strengths. 3. Develop a plan. 4. Specify goals and outcomes. 5. Identify problems that can be prevented. Answer: 1, 2, 5 Page Ref: 167 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 2. Identify major characteristics of the nursing process. MNL Learning Outcome: 1. Consider the phases and characteristics of the nursing process as applied to patient care.
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24) The nurse decides to seek wound care alternatives for a client's stasis ulcer that is not healing after treatment for 2 weeks. In which phase of the nursing process is the nurse functioning? 1. Diagnosis 2. Implementation 3. Evaluation 4. Assessment Answer: 3 Explanation: Evaluation is measuring the degree to which goals/outcomes have been achieved and identifying factors that positively or negatively influence goal achievement. Activities of evaluation include judging whether goals/outcomes have been achieved and making decisions about problem status. The client's wound is not healing and the nurse decides to modify the nursing interventions. Page Ref: 167 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1. Describe the phases of the nursing process. MNL Learning Outcome: 1. Consider the phases and characteristics of the nursing process as applied to patient care. 25) While preparing a client for a procedure, the nurse notes that the client has become unresponsive and respirations have become shallow. What type of assessment should the nurse complete at this time? 1. Initial assessment 2. Problem-focused assessment 3. Emergency assessment 4. Time-lapsed assessment Answer: 3 Explanation: An emergency assessment is performed during any physiologic or psychologic crisis of the client to identify life-threatening problems. Page Ref: 170 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Differentiate objective and subjective data and primary and secondary data. MNL Learning Outcome: 2. Recognize types of assessment, types of data, sources of data, and methods of collecting data. 16
26) Unlicensed assistive personnel measure a newly admitted client's vital signs to be: temperature = 99.3°F, respirations = 26, pulse = 98 bpm, and blood pressure = 200/146 mm Hg. What should the nurse do to validate this data? 1. Retake the vital signs. 2. Call the physician. 3. Continue with the physical assessment as soon as possible. 4. Report the findings to the charge nurse. Answer: 1 Explanation: Guidelines for validating assessment data that are out of normal range include repeating the measurements, using another piece of equipment as needed to confirm abnormalities, or asking someone else to collect the same data. In this situation, the nurse needs to be sure that the vital signs are accurate. Page Ref: 182 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Differentiate objective and subjective data and primary and secondary data. MNL Learning Outcome: 2. Recognize types of assessment, types of data, sources of data, and methods of collecting data.
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27) A nurse is performing an initial assessment on a new admission. What information should the nurse consider as being a part of the database? (Select all that apply.) 1. Reports from physical therapy the client received as an outpatient 2. Documentation of the nurse's physical assessment 3. Physician's orders 4. A list of current medications 5. Information about the client's cultural preferences 6. Discharge instructions Answer: 1, 2, 4, 5 Page Ref: 167 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Identify the purpose of assessing. MNL Learning Outcome: 1. Consider the phases and characteristics of the nursing process as applied to patient care. 28) The nurse is conducting an interview with a new client. Which actions indicate that the nurse is implementing effective communication guidelines? (Select all that apply.) 1. Looking directly at the client to ensure good eye contact 2. Managing the conversation to avoid periods of silence 3. Providing personal experiences to help the client focus 4. Sitting in a chair next to the client who is in bed 5. Keeping arms unfolded and in a relaxed position Answer: 1, 4, 5 Page Ref: 176 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9. Describe important aspects of the interview setting. MNL Learning Outcome: 3. Utilize techniques to collect data for a nursing assessment.
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29) The nurse manager observes a staff nurse perform actions within the nursing process. Which activities did the manager observe the nurse perform? (Select all that apply.) 1. Notifying the surgeon that a postoperative client is experiencing an increase in temperature 2. Advocating for a client who is mentally incapable of expressing her needs 3. Deciding to increase a client's nasal oxygen based on his current pulse oxygenation levels 4. Documenting all clients' pain level responses after the administration of pain medication 5. Attending in-services on a new hydraulic lift to be used to support safe client care Answer: 1, 2, 3, 4 Explanation: The nursing process has distinctive characteristics that include being dynamic so as to respond to clients' ever-changing needs; being client centered, as evidenced by actions such as acting as the client's advocate; decision making that enables the nurse to respond to the changing health status of the client; and universal applicability of care. Page Ref: 167 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2. Identify major characteristics of the nursing process. MNL Learning Outcome: 1. Consider the phases and characteristics of the nursing process as applied to patient care. 30) The nurse is completing a health history with a newly admitted client. What information should the nurse include when asking about the history of the client's present illness? (Select all that apply.) 1. Allergies 2. Immunization record 3. When the symptoms started 4. Exact location of the problem 5. Things that aggravate the problem Answer: 3, 4, 5 Page Ref: 171 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10. Contrast various frameworks used for nursing assessment. MNL Learning Outcome: 4. Recognize methods used to organize, validate, and document data.
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31) The nurse manager observes a new graduate nurse complete assessment activities for a newly admitted client. Which actions indicate that the graduate needs assistance with the assessment process? (Select all that apply.) 1. Reviews client record 2. Establishes a database 3. Performs nursing actions 4. Reviews nursing literature 5. Determines client's strengths, risks, and problems Answer: 3, 5 Explanation: Performing nursing actions is a part of the implementation phase of the nursing process. Determining the client's strengths, risks, and problems is a part of the diagnosis phase of the nursing process. Page Ref: 170 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 4. Identify the four major activities associated with the assessing phase. MNL Learning Outcome: 2. Recognize types of assessment, types of data, sources of data, and methods of collecting data.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 11 Diagnosing 1) After an assessment, the nurse reviews the list of client problems. For which problems should the nurse create nursing diagnoses? 1. The ones that the nurse is licensed to treat 2. The ones that address other health professionals' interventions 3. The ones that focus on the client's primary illness 4. The ones that have standardized care available Answer: 1 Explanation: The domain of nursing diagnoses includes only those health states that nurses are educated on and licensed to treat. A nursing diagnosis is a judgment made only after data collection. Nursing diagnoses describe a continuum of health states: deviations from health, presence of risk factors, and areas of enhanced personal growth. Page Ref: 187 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. B. 4. Function competently within own scope of practice as a member of the healthcare team | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Planning Learning Outcome: 3. Compare nursing diagnoses, medical diagnoses, and collaborative problems. MNL Learning Outcome: 1. Examine the components of a nursing diagnosis and the difference between medical, nursing, and collaborative diagnoses.
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2) A client who has been in a wheelchair for several years is currently experiencing problems with skin breakdown and urinary retention in addition to depression. Which diagnosis should the nurse select for this client? 1. Syndrome diagnosis 2. Risk nursing diagnosis 3. Actual diagnosis 4. Health promotion diagnosis Answer: 1 Explanation: A syndrome diagnosis is a diagnosis that is associated with a cluster of other diagnoses (in this situation, Urinary elimination alteration, Impaired skin integrity, and Powerlessness). Risk, actual, or health promotion diagnoses would not be appropriate for this client. Page Ref: 187 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: II. B. 4. Function competently within own scope of practice as a member of the healthcare team | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Diagnosis Learning Outcome: 1. Differentiate nursing diagnoses according to status. MNL Learning Outcome: 1. Examine the components of a nursing diagnosis and the difference between medical, nursing, and collaborative diagnoses. 3) An experienced nurse has just walked into the room of a newly assigned client. Which observation should the nurse use to include a new nursing diagnosis in this client's plan of care? 1. The client's eyes are closed. 2. The client's skin is pale and mottled. 3. The client's spouse is asleep in the chair next to the bed. 4. The television is on and the volume is turned up. Answer: 2 Explanation: Nurses draw on knowledge and experience to compare client data to standards and norms and to identify significant and relevant observations. An observation is considered significant if it points to changes in the client's health status or pattern, varies from norms of the client population, or indicates a developmental delay. Pale, mottled skin could indicate coldness, a problem with circulation, or even death. Closed eyes, visitors, and environmental noise are not used to identify a nursing diagnosis. Page Ref: 190 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: II. B. 4. Function competently within own scope of practice as a member of the healthcare team | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Diagnosis Learning Outcome: 4. Identify the basic steps in the diagnostic process. MNL Learning Outcome: 2. Recognize the basic steps in the diagnostic process. 2
4) The nurse selects the nursing diagnosis of Willingness to learn about spiritual well-being for a family. Which data cluster did the nurse use to support this diagnosis? 1. The family visits different congregations, the parents have been reflecting on their own spiritual upbringings, and the children are questioning rituals of their friends and friends' families. 2. The children attend Sunday school classes, one parent always attends services with the children, and the parents attempt interaction with congregational activities. 3. The grandparents go to weekly services and have formal interaction with clergy. 4. The children have attended private, religious schools, and the parents are involved in the school's activities. Answer: 1 Explanation: A health promotion diagnosis relates to clients' preparedness to implement behaviors to improve their health condition. These diagnosis labels begin with the phrase Willingness to learn about the health maintenance or Willingness to change health practices. The data cluster that describes the questioning, searching, and reflecting would support an attitude of readiness. Page Ref: 187 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: II. B. 4. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Planning Learning Outcome: 1. Differentiate nursing diagnoses according to status. MNL Learning Outcome: 1. Examine the components of a nursing diagnosis and the difference between medical, nursing, and collaborative diagnoses.
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5) The graduate nurse is struggling with identifying cues from clustered data. What should the nurse use to recognize data patterns and cues? 1. Depend on knowledge gained from peers' experiences. 2. Work with seasoned and experienced nurses and learn from them. 3. Take assessment notes and utilize information from textbooks for comparison. 4. Know that this will take time, and experience is the best teacher. Answer: 3 Explanation: The novice nurse must take careful assessment notes, search data for abnormal cues, and use textbook resources for comparing the client's cues with the defining characteristics and etiologic factors of the accepted nursing diagnoses. Page Ref: 191 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. B. 4. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 4. Identify the basic steps in the diagnostic process. MNL Learning Outcome: 2. Recognize the basic steps in the diagnostic process. 6) The nurse has formulated a diagnosis of Activity intolerance related to decreased airway capacity for a client with chronic asthma. In looking at the client's coping skills, the nurse realizes that the client has a vast knowledge about the disease and what exacerbates symptoms in particular situations. Why should the nurse utilize this information? 1. Strengths can be an aid to mobilizing health and the healing process. 2. The client will be more active in the plan. 3. It will be easier for the nurse to educate the client about other interventions. 4. The nurse won't have to spend time going over the pathology of the client's disease. Answer: 1 Explanation: Establishing strengths, resources, and ability to cope will help the client develop a more well-rounded self-concept and self-image. Strengths can be an aid to mobilizing health and regenerative processes. Page Ref: 192-193 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: II. B. 4. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 4. Identify the basic steps in the diagnostic process. MNL Learning Outcome: 2. Recognize the basic steps in the diagnostic process.
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7) A client has been having pain without any clear pathology for cause. Which nursing diagnosis should the nurse identify as being the most appropriate for this client? 1. Pain due to unknown factors 2. Pain related to unknown etiology 3. Pain caused by psychosomatic condition 4. Pain manifested by client's report Answer: 2 Explanation: The second part of the nursing diagnosis statement is the etiology (E)–the factors contributing to or probable causes–and should be joined to the first part, the problem (P), by the words "related to" rather than "due to." The phrase "related to" implies a relationship between the problem and the cause. In this situation, the cause is unknown, but the problem is evident. Page Ref: 187-188 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: II. B. 4. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Diagnosis Learning Outcome: 2. Identify the components of a nursing diagnosis. MNL Learning Outcome: 1. Examine the components of a nursing diagnosis and the difference between medical, nursing, and collaborative diagnoses. 8) The nurse is caring for a client recovering from a long and difficult childbirth experience. Which nursing diagnosis did the nurse write appropriately for this client? 1. Constipation, due to tissue trauma, manifested by no bowel movement for 2 days 2. Risk for infection, because of new incision, related to episiotomy 3. Ineffective breastfeeding, related to lack of motivation, secondary to exhaustion 4. Altered urinary elimination, secondary to childbirth Answer: 3 Explanation: The problem statement is listed first followed by the etiology–factors that contribute to or are the cause of the client's response. The two parts are joined by the words "related to," implying a relationship between the two. Adding a second part to the etiology statement makes it more descriptive and useful. Page Ref: 193-194 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: II. B. 4. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Diagnosis Learning Outcome: 6. List guidelines for writing a nursing diagnosis statement. MNL Learning Outcome: 3. Consider the guidelines used in formulating diagnostic statements. 5
9) The nurse is formulating a nursing diagnosis for a client with a long, extensive history of psychiatric problems, beginning in childhood, who is being placed in a long-term, structured institutional environment. Which diagnosis indicates the client's problem is adequately described? 1. Chronic low self-esteem, related to factors too numerous to mention 2. Risk for self-harm, related to many psychiatric problems 3. Impaired social interaction, due to long history of institutionalization 4. Alteration in thought processes, related to complex factors Answer: 4 Explanation: The phrase "complex factors" may be used when there are too many etiologic factors or when they are too complex to state in a brief phrase. The actual cause of this client's altered thought process may be due to psychiatric diagnoses, medication tolerances and noncompliance, history of institutionalization, and life history of mental disease. This is a variation of the basic two-part statement but is acceptable to use. Page Ref: 194 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: II. B. 4. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Diagnosis Learning Outcome: 6. List guidelines for writing a nursing diagnosis statement. MNL Learning Outcome: 4. Formulate nursing diagnoses from patient data.
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10) After communicating with the client and family, the nurse compares a client's problem list with identified nursing diagnoses. What action is the nurse performing to minimize diagnostic errors? 1. Understanding what is normal versus what is not normal 2. Verifying 3. Consulting resources 4. Basing diagnoses on patterns Answer: 2 Explanation: The nurse, while taking the information and collecting data, begins to hypothesize possible explanations of the data and then realizes all diagnoses are only tentative until they are verified. The client and family should be included in the beginning and also at the end of the diagnostic process to verify the nurse's diagnoses. Page Ref: 195 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. B. 4. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge: Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 6. List guidelines for writing a nursing diagnosis statement. MNL Learning Outcome: 3. Consider the guidelines used in formulating diagnostic statements. 11) After formulating several diagnoses, the nurse does not understand the reason for some of the discrepancies in the client's laboratory values and diagnostic tests, when comparing to norms and standards. Which action should the nurse take? 1. Verify the information with the client. 2. Compare all findings to the national norms and standards. 3. Consult other professionals and colleagues. 4. Improve critical thinking skills so answers come more easily. Answer: 3 Explanation: Both novices and experienced nurses should consult appropriate resources whenever in doubt about a diagnosis. Professional literature, nursing colleagues, and other professionals are all appropriate resources. Page Ref: 196 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. B. 4. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge: Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 4. Identify the basic steps in the diagnostic process. MNL Learning Outcome: 2. Recognize the basic steps in the diagnostic process. 7
12) The nurse has completed the initial assessment of a client and has analyzed and clustered the data. What should the nurse complete next in the diagnostic process? 1. Formulate a diagnosis. 2. Verify the data. 3. Research collaborative and nursing-related interventions. 4. Identify the client's problem, health risks, and strengths. Answer: 4 Explanation: The step that follows data analysis is identification of the client's health problems, health risks, and strengths. Page Ref: 190, 192 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: II. B. 4. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge: transcultural approaches to health | Nursing/Integrated Concepts: Diagnosis Learning Outcome: 4. Identify the basic steps in the diagnostic process. MNL Learning Outcome: 2. Recognize the basic steps in the diagnostic process. 13) The nurse has formulated the diagnosis of Activity intolerance, related to weakness and debilitation, manifested by reports of fatigue after any physical activity. What is the defining characteristic of this label? 1. Activity intolerance 2. Weakness and debilitation 3. Reports of fatigue 4. Physical activity Answer: 3 Explanation: The defining characteristics are those reports given by the client, or the signs and symptoms. Activity intolerance, weakness and debilitation, and physical activity are not defining characteristics. Page Ref: 188 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: II. B. 4. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge: transcultural approaches to health | Nursing/Integrated Concepts: Diagnosis Learning Outcome: 2. Identify the components of a nursing diagnosis. MNL Learning Outcome: 1. Examine the components of a nursing diagnosis and the difference between medical, nursing, and collaborative diagnoses.
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14) The nurse identifies the diagnosis of Anxiety, related to unfamiliarity of disease process, manifested by restlessness and tachycardia for a client newly diagnosed with pancreatic cancer. What is the etiology of this diagnosis? 1. Unfamiliarity of disease process 2. Anxiety 3. Restlessness 4. Tachycardia Answer: 1 Explanation: The etiology is the underlying cause and a contributing factor of the client's response. In this case, the uncertainty of the diagnosis, fear of the unknown, and response to the diagnosis cause the client to become anxious and upset. Anxiety, restlessness, and tachycardia are defining characteristics. Page Ref: 187-188 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: II. B. 4. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Diagnosis Learning Outcome: 2. Identify the components of a nursing diagnosis. MNL Learning Outcome: 1. Examine the components of a nursing diagnosis and the difference between medical, nursing, and collaborative diagnoses.
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15) The nurse formulates the nursing diagnosis of Acute pain, related to tissue damage, secondary to infarction, manifested by pallor, client report, and shallow, rapid breathing for a client experiencing an acute myocardial infarction. Which collaborative action would be appropriate for this client? 1. Provide a calm, quiet atmosphere in the client's room. 2. Administer pain medication. 3. Educate the client and family regarding treatment and therapies. 4. Monitor for changes in the client's condition. Answer: 2 Explanation: Collaboration occurs between the nurse, physician, and other healthcare professionals to treat the client's problem. In this case, the physician prescribes medications, and the nurse administers them–a primarily dependent action that requires physician orders. Page Ref: 189 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: II. B. 4. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge: Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 3. Compare nursing diagnoses, medical diagnoses, and collaborative problems. MNL Learning Outcome: 1. Examine the components of a nursing diagnosis and the difference between medical, nursing, and collaborative diagnoses. 16) The nurse has formulated a nursing diagnosis of Impaired skin integrity related to poor hygienic practice, secondary to current living conditions for a client. Which data did the nurse use to support this diagnosis? (Select all that apply.) 1. The client has dry, cracked skin. 2. The client has one large and several smaller open, ulcerated areas on his right leg. 3. The client does not drive. 4. The client states that he does not use alcohol or drugs. 5. The client's clothes are soiled. 6. The client has obvious body odor. Answer: 1, 2, 5, 6 Page Ref: 190-191 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: II. B. 4. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Diagnosis Learning Outcome: 4. Identify the basic steps in the diagnostic process. MNL Learning Outcome: 2. Recognize the basic steps in the diagnostic process. 10
17) The nurse is reviewing information about the formulation of nursing diagnoses. What should the nurse identify as the area in which nursing diagnoses differ from medical diagnoses and collaborative problems? 1. Mental status of the client 2. Chronic nature of the illness 3. Nursing care focus 4. Prognosis Answer: 3 Explanation: Nursing focus is an area that differs. Mental status, chronicity, and prognosis would not differ. Page Ref: 188-189 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. B. 4. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health to health | Nursing/Integrated Concepts: Diagnosis Learning Outcome: 3. Compare nursing diagnoses, medical diagnoses, and collaborative problems. MNL Learning Outcome: 1. Examine the components of a nursing diagnosis and the difference between medical, nursing, and collaborative diagnoses. 18) The nurse is reviewing assessment data collected for a client's care plan. What criteria should the nurse use when formulating this client's nursing diagnoses? (Select all that apply.) 1. Nonjudgmental statements 2. Stated in terms of a need 3. Must be legally advisable 4. Cause/effect correctly stated 5. Medical terminology used to describe the cause 6. Diagnosis worded specifically and precisely Answer: 1, 3, 4, 6 Page Ref: 195 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. B. 4. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Diagnosis Learning Outcome: 6. List guidelines for writing a nursing diagnosis statement. MNL Learning Outcome: 3. Consider the guidelines used in formulating diagnostic statements.
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19) The nurse is studying the taxonomy of nursing diagnosis. Which additional classifications are associated with the diagnoses that contribute to standardized nursing language? 1. Care maps 2. NIC and NOC 3. Minimum data sets 4. Standardized care plans Answer: 2 Explanation: Nursing diagnosis is part of a larger, developing system of standardized nursing language that includes classifications of nursing interventions (NIC) and nursing outcomes (NOC). Care maps, minimum data sets, and standardized care plans are not a part of a system of standardized nursing language. Page Ref: 196 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. B. 4. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Diagnosis Learning Outcome: 7. Describe the evolution of the nursing diagnosis movement, including work currently in progress. MNL Learning Outcome: 4. Formulate nursing diagnoses from patient data.
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20) The nurse is providing care to a client. Which nursing diagnoses can the nurse apply when providing client care? (Select all that apply.) 1. Ineffective Breathing Pattern 2. Risk of Infection 3. Willingness for Enhanced Nutrition 4. Willingness for Enhanced Family Coping 5. Anxiety Answer: 1, 5 Explanation: An actual diagnosis is a client problem that is present at the time of the nursing assessment. An actual nursing diagnosis is based on the presence of associated signs and symptoms. An actual diagnosis is a client problem that is present at the time of the nursing assessment. An actual nursing diagnosis is based on the presence of associated signs and symptoms. Page Ref: 187 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. B. 4. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge: Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 1. Differentiate nursing diagnoses according to status. MNL Learning Outcome: 1. Examine the components of a nursing diagnosis and the difference between medical, nursing, and collaborative diagnoses.
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21) The nurse is using the PES model to write a nursing diagnosis. Which nursing diagnoses demonstrate that the nurse used this model appropriately? (Select all that apply.) 1. Ineffective coping related to depression as evidenced by suicide attempt 2. Noncompliance (DASH diet) related to denial of having disease 3. Risk for infection related to recent surgery 4. Nutrition less than adequate related to anxiety as evidenced by weight loss of 10 pounds 5. Ineffective Breathing Pattern as evidenced by cyanotic lips Answer: 1, 4 Explanation: The basic three-part nursing diagnosis statement is called the PES format and includes the problem, etiology, and signs and symptoms. The basic three-part nursing diagnosis statement is called the PES format and includes the problem, etiology, and signs and symptoms. Page Ref: 193 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. B. 4. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Evaluation Learning Outcome: 5. Describe various formats for writing nursing diagnoses. MNL Learning Outcome: 3. Consider the guidelines used in formulating diagnostic statements. 22) The nurse is preparing to formulate nursing diagnoses for a client desiring information to help with chronic low back pain. Which human response patterns should the nurse keep in mind when formulating the diagnoses for this client? (Select all that apply.) 1. Moving 2. Choosing 3. Perceiving 4. Anticipating 5. Communicating Answer: 1, 2, 3, 5 Page Ref: 196 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: II. B. 4. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Planning Learning Outcome: 7. Describe the evolution of the nursing diagnosis movement, including work currently in progress. MNL Learning Outcome: 4. Formulate nursing diagnoses from patient data.
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23) The nurse formulates nursing diagnoses for a client with chronic renal failure. Which statements indicate the nurse appropriately used a two-part format? (Select all that apply.) 1. Pruritis related to toxin buildup in the blood 2. Hypertension related to fluid volume overload 3. Deficient fluid volume related to fluid restriction 4. Personal care challenges related to fistula in left arm 5. Acute confusion related to delayed hemodialysis treatment Answer: 3, 5 Explanation: The nursing diagnosis should include a problem statement, such as deficient fluid volume, and the etiology, which is fluid restriction. These two parts are connected by the phrase "related to." The nursing diagnosis should include a problem statement, such as acute confusion, and the etiology, which is delayed hemodialysis treatment. These two parts are connected by the phrase "related to." Page Ref: 193 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: II. B. 4. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Evaluation Learning Outcome: 5. Describe various formats for writing nursing diagnoses. MNL Learning Outcome: 4. Formulate nursing diagnoses from patient data.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 12 Planning 1) A client is admitted to a comprehensive rehabilitation center for continuing care following a motor vehicle crash. The admitting nurse will develop the initial plan of care, but who will be involved with the ongoing planning of this client's care? 1. The admitting nurse 2. All nurses who work with the client 3. Everybody involved in this client's care 4. The client and the client's support system Answer: 3 Explanation: Planning is basically the nurse's responsibility, but input from the client and support persons is essential if a plan is to be effective. In this case, therapies from other disciplines (occupational, physical, speech, etc.) would be involved because the client is in a comprehensive rehabilitation center. The client's support people and caregivers are also going to be involved in the plan of care, but not exclusively. Page Ref: 199-200 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Planning Learning Outcome: 1. Identify activities that occur in the planning process. MNL Learning Outcome: 1. Examine the types of planning and development of nursing care plans.
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2) A client is admitted for complications following a routine diagnostic procedure of the colon. Which type of care plan will most likely be implemented for this client? 1. Informal nursing care plan 2. Formal nursing care plan 3. Standardized care plan 4. Individualized care plan Answer: 4 Explanation: An individualized care plan is tailored to meet a specific client need that is not addressed by the standardized care plan. In this situation, the client had complications following a relatively routine procedure–something that is unplanned and a rare occurrence. Page Ref: 200 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Planning Learning Outcome: 3. Explain how standards of care and predeveloped care plans can be individualized and used in creating a comprehensive nursing care plan. MNL Learning Outcome: 2. Consider ways to format, organize, and write nursing care plans. 3) A client is scheduled for elective hip replacement and will be admitted postoperatively to the orthopedic unit for care. What should the nurses use to help plan this client's care? 1. Informal nursing care plan 2. Formal nursing care plan 3. Standardized care plan 4. Individualized care plan Answer: 3 Explanation: A standardized care plan is a formal plan that specifies the nursing care for groups of clients with common needs. For example, all clients undergoing hip replacement surgery would have basic, similar needs or problems such as pain, skin integrity disruption, risk for infection, decreased mobility, or risk for fall or injury. Page Ref: 200-201 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Planning Learning Outcome: 3. Explain how standards of care and predeveloped care plans can be individualized and used in creating a comprehensive nursing care plan. MNL Learning Outcome: 2. Consider ways to format, organize, and write nursing care plans.
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4) The nurse being oriented to a new position is reviewing the hospital's standards of care, standardized care plans, protocols, policies, and procedures. For which reasons should the nurse realize that these documents are being used by the nursing staff? (Select all that apply.) 1. Making sure all clients have the same types of care 2. Ensuring that minimally accepted standards are met 3. Promoting efficient use of the nurse's time 4. Eliminating care disparities among clients 5. Ensuring medication errors do not occur Answer: 2, 3 Page Ref: 200-201 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 3. Explain how standards of care and predeveloped care plans can be individualized and used in creating a comprehensive nursing care plan. MNL Learning Outcome: 2. Consider ways to format, organize, and write nursing care plans. 5) The neonatal intensive care nurse implements several actions to prevent further complications in a newly admitted premature infant. Which type of document did the nurse use to find these actions? 1. Standardized care plan 2. Protocol 3. Standards of care 4. Policy and procedure manual Answer: 2 Explanation: Protocols are preprinted to indicate the actions commonly required for a particular group of clients. Protocols may include both physicians' orders and nursing interventions. Page Ref: 202 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 3. Explain how standards of care and predeveloped care plans can be individualized and used in creating a comprehensive nursing care plan. MNL Learning Outcome: 2. Consider ways to format, organize, and write nursing care plans.
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6) A nurse in the intensive care unit consults unit policy and administers a routinely used medication to a client admitted to the unit with severe hypotension. What did the nurse implement in this situation? 1. A STAT order 2. A one-time order 3. A prn order 4. A standing order Answer: 4 Explanation: Standing orders are a written document about policies, rules, regulations, or orders regarding client care. Page Ref: 202 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 3. Explain how standards of care and predeveloped care plans can be individualized and used in creating a comprehensive nursing care plan. MNL Learning Outcome: 2. Consider ways to format, organize, and write nursing care plans. 7) According to the care plan, a client is to receive chest physiotherapy twice daily. The client lives alone in a rural area, does not drive, and is 40 miles away from a hospital. What should the home care nurse do when setting priorities for this client? 1. Ensure for reliable transportation to get to the client's home. 2. Assist the client in finding an alternative plan for achieving the therapy's outcomes. 3. Tell the client that this therapy will be impossible to receive. 4. Make arrangements to have the client moved to a long-term care facility. Answer: 2 Explanation: The nurse must consider a variety of factors when assigning priorities, including resources available to the nurse and client. Factors in this case include the distance between the client's home and the hospital and the fact that therapy is ordered on a twice-daily basis. Driving 80 miles two times a day may not be feasible, but perhaps there are other alternatives that could be considered (e.g., a neighbor who might be willing to drive the client or someone in the area who may be able to assist with the therapy). Page Ref: 206 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Planning Learning Outcome: 5. Identify factors that the nurse must consider when setting priorities. MNL Learning Outcome: 3. Determine priorities, goals, and criteria for choosing nursing interventions for patients. 4
8) A discharge goal for a client is to have improved mobility. Which outcome statement did the nurse write appropriately? 1. Client will ambulate without a walker by 6 weeks. 2. Client will ambulate freely in house. 3. Client will not fall. 4. Client will have freer movement in daily activities. Answer: 1 Explanation: Desired outcomes are the more specific, observable criteria used to evaluate whether the goals have been met. Ambulating without a walker by a certain date is specific as well as measurable. Page Ref: 209 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Evaluation Learning Outcome: 8. Identify guidelines for writing goals/desired outcomes. MNL Learning Outcome: 3. Determine priorities, goals, and criteria for choosing nursing interventions for patients. 9) The nurse identifies for a client the nursing diagnosis "Fluid volume deficit, related to active fluid loss, secondary to diarrhea." What would be an appropriate goal statement for this diagnosis? 1. Client will drink more fluids by tomorrow. 2. Client will have good skin turgor. 3. Client will have moist mucous membranes. 4. Client will have intake of at least 1000 mL within 24 hours. Answer: 4 Explanation: The goal statement must be specific with observable outcomes in order for the nurse to evaluate client progress, and all options must have a time frame for evaluating the desired performance. This option includes all necessary components. Page Ref: 209 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Planning Learning Outcome: 8. Identify guidelines for writing goals/desired outcomes. MNL Learning Outcome: 3. Determine priorities, goals, and criteria for choosing nursing interventions for patients.
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10) The nurse is reviewing the Nursing Outcomes Classification (NOC) taxonomy system. To what can the nurse compare this taxonomy? 1. Nursing diagnosis statement 2. Planning portion of the care plan 3. Goal statement of the traditional care plan 4. Implementation phase of the care plan Answer: 3 Explanation: The Nursing Outcomes Classification (NOC) describes client outcomes that respond to nursing interventions seen in traditional care plans. Page Ref: 208 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Planning Learning Outcome: 6. Discuss the Nursing Outcomes Classification, including an explanation of how to use the outcomes and indicators in care planning. MNL Learning Outcome: 3. Determine priorities, goals, and criteria for choosing nursing interventions for patients. 11) The nurse is caring for a client with Parkinson disease who desires to improve fine motor skills. Which statement should the nurse identify as an appropriate collaborative intervention for this client? 1. Provide assistance as needed with dressing and grooming. 2. Provide assistive devices and educate client to use grab bar and large-handled utensils. 3. Make sure lighting and space are adequate for client. 4. Administer medications to improve muscle tone. Answer: 2 Explanation: Collaborative interventions are actions the nurse carries out with other health team members, such as physical therapists, social workers, dietitians, and physicians. Collaborative nursing activities reflect the overlapping responsibilities of, and collegial relationships between, health personnel. Providing assistive devices and educating on their proper use would fall into the discipline of physical/occupational therapy, although the nurse will have to assist with reinforcing the teaching and information. Page Ref: 212 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 9. Describe the process of selecting and choosing nursing interventions. MNL Learning Outcome: 3. Determine priorities, goals, and criteria for choosing nursing interventions for patients. 6
12) The nurse is reviewing interventions written for a client's plan of care. Which intervention should the nurse recognize as being dependent? 1. Repositioning the client every 2 hours 2. Assisting the client with transfers to the bathroom 3. Providing ongoing physical assessment, especially of the incisional sites 4. Administering medications for pain Answer: 4 Explanation: Dependent interventions are those activities carried out under the physician's orders or supervision or according to specified routines. The nurse is responsible for assessing the need for and administering medications, but the physician prescribes them. Page Ref: 212 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 9. Describe the process of selecting and choosing nursing interventions. MNL Learning Outcome: 3. Determine priorities, goals, and criteria for choosing nursing interventions for patients. 13) One of the interventions for a client with a nursing diagnosis of Impaired swallowing is to position the client upright in a chair (60-90 degrees) during feeding times. What should the nurse identify as the modifier in this intervention? 1. 60-90 degrees during feeding times 2. Position in chair 3. Upright in a chair 4. Impaired swallowing Answer: 1 Explanation: Conditions or modifiers may be added to the verb to explain the circumstances under which the behavior is to be performed. They explain what, where, when, or how. In this case, defining "upright" as 60-90 degrees and "during feeding times" gives when this should be done. Page Ref: 212 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Planning Learning Outcome: 9. Describe the process of selecting and choosing nursing interventions. MNL Learning Outcome: 3. Determine priorities, goals, and criteria for choosing nursing interventions for patients. 7
14) A nurse is caring for a client who has a diagnosis of Impaired skin integrity, related to immobility, secondary to neurologic dysfunction. Which should the nurse identify as an observation intervention? 1. Turn and reposition client every 2 hours. 2. Cushion bony prominences with soft foam while in bed. 3. Provide ongoing assessment for skin breakdown every shift. 4. Apply lotion to dry skin twice daily. Answer: 3 Explanation: Observations include assessments made to determine whether a complication is developing as well as observations of the client's responses to nursing and other therapies. Assessment for skin breakdown would fall under this category. Page Ref: 213 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 9. Describe the process of selecting and choosing nursing interventions. MNL Learning Outcome: 3. Determine priorities, goals, and criteria for choosing nursing interventions for patients. 15) The nurse wants to create an intervention to assist a client with ambulation. Which statement is the most appropriate manner for the nurse to write this intervention? 1. Assist client with ambulation. 2. Ambulate with client, using a gait belt, twice daily for 15 minutes. 3. Make sure client understands the rationale for using the gait belt. 4. Client will ambulate in hallway twice daily. Answer: 2 Explanation: A well-written intervention should include a verb, conditions, and modifiers, plus a time element. Identifying what to do (ambulate), how to do it (with a gait belt), and how long (twice daily for 15 minutes) is the most precise statement. Page Ref: 212 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Planning Learning Outcome: 9. Describe the process of selecting and choosing nursing interventions. MNL Learning Outcome: 3. Determine priorities, goals, and criteria for choosing nursing interventions for patients.
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16) A hospital is implementing the use of the NIC (Nursing Interventions Classification) taxonomy. What purpose will the implementation of this taxonomy serve? 1. Help the nurse with documentation of the care plan 2. Require that the nurse use sound judgment and knowledge of the client 3. Match nursing diagnoses to exact interventions 4. Help the nurse choose activities that are individualized to the client Answer: 2 Explanation: The NIC taxonomy, like NOC, is similar to NANDA diagnoses–broadly stated interventions that are standardized in language and generalized in nature. Each nursing diagnosis contains suggestions for several interventions under the NIC taxonomy, and nurses must select the appropriate interventions based on their judgment and knowledge of the client. Page Ref: 213 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Planning Learning Outcome: 10. Discuss the Nursing Interventions Classification, including an explanation of how to use the interventions and activities in care planning. MNL Learning Outcome: 4. Apply the planning process to the care of patients. 17) The nurse identifies the diagnosis Risk for aspiration, related to neuromuscular dysfunction for a client who experienced a cerebrovascular accident. Which intervention should the nurse identify as including a rationale? 1. Have suction equipment available at all times. 2. Clear secretions from oral/nasal passageways as needed. 3. Keep client in low-Fowler position to prevent reflux. 4. Provide frequent assessment for presence of obstructive material in mouth and throat. Answer: 3 Explanation: A rationale is the scientific principle given as the reason for selecting a particular nursing intervention. It helps explain "why" an intervention would be implemented. Keeping the client in a position with the head elevated 30-45 degrees helps prevent the risk of reflux (food/liquids returning up through the esophagus after having been swallowed). Page Ref: 212 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Planning Learning Outcome: 9. Describe the process of selecting and choosing nursing interventions. MNL Learning Outcome: 3. Determine priorities, goals, and criteria for choosing nursing interventions for patients. 9
18) The nurse manager is implementing computerized care plans for the care area. Which guidelines should the manager emphasize when the staff is writing care plans? (Select all that apply.) 1. Plans must be dated and signed. 2. Categories must have headings. 3. Plans must be specific. 4. Plans must include preventive care and health maintenance. 5. Plans must include interventions for ongoing assessment. 6. Plans are standardized and generalized for all clients. Answer: 1, 2, 3, 4, 5 Page Ref: 205 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 4. Identify essential guidelines for writing nursing care plans. MNL Learning Outcome: 2. Consider ways to format, organize, and write nursing care plans. 19) The nursing staff is reviewing standards of care, standardized care plans, protocols, policies, and procedures for a multisystem healthcare facility. Why are these documents important to the nursing staff when providing client care? (Select all that apply.) 1. Make sure all clients have the same type of care 2. Ensure that minimally accepted standards of care are met 3. Promote efficient use of the nurse's time 4. Eliminate care disparities among clients 5. Minimize healthcare costs Answer: 2, 3 Page Ref: 200 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Planning Learning Outcome: 3. Explain how standards of care and predeveloped care plans can be individualized and used in creating a comprehensive nursing care plan. MNL Learning Outcome: 2. Consider ways to format, organize, and write nursing care plans.
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20) The nurse is devising a care plan for a client with complex health issues and current acute health problems. Which criteria should the nurse ensure is used when planning interventions for this client? (Select all that apply.) 1. Congruent with the client's values, beliefs, and culture 2. Are within established standards of care 3. Based on scientific and medical knowledge 4. Achievable with the resources available 5. Must be safe and appropriate for the client's age Answer: 1, 2, 4, 5 Explanation: This is a recognized guideline. This is a recognized guideline. This is a recognized guideline. This is a recognized guideline. Page Ref: 212 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Planning Learning Outcome: 9. Describe the process of selecting and choosing nursing interventions. MNL Learning Outcome: 4. Apply the planning process to the care of patients. 21) The nurse is reviewing a client's plan of care. Which statements indicate that this care plan has been completed accurately and appropriately? (Select all that apply.) 1. Ineffective coping related to drug abuse as evidenced by drug overdose. 2. The client will identify two healthy coping mechanisms by time of discharge. 3. The client has identified two health coping mechanisms to replace inappropriate drug use. 4. The client will be provided with guidance in identifying healthy coping mechanisms. 5. The client has apologized to his family for drug abuse behaviors. Answer: 1, 2, 3, 4 Page Ref: 206 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Evaluation Learning Outcome: 4. Identify essential guidelines for writing nursing care plans. MNL Learning Outcome: 2. Consider ways to format, organize, and write nursing care plans.
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22) The nurse attends an educational program that provides information about the Nursing Intervention Classifications (NIC) system. Which statements made by the nurse indicate that teaching has been effective? (Select all that apply.) 1. "I can look up interventions according to the nursing diagnosis that I've selected." 2. "The interventions connected to a diagnosis are appropriate for any client with that diagnosis." 3. "If there is a NANDA diagnosis, I should be able to find some appropriate interventions." 4. "Care plans are best written when the interventions are broad and flexible." 5. "I find NIC interventions a really good place to start when I'm working on client interventions." Answer: 1, 3, 5 Explanation: The nurse can look up a client's nursing diagnosis to see which nursing interventions are suggested. All NIC interventions have been linked to NANDA nursing diagnostic labels. Not all activities suggested for the intervention would be needed for every client, so the nurse chooses the activities appropriate for the client and individualizes them to fit the supplies, equipment, and other resources available in the agency. Page Ref: 213 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Evaluation Learning Outcome: 10. Discuss the Nursing Interventions Classification, including an explanation of how to use the interventions and activities in care planning. MNL Learning Outcome: 4. Apply the planning process to the care of patients.
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23) The nurse is collecting information to plan care for a client with a heart problem. Which information indicates that planning for this client's discharge was started by the nurse? (Select all that apply.) 1. The client is scheduled for cardiac catheterization and echocardiogram. 2. Recent laboratory data indicates the development of heart failure. 3. The client does not have a scale to perform daily weights at home. 4. The client's spouse has care needs that the client will not be able to complete going forward. 5. The client is pleasant and eager to learn how to control the newly diagnosed health problem. Answer: 3, 4 Page Ref: 200 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Evaluation Learning Outcome: 2. Compare and contrast initial planning, ongoing planning, and discharge planning. MNL Learning Outcome: 1. Examine the types of planning and development of nursing care plans.
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24) The nurse is creating goals for a client's plan of care. For what reasons should the nurse expect to use these goals? (Select all that apply.) 1. Serve as criteria to evaluate the client's progress 2. Determine when the problem has been resolved 3. Motivate the client to provide a sense of achievement 4. Use as a measuring stick to limit the use of hospital resources 5. Provide direction when planning the client's nursing interventions Answer: 1, 2, 3, 5 Explanation: Desired outcomes/goals serve as the criteria for judging the effectiveness of nursing interventions and client progress in the evaluation step. Desired outcomes/goals enable the client and nurse to determine when the problem has been resolved. Desired outcomes/goals help motivate the client and nurse by providing a sense of achievement. As goals are met, both client and nurse can see that their efforts have been worthwhile. This provides motivation to continue following the plan, especially when difficult lifestyle changes need to be made. Desired outcomes/goals provide direction for planning nursing interventions. Ideas for interventions come more easily if the desired outcomes state clearly and specifically what the nurse and client hope to achieve. Page Ref: 208 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. State the purposes of establishing client goals or desired outcomes. MNL Learning Outcome: 3. Determine priorities, goals, and criteria for choosing nursing interventions for patients.
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25) The nurse manager is preparing a teaching tool about the nursing process. Which activities should the manager identify that are completed during the planning phase of the process? (Select all that apply.) 1. Cluster data 2. Identify actions 3. Problem solving 4. Decision making 5. Evaluate outcomes Answer: 3, 4 Explanation: Problem solving occurs during the planning phase of the nursing process. Decision making occurs during the planning phase of the nursing process. Page Ref: 199 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Planning/Teaching and Learning Learning Outcome: 1. Identify activities that occur in the planning process. MNL Learning Outcome: 1. Examine the types of planning and development of nursing care plans.
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26) The nurse is reviewing care planned for a client. For which reason should the nurse complete daily planning for this client? (Select all that apply.) 1. Identify issues that are no longer client problems 2. Set priorities for the client's care during the shift 3. Determine if the client's health status has changed 4. Decide which problems to focus on during the shift 5. Coordinate activities so several problems can be addressed at each contact Answer: 2, 3, 4, 5 Explanation: Daily planning is done to set priorities for the client's care during the shift. Daily planning is done to determine if the client's health status has changed. Daily planning is done to decide which problems to focus on during the shift. Daily planning is done and to coordinate activities so several problems can be addressed at each contact. Daily planning is not done to identify issues that are no longer client problems. Page Ref: 200 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 2. Compare and contrast initial planning, ongoing planning, and discharge planning. MNL Learning Outcome: 1. Examine the types of planning and development of nursing care plans.
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27) During a home visit, the nurse notes that a client with heart failure does not have a scale to measure daily weights. Which action should the nurse take when prioritizing this intervention? 1. Buy the client a scale 2. Identify this action as low priority 3. Suggest that the client be hospitalized 4. Identify a resource where a scale can be obtained Answer: 4 Explanation: If equipment is scarce then a problem may be given a lower priority than usual. If the necessary resources are not available in the home setting, the client may need a referral to obtain the equipment. The nurse would not buy the client a scale. Daily weights would be a high priority for the client with heart failure. Hospitalization would not be warranted to measure daily weights. Page Ref: 206 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Identify factors that the nurse must consider when setting priorities. MNL Learning Outcome: 3. Determine priorities, goals, and criteria for choosing nursing interventions for patients.
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28) The nurse is using the Nursing Outcome Classification (NOC) when writing desired outcomes for a client. What information should the nurse include? (Select all that apply.) 1. Label 2. Indicators 3. Outcome target 4. Date of discharge 5. Rating at initiation Answer: 1, 2, 3, 5 Explanation: When using the NOC taxonomy to write a desired outcome on a care plan, the label, indicators, targeted outcome, and rating at initiation are included. When using the NOC taxonomy to write a desired outcome on a care plan, indicators are included. When using the NOC taxonomy to write a desired outcome on a care plan, the targeted outcome is included. When using the NOC taxonomy to write a desired outcome on a care plan, the rating at initiation is included. Page Ref: 208 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 6. Discuss the Nursing Outcomes Classification, including an explanation of how to use the outcomes and indicators in care planning. MNL Learning Outcome: 3. Determine priorities, goals, and criteria for choosing nursing interventions for patients.
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29) The nurse is planning care for a client. For which reason should the nurse identify desired outcomes before identifying interventions? 1. Provide direction 2. Provide a sense of achievement 3. Determine when problems are solved 4. Identify criteria for evaluating progress Answer: 1 Explanation: Ideas for interventions come more easily if the desired outcomes are stated and specify what is to be achieved. Identifying outcomes before interventions is not done to provide a sense of achievement, determine when problems are solved, or identify criteria for evaluating progress. Page Ref: 208 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. State the purposes of establishing client goals or desired outcomes. MNL Learning Outcome: 3. Determine priorities, goals, and criteria for choosing nursing interventions for patients.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 13 Implementing and Evaluating 1) The home health nurse uses creativity and critical thinking to devise a way for a client to receive intravenous medication while sitting outside on the porch. Which skill did the nurse use for this situation? 1. Technical 2. Interpersonal 3. Creativity 4. Cognitive Answer: 4 Explanation: Cognitive skills include problem solving, decision making, critical thinking, and creativity. Finding a unique way to provide the treatment while keeping the client's wishes in mind is an example of the nurse using cognitive abilities. Page Ref: 220 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 2. Describe three categories of skills used to implement nursing interventions. MNL Learning Outcome: 1. Examine the factors associated with implementing nursing interventions.
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2) A home care client must correctly self-administer insulin injections before being discharged from the agency. On what skill is this client being evaluated? 1. Technical 2. Cognitive 3. Interpersonal 4. Academic Answer: 1 Explanation: Technical skills are "hands-on" skills such as manipulating equipment, giving injections, bandaging, and moving, lifting, and repositioning clients. These skills can also be called tasks, procedures, or psychomotor skills. Page Ref: 220 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 2. Describe three categories of skills used to implement nursing interventions. MNL Learning Outcome: 2. Examine the factors associated with evaluating patient responses.
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3) The nurse provides care to clients admitted to a mental health facility who exhibit paranoid behavior. Which skill should the nurse use when caring for these clients? 1. Cognitive 2. Interpersonal 3. Technical 4. Therapeutic Answer: 2 Explanation: Interpersonal skills are all of the activities, verbal and nonverbal, people use when interacting directly with one another. The effectiveness of a nursing action often depends largely on the nurse's ability to communicate with others. Interpersonal skills are necessary for all nursing activities, including comforting, counseling, and supporting–all of which are extremely important in the acute psychiatric setting. Page Ref: 220 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 2. Describe three categories of skills used to implement nursing interventions. MNL Learning Outcome: 1. Examine the factors associated with implementing nursing interventions.
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4) The nurse is preparing to provide care planned for a client. What actions should the nurse complete during this phase of client care? (Select all that apply.) 1. Evaluating the outcome of the interventions 2. Reassessing the client 3. Documenting the history and physical 4. Supervising delegated care 5. Implementing the nursing interventions Answer: 1, 4, 5 Explanation: Evaluating outcomes occurs during the evaluation phase. Supervising delegated care occurs during the implementation phase. Implementing the nursing interventions occurs during the implementation phase. Page Ref: 220 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 3. Discuss the five activities of the implementing phase. MNL Learning Outcome: 1. Examine the factors associated with implementing nursing interventions.
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5) Upon entering a room, a client and spouse are found crying. The nurse decides to sit with both of them, offering presence and listening to their fears instead of providing the planned education. What action did the nurse perform? 1. Implementing nursing intervention 2. Determining the nurse's need for assistance 3. Supervising delegated care 4. Reassessing the client Answer: 4 Explanation: Just before implementing an intervention, the nurse must reassess the client to make sure the intervention is still needed or to discover if there are new data that indicate a need to change the priorities of care. In this case, the client and the spouse are not in a good frame of mind to listen to or retain any kind of teaching/learning experience. Instead, the nurse reassesses the situation and implements a more appropriate intervention. Page Ref: 220 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Discuss the five activities of the implementing phase. MNL Learning Outcome: 1. Examine the factors associated with implementing nursing interventions.
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6) The nurse is caring for a new mother and infant. Which action should the nurse take that allows the new parents to feel in control when being taught how to bathe their infant? 1. Telling the parents everything the nurse is doing and why 2. Letting the parents watch a video after the bath 3. Letting the parents bathe the baby with direction and guidance from the nurse 4. Giving lots of advice and suggestions about different methods Answer: 3 Explanation: Active participation enhances a client's sense of independence and control. In this situation, the baby and parents will do best with future bathing times if they are allowed to complete the bath themselves. Page Ref: 221 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 4. Identify guidelines for implementing nursing interventions. MNL Learning Outcome: 3. Recognize the factors involved in ensuring quality nursing care. 7) During teaching, the nurse makes sure the client understands how to activate the safety mechanism on the syringe to prevent needle stick injuries when self-administering insulin. Which guideline of implementing interventions is the nurse using? 1. Adapt activities to the individual client. 2. Encourage clients to participate actively in implementing nursing interventions. 3. Base nursing interventions on scientific knowledge, research, and standards of care. 4. Implement safe care. Answer: 4 Explanation: Showing the client how to avoid injury with injections is part of implementing safe care. Page Ref: 221 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 4. Identify guidelines for implementing nursing interventions. MNL Learning Outcome: 3. Recognize the factors involved in ensuring quality nursing care.
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8) On one of the first days working alone, the new nurse with limited patient teaching experience needs to instruct tracheostomy care to a client and spouse. What action should the nurse take? 1. Ask the nurse mentor to assist with the teaching after reviewing the procedure. 2. Read the policy and procedure manual before the teaching session. 3. Do the best the nurse can by remembering what was taught in nursing school. 4. Ask for a different assignment until the nurse feels comfortable with this one. Answer: 1 Explanation: When implementing some nursing interventions, the nurse may require assistance. In this case, the nurse lacks the knowledge or skills to implement a particular nursing activity (teaching). Page Ref: 221 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 4. Identify guidelines for implementing nursing interventions. MNL Learning Outcome: 3. Recognize the factors involved in ensuring quality nursing care. 9) A client is prescribed a medication that the nurse has never administered and information about the medication is not in the drug reference manual. What should the nurse do? 1. Follow the physician's orders as written and give the medication. 2. Call the pharmacy and do further investigating before administering the medication. 3. Ask the client about this medication. 4. Call the physician and ask what the medication is and what it is for. Answer: 2 Explanation: The nurse should clearly understand all nursing interventions to be implemented and question any that are not understood. The nurse is responsible for intelligent implementation of medical and surgical plans of care. The pharmacist would be the most appropriate reference point for this nurse to begin to research this problem. Page Ref: 221 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 4. Identify guidelines for implementing nursing interventions. MNL Learning Outcome: 3. Recognize the factors involved in ensuring quality nursing care.
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10) The nurse is providing care to an assigned client. Which action indicates that the nurse supports the client's respect for dignity? 1. Allowing the client to complete hygienic care when possible 2. Providing all care to the client whenever possible 3. Telling the other staff that the client is demanding, so they are able to meet the client's needs 4. Presenting information to the client's family about the client's condition Answer: 1 Explanation: Respecting the dignity of each client enhances their self-esteem and is an important aspect of implementing interventions. Providing privacy and allowing clients to make their own decisions, or do their own care when possible, is a way of respecting dignity and increasing selfesteem. Page Ref: 221 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 3. Discuss the five activities of the implementing phase. MNL Learning Outcome: 1. Examine the factors associated with implementing nursing interventions. 11) The nurse provides routine morning care to a client, including all the medications and scheduled treatments. What action should the nurse make next? 1. Move on to the next assignment to increase the nurse's efficiency. 2. Report this to the charge nurse. 3. Document all care in the progress notes. 4. Get supplies organized for the next client's medications and treatments. Answer: 3 Explanation: After carrying out the nursing activities, the nurse completes the implementing phase by recording the interventions and client responses in the progress notes. Page Ref: 222 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 3. Discuss the five activities of the implementing phase. MNL Learning Outcome: 1. Examine the factors associated with implementing nursing interventions. 8
12) The nurse is reviewing the difference between evaluation and assessment with a new graduate nurse. What should the nurse emphasize as the major difference between these two steps in the nursing process? 1. Assessment is done at the beginning of the process. 2. Evaluation is completed at the end of the process. 3. They are the same and there is no need to differentiate. 4. The difference is in how the data are used. Answer: 4 Explanation: Although the two processes overlap, there is a difference between the data collected. Assessment data are collected for the nurse to make a diagnosis and evaluate desired outcomes. Evaluation data are collected for the purpose of comparing them to prescribed goals and judging the effectiveness of the nursing care. Page Ref: 222-223 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Evaluation Learning Outcome: 5. Explain how evaluating relates to other phases of the nursing process. MNL Learning Outcome: 2. Examine the factors associated with evaluating patient responses. 13) The nurse notes that a client has the outcome goal "Client will have a decrease in pain level (down to a 3) within 45 minutes of receiving oral analgesic." Which client statement should the nurse use to evaluate this goal? 1. "I'm getting really sleepy from that medication. I think I'll take a nap." 2. "My pain is a 4." 3. "I still have some pain." 4. "Will the pain ever go away?" Answer: 2 Explanation: The nurse collects data so that conclusions can be drawn about whether goals have been met. If the goal is clearly stated, precise, and measurable, it will be easy to evaluate. If the goal was a pain level of 3, the client should be able to give a numerical rating to the pain in order for the nurse to evaluate it. Page Ref: 223 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Evaluation Learning Outcome: 6. Describe five components of the evaluation process. MNL Learning Outcome: 2. Examine the factors associated with evaluating patient responses. 9
14) A client has the goal statement "Client will be able to state two positive aspects of rehab therapy by the end of the week." What statement demonstrates that the nurse appropriately evaluated this goal? 1. Goal not met, client able to state one positive aspect by the end of the week. 2. Goal met, client able to state one positive aspect by the end of the week. 3. Goal met, client able to state two positive aspects of therapy by week's end. 4. Goal incomplete, client not able to positively state anything about rehab. Answer: 3 Explanation: An evaluation statement consists of two parts: a conclusion and supporting data. The conclusion is a statement that the goal/desired outcome was met, partially met, or not met. The supporting data are the list of the client responses that support the conclusion. In this situation, the goal was met if the client was able to state two positive aspects of rehab by the end of the week, and the evaluation statement should reveal that. Page Ref: 223 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Evaluation Learning Outcome: 6. Describe five components of the evaluation process. MNL Learning Outcome: 2. Examine the factors associated with evaluating patient responses. 15) A client has the goal statement "Client will have clear lung sounds bilaterally within 3 days." One intervention to meet this goal is for the nurse to teach the client to cough and deep-breathe and have the client do this several times every 2 hours. At the end of the third day, the client's lungs are indeed clear. What should the nurse do to relate the intervention to the outcome? 1. Ask how many times per day the client practiced the coughing and deep-breathing exercises. 2. Tell the client that the lungs are clear. 3. Document the assessment findings to show the effectiveness of the intervention. 4. Write this evaluation statement: Goal met, lung sounds clear by third day. Answer: 1 Explanation: Part of the evaluating process is determining whether the nursing activities had any relation to the outcomes. Did the lungs clear because the client actually did the coughing and deep breathing? In order to know for sure, the nurse must collect more data and not assume that this particular nursing intervention had any relation to the outcome. Page Ref: 223 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Evaluation Learning Outcome: 5. Explain how evaluating relates to other phases of the nursing process. MNL Learning Outcome: 2. Examine the factors associated with evaluating patient responses. 10
16) A nursing diagnosis of Risk for Deficient Fluid Volume related to excessive fluid loss, secondary to diarrhea and vomiting was implemented for a home health client who began with these symptoms 5 days ago. A goal was that the client's symptoms would be eliminated within 48 hours. The client is being seen after a week and has had no diarrhea or vomiting for the past 5 days. What should the nurse do? 1. Keep the problem on the care plan, in case the symptoms return. 2. Document that the problem has been resolved and discontinue the care for the problem. 3. Assume that whatever the cause was, the symptoms may return, but document that the goal was met. 4. Document that the potential problem is being prevented because the symptoms have stopped. Answer: 2 Explanation: In this case, the risk factors no longer exist because the causative factors have stopped. The nurse should document that the goal has been met and discontinue the care for the problem. If the problem returns, it can be implemented again and addressed at that time. Page Ref: 224 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Evaluation Learning Outcome: 7. Describe the steps involved in reviewing and modifying the client's care plan. MNL Learning Outcome: 2. Examine the factors associated with evaluating patient responses.
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17) A client with terminal cancer has this nursing diagnosis: Pain related to neuromuscular involvement of disease process. The goal statement is: Client will be free of pain within 48 hours. As an intervention, the nurse will administer narcotic analgesics and titrate to an appropriate level. What is the flaw in this plan? 1. The goal statement is written inaccurately. 2. The interventions are dependent of nursing. 3. The goal is unrealistic. 4. The interventions are not clear enough. Answer: 3 Explanation: When a care plan needs to be modified, discontinued, or changed in some manner, several decisions need to be made. If the nursing diagnosis is accurate, as it is in this case, the nurse should check to see if the goals are attainable and realistic–the flaw in this plan. A client with terminal cancer is not going to be pain-free, regardless of the amount of medication delivered. To think otherwise is inappropriate. Page Ref: 225 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Evaluation Learning Outcome: 7. Describe the steps involved in reviewing and modifying the client's care plan. MNL Learning Outcome: 4. Apply the process of implementing and evaluating to the care of patients.
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18) A teenage client has been having problems with peer support, school performance, and parental expectations, all of which contributed to an eating disorder. After gathering this assessment data, the nurse formulates the diagnosis Activity Intolerance related to weakness. What should the nurse realize after evaluating this diagnosis? 1. The data collected would support the diagnosis. 2. The diagnosis is directly related to the data presented. 3. The nursing diagnosis is not relevant to the data. 4. The data are not sufficient enough to support this diagnosis. Answer: 4 Explanation: An incomplete database influences all steps of the nursing process and care plan. The nurse must complete the assessment before formulating a diagnosis about weakness and fatigue. Perhaps this diagnosis is appropriate for this client, but there are not enough data presented to know that for sure. Page Ref: 225 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Evaluation Learning Outcome: 7. Describe the steps involved in reviewing and modifying the client's care plan. MNL Learning Outcome: 4. Apply the process of implementing and evaluating to the care of patients.
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19) A client has neurologic deficits that are causing tremors, unsteadiness, and weakness. An appropriate diagnosis of Risk for Falls related to unsteady gait, secondary to neurologic dysfunction has been formulated. A goal for this client is not to sustain any injuries for the next month; however, the client has fallen several times. In this situation, what should the nurse do? 1. Review the data and make sure that the diagnosis is relevant. 2. Investigate whether the best nursing interventions were selected. 3. Modify the whole nursing plan. 4. Discard the nursing plan and start over from the assessment phase. Answer: 2 Explanation: Even if all sections of the care plan appear to be satisfactory, the manner in which the plan was implemented may have interfered with goal achievement. The nurse needs to check and see if the interventions were appropriate for the client. If the interventions selected did not help the client achieve the goal, then rearranging or implementing new ones may be necessary. Page Ref: 225 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Evaluation Learning Outcome: 7. Describe the steps involved in reviewing and modifying the client's care plan. MNL Learning Outcome: 4. Apply the process of implementing and evaluating to the care of patients. 20) The nurse manager has been appointed to implement a quality assurance program at the hospital. Which components should the manager prepare to evaluate for this program? (Select all that apply.) 1. Methods 2. Structure 3. Finances 4. Process 5. Outcome Answer: 2, 4, 5 Page Ref: 226 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: IV. A. 1. Describe strategies for learning about the outcomes of care in the setting in which one is engaged in clinical practice | AACN Essentials Competencies: II. 10. Use improvement methods, based on data from the outcomes of care processes, to design and test changes to continuously improve the quality and safety of healthcare | NLN Competencies: Quality and Safety; Practice-Know-How; Contribute to assessment of outcome achievement | Nursing/Integrated Concepts: Evaluation Learning Outcome: 8. Describe three components of quality evaluation: structure, process, and outcomes. MNL Learning Outcome: 3. Recognize the factors involved in ensuring quality nursing care. 14
21) A care area has been short staffed for the past month with a heavy client load and high acuity. The nurses have been working extra shifts as well as double shifts and often do not have time to make sure that properly working equipment is cleaned, returned, and stored in the appropriate areas. At what level should this care area be evaluated? 1. Management 2. Structure 3. Process 4. Outcome Answer: 2 Explanation: Structure evaluation focuses on the setting in which care is given. Structural standards describe desirable environmental and organizational characteristics that influence care, such as equipment and staffing. Process evaluation focuses on how the care was given. Page Ref: 226 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: IV. A. 1. Describe strategies for learning about the outcomes of care in the setting in which one is engaged in clinical practice | AACN Essentials Competencies: II. 10. Use improvement methods, based on data from the outcomes of care processes, to design and test changes to continuously improve the quality and safety of healthcare | NLN Competencies: Quality and Safety; Practice-Know-How; Contribute to assessment of outcome achievement | Nursing/Integrated Concepts: Evaluation Learning Outcome: 8. Describe three components of quality evaluation: structure, process, and outcomes. MNL Learning Outcome: 3. Recognize the factors involved in ensuring quality nursing care.
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22) A nursing unit has had a large number of negative client responses about various aspects of their care in the previous quarter. When evaluating this care area, on which care component should the quality assurance officer focus? 1. Competency 2. Structure 3. Process 4. Outcome Answer: 3 Explanation: Process evaluation focuses on how the care was given. Is the care relevant to the clients' needs? Is it appropriate, complete, and timely? Process standards focus on the manner in which the nurse uses the nursing process. Page Ref: 226 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: IV. A. 1. Describe strategies for learning about the outcomes of care in the setting in which one is engaged in clinical practice | AACN Essentials Competencies: II. 10. Use improvement methods, based on data from the outcomes of care processes, to design and test changes to continuously improve the quality and safety of healthcare | NLN Competencies: Quality and Safety; Practice; Contribute to assessment of outcome achievement | Nursing/Integrated Concepts: Evaluation Learning Outcome: 8. Describe three components of quality evaluation: structure, process, and outcomes. MNL Learning Outcome: 3. Recognize the factors involved in ensuring quality nursing care. 23) A nursing unit's records of client care have been reviewed for accuracy in documentation. Which type of review is being completed on these records? 1. Nursing audit 2. Peer review 3. Individual audit 4. Concurrent audit Answer: 1 Explanation: An audit is an examination or review of records. A nursing audit is a type of peer review that focuses on evaluating nursing care through the review of records. The success of these audits depends on accurate documentation. Page Ref: 228 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Evaluation Learning Outcome: 8. Describe three components of quality evaluation: structure, process, and outcomes. MNL Learning Outcome: 3. Recognize the factors involved in ensuring quality nursing care.
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24) The nurse reviews clients' records and the care they received while in the hospital for an insurance company. Part of the job description requires the nurse to make sure that the client and insurance company were billed for services and treatment/therapies rendered and that there were no errors in billing. Which type of audit is the nurse completing? 1. Concurrent 2. Peer review 3. Nursing audit 4. Retrospective Answer: 4 Explanation: A retrospective audit is the evaluation of a client's record after discharge from an agency. The word retrospective means "relating to the past." If the nurse is reviewing records after the client has been discharged, the information being examined is in the past. Page Ref: 228 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Evaluation Learning Outcome: 9. Differentiate quality improvement from quality assurance. MNL Learning Outcome: 3. Recognize the factors involved in ensuring quality nursing care.
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25) The nurse assigns assistive personnel to measure vital signs for several clients. The task is completed and documented correctly; however, one of the clients had a blood pressure reading of 180/110 mm Hg. The nurse learns this information at the end of the shift. Which responsibility of delegation did the nurse fail to carry out? 1. Delegating to the appropriate staff 2. Delegating the appropriate task 3. Selecting the appropriate client 4. Appropriately supervising care Answer: 4 Explanation: The nurse has two responsibilities in delegating and assigning duties: (1) appropriate delegation of duties (i.e., giving people duties within their scope of practice) and (2) adequate supervision of personnel to whom work is delegated or assigned. In this situation, the nurse gave assistive personnel a duty that was appropriate. Assistive personnel completed the duty and documented the findings. The nurse is still responsible for analyzing data, planning care, and evaluating outcomes. In this case, the nurse failed to follow up (supervise) after the duty was performed and analyze the findings. Page Ref: 220, 222 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 4. Identify guidelines for implementing nursing interventions. MNL Learning Outcome: 1. Examine the factors associated with implementing nursing interventions.
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26) The nurse is implementing care and treatments for assigned clients. What actions should the nurse prepare to complete during this phase of the nursing process? (Select all that apply.) 1. Evaluating the outcome of the interventions 2. Reassessing the client 3. Documenting the history and physical 4. Supervising delegated care 5. Implementing the nursing intervention Answer: 2, 4, 5 Explanation: Reassessing the client is a component of the implementation process. Supervising delegated care is a component of the implementation process. Implementing nursing interventions is a component of the implementation process. Page Ref: 220 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 3. Discuss the five activities of the implementing phase. MNL Learning Outcome: 1. Examine the factors associated with implementing nursing interventions.
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27) After implementing interventions and reassessing the client's response, the nurse completes the process by evaluating. What attributes of evaluation should the nurse include when completing this step of the nursing process? (Select all that apply.) 1. Purposeful activity 2. Nursing accountability 3. Continuous 4. Judgments 5. Opinion Answer: 1, 2, 3, 4 Explanation: Evaluating is a planned, ongoing, purposeful activity in which clients and healthcare professionals determine the client's progress toward achievement of goals/outcomes and the effectiveness of the nursing care plan. Through evaluating, nurses demonstrate responsibility and accountability for their actions. Evaluation is continuous and done while or immediately after implementing a nursing order. To evaluate is to judge or appraise. Through evaluation, the nurse is able to establish whether nursing interventions should be terminated, continued, or changed. Page Ref: 222 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Evaluation Learning Outcome: 6. Describe five components of the evaluation process. MNL Learning Outcome: 2. Examine the factors associated with evaluating patient responses.
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28) The nurse is preparing to evaluate care provided to a client. What behaviors should the nurse demonstrate that show an understanding of the relationship of evaluation to the other phases of the nursing process? (Select all that apply.) 1. Effectively assessing the client's needs 2. Selecting the appropriate nursing diagnosis related to the client's needs 3. Collecting client-focused data with a specific need in mind 4. Evaluating by using assessment data to determine effective achievement of goals and outcomes 5. Basing evaluation on assessment data collected during the admission phase Answer: 1, 2, 3, 4 Explanation: Successful evaluation depends on the effectiveness of the steps that precede it. Assessment data must be accurate and complete so that the nurse can proceed with the nursing process. Successful evaluation depends on the effectiveness of the steps that precede it so that the nurse can formulate appropriate nursing diagnoses. Data are collected for different purposes at different points in the nursing process. During the evaluation step, the nurse collects data for the purpose of comparing it with preselected goals/outcomes and judging the effectiveness of the nursing care. Page Ref: 222 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 1. Explain how implementing relates to other phases of the nursing process. MNL Learning Outcome: 2. Examine the factors associated with evaluating patient responses.
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29) The nurse notes that assessment data indicate a change in a client's condition. What should the nurse ask before changing this client's plan of care? (Select all that apply.) 1. How difficult will it be to change the care plan? 2. Are the new data complete? 3. Are the new data accurate? 4. Do the new data require a change in the care plan? 5. Will the primary medical provider agree with the need to alter the care plan? Answer: 2, 3, 4 Explanation: Data must be complete before consideration is given to altering a client's care plan. Data must be accurate before consideration is given to altering a client's care plan. Determining if the new data requires a change in the plan of care must be done before consideration is given to altering a client's care plan. Page Ref: 225 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Planning Learning Outcome: 7. Describe the steps involved in reviewing and modifying the client's care plan. MNL Learning Outcome: 2. Examine the factors associated with evaluating patient responses. 30) The nurse is evaluating care provided to a client. Which nursing actions indicate that the phases of evaluation were completed by the nurse appropriately? (Select all that apply.) 1. Client problems updated 2. Data linked to NOC indicators 3. Data compared to desired outcomes 4. Interventions changed on the care plan 5. Physician notified of changes in the care plan Answer: 1, 2, 3, 4 Page Ref: 223 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Evaluation Learning Outcome: 6. Describe five components of the evaluation process. MNL Learning Outcome: 2. Examine the factors associated with evaluating patient responses.
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31) A client recovering from total knee replacement surgery falls out of bed on the night shift and dies. Which quality improvement actions should the nurse manager expect to complete for this client occurrence? (Select all that apply.) 1. A root cause analysis 2. Paperwork about a sentinel event 3. Analysis of the nurse assigned to the client 4. Number of times the client was observed on the night shift 5. Number of hours since the client last received pain medication Answer: 1, 2 Page Ref: 227 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: IV. A. 1. Describe strategies for learning about the outcomes of care in the setting in which one is engaged in clinical practice | AACN Essentials Competencies: II. 10. Use improvement methods, based on data from the outcomes of care processes, to design and test changes to continuously improve the quality and safety of healthcare | NLN Competencies: Quality and Safety; Practice-Know-How; Contribute to assessment of outcome achievement | Nursing/Integrated Concepts: Evaluation Learning Outcome: 9. Differentiate quality improvement from quality assurance. MNL Learning Outcome: 3. Recognize the factors involved in ensuring quality nursing care. 32) The nurse is asked to explain why so much time is spent on the assessment, diagnosing, and planning phases of the nursing process. Which response should the nurse make? 1. "They eliminate the need to reassess the client." 2. "They make it easier to provide care to the client." 3. "They help determine if the client has achieved outcomes." 4. "They provide the basis for the actions performed during the implementation phase." Answer: 4 Explanation: Assessing, diagnosing, and planning provide the basis for the nursing actions performed during the implementing step. These phases of the nursing process are not done to eliminate the need to reassess the client, make it easier to provide care to the client, or help determine if the client has achieved outcomes. Page Ref: 219 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Context and Environment; Knowledge; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 1. Explain how implementing relates to other phases of the nursing process. MNL Learning Outcome: 1. Examine the factors associated with implementing nursing interventions.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 14 Documenting and Reporting 1) A client who is being transferred to a rehabilitation center wants to take the medical record to the new facility. How should the nurse respond to this client's request? 1. "You'll have to ask your doctor for permission to do that." 2. "Actually, the original record is the property of the hospital, but you are welcome to copies of your records." 3. "We'll make sure that all of your records are sent ahead to the rehab hospital, so you don't really have to worry about those details." 4. "There's a new law that protects your records, so you're not going to be able to have access to them." Answer: 2 Explanation: Although the client's record is protected legally as private, access to the record is restricted to health professionals involved in the client's care. The institution or agency is the rightful owner of the client's record, but the client has the right to access all information contained within the record and to have a copy of the original record. The hospital has the right to charge a fee for the copying costs. The Health Insurance Portability and Accountability Act (HIPAA) is a law enacted to protect health information and maintain confidentiality of client records. Page Ref: 233 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: IV. C. 3. Protect confidentiality of protected health information in electronic health records | AACN Essentials Competencies: IV. 8. Uphold ethical standards related to data security, regulatory requirements, confidentiality, and clients' right to privacy | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Implementation Learning Outcome: 1. List the measures used to maintain confidentiality and security of computerized client records. MNL Learning Outcome: 1. Recognize the importance of privacy and the purpose and types of documentation systems.
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2) After classroom discussion regarding confidentiality policies and laws protecting client records, a student asks why it's permissible for them to review and have access to client records in the clinical area. How should the nursing instructor respond? 1. "Confidentiality and privacy laws don't apply to students." 2. "Most students review so many records and charts that they could not possibly remember details from any one of them." 3. "Records are used in educational settings and for learning purposes, but the student is bound to hold all information in strict confidence." 4. "As long as the clinical instructor is in the area, accessing client records is part of the education process." Answer: 3 Explanation: For purposes of education and research, most agencies allow students and graduate health professionals access to client records. The student or graduate is bound by a strict ethical code and legal responsibility to hold all information in confidence. It is the responsibility of the student or health professional to protect the client's privacy by not using a name or any statements in the notations that would identify the client. Page Ref: 234 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: IV. C. 3. Protect confidentiality of protected health information in electronic health records | AACN Essentials Competencies: IV. 8. Uphold ethical standards related to data security, regulatory requirements, confidentiality, and clients' right to privacy | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 1. List the measures used to maintain confidentiality and security of computerized client records. MNL Learning Outcome: 1. Recognize the importance of privacy and the purpose and types of documentation systems.
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3) The nurse works at an organization that is installing a new computerized record system. What should the nurse learn that has been implemented to help ensure the security of client records? (Select all that apply.) 1. A firewall to protect the server from unauthorized access 2. One unit password to protect the unit's information 3. Expectation to log off a terminal after using it 4. Expectation to turn the monitor away from view when unattended 5. Requirement to shred all computer-generated worksheets Answer: 1, 3, 5 Page Ref: 234 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: IV. C. 3. Protect confidentiality of protected health information in electronic health records | AACN Essentials Competencies: IV. 8. Uphold ethical standards related to data security, regulatory requirements, confidentiality, and clients' right to privacy | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Implementation Learning Outcome: 1. List the measures used to maintain confidentiality and security of computerized client records. MNL Learning Outcome: 1. Recognize the importance of privacy and the purpose and types of documentation systems. 4) A hospital is not able to be reimbursed for care a particular client received while in the emergency department. The client came in with chest pain, which was later diagnosed as gastric reflux. Which problem with documentation might have caused the lack of reimbursement? 1. The client's record contained an incorrect DRG. 2. The client was charged for an ECG. 3. A code cart was opened and the client was charged for medications opened but not used. 4. The physician made a diagnostic mistake. Answer: 1 Explanation: Documentation helps a facility receive reimbursement from the federal government. The client's clinical record must contain the correct diagnosis-related group (DRG) codes and reveal that the appropriate care has been given. Coded diagnoses, such as DRGs, are supported by accurate, thorough recording by nurses. Page Ref: 235 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: IV. A. 1. Explain why information and technology skills are essential for safe patient care | AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice | NLN Competencies: Knowledge and Science; Practice-Know-How; Document via electronic health records; Use software applications related to nursing practice | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Discuss purposes for client records. MNL Learning Outcome: 2. Recognize the general guidelines involved in documenting patient care and responses. 3
5) When attempting to locate recent laboratory results, the nurse notices that each department has a separate section in the client's chart. Which type of documentation system is the nurse using? 1. Source-oriented record 2. Problem-oriented record 3. Case management 4. Focus charting Answer: 1 Explanation: The traditional client record is a source-oriented record in which each person or department makes notations in a separate section or sections of the client's chart. Page Ref: 235 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: IV. B. 3. Navigate the electronic health record | AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice | NLN Competencies: Quality & Safety: Practice-Know-How; Carefully maintain and use electronic and/or written health records | Nursing/Integrated Concepts: Assessment/Communication and Documentation Learning Outcome: 3. Compare and contrast different documentation methods: source-oriented and problem-oriented medical records, PIE, focus charting, charting by exception, computerized records, and the case management model. MNL Learning Outcome: 1. Recognize the importance of privacy and the purpose and types of documentation systems.
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6) The nurse makes chronological entries in a client's chart that include documentation about the routine care provided, assessment findings, and client problems during a 12-hour shift. Which type of charting is this nurse completing? 1. Problem-oriented recording 2. Source-oriented recording 3. Narrative charting 4. Plan of care Answer: 3 Explanation: Narrative charting is a traditional part of the source-oriented record. It consists of written notes that include routine care, normal findings, and client problems. There is no right or wrong order to the information, although chronological order is frequently used. Page Ref: 235 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: IV. B. 4. Document and plan patient care in an electronic health record | AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice | NLN Competencies: Quality and Safety; Practice-Know-How: Carefully maintain and use electronic and/or written health records | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 3. Compare and contrast different documentation methods: source-oriented and problem-oriented medical records, PIE, focus charting, charting by exception, computerized records, and the case management model. MNL Learning Outcome: 1. Recognize the importance of privacy and the purpose and types of documentation systems.
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7) The nurse is reviewing a client's chart in a facility that utilizes problem-oriented recording. In which section would the nurse find the most recent physician orders? 1. Database 2. Problem list 3. Plan of care 4. Progress notes Answer: 3 Explanation: The initial list of orders or plan of care is made with reference to the client's active problems in this type of charting. Physicians write physician orders or the medical care plan. Page Ref: 237 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: IV. B. 4. Document and plan patient care in an electronic health record | AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice | NLN Competencies: Quality and Safety; Practice-Know-How; Carefully maintain and use electronic and/or written health records | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 3. Compare and contrast different documentation methods: source-oriented and problem-oriented medical records, PIE, focus charting, charting by exception, computerized records, and the case management model. MNL Learning Outcome: 1. Recognize the importance of privacy and the purpose and types of documentation systems.
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8) A client has specific cultural needs that affect the plan of care. In which part of the client's problem-oriented medical record should the nurse document this information? 1. Database 2. Problem list 3. Plan of care 4. Progress notes Answer: 2 Explanation: The problem list is derived from the database and is usually kept at the front of the chart. The problem list serves as an index to the numbered entries in the progress notes. All caregivers contribute to the problem list, which includes the client's physiologic, psychologic, social, cultural, spiritual, developmental, and environmental needs. Page Ref: 237 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: IV. B. 4. Document and plan patient care in an electronic health record | AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice | NLN Competencies: Quality and Safety; Practice-Know-How; Carefully maintain and use electronic and/or written health records | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 3. Compare and contrast different documentation methods: source-oriented and problem-oriented medical records, PIE, focus charting, charting by exception, computerized records, and the case management model. MNL Learning Outcome: 1. Recognize the importance of privacy and the purpose and types of documentation systems.
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9) The client states: "I really don't want anyone to visit me who has not been cleared by me first." If utilizing the SOAP format, in which category should the nurse document this statement? 1. Subjective data 2. Objective data 3. Assessment 4. Planning Answer: 1 Explanation: Subjective data consist of information obtained from what the client says. When possible, the nurse quotes the client's words; otherwise, they are summarized. Page Ref: 238 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: IV. B. 4. Document and plan patient care in an electronic health record | AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice | NLN Competencies: Quality and Safety; Practice-Know-How; Carefully maintain and use electronic and/or written health records | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 3. Compare and contrast different documentation methods: source-oriented and problem-oriented medical records, PIE, focus charting, charting by exception, computerized records, and the case management model. MNL Learning Outcome: 1. Recognize the importance of privacy and the purpose and types of documentation systems. 10) The nurse administered analgesic medications to an assigned client via central line. In which section of PIE charting should the nurse document this information? 1. Plan 2. Intervention 3. Evaluation 4. Progress notes Answer: 2 Explanation: The interventions employed to manage the problem are labeled "I" and numbered according to the problem. Page Ref: 239 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: IV. B. 4. Document and plan patient care in an electronic health record | AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice | NLN Competencies: Quality and Safety; Practice-Know-How; Carefully maintain and use electronic and/or written health records | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 3. Compare and contrast different documentation methods: source-oriented and problem-oriented medical records, PIE, focus charting, charting by exception, computerized records, and the case management model. MNL Learning Outcome: 1. Recognize the importance of privacy and the purpose and types of documentation systems. 8
11) The nurse is documenting client care on flow sheets that identify abnormal assessment findings. Which type of documentation system is the nurse using? 1. Computerized documentation 2. Focus charting 3. SOAP charting 4. Charting by exception Answer: 4 Explanation: Charting by exception (CBE) is a documentation system in which only abnormal or significant findings or exceptions to norms are recorded. Flow sheets, standards of nursing care, and bedside access to chart forms are all incorporated into CBE. Page Ref: 239 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: IV. B. 4. Document and plan patient care in an electronic health record | AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice | NLN Competencies: Quality and Safety; Practice-Know-How; Carefully maintain and use electronic and/or written health records | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 3. Compare and contrast different documentation methods: source-oriented and problem-oriented medical records, PIE, focus charting, charting by exception, computerized records, and the case management model. MNL Learning Outcome: 1. Recognize the importance of privacy and the purpose and types of documentation systems.
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12) The nurse working in a hospital that utilizes a charting by exception (CBE) documentation system notes that a client did not require care in all of the areas identified on a flow sheet. What action should the nurse take? 1. Leave the areas blank. 2. Leave the areas blank, but then add an extensive explanation in the progress notes section of the chart. 3. Write N/A on the flow sheet in the areas that are not applicable to that client. 4. Make sure this information gets passed along in the shift report. Answer: 3 Explanation: Many nurses are uncomfortable with the CBE system and believe that if something was not charted, it was not done. A suggestion to address this would be to write N/A on the flow sheets where the items are not applicable to the client, and not leave the spaces blank. This would avoid the possible assumption that the assessment or intervention was not done by the nurse. Page Ref: 239-241 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: IV. B. 4. Document and plan patient care in an electronic health record | AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice | NLN Competencies: Quality and Safety; Practice-Know-How; Carefully maintain and use electronic and/or written health records | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 3. Compare and contrast different documentation methods: source-oriented and problem-oriented medical records, PIE, focus charting, charting by exception, computerized records, and the case management model. MNL Learning Outcome: 1. Recognize the importance of privacy and the purpose and types of documentation systems.
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13) A client did not meet the goal of walking unassisted, without assistive devices, by discharge from rehabilitation. The case manager using a critical pathway should identify this outcome as being which of the following? 1. An unattainable goal 2. A variance 3. An error in care planning 4. An error in intervention implementation Answer: 2 Explanation: Critical pathways are a multidisciplinary approach to planning and documenting client care. Flow sheets, as well as some types of charting by exception, are utilized in critical pathways. When a goal is not reached, it is called a variance. Variances are deviations to what is planned in the critical pathway–unexpected occurrences that affect the planned care or the client's response to care. Page Ref: 242 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: IV. B. 4. Document and plan patient care in an electronic health record | AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice | NLN Competencies: Quality and Safety; Practice-Know-How; Carefully maintain and use electronic and/or written health records | Nursing/Integrated Concepts: Evaluation/Communication and Documentation Learning Outcome: 4. Explain how various forms in the client record (e.g., critical pathways care plans, Kardexes, flow sheets, progress notes, discharge/transfer forms) are used to document steps of the nursing process (assessing, diagnosing, planning, implementing, and evaluating). MNL Learning Outcome: 2. Recognize the general guidelines involved in documenting patient care and responses.
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14) A cardiac specialty hospital has several written plans in place for clients who are admitted, according to specific medical diagnoses and nursing interventions. Typical nursing diagnoses as well as standard nursing interventions are included in these plans. Which type of form is this hospital utilizing? 1. Standardized care plans 2. Traditional care plans 3. Critical pathways 4. Kardex Answer: 1 Explanation: Standardized care plans were developed to save documentation time. These plans may be based on an institution's standards of practice, thereby helping to provide a high quality of nursing care. Standardized care plans are usually individualized to address each client's specific needs. Page Ref: 243 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: IV. B. 4. Document and plan patient care in an electronic health record | AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice | NLN Competencies: Quality and Safety; Practice-Know-How; Carefully maintain and use electronic and/or written health records | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 4. Explain how various forms in the client record (e.g., critical pathways care plans, Kardexes, flow sheets, progress notes, discharge/transfer forms) are used to document steps of the nursing process (assessing, diagnosing, planning, implementing, and evaluating). MNL Learning Outcome: 2. Recognize the general guidelines involved in documenting patient care and responses.
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15) Before providing care, the nurse reviews the client's pertinent history, daily treatments, diagnostic procedures, allergies, problems, and other information. Which form should the nurse review to learn all of this information? 1. The client's medical record 2. The MAR (medication administration record) 3. The written care plan 4. The Kardex Answer: 4 Explanation: The Kardex is a concise method of organizing and recording data about a client, making information quickly accessible to all health professionals. The system is on either an index-type file or a computer-generated form. Information is usually organized into sections: client history/information, list of medications, IV fluids, daily treatments and procedures, diagnostic procedures, allergies, how the client's physical needs are met (type of diet, bathing needs, etc.), and a problem list with stated goals. Page Ref: 243-244 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: IV. B. 4. Document and plan patient care in an electronic health record | AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice | NLN Competencies: Quality and Safety; Practice-Know-How; Carefully maintain and use electronic and/or written health records | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 4. Explain how various forms in the client record (e.g., critical pathways care plans, Kardexes, flow sheets, progress notes, discharge/transfer forms) are used to document steps of the nursing process (assessing, diagnosing, planning, implementing, and evaluating). MNL Learning Outcome: 2. Recognize the general guidelines involved in documenting patient care and responses.
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16) The nurse is teaching medication administration to a client being discharged. Which instruction should the nurse rewrite for this client? 1. Lasix, 20 mg, po bid 2. Lasix, 20 mg tablet, twice daily 3. Lasix, 20 mg by mouth, two times a day a day 4. Lasix, 20 mg by mouth 8 AM and 2 PM Answer: 1 Explanation: If the discharge plan is given directly to the client and family, it is imperative that instructions be written in terms that can be readily understood. For example, medications, treatments, and activities should be written in layperson's terms, and use of medical abbreviations should be avoided. "Twice a day" should be written out, not abbreviated as "bid." Page Ref: 244 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: IV. B. 4. Document and plan patient care in an electronic health record | AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice | NLN Competencies: Quality and Safety; Practice-Know-How; Carefully maintain and use electronic and/or written health records | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 5. Compare and contrast the documentation needed for clients in acute care, long-term care, and home healthcare settings. MNL Learning Outcome: 3. Implement general guidelines for recording in the patient's record and reporting of patient information.
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17) A client in long-term care is scheduled for a review of the assessment and care screening process. Where should the nurse document this information? 1. MDS 2. OBRA 3. CBE 4. Kardex Answer: 1 Explanation: The Minimum Data Set (MDS) for assessment and care screening must be performed within 4 days of a client's admission to a long-term care facility and reviewed every 3 months. Laws influencing the kind and frequency of documentation required are the Health Care Financing Administration and the Omnibus Budget Reconciliation Act (OBRA) of 1987. Page Ref: 242, 245 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: IV. B. 4. Document and plan patient care in an electronic health record | AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice | NLN Competencies: Quality and Safety; Practice-Know-How; Carefully maintain and use electronic and/or written health records | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 5. Compare and contrast the documentation needed for clients in acute care, long-term care, and home healthcare settings. MNL Learning Outcome: 3. Implement general guidelines for recording in the patient's record and reporting of patient information.
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18) When responding to a call light, the nurse finds a client lying on the floor, with the bed linens around the legs. Which chart entry should the nurse document for this finding? 1. Client fell out of bed but did push the call button for assistance. 2. Client became tangled in the bed linens, then called for assistance after falling out of bed. 3. Recorder responded to client's call light, upon entering the room, found client on floor. 4. Client found on floor, appeared to have fallen out of bed as a result of getting tangled in bed linens. Answer: 3 Explanation: Accurate notations consist of facts or observations rather than opinions or interpretations. The client was found on the floor, and the call light was activated. Those are the only things known until the nurse learns further information from questioning the client. Page Ref: 248 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: IV. B. 4. Document and plan patient care in an electronic health record | AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice | NLN Competencies: Quality and Safety; Practice-Know-How; Carefully maintain and use electronic and/or written health records | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 6. Discuss guidelines for effective recording that meet legal and ethical standards. MNL Learning Outcome: 3. Implement general guidelines for recording in the patient's record and reporting of patient information.
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19) After completing the client care and documenting it in the progress notes, the nurse realizes that documentation was placed on the wrong medical record. What should the nurse do? 1. Use white-out over the mistake. 2. Take a wide permanent marker and blacken out all the documentation. 3. Put an "X" through the entire page, identify it as an "error," initial, and move on to the correct chart. 4. Draw a single line through the documentation, write "mistaken entry" next to the original entry, and initial it. Answer: 4 Explanation: When a mistake is recorded, a line should be drawn through it and the words "mistaken entry" written above or next to the original entry, then initial or signature–whichever is agency policy. The original entry must remain visible. Page Ref: 248 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: IV. B. 4. Document and plan patient care in an electronic health record | AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice | NLN Competencies: Quality and Safety; Practice-Know-How; Carefully maintain and use electronic and/or written health records | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 6. Discuss guidelines for effective recording that meet legal and ethical standards. MNL Learning Outcome: 3. Implement general guidelines for recording in the patient's record and reporting of patient information.
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20) The nurse manager is conducting a survey of personnel to see what the general feeling is before implementing computerized charting in an acute care hospital. What should the nurse select as positive aspects of implementing this type of system? (Select all that apply.) 1. The system is relatively inexpensive to maintain. 2. Bedside terminals eliminate worksheets and note taking. 3. The system links to various sources of client information. 4. The system better protects client privacy. 5. Information is legible. 6. Results, requests, and client information can be sent and received quickly. Answer: 2, 3, 5, 6 Page Ref: 241-242 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: IV. B. 4. Document and plan patient care in an electronic health record | AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice | NLN Competencies: Knowledge and Science; Practice-Know-How; Document via electronic health records; Use software applications related to nursing practice | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. List the measures used to maintain confidentiality and security of computerized client records. MNL Learning Outcome: 1. Recognize the importance of privacy and the purpose and types of documentation systems.
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21) The client had diminished wheezing in both lungs after receiving emergency treatment for an acute asthma attack. When utilizing focus charting, in which section should the nurse document this information? 1. Data (D) 2. Action (A) 3. Response (R) 4. Planning (P) Answer: 3 Explanation: The response (R) category reflects the evaluation phase of the nursing process and describes the client's response to any nursing and medical care. Page Ref: 239 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: IV. B. 4. Document and plan patient care in an electronic health record | AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice | NLN Competencies: Quality and Safety; Practice-Know-How; Carefully maintain and use electronic and/or written health records | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 3. Compare and contrast different documentation methods: source-oriented and problem-oriented medical records, PIE, focus charting, charting by exception, computerized records, and the case management model. MNL Learning Outcome: 1. Recognize the importance of privacy and the purpose and types of documentation systems. 22) The nurse wants to adhere to practice guidelines that meet legal and ethical standards when documenting client care. Which actions should the nurse take to prove adherence? (Select all that apply.) 1. Charting the client's response to pain medication taken 2. Describing the client as "appearing to be comfortable" 3. Leaving sufficient charting space for the previous shift to chart client teaching 4. Documenting that the client reports, "I'm so afraid of tomorrow's surgery" 5. Making a late entry regarding a client's request for pain medication Answer: 1, 4, 5 Page Ref: 249 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: IV. B. 4. Document and plan patient care in an electronic health record | AACN Essentials Competencies: IV. 8. Uphold ethical standards related to data security, regulatory requirements, confidentiality, and clients' right to privacy | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 6. Discuss guidelines for effective recording that meet legal and ethical standards. MNL Learning Outcome: 3. Implement general guidelines for recording in the patient's record and reporting of patient information. 19
23) The nurse is documenting care provided to a client. Which action should the nurse take to demonstrate the avoidance of potentially confusing abbreviations when documenting? (Select all that apply.) 1. Documenting vital signs as "TPR." 2. Charting that the "drsg was dry and intact." 3. Transcribing a verbal order as "Carbamazepine 12 mcg/ml IV push daily." 4. Documenting "Client consistently requesting IM MS for pain well before prescribed time." 5. Charting, "Client to be ambulated q.i.d." Answer: 1, 2, 5 Explanation: This is a commonly used and accepted abbreviation for temperature, pulse, and respirations (vital signs). This is a commonly used and accepted abbreviation for a treatment dressing. This is a commonly used and accepted abbreviation for four times a day. Page Ref: 247-248 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: IV. B. 4. Document and plan patient care in an electronic health record | AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice | NLN Competencies: Quality and Safety; Practice-Know-How; Carefully maintain and use electronic and/or written health records | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 7. Identify prohibited abbreviations, acronyms, and symbols that cannot be used in any form of clinical documentation. MNL Learning Outcome: 4. Apply the process of documentation and reporting used among health professionals in the care of patients.
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24) The nurse is using I-SBAR to provide a report to an intensive care nurse for a client transfer. Which statements indicate that the nurse is using this communication technique appropriately? (Select all that apply.) 1. "Mr. Collins has a history of peptic ulcer disease." 2. "Hi Susan, my name is Janie and I've been taking care of Mr. Collins all day." 3. "It's no wonder he's bleeding from his stomach; he drinks a six pack of beer every day." 4. "Late this morning Mr. Collins became nauseated and vomited 250 mL of bright red emesis." 5. "He has bowel sounds in all 4 quadrants, is not experiencing any pain, but has a heart rate of 110 and blood pressure of 98/50 mm Hg." Answer: 1, 2, 4, 5 Explanation: This statement provides background information. This statement serves as an introduction. This statement provides the situation. This statement provides the assessment. Page Ref: 251 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. B. 9. Communicate with team members, adapting own style of communicating to needs of the team and situation. | AACN Essentials Competencies: IV. 2. Use inter- and intraprofessional communication and collaborative skills to deliver evidencebased, patient-centered care | NLN Competencies: Quality and Safety; Practice; Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care | Nursing/Integrated Concepts: Evaluation/Communication and Documentation Learning Outcome: 8. Identify essential guidelines for reporting client data. MNL Learning Outcome: 4. Apply the process of documentation and reporting used among health professionals in the care of patients.
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25) A client's condition has deteriorated and the nurse needs to notify the healthcare provider. What information should the nurse include when providing a telephone report on this client? (Select all that apply.) 1. Client's medical diagnosis 2. Name of unit nurse manager 3. Names of family members visiting 4. Name and relationship to the client 5. Observed changes in the client's status Answer: 1, 4, 5 Explanation: When giving a telephone report to a primary care provider, it is important that the nurse be concise and accurate. Telephone reports usually include the client's medical diagnosis, the nurse providing his or her name and relationship to the client, and changes in nursing assessment, vital signs related to baseline vital signs, and significant laboratory data. Page Ref: 251 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II. B. 9. Communicate with team members, adapting own style of communicating to needs of the team and situation. | AACN Essentials Competencies: IV. 2. Use inter- and intraprofessional communication and collaborative skills to deliver evidencebased, patient-centered care | NLN Competencies: Quality and Safety; Practice; Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 8. Identify essential guidelines for reporting client data. MNL Learning Outcome: 4. Apply the process of documentation and reporting used among health professionals in the care of patients.
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26) A healthcare organization is planning to alter the types of services offered to clients. In which way would information from the medical records be used to assist with making this decision? 1. Establish the cost to provide the services 2. Identify the names of clients who would use the services 3. Identify the health insurance plans that would pay for the proposed services 4. List the number of clients hospitalized that would potentially need the services Answer: 1 Explanation: Information from records may assist healthcare planners to identify agency needs. Records can be used to establish the costs of various services and to identify those services that cost the agency money and those that generate revenue. The records would not be used to identify the names of clients who would use the services, identify the health insurance plans that would pay for the proposed services, or generate a list of clients that would potentially need the services. Page Ref: 235 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: IV. A. 1. Explain why information and technology skills are essential for safe patient care | AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice | NLN Competencies: Knowledge and Science; Practice-Know-How; Retrieve research findings and other sources of information | Nursing/Integrated Concepts: Planning Learning Outcome: 2. Discuss purposes for client records. MNL Learning Outcome: 1. Recognize the importance of privacy and the purpose and types of documentation systems.
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27) A client is prescribed to be out of bed three times a day. In which way should the nurse document this activity level? 1. OOB tid 2. OOB 3 x /day 3. Out of bed T.I.D. 4. OOB three times a day Answer: 1 Explanation: The abbreviation OOB is acceptable to be used for out of bed. The abbreviation tid is acceptable to be used for three times a day. The number 3, an "x" for times, and "/day" is not acceptable. The complete words do not need to be documented. Page Ref: 247 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: IV. B. 4. Document and plan patient care in an electronic health record | AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice | NLN Competencies: Quality and Safety; Practice-Know-How; Carefully maintain and use electronic and/or written health records | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 7. Identify prohibited abbreviations, acronyms, and symbols that cannot be used in any form of clinical documentation. MNL Learning Outcome: 4. Apply the process of documentation and reporting used among health professionals in the care of patients.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 15 Caring 1) The nurse is observing care being provided by a new nurse. Which behavior should be interpreted as caring? 1. Making sure that all medications and treatments are done on time 2. Using aseptic technique when performing a dressing change 3. Advising the physician that the client wants to speak to him or her prior to a procedure 4. Explaining an invasive procedure to the client, then asking if it is all right to begin the procedure Answer: 4 Explanation: Caring practice involves connection, mutual recognition, and involvement. It's a sense that the nurse has made a difference to someone else. Caring means that people, relationships, and things matter. Explaining a procedure, then seeking permission to begin, lets the client know that the nurse respects the client as an individual. Page Ref: 258 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse—patient relationship | NLN Competencies: Personal and Professional Development; Ethical Comportment; Demonstrate caring and compassion | Nursing/Integrated Concepts: Evaluation Learning Outcome: 4. Describe how nurses demonstrate caring in practice. MNL Learning Outcome: 3. Recognize how nurses demonstrate caring in practice and the importance of self-care.
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2) The nurse asks that a client being mechanically ventilated be reassigned so that proper care and attention can be provided. According to Roach's six C's of caring, which one is the nurse emulating? 1. Compassion 2. Confidence 3. Commitment 4. Conscience Answer: 4 Explanation: Conscience deals with morals, ethics, and an informed sense of right and wrong as well as an awareness of personal responsibility. This nurse understands the situation of taking on a critically ill client and makes an appropriate request for a change in assignment. Page Ref: 260 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse—patient relationship | NLN Competencies: Personal and Professional Development; Ethical Comportment; Demonstrate caring and compassion | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Describe the nursing theories of Roach, Watson, and Swanson. MNL Learning Outcome: 1. Apply the various theories of caring and types of knowledge that relate to caring in nursing practice. 3) The nurse requests to work overtime to help a client who is the midst of a difficult labor experience. What is this nurse demonstrating? 1. Compassion 2. Competence 3. Confidence 4. Conscience Answer: 1 Explanation: Compassion is being aware of one's relationship to others; sharing their joys, sorrows, pain, and accomplishments; and participating in the experience of another. The nurse exemplifies this by staying until the delivery is over and the birth is accomplished. Page Ref: 260 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse—patient relationship | NLN Competencies: Personal and Professional Development; Ethical Comportment; Demonstrate caring and compassion | Nursing/Integrated Concepts: Evaluation Learning Outcome: 3. Describe the nursing theories of Roach, Watson, and Swanson. MNL Learning Outcome: 1. Apply the various theories of caring and types of knowledge that relate to caring in nursing practice.
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4) A labor and delivery nurse wants to conduct research focused on the response of new parents toward their babies. The approach the nurse would like to use suggests that caring is a nurturing process. The nurse should review the ideas of which theorist because they are best in line with this research? 1. Swanson 2. Watson 3. Roach 4. Benner Answer: 1 Explanation: Swanson defines caring as a nurturing way of relating to a valued "other" toward whom one feels a personal sense of commitment and responsibility. Page Ref: 261 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse—patient relationship | NLN Competencies: Personal and Professional Development; Ethical Comportment; Demonstrate caring and compassion | Nursing/Integrated Concepts: Implementation Learning Outcome: 3. Describe the nursing theories of Roach, Watson, and Swanson. MNL Learning Outcome: 1. Apply the various theories of caring and types of knowledge that relate to caring in nursing practice. 5) The nurse working with students on a medical unit describes the pathophysiology of a client with a respiratory acidosis condition as well as specific assessment findings. Which type of knowledge is the nurse demonstrating? 1. Aesthetic 2. Empirical 3. Personal 4. Creative Answer: 2 Explanation: Empirical knowing ranges from factual, observable phenomena to theoretical analysis. Empirical knowledge is systematic and helps to describe, explain, and predict phenomena. Page Ref: 258 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IV. 4. Contribute the unique nursing perspective to interprofessional teams to optimize patient outcomes | NLN Competencies: Personal and Professional Development; Ethical Comportment; Demonstrate caring and compassion | Nursing/Integrated Concepts: Evaluation Learning Outcome: 2. Analyze the importance of different types of knowledge in nursing. MNL Learning Outcome: 1. Apply the various theories of caring and types of knowledge that relate to caring in nursing practice.
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6) During a midterm evaluation, the nurse educator tells the students they need to work on improving their aesthetic knowledge. How should the students plan to accomplish this recommendation? 1. Study harder. 2. Take better notes. 3. Read about the same topic from a variety of sources. 4. Spend time in the clinical area with seasoned nurses. Answer: 4 Explanation: Aesthetic knowing is the art of nursing and is expressed by the individual nurse through his or her creativity and style in meeting the needs of clients. Understanding how other nurses meet the needs of their clients and seeing a variety of methods to provide the same care will help improve this type of knowledge for the students. Page Ref: 259 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse—patient relationship | NLN Competencies: Personal and Professional Development; Ethical Comportment; Demonstrate caring and compassion | Nursing/Integrated Concepts: Implementation Learning Outcome: 2. Analyze the importance of different types of knowledge in nursing. MNL Learning Outcome: 1. Apply the various theories of caring and types of knowledge that relate to caring in nursing practice. 7) A nurse has been asked to be a member of a hospital's internal review board and evaluate research studies. Which characteristic does this nurse most likely possess? 1. Sound empirical knowledge 2. Sound personal knowledge 3. Sound aesthetic knowledge 4. Sound ethical knowledge Answer: 4 Explanation: Ethical knowing focuses on matters of obligation or what ought to be done and goes beyond simply following the ethical codes of the discipline. Internal review boards review research projects and determine whether they meet sound, ethical standards. The more sensitive and knowledgeable the nurse is to these issues, the more "ethical" the nurse will be. Page Ref: 259 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care | AACN Essentials Competencies: VIII. 11. Access interprofessional and intraprofessional resources to resolve ethical and other practice dilemmas | NLN Competencies: Personal and Professional Development; Ethical Comportment; Demonstrate caring and compassion | Nursing/Integrated Concepts: Implementation Learning Outcome: 2. Analyze the importance of different types of knowledge in nursing. MNL Learning Outcome: 1. Apply the various theories of caring and types of knowledge that relate to caring in nursing practice. 4
8) A student asks the nursing instructor which types of knowledge are important in the clinical area. How should the instructor respond to the student? 1. "Empirical knowledge–you have to know the physiology of the problem before you decide which interventions to use." 2. "A good nurse will have a mix of all four types of knowledge." 3. "Ethical knowledge–nurses must be able to identify principles and norms, handle conflicts, and be sensitive to sensitive issues." 4. "Aesthetic knowledge–a nurse must appreciate the special qualities of each client and the individual situation." Answer: 2 Explanation: The nurse who practices effectively is able to integrate all types of knowledge to understand situations more holistically. Page Ref: 258-259 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse—patient relationship | NLN Competencies: Personal and Professional Development; Ethical Comportment; Demonstrate caring and compassion | Nursing/Integrated Concepts: Implementation Learning Outcome: 2. Analyze the importance of different types of knowledge in nursing. MNL Learning Outcome: 1. Apply the various theories of caring and types of knowledge that relate to caring in nursing practice. 9) The nurse working on an acute psychiatric unit learns that a client with bipolar disorder is being admitted and says to a coworker, "We better be ready for a busy night." This nurse is exemplifying which process of Swanson's theory of caring? 1. Knowing 2. Being with 3. Doing for 4. Enabling Answer: 1 Explanation: Knowing, according to Swanson, is striving to understand an event as it has meaning in the life of the other. A subdimension of this process is avoiding assumptions. The nurse in this situation made an assumption about clients with bipolar disorder. Page Ref: 261 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse—patient relationship | NLN Competencies: Personal and Professional Development; Ethical Comportment; Demonstrate caring and compassion | Nursing/Integrated Concepts: Evaluation Learning Outcome: 3. Describe the nursing theories of Roach, Watson, and Swanson. MNL Learning Outcome: 1. Apply the various theories of caring and types of knowledge that relate to caring in nursing practice. 5
10) The nurse is working in the school system with a group of students who are struggling with the death of a classmate. The nurse encourages the students to talk about their friend, bring pictures, and share memories with each other. The nurse also invites the deceased's family members to come to the school and visit with their child's classmates. This nurse is working in which of Swanson's processes? 1. Knowing 2. Being with 3. Doing for 4. Enabling Answer: 4 Explanation: Enabling is facilitating the other's passage through life transitions and unfamiliar events. Being supportive of the students and encouraging them to share and talk about their friend is allowing them to move through the grief process. Enabling also includes supporting, assisting, guiding, and validating. Page Ref: 261 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse—patient relationship | NLN Competencies: Personal and Professional Development; Ethical Comportment; Demonstrate caring and compassion | Nursing/Integrated Concepts: Evaluation Learning Outcome: 3. Describe the nursing theories of Roach, Watson, and Swanson. MNL Learning Outcome: 1. Apply the various theories of caring and types of knowledge that relate to caring in nursing practice. 11) The manager determines that a staff nurse demonstrates compassion when providing client care. What did the manager observe to come to this conclusion? 1. A nurse who has expert technical skills and has the most experience with critical care 2. A nurse who routinely gives back rubs to clients before they go to sleep 3. A nurse who has written procedures and policies in language that is both professional and realistic 4. A nurse who takes time to understand the spiritual needs of clients Answer: 4 Explanation: Attention to spiritual needs is part of compassionate care, particularly in the face of death and bereavement. Page Ref: 262 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse—patient relationship | NLN Competencies: Personal and Professional Development; Ethical Comportment; Demonstrate caring and compassion | Nursing/Integrated Concepts: Evaluation Learning Outcome: 1. Discuss the meaning of caring. MNL Learning Outcome: 3. Recognize how nurses demonstrate caring in practice and the importance of self-care. 6
12) The nurse educator teaches students about caring nursing practice. Which situation demonstrates a nurse implementing the whole idea of caring? 1. The nurse who takes time for a favorite hobby, at least once a week 2. The nurse who volunteers at church and school events 3. The nurse who makes lists every morning so the day stays organized and planned 4. The nurse who takes care of elderly parents as well as providing care to immediate family members Answer: 1 Explanation: It is imperative that nurses attend to their own needs because caring for self is central to caring for others. Page Ref: 263 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse—patient relationship | NLN Competencies: Personal and Professional Development; Ethical Comportment; Demonstrate caring and compassion | Nursing/Integrated Concepts: Evaluation Learning Outcome: 5. Evaluate the importance of self-care for the professional nurse. MNL Learning Outcome: 3. Recognize how nurses demonstrate caring in practice and the importance of self-care. 13) The nurse has adopted a healthy lifestyle. What action demonstrates that the nurse is being successful in this endeavor? 1. Exercising every day, at least for an hour and a half 2. Buying only fat-free foods and allowing absolutely no deviation from this 3. Balancing good nutrition and exercise in moderation 4. Exercising more on days when feeling "guilty" about a snack Answer: 3 Explanation: Nutrition and exercise are necessary for a healthy lifestyle, but key words to remember are balance and moderation. Page Ref: 263 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse—patient relationship | NLN Competencies: Personal and Professional Development; Ethical Comportment; Demonstrate caring and compassion | Nursing/Integrated Concepts: Evaluation Learning Outcome: 5. Evaluate the importance of self-care for the professional nurse. MNL Learning Outcome: 3. Recognize how nurses demonstrate caring in practice and the importance of self-care.
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14) A nurse practitioner emphasizes the importance of the staff engaging in activities that help restore peace and balance between the mind and body. Which might be an appropriate therapy for this? 1. Bike riding 2. Cake decorating 3. Reading 4. Storytelling Answer: 4 Explanation: Mind—body therapies include storytelling, which is a complementary therapy that brings balance to thoughts and emotions. Page Ref: 264 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse—patient relationship | NLN Competencies: Personal and Professional Development; Ethical Comportment; Demonstrate caring and compassion | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Evaluate the importance of self-care for the professional nurse. MNL Learning Outcome: 3. Recognize how nurses demonstrate caring in practice and the importance of self-care.
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15) A nursing student was involved in a very difficult situation with a client, the client's family, and a physician. The student felt like she was caught in the middle and wasn't sure how to respond to some of the questions that were being asked about care, treatment, and scheduling. Instead of getting the instructor, the student fielded these questions to the best of her personal ability. In order to help the student work through this situation, the nursing instructor might advise the student to try which action? 1. Meditation 2. Guided imagery 3. Reflection 4. Music therapy Answer: 3 Explanation: Reflection is thinking from a critical point of view, analyzing why one acted in a certain way, and assessing the results of one's actions. Reflection must be personal and meaningful. In this example, it will help the student understand how the situation could have been handled better. Page Ref: 265 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse—patient relationship | NLN Competencies: Personal and Professional Development; Ethical Comportment; Demonstrate caring and compassion | Nursing/Integrated Concepts: Implementation Learning Outcome: 6. Identify the value of reflective practice in nursing. MNL Learning Outcome: 4. Using the nursing process, integrate the concept of caring to patient care.
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16) A nurse is providing bathing assistance to a young client who was seriously injured and is unable to care entirely for herself. Which action demonstrates the nurse implementing the doing for process in Swanson's theory of caring? 1. Allowing the client to wash her perineal area 2. Drying the client completely 3. Seeing the client is uncomfortable with the whole bathing process 4. Touching the client's shoulder when she starts to cry Answer: 1 Explanation: Doing for is providing for the client as she would do for herself if it were possible. Subdimensions of this process include preserving dignity. Page Ref: 261 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse—patient relationship | NLN Competencies: Personal and Professional Development; Ethical Comportment; Demonstrate caring and compassion | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Describe the nursing theories of Roach, Watson, and Swanson. MNL Learning Outcome: 1. Apply the various theories of caring and types of knowledge that relate to caring in nursing practice.
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17) The nurse is identifying strategies to support a client's empowerment. What strategies should the nurse use? (Select all that apply.) 1. Making it possible for the client diagnosed with mild Alzheimer's disease to continue to dance regularly, as it has always been a passion of hers 2. Being sure to polish the client's nails now that she is not able to do it herself, as it has always been important to her that she "have pretty hands" 3. Suggesting to a client's family members that they should insist that the client move into an assisted living facility so as to ensure her safety 4. Helping the client's family identify community support services that will make it possible for the client to remain in her own home 5. Encouraging the client to use a walker and stay indoors, "just in case she might fall" Answer: 1, 2, 4 Explanation: This nursing intervention supports and thus empowers the client to continue expressing herself and experiencing life in spite of a chronic disease. This nursing intervention supports and thus empowers the client by helping her to maintain her self-esteem and pride in her appearance. This nursing intervention supports and thus empowers the client by helping her to maintain her autonomy and independence longer. Page Ref: 262 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse—patient relationship | NLN Competencies: Personal and Professional Development; Ethical Comportment; Demonstrate caring and compassion | Nursing/Integrated Concepts: Implementation Learning Outcome: 4. Describe how nurses demonstrate caring in practice. MNL Learning Outcome: 3. Recognize how nurses demonstrate caring in practice and the importance of self-care.
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18) The new graduate nurse has committed to improving self-care activities. Which behaviors exemplify that the nurse is following through on this personal commitment? (Select all that apply.) 1. Using meditation to destress at the end of a long day at work 2. Eating a low-fat diet, as there is a family history of heart disease 3. Attending workshops designed to enhance professional skills at least twice yearly 4. Volunteering to cover a friend's weekend shifts so the friend can fully recover from a sprained ankle 5. Making sure to reserve the time to read a favorite book between 12 hours of shift work Answer: 1, 2, 5 Page Ref: 263 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse—patient relationship | NLN Competencies: Personal and Professional Development; Ethical Comportment; Demonstrate caring and compassion | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Evaluate the importance of self-care for the professional nurse. MNL Learning Outcome: 3. Recognize how nurses demonstrate caring in practice and the importance of self-care. 19) The graduate nurse learns of failing the NCLEX-RN examination but realizes that passing the examination is a challenge worth achieving. To improve her outlook, the graduate nurse writes positive affirmations that are reviewed daily before studying for the examination. Which affirmations would be the most beneficial for the graduate nurse to use? (Select all that apply.) 1. I will focus on a new career. 2. I should have studied harder. 3. I am doing what brings me joy. 4. This is an opportunity to grow. 5. I cannot remember everything. Answer: 3, 4 Page Ref: 264 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VIII. 7. Identify personal, professional, and environmental risks that impact personal and professional choices and behaviors | NLN Competencies: Personal and Professional Development; Ethical Comportment; Demonstrate caring and compassion | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Evaluate the importance of self-care for the professional nurse. MNL Learning Outcome: 3. Recognize how nurses demonstrate caring in practice and the importance of self-care.
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20) The nurse suspects that an older client has no living family members and observes the client sitting quietly in the room, crying. What actions should the nurse take to intentionally know this client? (Select all that apply.) 1. Seek cues from the client. 2. Assess the client thoroughly. 3. Avoid assumptions about the client. 4. Center actions on the client's needs. 5. Assume the client wants to be alone. Answer: 1, 2, 3, 4 Page Ref: 261 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse—patient relationship | NLN Competencies: Personal and Professional Development; Ethical Comportment; Demonstrate caring and compassion | Nursing/Integrated Concepts: Implementation Learning Outcome: 4. Describe how nurses demonstrate caring in practice. MNL Learning Outcome: 3. Recognize how nurses demonstrate caring in practice and the importance of self-care. 21) A client is seen sitting in a chair, crying. Which action should the nurse take that demonstrates caring? 1. Turns on the television 2. Opens the drape over the window 3. Closes the door to the client's room 4. Enters the room and sits with the client Answer: 4 Explanation: Caring practices involve connection, mutual recognition, and involvement between the nurse and client. Sitting with the client who is crying demonstrates caring. Turning on the television, opening the drape, or closing the door to the client's room do not demonstrate caring. Page Ref: 258 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse—patient relationship | NLN Competencies: Personal and Professional Development; Ethical Comportment; Demonstrate caring and compassion | Nursing/Integrated Concepts: Evaluation Learning Outcome: 1. Discuss the meaning of caring. MNL Learning Outcome: 3. Recognize how nurses demonstrate caring in practice and the importance of self-care.
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22) The nurse had a particularly stressful day at work and is at home writing down the activities that occurred. Which questions should the nurse answer when engaging in reflective journaling? (Select all that apply.) 1. Now what? 2. What happened? 3. What did I learn? 4. What did it mean? 5. How can I change? Answer: 1, 2, 3, 4 Explanation: Asking "now what," "what happened," "what did I learn," and "what did it mean" are questions when engaged in reflective journaling. Asking "what happened" is a question when engaged in reflective journaling. Asking "what did I learn" is a question when engaged in reflective journaling. Asking "what did it mean" is a question when engaged in reflective journaling. Page Ref: 265 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse—patient relationship | NLN Competencies: Personal and Professional Development; Ethical Comportment; Demonstrate caring and compassion | Nursing/Integrated Concepts: Implementation Learning Outcome: 6. Identify the value of reflective practice in nursing. MNL Learning Outcome: 4. Using the nursing process, integrate the concept of caring to patient care.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 16 Communicating 1) The nurse explains to a client that he will need to have a bowel prep before going to his esophagogastroscopy. On what should the nurse focus to improve communication skills? 1. Pace 2. Intonation 3. Simplicity 4. Clarity Answer: 3 Explanation: Simplicity includes the use of commonly understood words, brevity, and completeness. A "bowel prep" may be completely meaningless to a client but saying that the client needs to drink a gallon of laxative-like medication gets the point across better. Esophagogastroscopy is a complicated word. Using words like "small camera looking down your throat into your stomach" will make much more sense to the client. Page Ref: 271 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 13. Assess own level of communication skill in encounters with patients and families | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship Centered Care; Knowledge; Effective Communication | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 2. Discuss the various aspects that nurses need to consider when using the different forms of communication. MNL Learning Outcome: 2. Analyze factors that influence the communication process or that serve as a barrier to communication for both individuals and groups.
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2) The nurse observes during a dressing change that the client's wound has become infected. When asked by the client how the wound looks, the nurse says "it looks fine" but the nurse's facial expression does not support the response. Which aspect of communication should this nurse improve? 1. Adaptability 2. Credibility 3. Timing and relevance 4. Clarity and brevity Answer: 1 Explanation: Adaptability is adjusting tone of speech and facial expression to match the spoken message. Clearly, if the nurse's face does not match the words, the client will identify a problem with the situation. Page Ref: 272 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 13. Assess own level of communication skill in encounters with patients and families | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship Centered Care; Knowledge; Effective Communication | Nursing/Integrated Concepts: Implementation Learning Outcome: 1. Describe the components of the communication process. MNL Learning Outcome: 1. Recognize the process and forms of communication. 3) A spouse arrives to visit a client who is currently receiving cardiopulmonary resuscitation. Which statement should the nurse make to the spouse? 1. "I know you're worried about your loved one. I'm sure this is a difficult situation for you. Do you have any questions right now?" 2. "Your spouse's heart stopped. All these people are here to help get it started." 3. "Your spouse's physician will be here shortly and explain all of the medication and treatment that your spouse is receiving right now." 4. "Is there someone you would like to call? I'm sure this is a scary situation and you may feel more comfortable if someone were with you during this time." Answer: 2 Explanation: Clarity and brevity provide a message that is simple and clear. The other statements do not explain what is occurring with the client and would be inappropriate. Page Ref: 272 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 13. Assess own level of communication skill in encounters with patients and families | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship Centered Care; Knowledge; Effective Communication | Nursing/Integrated Concepts: Implementation Learning Outcome: 2. Discuss the various aspects that nurses need to consider when using the different forms of communication. MNL Learning Outcome: 1. Recognize the process and forms of communication. 2
4) The nurse enters a client's room and finds that the telephone is lying in the client's lap, tissues are wadded up on the bed, and the client's eyes are red and watery. What is the best response by the nurse? 1. "Can I hang that phone up for you?" 2. "Well, it's a beautiful day outside. Let's open the blinds." 3. "Has your doctor been in to talk to you yet?" 4. "You look upset. Is there anything you'd like to talk about?" Answer: 4 Explanation: Nonverbal communication, or body language, often tells the nurse more about what a person is feeling than what is actually said. The interpretation of such observations requires validation with the client. Page Ref: 272 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 13. Assess own level of communication skill in encounters with patients and families | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship Centered Care; Knowledge; Effective Communication | Nursing/Integrated Concepts: Implementation Learning Outcome: 3. Describe factors influencing the communication process. MNL Learning Outcome: 2. Analyze factors that influence the communication process or that serve as a barrier to communication for both individuals and groups. 5) A client who has been sullen and withdrawn since receiving the news of having cancer asks for assistance with a shower. Which comment by the nurse is the most appropriate? 1. "If you look better, you might feel better." 2. "Taking a shower might wash away some of that gloom and doom." 3. "This is a positive sign. I'll be right back with your supplies." 4. "Your spouse will be glad to see that you're feeling better." Answer: 3 Explanation: How a person dresses or looks may be an indicator of how the person feels. A change in grooming habits may signal that the client is feeling better. Page Ref: 273 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 13. Assess own level of communication skill in encounters with patients and families | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship Centered Care; Knowledge; Effective Communication | Nursing/Integrated Concepts: Implementation Learning Outcome: 3. Describe factors influencing the communication process. MNL Learning Outcome: 2. Analyze factors that influence the communication process or that serve as a barrier to communication for both individuals and groups.
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6) The nurse is working in a pediatric clinic and has to explain a nebulizer treatment to a child. Which approach should the nurse use? 1. Give the child's parent a full explanation, but make sure the child hears what is said. 2. Let the child handle the equipment first, then demonstrate on the child's doll. 3. Start the treatment, but make sure that the parent is there to comfort the child if she becomes afraid. 4. Make sure that the physician is available for questions. Answer: 2 Explanation: The knowledge of the client's developmental stage will allow the nurse to modify the message accordingly. The use of dolls and games with simple language may help explain a procedure to a child. Page Ref: 275 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 13. Assess own level of communication skill in encounters with patients and families | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship Centered Care; Knowledge; Effective Communication | Nursing/Integrated Concepts: Implementation Learning Outcome: 3. Describe factors influencing the communication process. MNL Learning Outcome: 2. Analyze factors that influence the communication process or that serve as a barrier to communication for both individuals and groups. 7) The nurse is giving a demonstration of new equipment to the rest of the staff. Which level of proxemics should the nurse use? 1. Intimate 2. Personal 3. Social 4. Public Answer: 3 Explanation: Social distance is characterized by a clear, visual perception of the whole person and generally 4-12 feet in distance. Social distance is important in accomplishing the business of the day. It is expedient in communicating with several people at the same time or within a short time, which would be the case in this situation. Page Ref: 275 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 13. Assess own level of communication skill in encounters with patients and families | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 3. Describe factors influencing the communication process. MNL Learning Outcome: 2. Analyze factors that influence the communication process or that serve as a barrier to communication for both individuals and groups. 4
8) The nurse must perform a catheterization on a male client. Which zone of proximity should the nurse use for this intervention? 1. Personal distance 2. Intimate distance 3. Social distance 4. Public distance Answer: 2 Explanation: Intimate distance is characterized by body contact and used frequently by nurses when they are required to perform a procedure. Distance in this category is touching to
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Page Ref: 275 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 13. Assess own level of communication skill in encounters with patients and families | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Implementation Learning Outcome: 3. Describe factors influencing the communication process. MNL Learning Outcome: 2. Analyze factors that influence the communication process or that serve as a barrier to communication for both individuals and groups. 9) A client grimaces and responds "I'm fine" when asked by the nurse to describe a level of pain. Which communication factor is the client struggling with? 1. Territoriality 2. Environment 3. Congruence 4. Attitude Answer: 3 Explanation: In congruent communication, the verbal and nonverbal aspects of the message match. Saying the pain level is "fine," but then showing with facial grimacing that it is not, would be in conflict. Page Ref: 277 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 9. Discuss principles of effective communication | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship Centered Care; Knowledge; Factors that contribute to or threaten health | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Describe factors influencing the communication process. MNL Learning Outcome: 2. Analyze factors that influence the communication process or that serve as a barrier to communication for both individuals and groups.
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10) The nurse is working with an elderly male client on a medical unit. Which statement demonstrates elderspeak by the nurse? 1. "It's time for us to go to physical therapy." 2. "I think it would be better if you were planning to go to a nursing home after discharge." 3. "Your children must really love their dad." 4. "Your wife must be having trouble adjusting to your illness." Answer: 1 Explanation: Elderspeak is a speech style, similar to baby talk that gives a message of dependence and incompetence to older adults. Characteristics of elderspeak include inappropriate terms of endearment, inappropriate plural pronoun use ("It's time for us to go to physical therapy"), tag questions, and slow, loud speech. Page Ref: 277 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 9. Discuss principles of effective communication | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship Centered Care; Knowledge; Factors that contribute to or threaten health | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Compare therapeutic communication techniques that facilitate communication and focus on client concerns. MNL Learning Outcome: 2. Analyze factors that influence the communication process or that serve as a barrier to communication for both individuals and groups. 11) A client has just lost a second baby to preterm complications. Which statement demonstrates the best therapeutic response for the nurse to make? 1. "Don't be so sad. You can always try again." 2. "Didn't your doctor advise you about genetic counseling?" 3. "I know how you feel. I have children of my own." 4. "I am so sad for you. I'll stay with you for a while if you need to talk." Answer: 4 Explanation: Therapeutic communication promotes understanding and is client directed. Nurses need to respond to the feelings expressed by the client. Sometimes clients need time to deal with personal feelings and the best thing the nurse can provide is presence and listening. Page Ref: 278 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 9. Discuss principles of effective communication | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship Centered Care; Knowledge; Effective Communication | Nursing/Integrated Concepts: Implementation Learning Outcome: 4. Compare therapeutic communication techniques that facilitate communication and focus on client concerns. MNL Learning Outcome: 2. Analyze factors that influence the communication process or that serve as a barrier to communication for both individuals and groups. 6
12) The nurse is conducting an admission interview. Which response indicates that the nurse is attentively listening to the client's explanations? 1. "Can you explain what your symptoms are like?" 2. "When was the last time you saw a doctor for this?" 3. "Uh-huh," while nodding the head 4. "I'm sorry, say that again?" Answer: 3 Explanation: A nurse can convey attentiveness in listening to clients in various ways. Common responses are nodding the head, uttering "uh-huh" or "mmm," repeating the words the client has used, or saying "I see what you mean." Page Ref: 278 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 9. Discuss principles of effective communication | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship Centered Care; Knowledge; Effective Communication | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Discuss how nurses use communication skills in each phase of the nursing process. MNL Learning Outcome: 3. Recognize the phases, tasks, and skills of the helping relationship. 13) During an interaction between a nurse and client, the nurse conveys respect and an attitude that shows the nurse takes the client's opinions seriously. In which stage of the working relationship are the nurse and client engaged? 1. Exploring and understanding thoughts and feelings 2. Facilitating and taking action 3. Confrontation 4. Concreteness Answer: 1 Explanation: The working phase has two major stages. Exploring and understanding thoughts and feelings would occur during the working relationship. Page Ref: 282 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 9. Discuss principles of effective communication | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship Centered Care; Knowledge; Effective Communication | Nursing/Integrated Concepts: Assessment Learning Outcome: 6. Describe the four phases of the helping relationship. MNL Learning Outcome: 3. Recognize the phases, tasks, and skills of the helping relationship.
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14) The nurse is identifying communication strategies for a client unable to speak. What would be appropriate for the client in this situation? 1. Using a picture board to facilitate communication 2. Facing the client when speaking 3. Employing an interpreter 4. Making sure that the language spoken is the client's dominant language Answer: 1 Explanation: The picture board would be of assistance because it does not rely on verbal communication. Page Ref: 285 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 9. Discuss principles of effective communication | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship Centered Care; Knowledge; Effective Communication | Nursing/Integrated Concepts: Implementation Learning Outcome: 4. Compare therapeutic communication techniques that facilitate communication and focus on client concerns. MNL Learning Outcome: 2. Analyze factors that influence the communication process or that serve as a barrier to communication for both individuals and groups. 15) The nurse needs to evaluate the effectiveness of a teaching session with a client. Which approach would provide the best feedback? 1. Client communication 2. Process recording 3. Therapeutic communication 4. Verbal communication Answer: 2 Explanation: A process recording is a word-for-word account of a conversation. It includes all verbal and nonverbal interactions of both the client and nurse. It would be appropriate to use for evaluating the effectiveness of a teaching session. Page Ref: 286 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 9. Discuss principles of effective communication | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship Centered Care; Knowledge; Effective Communication | Nursing/Integrated Concepts: Evaluation/Teaching and Learning Learning Outcome: 7. Discuss how nurses use communication skills in each phase of the nursing process. MNL Learning Outcome: 4. Utilize the nursing process as it relates to a patient with impaired communication.
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16) During a health history, a client admits to taking nutritional supplements instead of prescribed medication. Which responses by the nurse indicate effective communication? (Select all that apply.) 1. "What you did was wrong." 2. "Who do you think you are?" 3. "You shouldn't have done that." 4. "Tell me more about the supplements." 5. "Explain the reasoning behind your decision." Answer: 4, 5 Explanation: Asking the client to tell more about the supplements is an open-ended statement and encourages communication. Asking the client to explain the reasoning behind the decision is an open-ended statement and encourages communication. Page Ref: 280-281 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 9. Discuss principles of effective communication | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship Centered Care; Knowledge; Effective Communication | Nursing/Integrated Concepts: Evaluation Learning Outcome: 5. Recognize barriers to communication. MNL Learning Outcome: 2. Analyze factors that influence the communication process or that serve as a barrier to communication for both individuals and groups. 17) The nurse needs to communicate information about a client's status to a physician. Which approach demonstrates assertive communication by the nurse? 1. "You need to check the laboratory results of the client in room 423." 2. "You should visit with the client's family about the upcoming procedure." 3. "We need to be more aware of the situation among the client and the client's family." 4. "I am concerned that the client does not have adequate pain management." Answer: 4 Explanation: An important characteristic of assertive communication includes the use of "I" statements versus "you" statements. "I" statements encourage discussion. Page Ref: 291 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 9. Discuss principles of effective communication | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Teamwork; Knowledge: Effective strategies for communicating with different members of the health team, including patients and families, nurses, and other health professionals | Nursing/Integrated Concepts: Implementation Learning Outcome: 11. Differentiate the major characteristics of assertive and nonassertive communication. MNL Learning Outcome: 2. Analyze factors that influence the communication process or that serve as a barrier to communication for both individuals and groups. 9
18) The nurse wants to gain information about a client's situation. Which question should the nurse use to maximize communication with this patient? 1. "What brings you to the hospital?" 2. "Are you having pain?" 3. "Does your pain feel better or worse today?" 4. "Is there anything I can do for you?" Answer: 1 Explanation: An open-ended question is one that cannot be answered with a simple yes/no or a one-word response. Often, they begin with the words What, Describe for me, Explain, or Tell me about.... Page Ref: 279 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 9. Discuss principles of effective communication | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship Centered Care; Knowledge; Effective Communication | Nursing/Integrated Concepts: Implementation Learning Outcome: 4. Compare therapeutic communication techniques that facilitate communication and focus on client concerns. MNL Learning Outcome: 2. Analyze factors that influence the communication process or that serve as a barrier to communication for both individuals and groups.
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19) The nurse is communicating with an older client. Which actions demonstrate that the nurse understands the best approaches to communicate with this client? (Select all that apply.) 1. Asking, "What can I do to make you feel safe?" 2. Observed intently listening to the client describe how being alone makes her feel 3. Offering to take the client "out for a walk" 4. Consistently arranging for the client to have hair done 5. Managing to get a copy of the client's favorite magazine Answer: 1, 2, 5 Explanation: Good communication with the client will result in knowing what the client values. With this knowledge, the nurse can reduce vulnerability and enhance the quality of life. Good communication with the client will result in knowing what the client values. With this knowledge, the nurse can reduce vulnerability and enhance the quality of life. Good communication with the client will result in knowing what the client values. With this knowledge, the nurse can reduce vulnerability and enhance the quality of life. Page Ref: 284, 286, 290 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Relationship Centered Care; Knowledge; Effective Communication | Nursing/Integrated Concepts: Evaluation Learning Outcome: 8. State why effective communication is imperative among health professionals. MNL Learning Outcome: 2. Analyze factors that influence the communication process or that serve as a barrier to communication for both individuals and groups.
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20) The nurse is beginning a helping relationship with a newly admitted client. Which behaviors should the nurse demonstrate that support this type of relationship? (Select all that apply.) 1. Becoming familiar with the client's social history by reading the admission interview 2. Orienting the client to the physical layout of the facility as well as to the facility's policies 3. Gaining the client's trust by consistently keeping promises to return and "visit" 4. Respecting the client's wish to be alone after hearing about the loss of a family friend 5. Asking to remain with the client when he is experiencing symptoms of the flu Answer: 1, 3, 4, 5 Explanation: A caring relationship consists of four phases; preparing for the relationship is part of the pre-interaction phase. A caring relationship consists of four phases; gaining trust is part of the introductory phase. A caring relationship consists of four phases; showing respect for a client and his wishes is part of the ongoing maintaining phase. A caring relationship consists of four phases; showing concern for a client and his wishes is part of the ongoing maintaining phase. Page Ref: 282 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 9. Discuss principles of effective communication | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship Centered Care; Knowledge; Effective Communication | Nursing/Integrated Concepts: Implementation Learning Outcome: 6. Describe the four phases of the helping relationship. MNL Learning Outcome: 3. Recognize the phases, tasks, and skills of the helping relationship.
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21) The graduate nurse is thinking about leaving a new job because of actions demonstrated by the nurse manager. Which actions should the graduate nurse identify as bullying? (Select all that apply.) 1. Pairing the graduate with a seasoned nurse to assist with learning new skills 2. Asking the graduate to participate in client rounds with the new interns on the care area 3. Confronting the graduate by stating that refusing an assignment is grounds for dismissal 4. Stating that requests for vacation time will be denied because the nurse asks too many questions 5. Assigning the graduate nurse a complicated client with needs that the graduate is not comfortable performing Answer: 3, 4, 5 Explanation: Confronting the graduate by stating that refusing an assignment is grounds for dismissal is bullying behavior. It is intended to intimidate the graduate. Stating that requests for vacation time will be denied because the nurse asks too many questions is bullying behavior. It is intended to humiliate the graduate. Assigning the graduate nurse a complicated client with needs that the graduate is not comfortable performing is bullying behavior. It is intended to degrade and undermine and creates a risk to the safety of a client. Page Ref: 288 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 9. Discuss principles of effective communication | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Teamwork; Practice-Know-How; Navigate conflict skillfully | Nursing/Integrated Concepts: Assessment Learning Outcome: 9. Describe the following disruptive behaviors and how they affect the healthcare environment and client safety: incivility, bullying, and workplace violence. MNL Learning Outcome: 2. Analyze factors that influence the communication process or that serve as a barrier to communication for both individuals and groups.
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22) The nurse is preparing to explain a dressing change to a client. Which statement indicates the fourth component of the communication process? 1. "I don't understand when I should do this at home." 2. "Take off the old dressing and place it in the trash." 3. "Wash your hands with soap and water before beginning" 4. "Have all of your dressing supplies prepared before starting." Answer: 1 Explanation: The fourth component of the communication process is the response or feedback. This is what the client would say to the nurse who is explaining how to complete a dressing change. Saying the inability to understand when to do the dressing change at home is the response by the client. The statements about taking off the old dressing, washing hands, and having the supplies prepared are all statements made by the nurse who is the sender. Page Ref: 271 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 13. Assess own level of communication skill in encounters with patients and families | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship Centered Care; Knowledge; Effective Communication | Nursing/Integrated Concepts: Evaluation/Teaching and Learning Learning Outcome: 1. Describe the components of the communication process. MNL Learning Outcome: 1. Recognize the process and forms of communication. 23) The nurse is assessing a client with an exacerbation of a chronic illness. Which statement provides unwarranted reassurance to the client? 1. "You will feel better soon." 2. "Tell me more about your symptoms." 3. "When did you notice your breathing changed?" 4. "List the medications you took before you vomited." Answer: 1 Explanation: Unwarranted reassurance is using comforting statements of advices as a means to reassure the client. Asking the client to explain more about symptoms, explain when breathing changed, or list medications taken are all statements that support therapeutic communication. Page Ref: 280-281 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 9. Discuss principles of effective communication | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship Centered Care; Knowledge; Effective Communication | Nursing/Integrated Concepts: Evaluation Learning Outcome: 5. Recognize barriers to communication. MNL Learning Outcome: 2. Analyze factors that influence the communication process or that serve as a barrier to communication for both individuals and groups.
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24) A healthcare provider confronts a staff nurse for being contacted early in the morning for a client care issue. In which way will the healthcare provider's behavior impact client care in the future? 1. Enhance communication between the provider and nurses 2. Client information will not be shared and will jeopardize safety 3. All communication to this provider about client issues will occur through writing 4. Nursing staff will wait until the provider arrives to the care area before sharing client issues Answer: 2 Explanation: Communication problems among healthcare personnel threaten client well-being and safety. Because the provider confronted the nurse, the nurse will hesitate to contact the provider in the future. The provider's behavior will not enhance communication. There is no evidence that communication should be in writing with this provider or that the staff will wait until the provider arrives before sharing client information. Page Ref: 288 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 9. Discuss principles of effective communication | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship Centered Care; Knowledge; Effective Communication | Nursing/Integrated Concepts: Planning Learning Outcome: 8. State why effective communication is imperative among health professionals. MNL Learning Outcome: 2. Analyze factors that influence the communication process or that serve as a barrier to communication for both individuals and groups.
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25) A healthcare provider asks the nurse what school was attended because "Mickey Mouse is a better nurse." In which way should the nurse characterize this example of workplace violence? 1. Criminal intent 2. Customer or client 3. Worker-on-worker 4. Personal relationship Answer: 3 Explanation: Worker-on-worker workplace violence is commonly perceived as bullying. The comment made by the provider was intended to humiliate the nurse, which is bullying. The provider's comment was not an example of criminal intent, customer or client, or personal relationship workplace violence. Page Ref: 289 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 9. Discuss principles of effective communication | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Teamwork; Practice-Know-How; Navigate conflict skillfully | Nursing/Integrated Concepts: Assessment Learning Outcome: 9. Describe the following disruptive behaviors and how they affect the healthcare environment and client safety: incivility, bullying, and workplace violence. MNL Learning Outcome: 2. Analyze factors that influence the communication process or that serve as a barrier to communication for both individuals and groups.
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26) The nurse is using the situation, background, assessment, and recommendation (SBAR) model to report a change in a client's health status. For which category should the nurse describe the client's current condition? 1. Situation 2. Background 3. Assessment 4. Recommendation Answer: 3 Explanation: When using the SBAR communication model, assessment refers to the current condition of the client. The situation is the purpose of the communication. Background provides information pertinent to the current situation. Recommendation is what is suggested to address the client's problem. Page Ref: 290 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 9. Discuss principles of effective communication | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Teamwork; Knowledge: Effective strategies for communicating with different members of the health team, including patients and families, nurses, and other health professionals | Nursing/Integrated Concepts: Implementation Learning Outcome: 10. Discuss the differences between nurse and physician communication. MNL Learning Outcome: 2. Analyze factors that influence the communication process or that serve as a barrier to communication for both individuals and groups.
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27) The nurse is creating a teaching tool about emotional intelligence. Which personal skills should the nurse identify that are essential when using this framework? (Select all that apply.) 1. Self-esteem 2. Self-respect 3. Self-control 4. Self-awareness 5. Self-motivation Answer: 3, 4, 5 Explanation: Self-control is a personal skill needed to use emotional intelligence. Self-awareness is a personal skill needed to use emotional intelligence. Self-motivation is a personal skill needed to use emotional intelligence. Page Ref: 291 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 9. Discuss principles of effective communication | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Teamwork; Knowledge: Effective strategies for communicating with different members of the health team, including patients and families, nurses, and other health professionals | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 10. Discuss the differences between nurse and physician communication. MNL Learning Outcome: 2. Analyze factors that influence the communication process or that serve as a barrier to communication for both individuals and groups.
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28) The nurse is unjustly accused of wasting controlled substances by a colleague and chooses to say nothing in response to the accusation. Which communication technique is the nurse using in this situation? 1. Assertive 2. Aggressive 3. Self-silencing 4. Emotional intelligence Answer: 3 Explanation: Saying nothing even when been wronged is considered self-silencing. No response to an unfair accusation is not assertive communication. Aggressive communication is directed toward what one wants without considering the feelings of others. Emotional intelligence is a process of forming work relationships and resolving conflicts while taking into consideration the emotions of others. Page Ref: 291 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 9. Discuss principles of effective communication | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Teamwork; Knowledge: Effective strategies for communicating with different members of the health team, including patients and families, nurses, and other health professionals | Nursing/Integrated Concepts: Implementation Learning Outcome: 11. Differentiate the major characteristics of assertive and nonassertive communication. MNL Learning Outcome: 2. Analyze factors that influence the communication process or that serve as a barrier to communication for both individuals and groups.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 17 Teaching 1) The nurse has completed client teaching regarding medication administration. Which client statement best illustrates compliance? 1. "I'm glad to know about my medications. It makes taking them a lot easier." 2. "I already knew most of what you told me." 3. "I think you should have waited until I was ready to go home. Maybe I'd remember better." 4. "If I take my medications as prescribed, I'll feel better." Answer: 1 Explanation: Compliance is best illustrated when the person recognizes and accepts the need to learn, then follows through with appropriate behaviors that reflect learning. Learning about the medications helps the client understand why they are prescribed and improves the possibility for following the prescribed regimen. Page Ref: 297 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation/Teaching and Learning Learning Outcome: 1. Discuss the importance of the teaching role of the nurse. MNL Learning Outcome: 1. Recognize the use of teaching in nursing, various learning theories, cognitive domains, and implications of teaching for nursing.
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2) The nurse is planning a community health education program on organ donation for a group of adults. When following andragogy concepts, which information should the nurse include? 1. Past statistics about organ donors 2. Written pamphlets 3. Directions about how to become an organ donor 4. Information on how this group can influence their children Answer: 3 Explanation: An adult is more oriented to learning when the material is useful immediately, not sometime in the future. For this audience, giving clear directions on how to become an organ donor would be more helpful than past information and future activities such as influencing their children. Page Ref: 297 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning/Teaching and Learning Learning Outcome: 2. Compare and contrast andragogy, pedagogy, and geragogy. MNL Learning Outcome: 1. Recognize the use of teaching in nursing, various learning theories, cognitive domains, and implications of teaching for nursing. 3) The nurse is instructing a client on self-administration of a subcutaneous injection. Which theoretical construct of learning is the nurse using? 1. Thorndike's behaviorism 2. Skinner's positive reinforcement 3. Pavlov's conditioning response 4. Bandura's imitation Answer: 4 Explanation: Bandura claims that most learning comes from observation and instruction. Imitation is the process by which individuals copy or reproduce what they have observed. Page Ref: 298 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 4. Discuss the learning theories of behaviorism, cognitivism, and humanism and how nurses can use each of these theories. MNL Learning Outcome: 1. Recognize the use of teaching in nursing, various learning theories, cognitive domains, and implications of teaching for nursing. 2
4) The nurse is preparing a teaching project using each of Bloom's domains. Which activity should the nurse use as an example of the affective domain? 1. Each participant must identify two attitudinal changes that have occurred in their lives since beginning their nursing career. 2. All participants must list the technical skills they use routinely. 3. Participants must demonstrate a favorite skill at the end of the session. 4. Participants must read a paragraph about a new clinical trial, summarize the information, and present it to the rest of the attendees. Answer: 1 Explanation: The affective domain of Bloom's theory of learning is also known as the "feeling" domain. It includes emotional responses to tasks such as feelings, emotions, interests, attitudes, and appreciations. The cognitive domain is the "‘thinking" domain. The psychomotor domain is the "skill" domain. Page Ref: 297 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 3. Describe the three learning domains. MNL Learning Outcome: 1. Recognize the use of teaching in nursing, various learning theories, cognitive domains, and implications of teaching for nursing.
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5) The nurse explains the use, how it works, and the rationale for an incentive spirometer that a client needs to use after surgery. When mastering the use of this device, the client will demonstrate learning in which of Bloom's domains? 1. Cognitive 2. Psychomotor 3. Affective 4. Imitation Answer: 2 Explanation: The psychomotor domain is the "skill" domain and includes motor skills, such as being able to use an incentive spirometer. The cognitive domain is the "thinking" domain. The affective domain is the "feeling" domain. Imitation is not a domain. Page Ref: 297 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation/Teaching and Learning Learning Outcome: 3. Describe the three learning domains. MNL Learning Outcome: 1. Recognize the use of teaching in nursing, various learning theories, cognitive domains, and implications of teaching for nursing.
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6) The nurse is presenting teaching sessions to a group of residents in a home for long-term physical rehabilitation. Which client exhibits the highest motivation? 1. An individual who has been struggling with following nursing directives regarding discharge goals 2. The client who has just moved in and is already waiting for discharge 3. A client who is excited to learn about his new prosthesis 4. A client who has been there the longest and is a great "coach" for newcomers Answer: 3 Explanation: Motivation is the desire to learn and influences how quickly and to what extent a person learns. It is generally greatest when a person recognizes a need and believes the need will be met through learning. The client who is excited to learn about his prosthesis understands that learning about it will help take his recovery to a high level. The clients struggling with goals, waiting for discharge, or coaching others do not have the greatest desire to learn. Page Ref: 299 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment/Teaching and Learning Learning Outcome: 5. Identify factors that affect learning. MNL Learning Outcome: 2. Consider factors that facilitate and interfere with learning.
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7) The nurse provides care in a neonatal intensive care unit, teaching parents how to care for their babies while they are still in the hospital. Which statement by a parent reflects a readiness to learn? 1. "I'm so afraid I'll hurt my baby with all these tubes." 2. "I want to make sure my spouse is here, in case I don't hear everything that's said." 3. "When my baby is just a little bigger, I'll be able to handle him." 4. "You'll give us written instructions before we go home, correct?" Answer: 2 Explanation: Readiness to learn is the demonstration of behaviors or cues that reflect a learner's motivation, desire, and ability to learn at a specific time. The client who wants the spouse involved is demonstrating motivation and willingness, but also wants support from the spouse as well. Fear of hurting the baby, wanting to wait until the baby is larger, and asking for written instructions do not demonstrate readiness to learn. Page Ref: 299 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation/Teaching and Learning Learning Outcome: 5. Identify factors that affect learning. MNL Learning Outcome: 2. Consider factors that facilitate and interfere with learning. 8) The nurse is instructing a client on self-administration of insulin. Which statement should the nurse use when providing feedback to the client? 1. "You know, there are children who can learn to do this." 2. "Maybe it would be better if we taught your spouse to help you with this." 3. "Next time, dart the needle in your skin, instead of pushing it in." 4. "If you don't learn this, you can't be discharged." Answer: 3 Explanation: Feedback should be meaningful to the learner and should support the desired behavior through praise, positively worded corrections, and suggestions of alternative methods. Comments that do not support the learning process are inappropriate. Page Ref: 299 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 5. Identify factors that affect learning. MNL Learning Outcome: 2. Consider factors that facilitate and interfere with learning. 6
9) A client having difficulty keeping a medication schedule organized says that there are so many pills and does not know what they are for. Which action should the nurse take? 1. Help the client remember color and size in relationship to dosing time. 2. Write out the generic and trade name of all the pills for the client. 3. Fill a pill bar and tell the client not to worry, and just take the pills according to that system. 4. Have the physician talk to the client about the medications. Answer: 1 Explanation: Learning is facilitated by material that is logically organized and proceeds from the simple to the complex. This helps the learner comprehend new information, apply it to previous learning, and form new understandings. Naming the pills by color and size and dosing time helps the client move from that level to learning what each medication is for and why he is taking it– simple to complex. Using generic medication names, telling the client to take the pills according to the pill bar, and having the physician to talk to the client about the medication does not facilitate the client's learning. Page Ref: 299 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 5. Identify factors that affect learning. MNL Learning Outcome: 2. Consider factors that facilitate and interfere with learning. 10) A student is asked to administer a Z-track injection but has never performed the skill. What should the instructor respond that supports timing and learning environment? 1. "It will take me a moment to explain the procedure to the students because we've not practiced this, but I'll find somebody to administer it." 2. "Would it be OK if the students observed today? Then, we'll do it next time we're here." 3. "We're leaving now, but thanks for asking." 4. "I'll check with the students and see if one of them would like to volunteer." Answer: 2 Explanation: Allowing the student to observe the injection then coming back when they are more refreshed would allow a better learning experience for the student. Page Ref: 300 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 7. Assess learning needs of learners and the learning environment. MNL Learning Outcome: 2. Consider factors that facilitate and interfere with learning. 7
11) A client with an incision necessitating a complex dressing change is being discharged and will require continued dressings at home. Which statement by the client indicates a need to postpone teaching? 1. "It's going to take time for me to understand this whole thing." 2. "Let's make sure my spouse is around before you start explaining." 3. "I wish my doctor would have explained this more in depth." 4. "I'm feeling nauseous but go ahead and start anyway." Answer: 4 Explanation: Learning can be inhibited by physiologic events such as illness, pain, or sensory deficits. The client must be able to concentrate and apply adequate energy to the learning or the learning itself will be impaired. If the client is experiencing nausea, the nurse should first try to reduce this symptom before beginning the teaching session. Page Ref: 301 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation/Teaching and Learning Learning Outcome: 5. Identify factors that affect learning. MNL Learning Outcome: 2. Consider factors that facilitate and interfere with learning.
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12) The nurse is working with the family of a child who is hospitalized with asthma. The family members speak little English, and the child is being sent home on nebulizer treatments as well as an inhaler. In addition to enlisting an interpreter to help with the language barrier, which action is the nurse's highest priority? 1. Provide written instructions before discharge. 2. Address any healing beliefs the family has. 3. Make sure the child comes back for the follow-up appointment. 4. Make sure the parents can set up the treatments for their child. Answer: 2 Explanation: If the prescribed treatment conflicts with the client/family's cultural healing beliefs, the client/family may adhere to the recommended treatment plan. To be effective, nurses must deal directly with any conflicts and differing values held by the client. Page Ref: 301 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Implementation Learning Outcome: 12. Discuss strategies to use when teaching clients of different cultures. MNL Learning Outcome: 4. Determine appropriate teaching strategies for patients and groups based on their characteristics and learning goals.
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13) A client who is legally blind requires vitamin B12 injections every 2 weeks and insists on self-administration. What is the best way for the nurse to assist this client? 1. Teach the spouse to draw up the medication, then the client can give the injection. 2. Make sure that the injection is scheduled during a visit, so the nurse can supervise. 3. Prefill syringes with the correct dose, so the client can use them for self-administration. 4. Schedule the client's clinic appointments in accordance with the dosing schedule, then give the injection when the client is at the clinic. Answer: 3 Explanation: Clients who have visual impairment may need the assistance of a support person or creative care in order to remain compliant with their treatment. Because the client insists on selfadministration, prefilling syringes (and keeping them away from light and heat) would be a plausible solution. The client is concerned with independence and allowing the client to maintain that would be quite important. Page Ref: 301 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Assess learning needs of learners and the learning environment. MNL Learning Outcome: 2. Consider factors that facilitate and interfere with learning. 14) A client with diabetes mellitus must learn how to do capillary blood glucose measurements but has been sullen and uncommunicative since receiving the diagnosis. How can the nurse best increase the client's motivation to learn? 1. Demonstrating the finger stick on the nurse 2. Offering to do the procedure for the client each time it is scheduled 3. Teaching the client's support system how to perform the procedure 4. Encouraging the client's participation each time the procedure is performed Answer: 4 Explanation: Nurses can increase a client's motivation in several ways, including encouragement of self-direction and independence. Page Ref: 305 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 5. Identify factors that affect learning. MNL Learning Outcome: 2. Consider factors that facilitate and interfere with learning. 10
15) The nurse is working with a group of older clients through a community senior citizens center. In which way should the nurse support these clients' health literacy? 1. Provide information written at a third-grade level. 2. Use a variety of approaches when teaching 3. Provide information with pictures. 4. Ensure ample time for teaching. Answer: 4 Explanation: When working with the older population, the nurse must realize that increased time for teaching is necessary because processing of information is slower. Health literacy skills are often limited in older adults. Page Ref: 306 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 8. Discuss the implications of low health literacy skills. MNL Learning Outcome: 2. Consider factors that facilitate and interfere with learning. 16) A client prescribed new medications and a low-fat diet for a heart problem is concerned about understanding all of the new information. Which nursing diagnosis should be used to guide this client's care? 1. Health-Seeking Behavior 2. Deficient Knowledge 3. Noncompliance 4. Risk for Myocardial Infarction Answer: 2 Explanation: The NANDA label Deficient Knowledge is used when the client is seeking health information or when the nurse has identified a learning need, as in this case. The area of deficiency should always be included in the diagnosis. Page Ref: 308-309 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Diagnosis Learning Outcome: 9. Identify nursing diagnoses, outcomes, and interventions that reflect the learning needs of clients. MNL Learning Outcome: 4. Determine appropriate teaching strategies for patients and groups based on their characteristics and learning goals. 11
17) The nursing diagnosis Willingness for Enhanced Knowledge (Nutrition) related to desire to improve nutritional intake has been formulated for a client who has decided to change eating habits to be more nutritionally sound. What would be an appropriate outcome for this client? 1. Client will understand the importance of eating healthy. 2. Client will be able to lose weight. 3. Client will list foods that are nutritionally sound, low fat, and high fiber. 4. Client will appreciate the value of using the Food Guide Pyramid. Answer: 3 Explanation: Learning outcomes, like client outcomes, must be specific and observable so they can be measured. Page Ref: 309 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning/Teaching and Learning Learning Outcome: 9. Identify nursing diagnoses, outcomes, and interventions that reflect the learning needs of clients. MNL Learning Outcome: 4. Determine appropriate teaching strategies for patients and groups based on their characteristics and learning goals.
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18) The nurse is caring for a client who has pulmonary fibrosis. Of the following teaching priorities, which will take the highest priority? 1. Client will be able to set up and administer a nebulizer treatment by the end of the day. 2. Client will have increased activity level by the end of the week. 3. Client will be able to do activities of daily living (ADLs) without shortness of breath in 3 days. 4. Client will have a positive attitude about the diagnosis by the end of the month. Answer: 1 Explanation: Learning outcomes state the client behavior and are ranked according to priority. Nurses can use theoretical frameworks such as Maslow's hierarchy of needs to establish priorities. In this case, the physiological need of learning how to administer medication takes priority over activity and attitudinal needs. Page Ref: 309 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning/Teaching and Learning Learning Outcome: 9. Identify nursing diagnoses, outcomes, and interventions that reflect the learning needs of clients. MNL Learning Outcome: 4. Determine appropriate teaching strategies for patients and groups based on their characteristics and learning goals.
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19) A school nurse is creating a program for adolescents about positive lifestyle choices. What should the nurse keep in mind when preparing content to present to this age group? (Select all that apply.) 1. Based on learning outcomes 2. Current 3. Adjusted to the adolescent client 4. Based on sources available within the school system 5. Consistent with the teaching topics Answer: 1, 2, 3, 5 Explanation: Nurses can select among many sources of information, including books, nursing journals, and other nurses and physicians. Whatever sources the nurse chooses, content should be based on learning outcomes, current, adjusted to the learners' age, and consistent with the information that the nurse is teaching. Page Ref: 309-310 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 7. Assess learning needs of learners and the learning environment. MNL Learning Outcome: 3. Determine appropriate information to collect in order to assess learning readiness, ability, and needs.
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20) The nurse is going to be working with a client who has a permanent colostomy and is ready to go home within the next several days. Which should the nurse do when organizing the teaching/learning experience for the client? 1. Start from the beginning and proceed through all material. 2. Break up sessions into shortened time periods. 3. Discover what the learner knows before proceeding with further teaching. 4. Make sure the client's spouse is present before the teaching session begins. Answer: 3 Explanation: Nurses should save time in constructing their own teaching sessions and should follow basic guidelines when sequencing the learning experience. The nurse should find out what the learner knows, and then proceed to the unknown. This gives the learner confidence. This information can be elicited either by asking questions or by having the client take a pretest or fill out a form. Page Ref: 310 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning/Teaching and Learning Learning Outcome: 7. Assess learning needs of learners and the learning environment. MNL Learning Outcome: 2. Consider factors that facilitate and interfere with learning.
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21) A client needs discharge teaching regarding the use of a walker before going home however the client's room is small and adjacent to a soda machine and small lounge area. In planning a teaching session, which is the best thing the nurse can do? 1. Wait until just prior to discharge, then do the teaching in the hospital lobby. 2. Close the door to the client's room and make sure there is no clutter on the floor before the teaching session begins. 3. Take the client to a larger area (treatment room, for example) for teaching, then evaluate on the way back to the client's room. 4. Make sure a physical therapist is available to do the teaching and can see the client before discharge. Answer: 3 Explanation: Going to a larger area and then evaluating the learning by watching the client ambulate back to the room would be the best way to implement teaching in this particular situation. Page Ref: 310 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 7. Assess learning needs of learners and the learning environment. MNL Learning Outcome: 2. Consider factors that facilitate and interfere with learning. 22) The community health nurse is planning a smoking- cessation class for Mexican American and Native American clients. In order to adjust to their time orientation, which action should the nurse take? 1. Make sure that the classes are held at specific times. 2. Begin classes when a group of clients are gathered. 3. Mail letters ahead of time to make sure clients are informed about the upcoming class. 4. Make posters and place them in areas of the community frequented by these groups. Answer: 2 Explanation: The nurse must be quite flexible, treat the culture's beliefs with respect, and not expect that cultural practices will change to reflect the nurse's needs. Page Ref: 315 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 12. Discuss strategies to use when teaching clients of different cultures. MNL Learning Outcome: 2. Consider factors that facilitate and interfere with learning. 16
23) At the completion of a teaching session, the nurse wants to evaluate the effectiveness of instruction. In a situation where the client was learning a bandaging technique, which would be the most effective evaluation? 1. Shared by the nurse and client 2. A return demonstration by the client 3. When the nurse is satisfied that the client can complete the technique 4. If the wound heals Answer: 1 Explanation: Both the client and the nurse should evaluate the learning experience. The client can tell the nurse what was helpful and provide a demonstration that shows mastery of the skill. The nurse needs to evaluate whether the client has an understanding of the rationale behind the technique. Page Ref: 315-316 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation/Teaching and Learning Learning Outcome: 13. Identify methods to evaluate learning. MNL Learning Outcome: 4. Determine appropriate teaching strategies for patients and groups based on their characteristics and learning goals.
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24) The nurse has completed a teaching session for a client with a tracheostomy. Documentation of the session should include what information? (Select all that apply.) 1. Diagnosed learning needs 2. Supplies required 3. Client outcomes 4. Need for additional teaching 5. Topics taught Answer: 1, 3, 4, 5 Explanation: The parts of the teaching process that should be documented in the client's chart include diagnosed learning needs, client outcomes, need for additional teaching, and topics taught. Page Ref: 316 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 14. Describe effective documentation of teaching—learning activities. MNL Learning Outcome: 4. Determine appropriate teaching strategies for patients and groups based on their characteristics and learning goals.
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25) The nurse is assessing a client's learning needs. On which elements should the nurse focus? (Select all that apply.) 1. Nurse's own knowledge 2. Client's age 3. Client's understanding of health problem 4. Sensory acuity 5. Learning style Answer: 2, 3, 4, 5 Explanation: The client's age provides information on the person's developmental status that might indicate health teaching content and teaching approaches. The client's understanding of health problems might indicate deficient knowledge or misinformation. Sensory acuity is part of the psychomotor ability of which the nurse must be aware when planning a teaching session. Learning style identifies the client's best way to learn so that the nurse can adapt teaching accordingly. Page Ref: 303 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment/Teaching and Learning Learning Outcome: 7. Assess learning needs of learners and the learning environment. MNL Learning Outcome: 3. Determine appropriate information to collect in order to assess learning readiness, ability, and needs.
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26) A school nurse is planning a program for adolescents about positive lifestyle choices. Which should the nurse keep in mind when planning content for this age group? (Select all that apply.) 1. Based on learning outcomes 2. Current 3. Adjusted to the adolescent client 4. Based on sources available within the school system 5. Accurate Answer: 1, 2, 3, 5 Explanation: Whatever sources the nurse chooses, content should be based on learning outcomes, current, adjusted to the learners' age, and accurate. Page Ref: 309 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning/Teaching and Learning Learning Outcome: 7. Assess learning needs of learners and the learning environment. MNL Learning Outcome: 3. Determine appropriate information to collect in order to assess learning readiness, ability, and needs. 27) A client is being discharged after a 23-hour stay for a surgical procedure. When preparing the instructions for this client, what does the nurse need to do? (Select all that apply.) 1. Ensure the client's safe transition to home. 2. Include information about what the client has been taught. 3. Include what the client still needs to learn when discharged. 4. Check the client's insurance for hospitalization coverage. 5. Call the client's prescriptions in to the client's local pharmacy. Answer: 1, 2, 3 Explanation: Because of decreased lengths of stay, time constraints on client education can occur. The nurse needs to provide education that will ensure the client's safe transition to home. Discharge plans must include information about what the client has been taught. Discharge plans must include what the client still needs to learn when discharged. Page Ref: 296 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 7. Assess learning needs of learners and the learning environment. MNL Learning Outcome: 3. Determine appropriate information to collect in order to assess learning readiness, ability, and needs. 20
28) The nurse serves as an educator of other healthcare personnel. In what capacity will this nurse participate in education? (Select all that apply.) 1. Preceptor of new graduate nurses 2. Instructing a part of the critical care course 3. Clinical instruction of nursing students 4. One-to-one teaching of clients 5. Teaching grandparents how to care for children Answer: 1, 2, 3 Explanation: Nurses are involved in the instruction of professional colleagues, such as functioning as preceptors for new graduate nurses. Nurses with specialized knowledge and experience may share that knowledge and experience with nurses by instructing a part of the critical care course. Nurses in nursing practice settings are often involved in the clinical instruction of nursing students. Page Ref: 296 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment/Teaching and Learning Learning Outcome: 1. Discuss the importance of the teaching role of the nurse. MNL Learning Outcome: 1. Recognize the use of teaching in nursing, various learning theories, cognitive domains, and implications of teaching for nursing.
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29) The nurse is planning an educational session for adult clients. Which andragogy concepts should the nurse include? (Select all that apply.) 1. People move from dependence to independence with maturity. 2. Previous experiences can be used as a resource for learning. 3. Learning is related to an immediate need or problem. 4. Learning is reinforced by prompt feedback. 5. Adults are oriented to learning when the material is useful sometime in the future. Answer: 1, 2, 3, 4 Explanation: An andragogy concept about adult learners is that as people mature, they move from dependence to independence. An adult's previous experiences can be used as a resource for learning. Learning is related to an immediate need or problem. Learning is reinforced by prompt feedback. Page Ref: 297 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning/Teaching and Learning Learning Outcome: 2. Compare and contrast andragogy, pedagogy, and geragogy. MNL Learning Outcome: 1. Recognize the use of teaching in nursing, various learning theories, cognitive domains, and implications of teaching for nursing.
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30) The nurse is utilizing humanistic theory when instructing a client. What will the nurse demonstrate when utilizing this theory? (Select all that apply.) 1. Empathy 2. Encouraging the client to establish goals 3. Encouraging the client to participate in self-directed learning 4. Multisensory teaching strategies 5. Providing a physical environment conducive to learning Answer: 1, 2, 3 Explanation: Conveying empathy, encouraging the client to establish goals, and encouraging the client to participate in self-directed learning are characteristics of humanism. Page Ref: 298 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 4. Discuss the learning theories of behaviorism, cognitivism, and humanism and how nurses can use each of these theories. MNL Learning Outcome: 1. Recognize the use of teaching in nursing, various learning theories, cognitive domains, and implications of teaching for nursing. 31) A client reports having no questions about an illness because an Internet search was done. What should the nurse do? 1. Ask the client to share the information obtained from the Internet search. 2. Document that the client has received instruction. 3. Tell the client that the Internet is a form of entertainment, not instruction. 4. Document that the client refused instruction. Answer: 1 Explanation: The Internet is an important source of health information for many adult clients in the United States. Nurses need to know and be able to integrate this technology into the teaching plans for those clients who use the Internet. The nurse should ask the client to share the information obtained from the Internet search in order to integrate the content into the client's teaching plan. Page Ref: 301-302 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IV. 6. Evaluate data from all relevant sources, including technology, to inform the delivery of care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 6. Discuss the implications of using the Internet as a source of health information. MNL Learning Outcome: 2. Consider factors that facilitate and interfere with learning. 23
32) An older client needs to access the Internet to complete a post hospitalization survey and update health information but the client does not have a computer and would not know how to use one. What should the nurse do? (Select all that apply.) 1. Suggest the client learn how to use a computer through classes held at a local library. 2. Provide times for the client to attend basic computer use classes through the community learning center. 3. Document that the client is resistant to instruction. 4. Notify the physician that the client will not be adhering to medical instruction as planned. 5. Identify the client as being noncompliant with instruction. Answer: 1, 2 Explanation: The older client might not own a computer or have Internet access. The nurse could suggest that the client learn how to use a computer through classes held at a local learning center. The nurse should provide times for the older client to attend basic computer use classes through the community learning center. Page Ref: 302 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IV. 2. Use telecommunication technologies to assist in effective communication in a variety of healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 6. Discuss the implications of using the Internet as a source of health information. MNL Learning Outcome: 2. Consider factors that facilitate and interfere with learning.
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33) The nurse suspects a client has low literacy. What did the nurse assess to come to this conclusion? (Select all that apply.) 1. Incorrect completion of previous hospitalizations form 2. Client refusing to sign forms because eyeglasses are at home 3. Client saying he forgot to report for laboratory testing 4. Score of 6 on the Newest Vital Sign assessment tool 5. Questioning the dosage pattern on a newly prescribed medication Answer: 1, 2, 3 Explanation: The nurse should suspect a literacy problem when a client incorrectly completes forms. Refuses to sign forms because of lack of eyeglasses. Appointments are missed. Page Ref: 305-306 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment/Teaching and Learning Learning Outcome: 7. Assess learning needs of learners and the learning environment. MNL Learning Outcome: 3. Determine appropriate information to collect in order to assess learning readiness, ability, and needs. 34) The nurse is designing a teaching plan for a client to learn a new psychomotor skill. What strategies can the nurse use to facilitate learning for this client? (Select all that apply.) 1. Demonstration 2. Practice 3. Modeling 4. Discovery 5. Role playing Answer: 1, 2, 3 Explanation: Demonstration, practice, and modeling are used to learn a psychomotor skill. Page Ref: 311 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning/Teaching and Learning Learning Outcome: 3. Describe the three learning domains. MNL Learning Outcome: 1. Recognize the use of teaching in nursing, various learning theories, cognitive domains, and implications of teaching for nursing. 25
35) The nurse instructs a client on self-care for a new ostomy. Which client behaviors demonstrate that instruction has been effective? (Select all that apply.) 1. Client provides skin care and changes ostomy device. 2. Client states what items are needed to perform ostomy care. 3. Client is unable to identify changes in skin around the stoma. 4. Client does not want to do the care. 5. Client asks the spouse to learn how to perform the care. Answer: 1, 2 Explanation: The acquisition of psychomotor skills is best evaluated by observing how well the client carries out a procedure such as self-care for an ostomy. In cognitive learning, the client demonstrates acquisition of knowledge by responding appropriately to oral questions. Page Ref: 311 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation/Teaching and Learning Learning Outcome: 13. Identify methods to evaluate learning. MNL Learning Outcome: 4. Determine appropriate teaching strategies for patients and groups based on their characteristics and learning goals.
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36) The nurse is documenting the teaching plan for a client. What should be included in this documentation? (Select all that apply.) 1. Actual information to be taught 2. Teaching strategies to use 3. Skills to be taught 4. Amount of time needed to teach each topic 5. Vital signs before and after each teaching session Answer: 1, 2, 3, 4 Explanation: The written teaching plan that the nurse uses to guide future teaching sessions can include the actual information to be taught. Teaching strategies to use. Skills to be taught. Amount of time needed to teach each topic. Page Ref: 308 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 14. Describe effective documentation of teaching—learning activities. MNL Learning Outcome: 4. Determine appropriate teaching strategies for patients and groups based on their characteristics and learning goals.
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37) The nurse has completed a teaching session for a client with a tracheostomy. What should the documentation include? (Select all that apply.) 1. Diagnosed learning needs 2. Supplies required 3. Client outcomes 4. Need for additional teaching 5. Topics taught Answer: 1, 3, 4, 5 Explanation: The parts of the teaching process that should be documented in the client's chart include diagnosed learning needs, client outcomes, need for additional teaching, and topics taught. Page Ref: 316 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 14. Describe effective documentation of teaching—learning activities. MNL Learning Outcome: 4. Determine appropriate teaching strategies for patients and groups based on their characteristics and learning goals. 38) The nurse is creating a teaching plan for a client recovering from total hip replacement surgery. What should the nurse include in this client's plan? (Select all that apply.) 1. The content to be included 2. The outcome for the teaching 3. The approaches used to teach the content 4. The evaluation of the effectiveness of teaching 5. The amount of time needed to cover the content Answer: 1, 2, 3, 5 Explanation: Elements of a teaching plan include the content, learning outcomes, teaching strategies, and time frame needed for teaching. Page Ref: 308 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning/Teaching and Learning Learning Outcome: 10. Describe the essential aspects of a teaching plan. MNL Learning Outcome: 4. Determine appropriate teaching strategies for patients and groups based on their characteristics and learning goals. 28
39) The nurse is preparing to teach a client on skin care and application of a stoma device. What should the nurse keep in mind when teaching the client this information? (Select all that apply.) 1. Address the client's concerns first. 2. Assess what the client knows already. 3. Address anxiety-producing issues last. 4. Teach the basics before complicated tasks. 5. Leave time for review and answering questions. Answer: 1, 2, 4, 5 Explanation: The nurse should start with something that the client is concerned about. The nurse should assess what the client knows and then proceed to the unknown. This gives the learner confidence. The nurse should teach the basics before proceeding to variations, adjustments, or complicated steps. The nurse should schedule time for the review of content and any questions the client may have to clarify information. Page Ref: 311-312 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 11. Discuss guidelines for effective teaching. MNL Learning Outcome: 4. Determine appropriate teaching strategies for patients and groups based on their characteristics and learning goals.
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40) The nurse is preparing a teaching tool for clients. Which action should the nurse take to ensure that it can be used for clients with low health literacy? 1. Use passive phrases 2. Write long sentences 3. Use all capital letters 4. Write at the fifth- to sixth-grade level Answer: 4 Explanation: Teaching materials should be written at the fifth- to sixth-grade level. Active phrases should be used. Sentences should be short. All capital letters should be avoided. Page Ref: 307 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 8. Discuss the implications of low health literacy skills. MNL Learning Outcome: 2. Consider factors that facilitate and interfere with learning. 41) The nurse is preparing a teaching plan for a client. Which information should the nurse omit from the plan? 1. Content outline 2. Name of the nurse 3. Teaching methods 4. Learning outcomes Answer: 2 Explanation: The nurse's name is not a part of the teaching plan. The content outline, teaching methods, and learning outcomes are included on the teaching plan. Page Ref: 308 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning/Teaching and Learning Learning Outcome: 10. Describe the essential aspects of a teaching plan. MNL Learning Outcome: 4. Determine appropriate teaching strategies for patients and groups based on their characteristics and learning goals.
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42) The nurse is concluding a teaching session with a client. For which reason should the nurse summarize the content covered with the client? 1. Permits exploration 2. Provides immediate feedback 3. Reinforces the material reviewed 4. Permits expression of values and emotions Answer: 3 Explanation: Summarizing the content covered after a teaching session is done to reinforce the material. It is not done to permit exploration, provide immediate feedback, or to permit the exploration of values and emotions. Page Ref: 311-312 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 11. Discuss guidelines for effective teaching. MNL Learning Outcome: 4. Determine appropriate teaching strategies for patients and groups based on their characteristics and learning goals.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 18 Leading, Managing, and Delegating 1) The nurse is preparing to assign a task to unlicensed assistive personnel (UAP). Which rights of delegation should the nurse follow? (Select all that apply.) 1. Supervision 2. Supplies 3. Client 4. Time 5. Task Answer: 1, 3, 4, 5 Explanation: The nurse needs to identify the right client to the AP. The nurse needs to identify when each task is to be done. The nurse needs to identify the task to be done. Page Ref: 327 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the healthcare team | NLN Competencies: Teamwork; Practice-Know-How; Manage delegation effectively | Nursing/Integrated Concepts: Implementation Learning Outcome: 9. List the five rights of delegation. MNL Learning Outcome: 3. Consider the delegation process and its components as it relates to managing care. 2) An unlicensed assistive person is working on a rehabilitation unit. Which task would be appropriate for this person to delegate? 1. Taking and recording vital signs 2. Assisting with bathing 3. Making a bed 4. A UAP may not delegate tasks. Answer: 4 Explanation: The UAP may not delegate tasks to another person. Delegation is part of the registered nurse's role. Page Ref: 327 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the healthcare team | NLN Competencies: Teamwork; Practice-Know-How; Manage delegation effectively | Nursing/Integrated Concepts: Implementation Learning Outcome: 8. Describe the characteristics of tasks appropriate to assign or delegate to unlicensed and licensed assistive personnel. MNL Learning Outcome: 3. Consider the delegation process and its components as it relates to managing care. 1
3) The RN delegates the task of taking a newly admitted client's vital signs to a nurse's aide. The client's blood pressure was 182/98 mm Hg but did not get reported to the physician for several hours. Who is responsible for the lapse in time between discovery and action? 1. Nurse manager 2. Aide 3. Client 4. RN Answer: 4 Explanation: The RN is ultimately responsible for the action, for reporting it, and for following through on any action. Part of delegation is supervision and evaluation–ultimate responsibilities that belong to the RN. Page Ref: 327 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the healthcare team | NLN Competencies: Teamwork; Practice-Know-How; Manage delegation effectively | Nursing/Integrated Concepts: Evaluation Learning Outcome: 6. Discuss the roles and functions of nurse managers. MNL Learning Outcome: 3. Consider the delegation process and its components as it relates to managing care.
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4) The nurse manager has the reputation of being an autocratic leader. Which statement by this manager would support that reputation? 1. "I'd like to hear from you (addressing the staff) what your ideas are for promoting better morale in this unit." 2. "I'm putting a suggestion box in the break room if anyone has ideas that would be helpful to the unit." 3. "The new work schedule is posted for the next 6 weeks." 4. "I put the new procedure manual out. Please add your comments to the blank sheet of paper attached to the front." Answer: 3 Explanation: An autocratic leader makes decisions for the group. This style is likened to a dictator in that the autocratic leader gives orders and directions to the group, determines policies, and solves problems without input from the group. Page Ref: 321 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the healthcare team | NLN Competencies: Teamwork; Practice-Know-How; Manage delegation effectively | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Compare and contrast different leadership styles. MNL Learning Outcome: 1. Recognize the differences between a leader and a manager, and the various leadership theories. 5) During a particularly heated staff meeting regarding staff assignments, the nurse manager makes this comment: "When you all can come to a decision, let me know and we'll move on from there." Which term should be used to describe this manager? 1. Democratic leader 2. Permissive leader 3. Bureaucratic leader 4. Situational leader Answer: 2 Explanation: The permissive leader recognizes the group's need for autonomy and selfregulation by assuming a "hands-off" approach. Allowing the group to come to its own decision and then accepting that decision reflects the style of a permissive leader. Page Ref: 321 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the healthcare team | NLN Competencies: Teamwork; Practice-Know-How; Manage delegation effectively | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Compare and contrast different leadership styles. MNL Learning Outcome: 1. Recognize the differences between a leader and a manager, and the various leadership theories. 3
6) The nurse manager allows the staff members to self-schedule and self-assign but during a code situation, the manager will make decisions for the staff by instructing which nurse to assume which responsibility. This manager is exemplifying which style of leadership? 1. Permissive 2. Democratic 3. Situational 4. Bureaucratic Answer: 3 Explanation: According to contingency theorists, effective leaders adapt their leadership style to the situation. Unlike the singular style of authoritarian, democratic, and permissive leaders, the situational leader adapts his or her leadership to the readiness and willingness of the group to perform the assigned task. Page Ref: 321 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the healthcare team | NLN Competencies: Teamwork; Practice-Know-How; Manage delegation effectively | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Compare and contrast different leadership styles. MNL Learning Outcome: 1. Recognize the differences between a leader and a manager, and the various leadership theories.
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7) A group of community health nurses are responsible for individual caseloads and scheduling of appointments but major leadership directives come from the state health office, several hundred miles away. This group of nurses is functioning under what type of leadership? 1. Charismatic 2. Shared 3. Transformational 4. Transactional Answer: 2 Explanation: Shared leadership recognizes that a professional workforce is made up of many leaders. No one person is considered to have knowledge or ability beyond that of other members of the work group, as in this situation. Page Ref: 322 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the healthcare team | NLN Competencies: Teamwork; Practice-Know-How; Function competently within one's own scope of practice as leader or member of the healthcare team and manage delegation effectively | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Compare and contrast different leadership styles. MNL Learning Outcome: 1. Recognize the differences between a leader and a manager, and the various leadership theories. 8) The charge nurse's responsibilities include the day-to-day management and coordination of therapies for the clients, client assignments, and scheduling. Which type of management is the charge nurse performing? 1. Top level 2. Middle level 3. First level 4. Upper level Answer: 3 Explanation: First-level managers are responsible for managing the work of nonmanagerial personnel and the day-to-day activities of a specific work group (rehabilitation unit in this case). Page Ref: 323 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the healthcare team | NLN Competencies: Teamwork; Practice-Know-How; Function competently within one's own scope of practice as leader or member of the healthcare team and manage delegation effectively | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Compare and contrast the levels of management. MNL Learning Outcome: 1. Recognize the differences between a leader and a manager, and the various leadership theories. 5
9) The nurse manager is implementing risk management for a client-care issue. In what order will the manager implement this process? 1. Analyzing, classifying, and prioritizing risks 2. Evaluating and modifying risk reduction programs 3. Anticipating and seeking sources of risk 4. Developing a plan to avoid and manage risk 5. Gathering data that indicate success at avoiding or minimizing risk Answer: 3, 1, 4, 5, 2 Explanation: 1. Analyzing, classifying, and prioritizing risks is the second step of the risk management process. 2. Evaluating and modifying risk reduction programs is the fifth step of the risk management process. 3. Anticipating and seeking sources of risk is the first step of the risk management process. 4. Developing a plan to avoid and manage risk is the third step in the risk management process. 5. Gathering data that indicate success at avoiding or minimizing risk is the fourth step of the risk management process. Page Ref: 323 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the healthcare team | NLN Competencies: Teamwork; Practice-Know-How; Function competently within one's own scope of practice as leader or member of the healthcare team and manage delegation effectively | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Describe the four functions of management. MNL Learning Outcome: 2. Examine management, its functions, and the skills/competencies required of the nurse manager.
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10) A The nurse manager is working on new job descriptions for all nursing units of the hospital. Which management function is this nurse conducting? 1. Planning 2. Organizing 3. Directing 4. Coordinating Answer: 2 Explanation: Organizing is an ongoing process of management that involves determining responsibilities, communicating expectations (which job descriptions would fall under), and establishing the chain of command for authority and communication. Page Ref: 323-324 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the healthcare team | NLN Competencies: Teamwork; Practice-Know-How; Function competently within one's own scope of practice as leader or member of the healthcare team and manage delegation effectively | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Describe the four functions of management. MNL Learning Outcome: 2. Examine management, its functions, and the skills/competencies required of the nurse manager. 11) A hospital was named in a lawsuit after a client had to undergo a second surgical procedure because an arthroscopy was performed on the wrong knee during surgery. The hospital settled out of court with the client for damages. This is an example of which principle of management? 1. Authority 2. Responsibility 3. Coordination 4. Accountability Answer: 4 Explanation: Accountability is the ability and willingness to assume responsibility for one's actions and to accept the consequences of one's behavior. The hospital had a responsibility to the client for quality care and service. That was not provided; therefore, the hospital was willing to accept the consequences of the injury experienced by the client. Page Ref: 324 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the healthcare team | NLN Competencies: Teamwork; Practice-Know-How; Function competently within one's own scope of practice as leader or member of the healthcare team and manage delegation effectively | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Describe the four functions of management. MNL Learning Outcome: 2. Examine management, its functions, and the skills/competencies required of the nurse manager. 7
12) The nurse manager has had to handle a particularly difficult physician who is demanding as well as demeaning. Through this situation, the nurse manager has learned that accuracy and honesty are attributes of which skill necessary for managers? 1. Critical thinking 2. Communication 3. Networking 4. Responsibility Answer: 2 Explanation: Good communication skills are essential to managers and include assertiveness, clear expression of ideas, accuracy, and honesty. Page Ref: 324 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the healthcare team | NLN Competencies: Teamwork; Practice-Know-How; Function competently within one's own scope of practice as leader or member of the healthcare team and manage delegation effectively | Nursing/Integrated Concepts: Assessment Learning Outcome: 7. Identify the skills and competencies needed by a nurse manager. MNL Learning Outcome: 2. Examine management, its functions, and the skills/competencies required of the nurse manager. 13) A nursing student would like to do an observation on one of the inpatient units at a hospital. In assisting the student to meet this desire, the educator would look for which type of nurse? 1. Mentor 2. Manager 3. Team leader 4. Preceptor Answer: 4 Explanation: The preceptor is a person of experience who assists a "new" nurse in improving clinical skills and nursing judgment. Page Ref: 325 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the healthcare team | NLN Competencies: Teamwork; Practice-Know-How; Function competently within one's own scope of practice as leader or member of the healthcare team and manage delegation effectively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Discuss the roles and functions of nurse managers. MNL Learning Outcome: 2. Examine management, its functions, and the skills/competencies required of the nurse manager.
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14) A hospital is implementing a computerized charting system, and all nursing staff is required to be oriented to the system by a specific deadline. Which type of change is occurring with the staff? 1. Overt change 2. Covert change 3. Unplanned change 4. Drift Answer: 1 Explanation: An overt change is one that is planned and that people are aware of. Implementing a new computer system is a planned, purposeful event. Page Ref: 326 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the healthcare team | NLN Competencies: Teamwork; Practice-Know-How; Function competently within one's own scope of practice as leader or member of the healthcare team and manage delegation effectively | Nursing/Integrated Concepts: Assessment Learning Outcome: 10. Describe the role of the leader/manager in planning for and implementing change. MNL Learning Outcome: 4. Consider the role of the leader/manager in planning for and implementing change. 15) The nursing staff is informed that the current system of record keeping is going to be changed to make it more efficient. In which stage of change is the nursing staff? 1. Refreezing 2. Unfreezing 3. Moving 4. Drift Answer: 2 Explanation: During the unfreezing stage, the need for change is recognized, driving and restraining forces are identified, alternative solutions are generated, and participants are motivated to change. Page Ref: 326 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the healthcare team | NLN Competencies: Teamwork; Practice-Know-How; Function competently within one's own scope of practice as leader or member of the healthcare team and manage delegation effectively | Nursing/Integrated Concepts: Implementation Learning Outcome: 10. Describe the role of the leader/manager in planning for and implementing change. MNL Learning Outcome: 4. Consider the role of the leader/manager in planning for and implementing change. 9
16) Prior to delegating a task, the nurse reviews the "rights" of delegation. Which rights does the nurse include?? (Select all that apply.) 1. Supervision 2. Evaluation 3. Client 4. Time 5. Task Answer: 1, 2, 5 Page Ref: 327 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the healthcare team | NLN Competencies: Teamwork; Practice-Know-How; Function competently within one's own scope of practice as leader or member of the healthcare team and manage delegation effectively | Nursing/Integrated Concepts: Implementation Learning Outcome: 9. List the five rights of delegation. MNL Learning Outcome: 3. Consider the delegation process and its components as it relates to managing care. 17) The nurse has been promoted to the role of manager for a client care area. What responsibilities of the nurse will this new role include? (Select all that apply.) 1. Accomplish the goals of the organization. 2. Use the organization's resources efficiently. 3. Ensure effective client care. 4. Ensure compliance with regulatory standards. 5. Manage relationships. Answer: 1, 2, 3, 4 Page Ref: 324 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the healthcare team | NLN Competencies: Teamwork; Practice-Know-How; Function competently within one's own scope of practice as leader or member of the healthcare team and manage delegation effectively | Nursing/Integrated Concepts: Planning Learning Outcome: 6. Discuss the roles and functions of nurse managers. MNL Learning Outcome: 2. Examine management, its functions, and the skills/competencies required of the nurse manager.
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18) The nurse is identified as being an effective leader. With this designation, the nurse will most likely demonstrate which characteristics? (Select all that apply.) 1. Self-aware 2. Focus on people 3. Excellent communicator 4. Mentor to others 5. Focus on systems Answer: 1, 2, 3, 4 Page Ref: 319 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the healthcare team | NLN Competencies: Teamwork; Practice-Know-How; Function competently within one's own scope of practice as leader or member of the healthcare team and manage delegation effectively | Nursing/Integrated Concepts: Implementation Learning Outcome: 3. Identify characteristics of an effective leader. MNL Learning Outcome: 1. Recognize the differences between a leader and a manager, and the various leadership theories. 19) A staff nurse has been identified by others as being an effective leader. With this designation, the nurse implements which principles? (Select all that apply.) 1. Vision 2. Influence 3. Serve as a role model 4. Planning 5. Organizing Answer: 1, 2, 3 Page Ref: 322 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the healthcare team | NLN Competencies: Teamwork; Practice-Know-How; Function competently within one's own scope of practice as leader or member of the healthcare team and manage delegation effectively | Nursing/Integrated Concepts: Implementation Learning Outcome: 1. Compare and contrast leadership and management. MNL Learning Outcome: 1. Recognize the differences between a leader and a manager, and the various leadership theories.
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20) The nurse is reviewing feedback from other staff members on leadership behaviors. Which characteristics are consistent with being an effective leader? (Select all that apply.) 1. Energetic 2. Creative 3. Optimistic 4. Open 5. Risk taking Answer: 1, 2, 3, 4 Page Ref: 323 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the healthcare team | NLN Competencies: Teamwork; Practice-Know-How; Function competently within one's own scope of practice as leader or member of the healthcare team and manage delegation effectively | Nursing/Integrated Concepts: Implementation Learning Outcome: 3. Identify characteristics of an effective leader. MNL Learning Outcome: 1. Recognize the differences between a leader and a manager, and the various leadership theories. 21) The nurse has been promoted to a position that includes the supervision of first-level management and responsibility for activities in a specific department. This nurse will most likely have which title? (Select all that apply.) 1. Supervisor 2. Nurse manager 3. Head nurse 4. Primary care nurse 5. Vice president Answer: 1, 2, 3 Page Ref: 323 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the healthcare team | NLN Competencies: Teamwork; Practice-Know-How; Function competently within one's own scope of practice as leader or member of the healthcare team and manage delegation effectively | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Compare and contrast the levels of management. MNL Learning Outcome: 2. Examine management, its functions, and the skills/competencies required of the nurse manager.
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22) The nurse practices responsibility when functioning in the role of manager of a care area. What will the nurse manager demonstrate as evidence of responsibility? (Select all that apply.) 1. Effective utilization of resources 2. Communication to subordinates 3. Implementation of organizational goals and objectives 4. Problem solving 5. Managing the work team Answer: 1, 2, 3 Page Ref: 324 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the healthcare team | NLN Competencies: Teamwork; Practice-Know-How; Function competently within one's own scope of practice as leader or member of the healthcare team and manage delegation effectively | Nursing/Integrated Concepts: Assessment Learning Outcome: 7. Identify the skills and competencies needed by a nurse manager. MNL Learning Outcome: 2. Examine management, its functions, and the skills/competencies required of the nurse manager. 23) The nurse is determining whether an activity can be delegated to a UAP. What will the nurse use to make this determination? (Select all that apply.) 1. Determine whether it is the right task. 2. Determine whether it is under the right circumstances. 3. Determine whether it is to the right person. 4. Determine the type of communication. 5. Determine whether there is enough time. Answer: 1, 2, 3, 4 Page Ref: 327 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the healthcare team | NLN Competencies: Teamwork; Practice-Know-How; Function competently within one's own scope of practice as leader or member of the healthcare team and manage delegation effectively | Nursing/Integrated Concepts: Assessment Learning Outcome: 8. Describe the characteristics of tasks appropriate to assign or delegate to unlicensed and licensed assistive personnel. MNL Learning Outcome: 3. Consider the delegation process and its components as it relates to managing care.
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24) The manager identifies a staff nurse to serve as a change agent for the implementation of a computerized documentation system. What attributes did the manager observe to designate the staff nurse to have this role? (Select all that apply.) 1. Self-confident 2. Skilled in teaching 3. Hesitant with decision making 4. Excellent communication skills 5. Effective utilization of resources Answer: 1, 2, 4, 5 Page Ref: 325 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the healthcare team | NLN Competencies: Teamwork; Practice-Know-How; Function competently within one's own scope of practice as leader or member of the healthcare team and manage delegation effectively | Nursing/Integrated Concepts: Evaluation Learning Outcome: 10. Describe the role of the leader/manager in planning for and implementing change. MNL Learning Outcome: 4. Consider the role of the leader/manager in planning for and implementing change. 25) The manager determines that a new graduate nurse needs additional training on the principles of delegation. What delegation to unlicensed assistive personnel did the manager observe to make this decision? (Select all that apply.) 1. Bathing a patient recovering from surgery 2. Weighing a patient who is prescribed diuretics 3. Discharge instruction teaching 4. Transferring and ambulating a client after hip replacement surgery 5. The care of an intravenous access device Answer: 3, 5 Explanation: Client education may not be delegated to unlicensed assistive personnel. The care of invasive lines may not be delegated to unlicensed assistive personnel. Page Ref: 327 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the healthcare team | NLN Competencies: Teamwork; Practice-Know-How; Function competently within one's own scope of practice as leader or member of the healthcare team and manage delegation effectively | Nursing/Integrated Concepts: Evaluation Learning Outcome: 8. Describe the characteristics of tasks appropriate to assign or delegate to unlicensed and licensed assistive personnel. MNL Learning Outcome: 3. Consider the delegation process and its components as it relates to managing care. 14
26) The nurse was recently promoted to the position of manager. Which activities should the nurse expect to perform in this role? (Select all that apply.) 1. Focus on systems 2. Carry out policies 3. Focus on resources 4. Manage relationships 5. Maintain a controlled structure Answer: 1, 2, 3, 5 Explanation: As a manager, the nurse will focus on systems. As a manager, the nurse will carry out policies. As a manager, the nurse will focus on resources, and maintain a controlled structure. As a manager, the nurse will maintain a controlled structure. Page Ref: 320 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the healthcare team | NLN Competencies: Teamwork; Practice-Know-How; Function competently within one's own scope of practice as leader or member of the healthcare team and manage delegation effectively | Nursing/Integrated Concepts: Implementation Learning Outcome: 1. Compare and contrast leadership and management. MNL Learning Outcome: 1. Recognize the differences between a leader and a manager, and the various leadership theories.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 19 Health Promotion 1) The nurse is providing care within the total care context. What should the nurse consider when using this care approach? 1. The individualism of the client 2. Principles applicable to the client at this moment 3. Principles general to all clients of the same age and condition 4. The person's self-identity Answer: 3 Explanation: In the total care context, the nurse considers all the principles and areas that apply when taking care of any client of that age and condition. Page Ref: 337 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 1. Explain the relationship of individuality and holism to nursing practice. MNL Learning Outcome: 1. Consider concepts of individual health to health promotion.
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2) The nurse is practicing the concept of holism with a client. Which action is the nurse most likely making? 1. Considering how the loss of a client's job will affect the regulation of the client's diabetes 2. Making sure to do complete teaching regarding pharmacological interventions 3. Following physician treatments on schedule 4. Prioritizing the needs of the client assigned according to Maslow's hierarchy Answer: 1 Explanation: The concept of holism emphasizes that nurses must keep the whole person in mind and strives to understand how one area of concern relates to the whole person. In this situation, the stress from a job loss will affect the person's chronic condition. The nurse must also consider the relationship of the individual to the external environment and to others. Page Ref: 337 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 1. Explain the relationship of individuality and holism to nursing practice. MNL Learning Outcome: 1. Consider concepts of individual health to health promotion. 3) Psychologic homeostasis is maintained by a variety of mechanisms. Which client should the nurse identify as being the most likely candidate to obtain psychologic homeostasis? 1. A child who is used to getting ready for school alone 2. A teenager whose circle of friends includes single parents of the same age 3. An older adults who has just moved to a long-term care facility 4. A young adult who is in a long-term relationship Answer: 4 Explanation: Individuals also need a stable psychologic environment from infancy onward so that feelings of love and trust develop, a social environment that includes adults who are healthy role models, and a life experience that provides satisfaction. A young adult who has a relationship that lasts is the one option that would fit most of these mechanisms. Page Ref: 339 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. List four main characteristics of homeostatic mechanisms. MNL Learning Outcome: 1. Consider concepts of individual health to health promotion. 2
4) A client is having difficulty with feelings of self-loathing and disgust after being attacked and raped. According to Maslow's human needs theory, at which level should the nurse recognize that the client is struggling? 1. Physiological 2. Safety and security 3. Love and belonging 4. Self-esteem Answer: 4 Explanation: Self-esteem and esteem from others includes feelings of independence, competence, self-respect, recognition, respect, and appreciation. Self-hatred and disgust is opposite of what one would expect in the self-esteem level of Maslow's model. Page Ref: 339 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify theoretical frameworks used in individual health promotion. MNL Learning Outcome: 2. Recognize the theoretical frameworks that provide the nurse with a holistic overview of health promotion, Healthy People 2020, and the levels of health promotion.
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5) A client is hospitalized with numerous acute health problems. According to Maslow's basic needs model, which nursing diagnosis should the nurse identify as being the highest priority for this client? 1. Risk for Injury related to unsteady gait 2. Altered Nutrition, Less Than Body Requirements related to inability to absorb nutrients 3. Self-Care Deficit related to weakness and debilitation 4. Powerlessness related to chronic disease state Answer: 2 Explanation: In needs theories, human needs are ranked on an ascending scale according to how essential the needs are for survival. Physiologic needs are those such as air, food, water, shelter, rest, sleep, activity, and temperature maintenance, which are all crucial for survival. Nutritional deficits would fall into this level and take priority over the others listed. Page Ref: 339 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify theoretical frameworks used in individual health promotion. MNL Learning Outcome: 2. Recognize the theoretical frameworks that provide the nurse with a holistic overview of health promotion, Healthy People 2020, and the levels of health promotion. 6) The nurse is using Kalish's adaptation of Maslow's hierarchy of needs when planning client care. Which client should the nurse identify as exhibiting a level of Kalish's adaptation? 1. Has a sexual encounter for the first time 2. Has a need to participate in school sports and be "on the team" 3. Strives to become the CEO of a company 4. Is sleep deprived because of musculoskeletal discomfort Answer: 1 Explanation: Richard Kalish added a sixth level to Maslow's five levels and referred to it as stimulation needs. This level includes sexual activity, exploration, manipulation, and novelty. Page Ref: 339-340 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify theoretical frameworks used in individual health promotion. MNL Learning Outcome: 2. Recognize the theoretical frameworks that provide the nurse with a holistic overview of health promotion, Healthy People 2020, and the levels of health promotion. 4
7) A client comes to the clinic seeking information regarding smoking-cessation classes and ways to improve respiratory function. This client is modeling which behavior? 1. Health promotion 2. Health protection 3. Tertiary prevention 4. Primary prevention Answer: 2 Explanation: Health protection or illness prevention is "behavior motivated by a desire to actively avoid illness, detect it early, or maintain functioning within the constraints of illness." Expressing a desire to quit smoking would be modeling this behavior. The information we are given does not tell us if the client has pathology or not, but the client certainly has been exposed to a health hazard. Page Ref: 341 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation Learning Outcome: 5. Differentiate health promotion from health protection or illness prevention. MNL Learning Outcome: 2. Recognize the theoretical frameworks that provide the nurse with a holistic overview of health promotion, Healthy People 2020, and the levels of health promotion.
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8) A community health nurse wants to provide health promotion classes through the local hospital. Which topics should the nurse include in this endeavor? (Select all that apply.) 1. Time management 2. Healthy eating habits 3. Exercise after stroke 4. Bicycle safety for children 5. Performing self-examination of the breasts Answer: 1, 2, 4 Explanation: Health promotion activities include those items that increase well-being and overall health, such as time management, healthy eating habits, and bicycle safety for children. Page Ref: 342-343 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 6. Identify various types and sites of health promotion programs. MNL Learning Outcome: 2. Recognize the theoretical frameworks that provide the nurse with a holistic overview of health promotion, Healthy People 2020, and the levels of health promotion.
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9) A client has joined a fitness club even though exercise has not been effective for fitness and weight management in the past. In order to assess the potential for success with this client, the nurse should evaluate which behavior-specific cognitions? 1. Interpersonal influences 2. Perceived benefits of action 3. Situational influences 4. Perceived self-efficacy Answer: 2 Explanation: Behavior-specific cognitions and affect are considered to be of major motivational significance for acquiring and maintaining health-promoting behaviors. Perceived benefits of action affect the person's plan to participate in health-promoting behaviors and may facilitate continued practice. If this client has prior positive experience with the behavior or observations of others engaged in the behavior, the client may be motivated to success. Page Ref: 344 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 7. Discuss the health promotion model. MNL Learning Outcome: 3. Recognize how the health promotion model and stages of health behavior change relate to health promotion.
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10) A client in rehabilitation following a traumatic brain injury has a weak support system in that family lives far away and coworkers are not involved. On which behavior-specific cognitions should the nurse focus to assist this client with success in the rehabilitation program? 1. Situational influences 2. Perceived benefits of action 3. Perceived barriers to action 4. Interpersonal influences Answer: 4 Explanation: Interpersonal influences are a person's perceptions concerning the behaviors, beliefs, or attitudes of others. Family, peers, and health professionals are sources of interpersonal influences that can affect a person's health-promoting behaviors. Because this particular client does not have a close support system, the nurse will look to other possibilities (i.e., the other health professionals involved in the client's care such as other nurses, therapists, and physicians). Page Ref: 345 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 7. Discuss the health promotion model. MNL Learning Outcome: 3. Recognize how the health promotion model and stages of health behavior change relate to health promotion.
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11) A client learning how to manage asthma is instructed on the importance of using the peak flow meter every morning to help determine changes in respiratory status. The nurse is stressing which health promotion behavior? 1. Competing preferences 2. Competing demands 3. Situational influences 4. Interpersonal influences Answer: 1 Explanation: Competing preferences are behaviors over which an individual has a high level of control and depend on the individual's ability to be self-regulating. In this case, the individual must make a choice to use his peak flow meter every day. Either it is used or not used. Page Ref: 345 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Discuss the health promotion model. MNL Learning Outcome: 3. Recognize how the health promotion model and stages of health behavior change relate to health promotion.
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12) Before helping a client with smoking cessation, the nurse reviews the steps of the change process. In which order should the nurse expect the client to progress through the stages of health change behavior? Arrange the following stages in the correct order: 1. Preparation stage 2. Contemplation stage 3. Maintenance stage 4. Precontemplation stage 5. Termination stage 6. Action Stage Answer: 4, 2, 1, 6, 3, 5 Explanation: 1. This is the third stage, where the client intends to take action in the immediate future (e.g., within the next month). Some people in this stage may have already started making small behavioral changes, such as buying a self-help book. At this stage, the person makes the final specific plans to accomplish the change. 2. This is the second stage, where the client acknowledges having a problem, seriously considers changing a specific behavior, actively gathers information, and verbalizes plans to change the behavior in the near future (e.g., next 6 months). 3. This is the fifth stage, where the client strives to prevent relapse by integrating newly adopted behaviors into his or her lifestyle. This stage lasts until the person no longer experiences temptation to return to previous unhealthy behaviors. It is estimated that maintenance lasts from 6 months to 5 years. 4. This is the first stage, where the client is not contemplating change for at least 6 months. 5. This is the sixth and last stage (the ultimate goal), where the individual has complete confidence that the problem is no longer a temptation or threat. It is as if the individual never acquired the habit in the first place or the new behavior has become automatic. 6. This is the fourth stage, where the client actively implements behavioral and cognitive strategies of the action plan to interrupt previous health risk behaviors and adopt new ones. This stage requires the greatest commitment of time and energy. Page Ref: 345-346 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 8. Explain the stages of health behavior change. MNL Learning Outcome: 3. Recognize how the health promotion model and stages of health behavior change relate to health promotion.
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13) Several nursing students have been discussing the benefits of joining a study group to improve with retention and application of content. Which stage of behavior change are they exemplifying? 1. Termination stage 2. Preparation stage 3. Contemplation stage 4. Action stage Answer: 3 Explanation: During the contemplation stage, the person acknowledges the problem, considers changing a specific behavior, actively gathers information, and verbalizes plans to change the behavior in the near future. Discussing benefits of a study group would fall into this stage. They have not started a group nor have they made any preparation toward it; they have merely been talking about it. Page Ref: 346 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 8. Explain the stages of health behavior change. MNL Learning Outcome: 3. Recognize how the health promotion model and stages of health behavior change relate to health promotion.
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14) A client wanting to better control diabetes monitors blood glucose twice a day and has appointments with a nutritionist. This client is modeling which stage of health behavior change? 1. Termination stage 2. Maintenance stage 3. Contemplation stage 4. Action stage Answer: 4 Explanation: The action stage occurs when the person actively implements behavioral and cognitive strategies to interrupt previous behavior patterns and adopt new ones. This stage requires the greatest commitment of time and energy and is where the person is actually doing something to change the behavior. Page Ref: 346 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation Learning Outcome: 8. Explain the stages of health behavior change. MNL Learning Outcome: 3. Recognize how the health promotion model and stages of health behavior change relate to health promotion.
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15) The nurse on a college campus is implementing a health promotion activity by placing posters about proper handwashing in all of the public restrooms on campus. Which type of health promotion program is the nurse implementing? 1. Environmental control 2. Information dissemination 3. Health risk appraisal and wellness assessment 4. Lifestyle and behavior change Answer: 2 Explanation: Information dissemination is the most basic type of health promotion program. This method makes use of a variety of media to offer information to the public about the risk of a particular lifestyle choice and personal behavior as well as the benefits of changing that behavior. Page Ref: 346 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 6. Identify various types and sites of health promotion programs. MNL Learning Outcome: 3. Recognize how the health promotion model and stages of health behavior change relate to health promotion. 16) The nurse is preparing information packets for incoming college students regarding sexually transmitted disease, drug and alcohol abuse, and the use of stimulants among this age group. In this situation, the nurse has assumed which role? 1. Facilitator 2. Advocate 3. Teacher 4. Coordinator of services Answer: 3 Explanation: The teaching role focuses on self-care strategies such as enhancing fitness, improving nutrition, managing stress, and enhancing relationships. Page Ref: 347 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 9. Discuss the nurse's role in health promotion. MNL Learning Outcome: 3. Recognize how the health promotion model and stages of health behavior change relate to health promotion. 13
17) The nurse suggests that a client make a list of past experiences that have brought joy, peace, and hope into the client's life. What action is the nurse assisting the client to complete? 1. Lifestyle assessment 2. Social support systems review 3. Health beliefs review 4. Spiritual health assessment Answer: 4 Explanation: Spiritual health is the ability to develop one's spiritual nature to its fullest potential, including the discovery of how to experience love, joy, peace, and fulfillment. An assessment of spiritual well-being is a part of evaluating the person's overall health. Page Ref: 348 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 18. Develop an awareness of patients' as well as healthcare professionals' spiritual beliefs and values and how those beliefs and values impact healthcare | NLN Competencies: Context and Environment; Practice-KnowHow; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 10. Describe components of health assessment that pertain to health promotion. MNL Learning Outcome: 4. Apply the nursing process to health promotion. 18) A client has received a high score on the Life-Change Index. For which part of the client's assessment should the nurse use this information? 1. Life stress review 2. Social support systems review 3. Lifestyle assessment 4. Health beliefs review Answer: 1 Explanation: The Life-Change Index is a tool that assigns numerical values to life events and is a way to identify clients in stress. Studies have shown that high levels of stress are associated with an increased possibility of illness in an individual. Page Ref: 349 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 10. Describe components of health assessment that pertain to health promotion. MNL Learning Outcome: 4. Apply the nursing process to health promotion. 14
19) The nurse educator provides developmental testing for kindergarten through third-grade students. Which level of prevention is the nurse performing? 1. Primary 2. Secondary 3. Tertiary 4. Community Answer: 2 Explanation: Secondary prevention emphasizes early detection of disease and health maintenance for individuals experiencing health problems. This would include providing assessment of the growth and development of children. Page Ref: 341 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 6. Identify various types and sites of health promotion programs. MNL Learning Outcome: 1. Recognize the theoretical frameworks that provide the nurse with a holistic overview of health promotion, Healthy People 2020, and the levels of health promotion. 20) A client in rehabilitation for a severe brain injury develops pneumonia and is currently on intravenous antibiotic therapy. Which level of prevention should the nurse use to address the health problem of pneumonia? 1. Primary 2. Secondary 3. Tertiary 4. Acute Answer: 2 Explanation: Secondary prevention emphasizes early detection of disease, prompt intervention, and health maintenance for individuals experiencing health problems. Because the pneumonia is a current health problem, interventions focused on that would be considered secondary prevention. Page Ref: 341-342 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Discuss the health promotion model. MNL Learning Outcome: 3. Recognize how the health promotion model and stages of health behavior change relate to health promotion. 15
21) The nurse in charge of an assisted living complex that includes independent living apartments understands the unique needs of individuals of this age group. When planning health promotion strategies, what factor should the nurse take into consideration? 1. Rest and exercise 2. Adjusting to physiologic changes and limitations 3. High obesity percentages 4. Safety promotion and injury prevention Answer: 2 Explanation: In the elderly population, health promotion and illness prevention are important, but the focus is often on learning to adapt to and live with increasing changes and limitations. Maximizing strengths continues to be of prime importance in maintaining optimal function and quality of life. Page Ref: 350 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 11. Discuss nursing diagnosing, planning, implementing, and evaluating as they relate to health promotion. MNL Learning Outcome: 4. Apply the nursing process to health promotion.
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22) The nurse is reviewing the characteristics of homeostatic mechanisms prior to assessing a client. Which characteristics should the nurse keep in mind during this assessment? (Select all that apply.) 1. They are self-regulating. 2. They are compensatory. 3. They are regulated by negative feedback systems. 4. They can require several feedback mechanisms to correct only one physiologic imbalance. 5. They are related to a closed system. Answer: 1, 2, 3, 4 Explanation: Homeostatic mechanisms are self-regulating, compensatory, are regulated by negative feedback systems. Can require several feedback mechanisms to correct a physiologic imbalance. Page Ref: 337 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. List four main characteristics of homeostatic mechanisms. MNL Learning Outcome: 1. Consider concepts of individual health to health promotion.
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23) The nurse is an advocate for health promotion activities. Which nursing actions demonstrate this nurse's advocacy? (Select all that apply.) 1. Participating in a community-focused 5-mile run. 2. Attending the local high school's football games. 3. Providing an educational program to senior citizens on blood pressure—control strategies. 4. Attending a community meeting that is promoting the creation of a walking path in the city park. 5. Encouraging an anxious client to practice Practice-Know-How relaxation techniques. Answer: 1, 3, 4, 5 Explanation: The nurse's role in health promotion includes modeling healthy lifestyle behaviors and attitudes. The nurse's role in health promotion includes assisting clients, families, and communities to develop and choose health-promoting options. The nurse's role in health promotion includes advocating in the community for changes that promote a healthy environment. The nurse's role in health promotion includes teaching clients self-care strategies to enhance fitness, improve nutrition, manage stress, and enhance relationships. Page Ref: 346-347 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 9. Discuss the nurse's role in health promotion. MNL Learning Outcome: 3. Recognize how the health promotion model and stages of health behavior change relate to health promotion.
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24) The nurse is reviewing information collected while providing client care. Which findings should the nurse identify as being a homeostatic mechanism? (Select all that apply.) 1. The client's heart rate increases when walking up a flight of stairs. 2. The client shivers when core body temperature drops. 3. A child's bone growth occurs in spurts. 4. Decreased secretion of insulin occurs when food is not ingested. 5. Lactation occurs in a pregnant woman. Answer: 1, 2, 4 Explanation: Homeostatic mechanisms have characteristics that include self-regulation, such as automatically increased respiratory rates. Shivering to create body heat; and regulation by negative feedback systems. Page Ref: 337 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. List four main characteristics of homeostatic mechanisms. MNL Learning Outcome: 1. Consider concepts of individual health to health promotion.
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25) The nurse is structuring activities that take a client's developmental stage into consideration. Which activities should the nurse include? (Select all that apply.) 1. Implementing seizure precautions 2. Creating a schedule for daily wound care 3. Monitoring intake, output, and daily weights 4. Preparing newborn care classes for new parents 5. Scheduling instruction sessions on self-administration of insulin Answer: 4, 5 Explanation: Developmental stage theories allow nurses to describe typical behaviors of an individual within a certain age group, explain the significance of those behaviors, predict behaviors that might occur in a given situation, and provide a rationale to control behavioral manifestations. Individuals can be compared with a representative group of people at the same point in time or compared at different points in time. The nurse's knowledge of developmental stage theories can be used in parental and client education. Developmental stage theories allow nurses to describe typical behaviors of an individual within a certain age group, explain the significance of those behaviors, predict behaviors that might occur in a given situation, and provide a rationale to control behavioral manifestations. Individuals can be compared with a representative group of people at the same point in time or compared at different points in time. The nurse's knowledge of developmental stage theories can be used in parental and client education. Page Ref: 340 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 3. Identify theoretical frameworks used in individual health promotion. MNL Learning Outcome: 2. Recognize the theoretical frameworks that provide the nurse with a holistic overview of health promotion, Healthy People 2020, and the levels of health promotion.
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26) During a home visit, the nurse is planning to complete a physical fitness assessment of a client. What should the nurse include in this assessment? (Select all that apply.) 1. Flexibility 2. Range of motion 3. Body composition 4. Muscle endurance 5. Cardiorespiratory endurance Answer: 1, 3, 4, 5 Explanation: During an evaluation of physical fitness, the nurse assesses several components of the body's physical functioning, including flexibility, body composition, muscle endurance, and cardiorespiratory endurance. Page Ref: 347 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 10. Describe components of health assessment that pertain to health promotion. MNL Learning Outcome: 3. Recognize how the health promotion model and stages of health behavior change relate to health promotion.
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27) The nurse is reviewing the Healthy People 2020 information which should the nurse identify as the foundation for this initiative? 1. Individual and community health are closely linked 2. The government is responsible for individual health 3. Businesses have no role in the health of the communities 4. Communities should expect local organizations to pay for healthcare Answer: 1 Explanation: The foundation for Healthy People 2020 is the belief that individual health is closely linked to community health, and the reverse. The foundation for Healthy People 2020 does not identify the government as being responsible for individual health. The foundation for Healthy People 2020 believes partnerships with businesses are participants in community health. The foundation for Health People 2020 does not believe that local organizations should pay for healthcare. Page Ref: 340 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Describe the vision, mission, and goals of Healthy People 2020 to help improve the health of a community. MNL Learning Outcome: 2. Recognize the theoretical frameworks that provide the nurse with a holistic overview of health promotion, Healthy People 2020, and the levels of health promotion.
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28) The nurse reviews the progress of leading health indicators as identified by Healthy People 2020. Which indicator has been met? (Select all that apply.) 1. Oral health 2. Mental health 3. Injury and violence 4. Environmental quality 5. Maternal, infant, and child health Answer: 3, 4, 5 Explanation: Injury deaths improving and homicides. The target has been met for improving injury and homicide death rates. The target has been met for the air quality index and children exposed to second-hand smoke. The target has been met for maternal, infant, and child health. Page Ref: 341 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation Learning Outcome: 4. Describe the vision, mission, and goals of Healthy People 2020 to help improve the health of a community. MNL Learning Outcome: 2. Recognize the theoretical frameworks that provide the nurse with a holistic overview of health promotion, Healthy People 2020, and the levels of health promotion.
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29) The nurse is asked to explain the difference between health promotion from health protection. Which information should the nurse include in the response? 1. Health protection activities focus on improving overall health. 2. Health promotion activities focus on reducing the risk of disease. 3. Health protection must address physical and social situations that cause poor health. 4. Health promotion must address physical and social situations that cause poor health. Answer: 4 Explanation: Health promotion is different from disease prevention or health protection. Health promotion must address physical and social situations that cause poor health. The individual's underlying motivation for the behavior is the major difference. Health promotion activities focus on improving health whereas health protection activities focus on reducing the risk of disease. Page Ref: 341 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Differentiate health promotion from health protection or illness prevention. MNL Learning Outcome: 2. Recognize the theoretical frameworks that provide the nurse with a holistic overview of health promotion, Healthy People 2020, and the levels of health promotion.
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30) The nurse is planning a community program to promote health. Which topics should the nurse consider for this program? (Select all that apply.) 1. Information dissemination 2. Medication teaching sessions 3. Lifestyle and behavior change 4. Environmental control programs 5. Health risk appraisal and wellness assessment Answer: 1, 3, 4, 5 Explanation: Information dissemination is the most basic type of health promotion program. Lifestyle and behavior change is an appropriate topic to promote health. Environmental control programs would be an appropriate topic to promote health. Health risk appraisals and wellness assessments would be appropriate to promote health. Page Ref: 347 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning/Teaching and Learning Learning Outcome: 9. Discuss the nurse's role in health promotion. MNL Learning Outcome: 4. Apply the nursing process to health promotion.
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31) The nurse cares for clients in a community health clinic. Which action should the nurse take to support health promotion when providing client care? (Select all that apply.) 1. Teach client self-care strategies 2. Reinforce health-promoting behaviors 3. Guide clients with effective problem solving 4. Educate clients to be effective healthcare consumers 5. Contact the healthcare provider for a medication prescription Answer: 1, 2, 3, 4 Explanation: The nurse's role in health promotion includes teaching clients self-care strategies. The nurse's role in health promotion includes reinforcing health-promoting behaviors. The nurse's role in health promotion includes guiding clients with problem solving. The nurse's role in health promotion includes educating clients to be effective healthcare consumers. Page Ref: 347 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 9. Discuss the nurse's role in health promotion. MNL Learning Outcome: 4. Apply the nursing process to health promotion.
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32) A client desires to make a health behavior change but needs to "see what it looks like" when someone else does it. Which should the nurse suggest to serve as a model for the client's behavior change? 1. A movie star 2. A sports figure 3. A family healthcare provider 4. A person who the client respects Answer: 4 Explanation: The nurse and client should mutually select models with whom the client can identify because the cultural and ethnic backgrounds and age of the nurse and client often differ. Models should be people the client respects. Individuals who model the desired behavior are not necessarily movie starts, sports figures, or the family healthcare provider. Page Ref: 353 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 11. Discuss nursing diagnosing, planning, implementing, and evaluating as they relate to health promotion. MNL Learning Outcome: 4. Apply the nursing process to health promotion.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 20 Health, Wellness, and Illness 1) The nurse is explaining the concept of health and parallels this with interruption of body systems and symptoms of disease or injury. Which model is the nurse using to interpret health? 1. Health—illness continua 2. Eudemonistic 3. Adaptive 4. Clinical Answer: 4 Explanation: The narrowest interpretation of health occurs in the clinical model, where people are viewed as physiologic systems with related functions and health is defined by the absence of signs and symptoms of disease or injury. Page Ref: 358 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 3. Compare various models of health. MNL Learning Outcome: 3. Examine health belief models and how the nurse can influence healthcare adherence.
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2) The nurse is helping a client with a serious injury cope with physical limitations. Which model of health is the nurse using for this client's care? 1. Role performance 2. Adaptive 3. Eudemonistic 4. Clinical Answer: 2 Explanation: In the adaptive model, health is a creative process; disease is a failure in adaptation or maladaptation. The aim of treatment is to restore the ability of the person to adapt and cope, as in a rehabilitation setting. Page Ref: 358 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 3. Compare various models of health. MNL Learning Outcome: 3. Examine health belief models and how the nurse can influence healthcare adherence. 3) The nurse is conducting a community assessment to determine which diseases are prevalent and most likely to occur. On which model of health is the nurse basing this assessment? 1. Role performance 2. Eudemonistic 3. Ecological 4. Adaptive Answer: 3 Explanation: The ecological model–also called the agent—host—environment model of health and illness–is used primarily in predicting illness rather than promoting wellness. Identification of risk factors results from interactions between agent, host, and environment and is helpful in promoting and maintaining health. Page Ref: 358 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 3. Compare various models of health. MNL Learning Outcome: 3. Examine health belief models and how the nurse can influence healthcare adherence. 2
4) The nurse is assessing a client who practices yoga for relaxation, is following a nutritionally sound diet, and has supportive, sound relationships with family members. According to Dunn's high-level wellness grid, this client would exemplify which health characteristic? 1. Emergent high-level wellness in a favorable environment 2. Emergent high-level wellness in an unfavorable environment 3. Protected health in a favorable environment 4. High-level wellness in a favorable environment Answer: 4 Explanation: Dunn describes a health grid in which a health axis and an environmental axis intersect. The intersection of the two axes forms four quadrants of health and wellness. Highlevel wellness in a favorable environment involves biopsychosocial, spiritual, and economic resources that support healthy lifestyles. Page Ref: 359 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Identify variables affecting health status, beliefs, and practices. MNL Learning Outcome: 2. Recognize the variables and dimensions that influence an individual's health and wellness and how nurses can influence behavior.
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5) The nurse has volunteered to go on a health mission to rural Haiti, where the majority of the people do not have access to healthcare and live in poverty. According to Dunn's high-level wellness grid, the nurse will be working with clients in which quadrant? 1. Emergent high-level wellness in an unfavorable environment 2. Protected poor health in a favorable environment 3. Poor health in an unfavorable environment 4. Protected poor health in an unfavorable environment Answer: 3 Explanation: According to Dunn's grid, the health axis extends from peak wellness to death, and the environmental axis extends from very favorable to very unfavorable. A health mission to an environment such as rural Haiti would involve clients who are not being treated for problems because of poor access and who also live in poor environmental conditions such as poverty and below-standard sanitation. Page Ref: 359 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 4. Identify variables affecting health status, beliefs, and practices. MNL Learning Outcome: 2. Recognize the variables and dimensions that influence an individual's health and wellness and how nurses can influence behavior. 6) The nurse educator is reviewing internal variables that affect people's health status. On which variables is this nurse focusing? (Select all that apply.) 1. Genetic makeup 2. Age 3. Developmental level 4. Environment 5. Spiritual and religious beliefs Answer: 1, 2, 3, 5 Page Ref: 360-361 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Identify variables affecting health status, beliefs, and practices. MNL Learning Outcome: 2. Recognize the variables and dimensions that influence an individual's health and wellness and how nurses can influence behavior. 4
7) An occupational health nurse is surveying employees. Which employee should the nurse identify as being predisposed to an illness? 1. An employee who is in a middle-management position and takes stress from administration as well as the employees 2. An employee who works in the janitorial department 3. An employee who works 12-hour days, 3 days a week 4. An employee who works 4 days on and 3 days off Answer: 1 Explanation: People who hold management positions are in stressful occupational roles that predispose them to stress-related diseases. Page Ref: 362 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Identify variables affecting health status, beliefs, and practices. MNL Learning Outcome: 2. Recognize the variables and dimensions that influence an individual's health and wellness and how nurses can influence behavior. 8) The community health nurse is testing the theory of locus of control (LOC). Which client demonstrates the internal control concept of this theory? 1. A client who takes an active role in all health decisions 2. A client who allows the primary care provider to make all the decisions 3. A client who does not make any decisions without his or her spouse's input 4. A client who relies on information from the local hospital for his or her health needs Answer: 1 Explanation: Locus of control (LOC) is a concept from social learning theory. People who exercise internal control are more likely than others to take the initiative on their own healthcare and to be more knowledgeable about their health. They are also more likely to adhere to prescribed healthcare regimens such as taking medication, making and keeping appointments with physicians, maintaining diets, and giving up smoking. Page Ref: 362-363 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Identify variables affecting health status, beliefs, and practices. MNL Learning Outcome: 2. Recognize the variables and dimensions that influence an individual's health and wellness and how nurses can influence behavior. 5
9) The nurse case manager is concerned about a particular client being discharged from the hospital. Which factors should alert the nurse to possible problems with this client's adherence to treatment? 1. The prescribed therapy is costly and of unknown duration. 2. The therapy will require no lifestyle changes of the client. 3. The client has not had difficulty understanding the regimen. 4. The client's culture is supportive of Western medicine. Answer: 1 Explanation: Adherence to a particular therapy can be compromised if the therapy is expensive or if the duration of the proposed therapy is long. Page Ref: 364 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Describe factors affecting healthcare adherence. MNL Learning Outcome: 3. Examine health belief models and how the nurse can influence healthcare adherence.
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10) During a home visit with a new community member, the nurse suspects that a client has a chronic illness. What did the nurse assess to make this clinical decision? (Select all that apply.) 1. Experienced symptoms for 8 months 2. Has periods where the symptoms disappear 3. Altered activities of daily living because of the illness 4. Problem disappeared with over-the-counter medication 5. Symptoms appeared abruptly and disappeared after treatment Answer: 1, 2, 3 Explanation: A chronic illness is one that lasts for an extended period, usually 6 months or longer, and often for the person's life. Chronic illnesses usually have a slow onset and often have periods of remission, when the symptoms disappear. With chronic illnesses clients often need to modify activities of daily living. Page Ref: 365 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 6. Differentiate illness from disease and acute illness from chronic illness. MNL Learning Outcome: 4. Examine illness behavior and how nurses' can affect the impact of illness on the patient and family. 11) The nurse determines that an older client is in the medical care contact stage of an illness. What did the client demonstrate to cause the nurse to make this decision? (Select all that apply.) 1. The client asked if the illness can be treated or recovery is possible. 2. The client asked if the symptoms experienced are a part of an illness. 3. The client asked if the symptoms can be explained in plain language. 4. The client stated that the illness is not acceptable and wants a second opinion. 5. The client stated that treatment is accepted and will be completed as identified. Answer: 1, 2, 3, 4 Page Ref: 366-367 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 8. Explain Suchman's stages of illness. MNL Learning Outcome: 4. Examine illness behavior and how nurses' can affect the impact of illness on the patient and family. 7
12) A client describes self as being healthy despite having several chronic illnesses. In which way should the nurse interpret the client's statement about health? 1. The client is in denial 2. The client is delusional 3. The client has a different perception of health 4. The client has no idea of the extent of the illnesses Answer: 3 Explanation: Health is a highly individual perception. The client who views personal self as healthy has a different perception of health. There is no evidence that the client is in denial, is delusional, or has not idea of the extent of the chronic illnesses. Page Ref: 357 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1. Identify influences on clients' definitions of health, wellness, and wellbeing. MNL Learning Outcome: 1. Examine the concepts of health, wellness, and well-being.
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13) The nurse is preparing a teaching tool about population health. Which should the nurse include as upstream determinants of health? (Select all that apply.) 1. Culture 2. Biology 3. Housing 4. Education 5. Government policies Answer: 1, 3, 4, 5 Explanation: Upstream determinants refer to macro-level factors such as culture, housing, education, and government policies. Upstream determinants refer to macro-level factors such as housing. Upstream determinants refer to macro-level factors such as education. Upstream determinants refer to macro-level factors such as government policies. Page Ref: 358 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching and Learning Learning Outcome: 1. Identify influences on clients' definitions of health, wellness, and wellbeing. MNL Learning Outcome: 1. Examine the concepts of health, wellness, and well-being.
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14) A client has not been adhering to a previously agreed-upon plan to improve health. Which action should the nurse take? (Select all that apply.) 1. Reinforce teaching 2. Demonstrate caring 3. Provide positive reinforcement 4. Report to the healthcare provider 5. Establish a therapeutic relationship Answer: 1, 2, 3, 5 Explanation: Steps to take when nonadherence is identified includes reinforcing teaching. Steps to take when nonadherence is identified includes demonstrating caring. Steps to take when nonadherence is identified includes providing positive reinforcement, and establishing a therapeutic relationship. Steps to take when nonadherence is identified includes establishing a therapeutic relationship. Page Ref: 364 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Describe factors affecting healthcare adherence. MNL Learning Outcome: 3. Examine health belief models and how the nurse can influence healthcare adherence.
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15) A client with a chronic illness is experiencing an exacerbation. Which should the nurse expect to assess? 1. Reduction in symptoms 2. Abrupt onset of symptoms 3. Reappearance of symptoms 4. Elimination of symptoms without treatment Answer: 3 Explanation: The reappearance of symptoms in a chronic illness is termed an exacerbation. A reduction in symptoms occurs in remission. An abrupt onset of symptoms and elimination of symptoms without treatment are characteristics of an acute illness. Page Ref: 365 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 6. Differentiate illness from disease and acute illness from chronic illness. MNL Learning Outcome: 4. Examine illness behavior and how nurses' can affect the impact of illness on the patient and family. 16) A client is seeking medical attention for an acute illness. Which right does the client have when assuming the sick role? 1. The client must seek competent help. 2. The client believes something is wrong. 3. The client has to get well as soon as possible. 4. The client is not responsible for the health problem. Answer: 4 Explanation: One client right of the sick role is the client is not responsible for the health problem. The client seeking competent help and getting well as soon as possible are obligations of the sick role. Believing that something is wrong is a characteristic of the first stage of illness. Page Ref: 366 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Identify Parsons's four aspects of the sick role. MNL Learning Outcome: 4. Examine illness behavior and how nurses' can affect the impact of illness on the patient and family.
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17) The nurse visits the home of a client with an acute illness. Which observation indicates to the nurse that the client is exercising a right of the sick role? 1. Client lying in bed 2. Client asks if recovery will occur 3. Client taking prescribed medication 4. Spouse preparing dinner for the family Answer: 4 Explanation: One right of the sick role is being excused from social roles such as preparing meals. Lying in bed and taking medication are obligations to get well as soon as possible. Asking if recovery will occur is a characteristic of stage 3 of an illness. Page Ref: 366 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 7. Identify Parsons's four aspects of the sick role. MNL Learning Outcome: 4. Examine illness behavior and how nurses' can affect the impact of illness on the patient and family. 18) A client with an acute illness is observed washing dishes and making the bed. Which stage of the illness is this client demonstrating? 1. Recovery 2. Medical care contact 3. Symptom experience 4. Dependent client role Answer: 1 Explanation: In the stage of recovery, the client resumes former roles and responsibilities. The client seeks medical attention during the medical care contact stage. Symptoms of the illness occur during the stage of symptom experience. Being dependent upon professional help occurs during the dependent client role stage. Page Ref: 366 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8. Explain Suchman's stages of illness. MNL Learning Outcome: 4. Examine illness behavior and how nurses' can affect the impact of illness on the patient and family. 12
19) A client is having difficulty accepting physical limitations because of an illness. Which action should the nurse take to help the client? (Select all that apply.) 1. Reinforce desirable changes 2. Explain the necessary adjustments 3. Discuss characteristics of the sick role 4. Support healthy aspects of the client's lifestyle 5. Make accommodations for the client's lifestyle Answer: 1, 2, 4, 5 Explanation: Nurses can help clients adjust to an illness by reinforcing desirable changes. Nurses can help clients adjust to an illness by explaining necessary adjustments. Nurses can help clients adjust to an illness by supporting healthy aspects of the client's lifestyle. Nurses can help clients adjust to an illness by making accommodations for the client's lifestyle. Page Ref: 367 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Describe the effects of illness on clients' and family members' roles and functions. MNL Learning Outcome: 4. Examine illness behavior and how nurses' can affect the impact of illness on the patient and family.
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20) The nurse visits the home of a client with a chronic illness. For which factor should the nurse assess to determine the impact of the client's illness on the family? (Select all that apply.) 1. Seriousness of the illness 2. Length of time of the illness 3. Change in the client's lifestyle 4. Cultural customs of the family 5. Member of the family who is ill Answer: 1, 2, 4, 5 Explanation: The extent of an illness on the family depends upon the seriousness of the illness. The extent of an illness on the family depends upon the length of time of the illness, cultural customs of the family, and the member of the family who is ill. The extent of an illness on the family depends upon the cultural customs of the family. The extent of an illness on the family depends upon the member of the family who is ill. Page Ref: 367 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9. Describe the effects of illness on clients' and family members' roles and functions. MNL Learning Outcome: 4. Examine illness behavior and how nurses' can affect the impact of illness on the patient and family.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 21 Culturally Responsive Nursing Care 1) A community health nurse is learning about the REACH initiative and has decided to implement community education on this approach. What topics should the nurse include in this education? (Select all that apply.) 1. Child and adult immunizations 2. Cardiovascular disease 3. Chronic lower respiratory disease 4. Stroke 5. Infant mortality Answer: 1, 2, 5 Explanation: Racial and Ethnic Approaches to Community Health is an initiative of the Centers for Disease Control and Prevention. Topics within the REACH initiative include child and adult immunizations. Racial and Ethnic Approaches to Community Health is an initiative of the Centers for Disease Control and Prevention. Topics within the REACH initiative include cardiovascular diseases, and infant mortality. Page Ref: 375 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Planning/Teaching and Learning Learning Outcome: 3. Describe the role of federal agencies and initiatives regarding the provision of culturally responsive healthcare. MNL Learning Outcome: 2. Examine issues of immigration and cultural models of health care.
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2) The nurse works in a hospital located in a culturally diverse area of the city. In striving to be culturally sensitive, what should the nurse do? 1. Try to learn about the attitudes toward healthcare and traditions of the different cultures in that area. 2. Understand and attend to the total context of the client's situation, using knowledge, attitudes, and skills. 3. Possess the underlying background knowledge that will provide these clients with the best possible healthcare. 4. Continuously strive to be culturally competent. Answer: 1 Explanation: Cultural sensitivity implies that nurses possess some basic knowledge of and constructive attitudes toward the health traditions observed among the diverse cultural groups found in the setting in which they are practicing. Page Ref: 386 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Implementation Learning Outcome: 6. Differentiate culturally influenced approaches to healing and treatment. MNL Learning Outcome: 4. Utilize the nursing process in the provision of culturally competent care to patients.
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3) A client with an African American father and Asian American mother has been exposed to cultural foods, traditions, and customs from both parents throughout life. What term should the nurse use to describe this client's cultural development? 1. Diversity 2. Subculture 3. Multicultural 4. Cultural sensitivity Answer: 3 Explanation: Multicultural is used to describe a person who has multiple patterns of identification or crosses several cultures, lifestyles, and sets of values. Page Ref: 372 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Describe concepts related to culture such as race, ethnicity, and acculturation. MNL Learning Outcome: 1. Examine the concept of culture, health disparities, and demographics. 4) The nurse notes that a client born in a different country has adopted aspects of a spouse who was born in the United States. Which process should the nurse identify as occurring with the client? 1. Acculturation 2. Assimilation 3. Diversity 4. Heritage consistency Answer: 2 Explanation: Assimilation is the process by which an individual develops a new cultural identity. It encompasses various aspects such as behavior, marital roles, identification, and civic duties. The underlying assumption is that the person from a given cultural group loses his or her original cultural identity to acquire the new one. Page Ref: 375 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Describe concepts related to culture such as race, ethnicity, and acculturation. MNL Learning Outcome: 1. Examine the concept of culture, health disparities, and demographics. 3
5) The nurse manager is concerned that a staff nurse provides client care with a cultural prejudice. Which situation did the manager observe to come to this conclusion? 1. Making an assumption that all members of each culture are alike 2. Believing that all culture members will have the same beliefs 3. Bringing previous negative information and experiences into this situation 4. Taking general knowledge from literature and applying it to the situation Answer: 3 Explanation: Prejudice is a negative belief or preference that is generalized about a group, which leads to "prejudgment." Prejudice occurs when the person making the judgment generalizes an experience of one individual from a culture to all members of that group. Page Ref: 373 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Evaluation Learning Outcome: 1. Describe concepts related to culture such as race, ethnicity, and acculturation. MNL Learning Outcome: 1. Examine the concept of culture, health disparities, and demographics. 6) The nurse from a rural community accepts a position at a large, urban, multi-cultural urban healthcare organization. What might be this nurse's greatest challenge? 1. Prejudice 2. Stereotyping 3. Discrimination 4. Assimilation Answer: 4 Explanation: Assimilation is the process by which an individual develops a new cultural identity. Assimilation means becoming like the members of the dominant culture. Because this is a conscious effort, it is not always possible, and the process may cause severe stress and anxiety. Page Ref: 375 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Assessment Learning Outcome: 8. Create self-awareness of your own culture, beliefs, biases, and assumptions. MNL Learning Outcome: 3. Consider the factors involved in providing culturally responsive care. 4
7) A client requests a special item present in the room because it provides a feeling of comfort and a sense of organization. On which psychosocial component is this client focusing? 1. Culture 2. Religion 3. Ethnicity 4. Socialization Answer: 2 Explanation: Religion may be defined by a system of beliefs, practices, and ethical values about divine or superhuman power and is closely related to ethnicity. Religion gives a person a frame of reference and a perspective with which to organize information. Page Ref: 373 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Describe concepts related to culture such as race, ethnicity, and acculturation. MNL Learning Outcome: 1. Examine the concept of culture, health disparities, and demographics. 8) A client requests to have a spiritual leader present to pray before a surgical procedure. According to the HEALTH traditions model, which traditional method is the client invoking? 1. Maintaining HEALTH 2. Protecting HEALTH 3. Restoring HEALTH 4. Changing HEALTH Answer: 3 Explanation: Traditional methods of restoring HEALTH–physical, mental, and spiritual–include the use of herbal remedies, exorcism, and health rituals. This situation describes a healing ritual. Page Ref: 377 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Describe health views from culturally diverse perspectives. MNL Learning Outcome: 2. Examine issues of immigration and cultural models of health care.
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9) A client says, "I must be paying for all the wrongs I did in my life, to have such a diagnosis as this." The nurse suspects that this client views health from which type of belief? 1. Magico-religious belief 2. Holistic health belief 3. Biomedical health belief 4. Folk medicine Answer: 1 Explanation: In the magico-religious health belief view, health and illness are controlled by supernatural forces. The client may believe that illness is the result of "being bad" or opposing God's will. Page Ref: 378 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Describe health views from culturally diverse perspectives. MNL Learning Outcome: 2. Examine issues of immigration and cultural models of health care. 10) A client of Chinese descent is hospitalized with a fever of unknown origin and follows a very traditional, cultural view of illness. Which food should the nurse offer the client? 1. Hot tea 2. Warm soup 3. Spicy meat 4. Cold liquids Answer: 4 Explanation: The concept of yin and yang in the Chinese culture is an example of a holistic health belief. A Chinese client who has a yang illness, or a "hot" illness, may prefer a yin or "cold" treatment. In this case, the fever would be considered a "hot" illness and the client may prefer the opposite or yin treatment. Page Ref: 379 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Assessment Learning Outcome: 6. Differentiate culturally influenced approaches to healing and treatment. MNL Learning Outcome: 2. Examine issues of immigration and cultural models of health care.
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11) The nurse works with a variety of cultures providing healthcare services that include preventive care, acute treatment, and education. Of the following clients, which is most likely to use folk medicine? 1. The client who speaks little English and recently immigrated 2. A bilingual family with numerous relatives in the area 3. A female client whose culture is one of male dominance 4. A Chinese client who has a small, family-run business in the area Answer: 1 Explanation: Folk medicine is defined as beliefs and practices that relate illness prevention and healing to cultural traditions rather than modern medicine's scientific base. A recent immigrant who speaks little English is more likely to engage in heritage-consistent behavior. Because folk healing is more culturally based, it may be more comfortable and less frightening for the client who is not fluent in the English language and only recently arrived in the United States. Page Ref: 379 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Assessment Learning Outcome: 6. Differentiate culturally influenced approaches to healing and treatment. MNL Learning Outcome: 3. Consider the factors involved in providing culturally responsive care.
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12) A female client from a male-dominated culture is being discharged. Before discharge instructions are given, which action should the nurse take? 1. Make sure instructions are understood by the client. 2. Arrange for teaching when the spouse is available. 3. Make sure that the physician gives the instructions. 4. Ask the client when the best time for teaching would be. Answer: 2 Explanation: The nurse needs to identify who has the "authority" to make decisions in a client's family. If the decision maker is someone other than the client, as in this situation, the nurse needs to include that person in healthcare discussions. In this situation, the best answer with the information available is to arrange for teaching when the spouse is present. Page Ref: 379 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 6. Differentiate culturally influenced approaches to healing and treatment. MNL Learning Outcome: 3. Consider the factors involved in providing culturally responsive care.
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13) A newly immigrated client who is constantly attended to by family members is causing a problem with the nursing staff and the delivery of nursing care. In order to address this issue in a culturally sensitive manner, the nurse should take which action? 1. Explain to the client that he has to limit visitors. 2. Evaluate the benefits of family participation in the client's care. 3. Question the family members as to how they see their interaction with the client. 4. Have the physician limit the number of visitors the client can have. Answer: 2 Explanation: Cultural family values may dictate the extent of the family's involvement in the hospitalized client's care. In some cultures, the entire community may want to visit and participate in the client's care. The nurse should evaluate the positive benefits of family participation in the client's care and modify visiting policies as appropriate. Page Ref: 380 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Implementation Learning Outcome: 6. Differentiate culturally influenced approaches to healing and treatment. MNL Learning Outcome: 3. Consider the factors involved in providing culturally responsive care.
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14) The nurse is planning to conduct a physical assessment with a client from a different culture. What is the best way for the nurse to show cultural sensitivity when addressing the personal questions required of the nursing history? 1. Break the assessment into shorter intervals and discuss general topics first. 2. Thoroughly explain the reason for asking many questions before beginning the assessment. 3. Pick a time when the family is present and can help with the admission assessment questions. 4. Wait until the nurse—client relationship has been established. Answer: 1 Explanation: Clients may be offended when the nurse immediately asks personal questions. In some cultures, courtesies should be established before business or personal topics are discussed. Discussing general topics can convey that the nurse is interested and has time for the client. This enables the nurse to develop a rapport with the client before progressing to discussion that is more personal. Page Ref: 380 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Implementation Learning Outcome: 9. Identify methods of cultural assessment. MNL Learning Outcome: 4. Utilize the nursing process in the provision of culturally competent care to patients.
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15) A client who does not speak English is learning about an emergency surgical procedure through an interpreter. In which way should the nurse support this process? 1. Asking the interpreter to use words the client is familiar with for the best understanding. 2. Requesting that the interpreter translate, as closely as possible, the same words used by the professional staff. 3. Suggesting that the questions be directed to the interpreter, so nothing is omitted. 4. Addressing the questions to the client's family. Answer: 2 Explanation: An interpreter is an individual who mediates spoken or signed communication between people using different languages without adding, omitting, or distorting meaning or editorializing. The objective of the professional interpreter is for the complete transfer of the thought behind the utterance in one language into an utterance in a second language. Page Ref: 381 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Describe ways culture influences communication patterns and how to provide linguistically appropriate care. MNL Learning Outcome: 4. Utilize the nursing process in the provision of culturally competent care to patients.
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16) During the admission interview, a culturally diverse client averts the eyes and refrains from answering questions for long periods of time. Which action should the nurse take to demonstrate cultural sensitivity? 1. Come back at a different time, when the client is feeling more communicative. 2. Have another nurse finish the interview, as there is something uncomfortable the client senses. 3. Understand that this may be completely appropriate and take cues accordingly. 4. Leave the room and come back after having learned more about this particular culture. Answer: 3 Explanation: Nonverbal communication includes silence, touch, eye movement, facial expressions, and body posture. Some cultures are quite comfortable with long periods of silence. Many people value silence and view it as essential to understanding a person's needs or use silence to preserve privacy. Before assigning meaning to nonverbal behavior, the nurse must consider the possibility that the behavior may have a different meaning for the client and family. Page Ref: 382 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Describe ways culture influences communication patterns and how to provide linguistically appropriate care. MNL Learning Outcome: 3. Consider the factors involved in providing culturally responsive care.
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17) The school nurse is conducting head lice screenings. Before checking the head of a child of Asian heritage, the nurse should first take which action? 1. Ask permission. 2. Make sure the child understands the reason for the contact. 3. Put gloves on. 4. Ask the child to wait until last, to avoid embarrassing the child. Answer: 1 Explanation: In some Asian cultures, only certain elders are permitted to touch the head of others, and children are never patted on the head. Nurses should, therefore, touch a client's head only with permission. Page Ref: 382 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Implementation Learning Outcome: 6. Differentiate culturally influenced approaches to healing and treatment. MNL Learning Outcome: 3. Consider the factors involved in providing culturally responsive care. 18) The nurse needs to determine the apical pulse of a client from a different culture. In order to show appropriate sensitivity to the client, the nurse should take which action? 1. Explain the procedure, then wait for permission to continue. 2. Explain to the client what will occur during the assessment. 3. Ask the client to stay quiet because the nurse will be listening to the heart. 4. Take the baseline vital signs, then determine if cardiac auscultation is necessary. Answer: 1 Explanation: Cardiac assessment requires that the nurse move into the client's intimate space. Before beginning this, the nurse should explain the procedure and then await permission to continue. Page Ref: 382 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Implementation Learning Outcome: 6. Differentiate culturally influenced approaches to healing and treatment. MNL Learning Outcome: 3. Consider the factors involved in providing culturally responsive care.
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19) The nurse is teaching a client from a culture that is "present oriented" about a dressing change that should be performed twice a day. How should the nurse address the cultural issue? 1. Allow the client to select the times the dressing will be changed. 2. Instruct the client to change the dressing after breakfast and before going to bed. 3. Explain that the client should complete the dressing change at 10:00 AM and 4:00 PM. 4. Suggest that the dressing change can be performed whenever the client chooses, as long as it gets done twice daily. Answer: 2 Explanation: For clients who are "present oriented," it is important to avoid fixed schedules. The nurse can offer a time range for activities and treatments, such as in the morning or after breakfast, and in the evening or before going to bed. This would fit better with the client who isn't focused on times of the day, such as 10:00 AM and 4:00 PM, but will provide for a dressing change twice daily. Page Ref: 383 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 6. Differentiate culturally influenced approaches to healing and treatment. MNL Learning Outcome: 3. Consider the factors involved in providing culturally responsive care.
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20) The nurse is preparing a menu for a Jewish client who observes kosher customs. Which food items would be appropriate to serve this client, assuming all have been properly inspected and prepared? 1. Hamburger, fruit, and milk 2. Fish, vegetables, and hot tea 3. Ham, baked potato, and fresh fruit 4. Cream soup, sausage, and toast Answer: 2 Explanation: This menu is in accordance with the kosher tradition because there is no pork being served and dairy and meat are not served together. Page Ref: 383 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Implementation Learning Outcome: 6. Differentiate culturally influenced approaches to healing and treatment. MNL Learning Outcome: 3. Consider the factors involved in providing culturally responsive care. 21) The nurse is working in a clinic setting and is meeting a new client for the first time. In order to convey cultural sensitivity, how should the nurse introduce herself? 1. "I'm Jane, and I'll be your nurse today." 2. "I'm Dr. Smith's nurse, Jane." 3. "I'm Jane Brown, and I'm a nurse here at the clinic." 4. "I'm glad to meet you. You can call me Jane." Answer: 3 Explanation: Ways for nurses to be culturally sensitive and to convey sensitivity to clients include introducing themselves by full name, then explaining their role. This helps establish a relationship and provides an opportunity for clients, others, and nurses to learn the pronunciation of one another's names and their roles. Page Ref: 384 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Describe ways culture influences communication patterns and how to provide linguistically appropriate care. MNL Learning Outcome: 4. Utilize the nursing process in the provision of culturally competent care to patients. 15
22) A home health client participates in cultural health practices that may be harmful. In order to remain attentive to cultural sensitivity and provide appropriate cultural nursing care, the nurse should take which action? 1. Explain the right and wrong of the client's treatment and encourage to follow the scientific perspective. 2. Have the client's physician explain the care to the client in a firm but gentle manner. 3. Validate the client's practices and understand that for this client, it may be beneficial to continue with the client's preferences. 4. Try to negotiate with the client by exploring views and then provide relevant scientific information. Answer: 4 Explanation: Negotiation acknowledges that the nurse—client relationship is reciprocal and that different views exist of health, illness, and treatment. During the negotiation process, the client's views are explored and acknowledged, then relevant scientific information is provided. Page Ref: 386 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Implementation Learning Outcome: 10. Create a culturally responsive nursing care plan. MNL Learning Outcome: 4. Utilize the nursing process in the provision of culturally competent care to patients.
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23) A client who is from a different culture than the nurse has not been able to achieve this goal: Client will select low-fat foods from a list by the end of the month. What should the nurse do? 1. Consider whether the client's belief system has been an influencing factor. 2. Extend the time frame and give the client a longer period to achieve the goal. 3. Make sure that the client understands the importance of the goal. 4. Select a different goal. Answer: 1 Explanation: If the outcomes are not achieved for a client from a different culture, the nurse should be especially careful to consider whether the client's belief system has been adequately included as an influencing factor. Page Ref: 388 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Evaluation Learning Outcome: 10. Create a culturally responsive nursing care plan. MNL Learning Outcome: 4. Utilize the nursing process in the provision of culturally competent care to patients. 24) The nurse follows Madeleine Leininger's model when providing client care. What type of nursing is being practiced? 1. Transcultural nursing 2. Cultural competence 3. Cultural knowledge 4. Competent nursing Answer: 1 Explanation: Transcultural nursing focuses on providing care within the differences and similarities of the beliefs, values, and patterns of cultures. Page Ref: 376 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Implementation Learning Outcome: 4. Describe cultural models of care, such as cultural competency. MNL Learning Outcome: 2. Examine issues of immigration and cultural models of health care.
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25) The community health nurse is using the Heritage Assessment Interview tool with a group of community members. Which data indicate heritage consistency? (Select all that apply.) 1. A client frequently visits the "old country neighborhood" he grew up in. 2. A client is raised by a single parent. 3. The client's education occurred at a religious school. 4. The client participates in religious festivals and cultural events. 5. The client has been the first in the family to earn a college degree. Answer: 1, 3, 4 Explanation: The tool is designed to enhance the process of determining whether clients are identifying with their traditional cultural heritage (heritage consistent), such as by visiting an ethnic neighborhood, attending a religiously affiliated school, and attending and participating in religious and cultural events. Page Ref: 385 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Assessment Learning Outcome: 9. Identify methods of cultural assessment. MNL Learning Outcome: 4. Utilize the nursing process in the provision of culturally competent care to patients.
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26) The nurse is planning to provide culturally responsive care to a client and family from a different culture. What actions should the nurse perform when providing this care? (Select all that apply.) 1. Personally reflecting on feelings related to the client's nationality 2. Making an effort to direct all assessment questions initially to the client 3. Involving the family with the client's permission 4. Assessing the client's interest in alternative healing methods 5. Educating the client and family when appropriate Answer: 1, 3, 4, 5 Explanation: Culturally responsive care that involves family appropriately includes selfreflection to identify personal assumptions, biases, attitudes, prejudices, and stereotypes. Culturally responsive care that involves family appropriately includes explaining in detail the client's condition and the treatment plan with the family if the client is willing for the nurse to do so. Culturally responsive care that involves family appropriately includes asking about the client's use of cultural or alternative approaches to healing. Culturally responsive care that involves family appropriately includes explaining in detail the client's condition and treatment plan with the family if the client is willing for the nurse to do so. Page Ref: 384 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Implementation Learning Outcome: 9. Identify methods of cultural assessment. MNL Learning Outcome: 4. Utilize the nursing process in the provision of culturally competent care to patients.
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27) The nurse is planning to explain the importance of culturally appropriate care to a new nursing assistant. What should the nurse include when explaining the term "culture" to this staff person? (Select all that apply.) 1. "Culture involves groups who share biological markers." 2. "Cultures seldom have diversity within them." 3. "Male nurses are an example of a culture." 4. "A culture is primarily exhibited through shared thoughts, actions, and beliefs." 5. "A culture shapes its members' view of the world." Answer: 4, 5 Explanation: Culture is the thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups. Macro- and microcultures combine to shape the individual's worldview and influence interaction with the others. Page Ref: 372 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Describe concepts related to culture such as race, ethnicity, and acculturation. MNL Learning Outcome: 1. Examine the concept of culture, health disparities, and demographics.
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28) After an assessment, the nurse determines that an African American client is experiencing disparities that are a part of behavioral health determinants. What assessment data did the nurse use to come to this conclusion? (Select all that apply.) 1. Treated for asthma 2. Body mass index of 32 3. Unemployed for 9 months 4. Smokes 1 ppd of cigarettes 5. Mother diagnosed with heart disease Answer: 2, 4 Explanation: Behavioral determinants of health include obesity. Behavioral determinants of health include use of drugs, tobacco, or alcohol. Page Ref: 374 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Examine factors that contribute to health disparities among racial and ethnic groups. MNL Learning Outcome: 1. Examine the concept of culture, health disparities, and demographics.
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29) The nurse is concerned that many ethnically diverse clients are not receiving a consistently high level of healthcare within a community. What information should the nurse access to learn how to improve these clients' level of healthcare? (Select all that apply.) 1. The National Partnership for Action to End Health Disparities website 2. The National Stakeholder Strategy for Achieving Health Equity goals 3. The Office of Minority Health's standards for cultural and linguistic programs 4. The National Center on Minority Health and Health Disparities mission statement 5. The Centers for Disease Control and Prevention website for employment opportunities Answer: 1, 2, 3, 4 Explanation: The National Partnership for Action to End Health Disparities (NPA) was established to mobilize a nationwide, comprehensive, community-driven, and sustained approach to combating health disparities and to move the nation toward achieving health equity. The mission of the NPA is to increase the effectiveness of programs that target the elimination of health disparities through the coordination of partners, leaders, and stakeholders committed to action. The NPA released the National Stakeholder Strategy for Achieving Health Equity in 2011, a common set of goals and objectives for public- and private-sector initiatives and partnerships to help people and communities of color and other underserved groups reach their full health potential. The Office of Minority Health, in collaboration with other organizations, developed the National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS). These CLAS Standards are intended to advance health equity, improve quality, and help eliminate healthcare disparities by establishing a blueprint for health and healthcare organizations to provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs. The mission of the National Center on Minority Health and Health Disparities (NCMHD), within the National Institutes of Health (NIH), is also to improve minority health and eliminate health disparities for people and communities of color. It plans, reviews, coordinates, evaluates, translates, and disseminates all minority health and health disparities research and activities of the National Institutes of Health. Page Ref: 374 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Examine factors that contribute to health disparities among racial and ethnic groups. MNL Learning Outcome: 1. Examine the concept of culture, health disparities, and demographics.
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30) The nurse is reviewing federal initiatives to improve the profession of nursing. Which agency is responsible for providing grants and scholarships to increase the number of underrepresented racial and ethnic groups in nursing? 1. CDC Office of Minority Health 2. Office of Minority Health (OMH) 3. U.S. Department of Health and Human Services. 4. Health Resources and Services Administration (HRSA) Answer: 4 Explanation: HRSA aims to increase the number of underrepresented racial and ethnic groups entering the nursing profession through grants and scholarships. This is not an action by the other agencies identified. Page Ref: 375 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Describe the role of federal agencies and initiatives regarding the provision of culturally responsive healthcare. MNL Learning Outcome: 2. Examine issues of immigration and cultural models of health care. 31) The nurse is conducting a wellness visit with a client. Which physical actions does the nurse identify that the client uses to maintain health? (Select all that apply.) 1. Engages in exercise 2. Wears proper clothing 3. Follows an adequate diet 4. Engages in woodworking 5. Sleeps 7 to 8 hours a night Answer: 1, 2, 3, 5 Explanation: Exercising, wearing proper clothing, following an adequate diet and getting adequate sleep are physical actions to maintain health. Wearing proper clothing is a physical action to maintain health. Following an adequate diet is a physical action to maintain health. Adequate sleep is a physical action to maintain health. Page Ref: 377 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Describe cultural models of care, such as cultural competency. MNL Learning Outcome: 2. Examine issues of immigration and cultural models of health care. 23
32) The nurse manager overhears staff refusing to care for a client from a non-English- speaking culture because the client finds fault with every intervention. Which action should the manager take? 1. Ask if family can provide the care 2. Discuss the cultural differences with the staff 3. Ask the healthcare provider to discharge the client 4. Suggest the client be transferred to another care area Answer: 2 Explanation: Approaches when caring for clients from a different culture should be discussed with the staff. The family should not be asked to provide the care. The client should not be discharged until medically stable. The client should not be transferred because of cultural differences. Page Ref: 384-385 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Implementation Learning Outcome: 8. Create self-awareness of your own culture, beliefs, biases, and assumptions. MNL Learning Outcome: 3. Consider the factors involved in providing culturally responsive care.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 22 Complementary and Alternative Healing Modalities 1) A client receiving hospice care is encouraged to focus on self-worth, accomplishments, and having positive self-esteem in order to process end-of-life decisions. In which component is the nurse helping the client achieve balance? 1. Environmental 2. Physical 3. Mental 4. Spiritual Answer: 3 Explanation: Mental aspects include feelings of self-worth, a positive identity, a sense of accomplishment, and the ability to appreciate and create. In terms of optimal wellness, balance consists of mental, physical, emotional, spiritual, and environmental components. Each component needs to be balanced, and a sense of equality among the components is needed. Page Ref: 394 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in healthcare | NLN Competencies: Knowledge and Science; Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation Learning Outcome: 2. Give examples of healing environments. MNL Learning Outcome: 1. Examine the basic concepts common to most alternative practices and systematic healthcare practices.
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2) A client states that life has no meaning or purpose anymore and feels lonely and abandoned. On which dimension should the nurse focus when providing care to this client? 1. Holism 2. Humanism 3. Spirituality 4. Energy Answer: 3 Explanation: Spirituality is that which gives people meaning and purpose in their lives. It involves finding significant meaning in the entirety of life, including illness and death. The feelings the client expresses have little to do with holism, humanism, or energy. Page Ref: 394 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in healthcare | NLN Competencies: Knowledge and Science; Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Planning Learning Outcome: 1. Describe the basic concepts of alternative practices. MNL Learning Outcome: 1. Examine the basic concepts common to most alternative practices and systematic healthcare practices. 3) The nurse is caring for a client who expresses feelings of groundedness. In which way should this statement be interpreted? 1. Full of energy 2. Feels connected to reality 3. Focused on center of energy 4. Feels "down in the dumps" Answer: 2 Explanation: Grounding relates to one's connection with reality. Being grounded suggests stability, security, independence, having a solid foundation, and living in the present. Page Ref: 394 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in healthcare | NLN Competencies: Knowledge and Science; Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Give examples of healing environments. MNL Learning Outcome: 2. Examine the basic botanical healing and nutritional approaches used in complementary and alternative healing.
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4) After agreeing to work another overtime shift, the nurse begins to feel overwhelmed and irritable. As a method to most effectively promote self-healing, what should this nurse do? 1. Clarify values and beliefs. 2. Set realistic goals. 3. Learn to manage stress. 4. Challenge the belief that others always come first. Answer: 4 Explanation: Overwork and overinvolvement leave little time for fulfillment of personal needs. Nurses need to learn to ask for what they need and avoid feelings of selfishness when not responding to someone else's needs. Page Ref: 394 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in healthcare | NLN Competencies: Knowledge and Science; Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Planning Learning Outcome: 2. Give examples of healing environments. MNL Learning Outcome: 2. Examine the basic botanical healing and nutritional approaches used in complementary and alternative healing.
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5) During an interview assessment, the client states a belief in nutritional lifestyle counseling and that the body's vital energy circulates through the body, which can be manipulated through specific anatomical points. Which type of healing practice should the nurse identify that this patient is following? 1. Traditional Chinese medicine 2. Native American healing 3. Ayurveda 4. Curanderismo Answer: 1 Explanation: Traditional Chinese medicine (TCM) is based on the premise that the body's vital energy or qi circulates through pathways and meridians and can be accessed and manipulated through specific anatomical points along the surface of the body. Practitioners use a variety of ancient methods, including acupuncture, acupressure, herbal medicine, massage, heat therapy, qigong, tai chi, and nutritional counseling. Page Ref: 395-396 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in healthcare | NLN Competencies: Knowledge and Science; Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Describe the basic principles of healthcare practices such as Ayurveda, traditional Chinese medicine, Native American healing, and curanderismo. MNL Learning Outcome: 2. Examine the basic botanical healing and nutritional approaches used in complementary and alternative healing.
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6) A client asks whether herbal medicines are a "good idea." What should the nurse respond? 1. "Things found in nature are always healthy." 2. "If your doctor didn't prescribe it, don't take it." 3. "Are there specific ones you're wondering about?" 4. "Everything is good in moderation." Answer: 3 Explanation: Not all plant life is beneficial. Nurses must be open to exploring and discussing their clients' uses of and questions regarding herbal medicine. There are cautions and contraindications with some herbal preparations and over-the-counter (OTC) as well as prescription drugs. The most important role the nurse plays in regard to herbal medicine is to find out what the client is taking and at what dosage, and have a full list of the client's prescription medications as well as anything taken that is OTC. Page Ref: 396 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in healthcare | NLN Competencies: Knowledge and Science; Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation Learning Outcome: 2. Give examples of healing environments. MNL Learning Outcome: 2. Examine the basic botanical healing and nutritional approaches used in complementary and alternative healing. 7) A client taking an oral contraceptive reports using some "natural medicines." Which herbal preparation should alert the nurse to a possible interaction with oral contraceptives? 1. Valerian 2. Echinacea 3. Garlic 4. Milk thistle Answer: 4 Explanation: Milk thistle reduces the effectiveness of oral contraceptives. Page Ref: 397 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in healthcare | NLN Competencies: Knowledge and Science; Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 10. Teach clients the uses and safety precautions regarding complementary and alternative therapies. MNL Learning Outcome: 2. Examine the basic botanical healing and nutritional approaches used in complementary and alternative healing.
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8) A client who has a long-standing history of depression has been on a prescribed antidepressant for several months and states trying St. John's wort. Which vital sign should the nurse assess for possible adverse effects? 1. Temperature 2. Respiratory rate 3. Oxygen saturation 4. Pulse rate Answer: 4 Explanation: St. John's wort may potentiate antidepressant medications, causing severe agitation, nausea, confusion, and possible cardiac problems. Page Ref: 397 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in healthcare | NLN Competencies: Knowledge and Science; Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 10. Teach clients the uses and safety precautions regarding complementary and alternative therapies. MNL Learning Outcome: 2. Examine the basic botanical healing and nutritional approaches used in complementary and alternative healing. 9) During a clinic appointment, a client prescribed medication for glaucoma reports vision problems. When taking a medication history, which herbal preparation should the nurse identify as being problematic for this client? 1. Ginseng 2. Echinacea 3. Valerian 4. St. John's wort Answer: 1 Explanation: Ginseng may interact with caffeine and cause irritability and may also decrease the effectiveness of glaucoma medication. Page Ref: 397 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in healthcare | NLN Competencies: Knowledge and Science; Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 10. Teach clients the uses and safety precautions regarding complementary and alternative therapies. MNL Learning Outcome: 2. Examine the basic botanical healing and nutritional approaches used in complementary and alternative healing.
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10) A client being treated for hypertension has a low blood pressure and reports using an herbal remedy. Which is most likely interfering with the client's antihypertensive? 1. Valerian 2. Milk thistle 3. Ginseng 4. Garlic Answer: 4 Explanation: Garlic reduces high blood pressure. Page Ref: 397 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in healthcare | NLN Competencies: Knowledge and Science; Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 10. Teach clients the uses and safety precautions regarding complementary and alternative therapies. MNL Learning Outcome: 2. Examine the basic botanical healing and nutritional approaches used in complementary and alternative healing. 11) The nurse is preparing to assess a group of assigned clients with chronic illnesses who use essential oils. For which health problem should the nurse particularly assess the clients? 1. Hypertension 2. Cardiac problems 3. Asthma 4. Cancer Answer: 3 Explanation: Some oils can trigger bronchial spasms, so persons with asthma should consult their primary healthcare provider before using oils. Page Ref: 397 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in healthcare | NLN Competencies: Knowledge and Science; Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 10. Teach clients the uses and safety precautions regarding complementary and alternative therapies. MNL Learning Outcome: 2. Examine the basic botanical healing and nutritional approaches used in complementary and alternative healing.
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12) A client with degenerative joint disease asks about an essential oil that is helpful for "stomach problems." The nurse should offer the client information about the use of which oil? 1. Chamomile 2. Eucalyptus 3. Lavender 4. Tea tree Answer: 1 Explanation: Chamomile oil soothes muscle aches, sprains, and swollen joints and is helpful as a GI antispasmodic. Page Ref: 398 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in healthcare | NLN Competencies: Knowledge and Science; Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 10. Teach clients the uses and safety precautions regarding complementary and alternative therapies. MNL Learning Outcome: 2. Examine the basic botanical healing and nutritional approaches used in complementary and alternative healing. 13) A client asks the nurse about chiropractic medicine. What should the nurse explain as being among the goals of this type of health intervention? (Select all that apply.) 1. Improvement of blood and lymph flow through the body 2. Stimulation of specific points to help with pain relief, cure certain illnesses, and promote wellness 3. Reduce or eliminate pain 4. Correct spinal dysfunction 5. Preventive maintenance Answer: 3, 4, 5 Explanation: The first clinical goal of chiropractic care is to reduce or eliminate pain. By correcting spinal dysfunction, biomechanical balance is restored to the body to reestablish shock absorption, leverage, and range of motion. Muscles and ligaments are strengthened by spinal rehabilitative exercises to increase resistance to further injury. Preventive maintenance of chiropractic medicine ensures that the problem does not recur. Page Ref: 399 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in healthcare | NLN Competencies: Knowledge and Science; Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Discuss the principles of naturopathic medicine. MNL Learning Outcome: 3. Examine the various manual healing methods and mind—body therapies used in complementary and alternative healing. 8
14) A client who resides in a long-term care facility and has no family or friends receives massage therapy three times a week. What is the main benefit of this intervention for this client? 1. Stretch and loosen the muscles 2. Speed the removal of metabolic waste products 3. Help satisfy the need for caring and nurturing touch 4. Relieve pain Answer: 3 Explanation: Because she has no family, no visitors, and her only contacts are with the staff, this client will benefit at the emotional level, as massage satisfies the need for caring and nurturing touch. It also increases feelings of well-being, decreases mild depression, enhances self-image, reduces levels of anxiety, and increases awareness of mind—body connection. Page Ref: 399 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in healthcare | NLN Competencies: Knowledge and Science; Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Discuss the principles of naturopathic medicine. MNL Learning Outcome: 3. Examine the various manual healing methods and mind—body therapies used in complementary and alternative healing. 15) A client visits a clinic that integrates Western medicine with complementary therapies. Which therapies might the client utilize and believe to keep the flow of qi at a therapeutic level? 1. Acupressure and reflexology 2. Therapeutic touch and Reiki 3. Aromatherapy and naturopathic remedies 4. Chiropractic and massage therapy Answer: 1 Explanation: Reflexology and acupressure are treatments rooted in the traditional Eastern philosophy that qi, or life energy, flows through the body along pathways known as meridians. When the flow of energy becomes blocked or congested, people experience discomfort or pain on a physical level. They may feel frustrated or irritable on an emotional level and may experience a sense of vulnerability or lack of purpose in life on a spiritual level. Page Ref: 399 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in healthcare | NLN Competencies: Knowledge and Science; Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Planning Learning Outcome: 6. Identify the role of manual healing methods in health and illness. MNL Learning Outcome: 3. Examine the various manual healing methods and mind—body therapies used in complementary and alternative healing. 9
16) A client reports feelings of spiritual anguish and depression as a result of experiencing numerous somatic complaints that make the client feel like "everything is out of order." For which problem should the nurse plan care for this client? 1. Energy-field disturbance 2. Powerlessness 3. Hopelessness 4. Anxiety Answer: 1 Explanation: Energy-field disturbance is defined as a state in which a disruption of the flow of energy surrounding a person's being results in a disharmony of the body, mind, or spirit. Page Ref: 400 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in healthcare | NLN Competencies: Knowledge and Science; Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Planning Learning Outcome: 6. Identify the role of manual healing methods in health and illness. MNL Learning Outcome: 3. Examine the various manual healing methods and mind—body therapies used in complementary and alternative healing. 17) A client undergoing chemotherapy becomes very anxious and stressed just before the treatments. Which would be an appropriate therapy for this person to learn? 1. Meditation 2. Aromatherapy 3. Homeopathy 4. Yoga Answer: 1 Explanation: Meditation is a general term for a wide range of practices that involve relaxing the body and easing the mind. Meditation is a process that individuals can use to calm themselves, cope with stress, and, for those with spiritual inclinations, feel as one with God or the universe. Page Ref: 401 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in healthcare | NLN Competencies: Knowledge and Science; Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Planning Learning Outcome: 7. Describe the goals that yoga, meditation, hypnotherapy, guided imagery, qigong, and tai chi have in common. MNL Learning Outcome: 4. Examine the various spiritual therapies and miscellaneous therapies used in complementary and alternative healing.
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18) A client undergoing therapy as a victim of severe emotional abuse wants to gain self-control of the situation, improve self-esteem, and become self-sufficient. Which application should the nurse suggest as a part of the client's therapy sessions? 1. Yoga 2. Meditation 3. Hypnotherapy 4. Guided imagery Answer: 3 Explanation: Hypnotherapy is an advanced form of relaxation and can be used to help people gain self-control, improve self-esteem, and become more autonomous. Page Ref: 401 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in healthcare | NLN Competencies: Knowledge and Science; Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Describe the goals that yoga, meditation, hypnotherapy, guided imagery, qigong, and tai chi have in common. MNL Learning Outcome: 4. Examine the various spiritual therapies and miscellaneous therapies used in complementary and alternative healing. 19) A client has been diagnosed with posttraumatic stress disorder and has difficulty sleeping because of recurrent nightmares. In working with this client to overcome the problem, what should the nurse implement as part of therapy? 1. Guided imagery 2. Hypnotherapy 3. Yoga 4. Meditation Answer: 1 Explanation: Guided imagery is a state of focused attention that encourages changes in attitudes, behavior, and physiologic reactions. Guided imagery can help people learn how to stop troublesome thoughts and focus on images that promote relaxation and decrease the negative impact of stressors. Page Ref: 401-402 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in healthcare | NLN Competencies: Knowledge and Science; Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Describe the goals that yoga, meditation, hypnotherapy, guided imagery, qigong, and tai chi have in common. MNL Learning Outcome: 4. Examine the various spiritual therapies and miscellaneous therapies used in complementary and alternative healing. 11
20) The nurse has been having difficulty with concentration after a long day's work. Which therapy should the nurse consider doing to help with this problem? 1. Guided imagery 2. Hypnotherapy 3. Qigong 4. Aromatherapy Answer: 3 Explanation: Qigong is a Chinese discipline consisting of breathing and mental exercises combined with body movements. The softness of movements develops energy without nervousness. The slowness of movements quiets the mind and develops one's powers of awareness and concentration. Page Ref: 402 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in healthcare | NLN Competencies: Knowledge and Science; Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Describe the goals that yoga, meditation, hypnotherapy, guided imagery, qigong, and tai chi have in common. MNL Learning Outcome: 4. Examine the various spiritual therapies and miscellaneous therapies used in complementary and alternative healing. 21) The nurse notes that clients with Alzheimer's disease experience sundowning in the evening. Which therapy should the nurse suggest for these clients? 1. Biofeedback 2. Music therapy 3. Pilates 4. Spiritual therapy Answer: 2 Explanation: Quiet, soothing music without words is often used to induce relaxation. Music therapy can be used in a variety of settings, without much added cost and with little extra work on the part of staff. In this particular setting, the music may help to soothe the residents and promote a sense of balance or harmony. Page Ref: 403 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in healthcare | NLN Competencies: Knowledge and Science; Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation Learning Outcome: 6. Identify the role of manual healing methods in health and illness. MNL Learning Outcome: 4. Examine the various spiritual therapies and miscellaneous therapies used in complementary and alternative healing. 12
22) A client asks how colonics would work to improve overall well-being. What should the nurse respond to this client? 1. "Colonics is a dangerous and not useful technique that no one should try." 2. "There is much controversy about colonics. What do you know about it?" 3. "This is a good way to get rid of toxins in your system." 4. "You'd better ask your doctor about this." Answer: 2 Explanation: Although colon cleansing is a controversial method of detoxification, establishing a baseline regarding the client's knowledge regarding the process is most appropriate. Page Ref: 404 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in healthcare | NLN Competencies: Knowledge and Science; Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 8. Identify types of detoxification therapies. MNL Learning Outcome: 4. Examine the various spiritual therapies and miscellaneous therapies used in complementary and alternative healing. 23) A client received a spinal cord injury during a motor-vehicle crash and has difficulty with balance and posture. Which should the nurse suggest the client consider? 1. Animal-assisted therapy 2. Hypnotherapy 3. Chelation therapy 4. Detoxification Answer: 1 Explanation: Therapeutic horseback riding, a type of animal-assisted therapy, is the use of the rhythmic movement of the horse to increase sensory processing and improve posture, balance, and mobility in people with movement dysfunctions. Page Ref: 404 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in healthcare | NLN Competencies: Knowledge and Science; Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation Learning Outcome: 9. Discuss uses of animals, prayer, and humor as treatment modalities. MNL Learning Outcome: 4. Examine the various spiritual therapies and miscellaneous therapies used in complementary and alternative healing.
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24) A client living in a long-term care center is withdrawn and subdued and does not eat in the dining room because of embarrassment about physical decline. What might the nurse suggest that provides opportunities for unconditional love, achievement of trust, responsibility, and empathy toward others? 1. Chelation therapy 2. Animal-assisted therapy 3. Meditation 4. Pilates Answer: 2 Explanation: Animal-assisted therapy is defined as the use of specifically selected animals as a treatment modality in health and human service settings. The contributions include opportunities for affection, achievement of trust, responsibility, and empathy toward others. Pets in long-term care facilities become so perceptive that they actually gravitate to the rooms of people who are most isolated or depressed. Page Ref: 404 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in healthcare | NLN Competencies: Knowledge and Science; Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation Learning Outcome: 9. Discuss uses of animals, prayer, and humor as treatment modalities. MNL Learning Outcome: 4. Examine the various spiritual therapies and miscellaneous therapies used in complementary and alternative healing.
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25) The nurse is reviewing systems of healing that emphasize client responsibility, client education, disease prevention, or natural substances that stimulate a person's self-healing capacity. On which systems is the nurse focusing? (Select all that apply.) 1. Naturopathic medicine 2. Homeopathic medicine 3. Aromatherapy 4. Chiropractic 5. Hypnosis Answer: 1, 2, 3, 4 Explanation: Naturopathic medicine is a self-healing system that utilizes remedies to stimulate a person's self-healing capacity. Homeopathy is a self-healing system that utilizes remedies to stimulate a person's self-healing capacity. Aromatherapy is the use of essential oils of plants in which the odor or fragrance, when applied or in proximity to the body, results in physiologic or psychologic benefit. Chiropractic is a type of manual healing method. Page Ref: 396-398 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in healthcare | NLN Competencies: Knowledge and Science; Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Describe the basic concepts of alternative practices. MNL Learning Outcome: 4. Examine the various spiritual therapies and miscellaneous therapies used in complementary and alternative healing.
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26) The nurse is teaching a client regarding the use of herbal preparations. Which statements should the nurse include in this teaching? (Select all that apply.) 1. "Echinacea might reduce the effectiveness of the immunosuppressant medications you've been prescribed since your transplant." 2. "Gingko could affect the results of your aspirin therapy." 3. "Ginger could be contraindicated because you are taking anticoagulant medications." 4. "With your history of glaucoma, I don't believe you should be supplementing with ginseng." 5. "St. John's wort is a safe supplement when being medicated for depression." Answer: 1, 2, 3, 4 Explanation: Although it is believed by some to enhance the immune system, echinacea can reduce the effectiveness of immunosuppressants. Gingko can increase the anticoagulant effects of aspirin and anticoagulant medications. Ginger can increase the anticoagulant effects of aspirin and anticoagulant medications. Ginseng can decrease the effectiveness of glaucoma medications. Page Ref: 397 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in healthcare | NLN Competencies: Knowledge and Science; Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 4. Explain how herbs are similar to many prescription drugs. MNL Learning Outcome: 2. Examine the basic botanical healing and nutritional approaches used in complementary and alternative healing.
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27) The nurse is instructing a client on meditation and relaxation. Which information should the nurse include in this teaching? (Select all that apply.) 1. "Perform these techniques at least 2 hours after eating so as to concentrate all your body's energies." 2. "Practice these techniques in a comfortable, upright position." 3. "Remember to relax your muscles after you have successfully tightened a muscle group." 4. "Find a quiet, peaceful place to meditate." 5. "Set aside 60 minutes daily for meditation and relaxation." Answer: 1, 2, 3, 4 Explanation: Ideally, choose the early morning or evening, and wait at least 2 hours after eating so that complete energy is devoted to meditation rather than to digestive demands. Avoid a lying position because it increases the tendency to fall asleep. Progressively tighten and relax each muscle group in the body. A quiet, comfortable place, devoid of distractions, is helpful. Page Ref: 401 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in healthcare | NLN Competencies: Knowledge and Science; Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 6. Identify the role of manual healing methods in health and illness. MNL Learning Outcome: 4. Examine the various spiritual therapies and miscellaneous therapies used in complementary and alternative healing.
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28) A client tells the nurse about an appointment to see an Ayurveda healthcare practitioner for a specific chronic health problem. What should the nurse instruct the client to expect when visiting this practitioner? (Select all that apply.) 1. A diet 2. Sitting in a sweat lodge 3. An exercise program 4. Acupuncture treatment 5. A list of herbal preparations Answer: 1, 3, 5 Explanation: Specific lifestyle interventions are a major preventive and therapeutic approach in Ayurveda. Each person is prescribed an individualized diet. Specific lifestyle interventions are a major preventive and therapeutic approach in Ayurveda. Each person is prescribed an individualized exercise program. In Ayurveda, herbal preparations are added to the diet for preventive or regenerative purposes as well as for the treatment of specific disorders. Page Ref: 395 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in healthcare | NLN Competencies: Knowledge and Science; Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 3. Describe the basic principles of healthcare practices such as Ayurveda, traditional Chinese medicine, Native American healing, and curanderismo. MNL Learning Outcome: 2. Examine the various manual healing methods and mind-body therapies used in complementary and alternative healing.
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29) While completing a health history and assessment, the nurse suspects that a client of Latino descent uses curanderismo for healthcare. What client information did the nurse use to make this determination? (Select all that apply.) 1. The client stated that the healthcare provider prescribes specific herbs. 2. The client stated that the same healthcare provider helped in the delivery of all of her children. 3. The client stated that small needles are inserted along certain parts of the body to help with healing. 4. The client stated that the healthcare provider visits the home to pray with the family members. 5. The client stated that specific areas of the body are pressed by the healthcare provider to increase energy. Answer: 1, 2, 4 Explanation: Curanderismo is a cultural healing tradition found in Latin America and among many Latinos in the United States. Healers are called curanderos (men) and curanderas (women) and may specialize as herbalists. Curanderismo is a cultural healing tradition found in Latin America and among many Latinos in the United States. Healers are called curanderos (men) and curanderas (women) and may specialize as midwives. Curanderismo is a cultural healing tradition found in Latin America and among many Latinos in the United States. Healers are called curanderos (men) and curanderas (women) and may utilize religious rituals, cleansing rites, and prayers in their healing practices. Page Ref: 396 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in healthcare | NLN Competencies: Knowledge and Science; Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Evaluation Learning Outcome: 3. Describe the basic principles of healthcare practices such as Ayurveda, traditional Chinese medicine, Native American healing, and curanderismo. MNL Learning Outcome: 4. Examine the various spiritual therapies and miscellaneous therapies used in complementary and alternative healing.
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30) The nurse is asked which medications originate from herbs. Which drug should the nurse say in response? (Select all that apply.) 1. Aspirin 2. Digoxin 3. Quinine 4. Atropine 5. Epinephrine Answer: 1, 2, 3, 4 Explanation: Aspirin is from willow tree bark. Digoxin is from foxglove. Quinine is from Peruvian bark. Atropine is from deadly nightshade. Page Ref: 396 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care | NLN Competencies: Knowledge and Science; Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation Learning Outcome: 4. Explain how herbs are similar to many prescription drugs. MNL Learning Outcome: 2. Examine the basic botanical healing and nutritional approaches used in complementary and alternative healing. 31) A client is diagnosed with lead poisoning. Which detoxification process should the nurse prepare teaching for this client? 1. Colonics 2. Acupuncture 3. Massage therapy 4. Chelation therapy Answer: 4 Explanation: Chelation therapy is the introduction of chemicals into the bloodstream that bind with heavy metals in the body. Ethylene diamine tetraacetic acid (EDTA) is a synthetic amino acid that readily binds to lead. The U.S. Food and Drug Administration has approved EDTA for the treatment of lead poisoning. Colonics, acupuncture, and massage therapy are not used to treat lead poisoning. Page Ref: 404 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care | NLN Competencies: Knowledge and Science; Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Planning/Teaching and Learning Learning Outcome: 8. Identify types of detoxification therapies. MNL Learning Outcome: 4. Examine the various spiritual therapies and miscellaneous therapies used in complementary and alternative healing. 20
Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 23 Concepts of Growth and Development 1) The nurse is plotting the height and weight of children during a school assessment clinic. Which aspect of the children's health is the nurse assessing? 1. Development 2. Health 3. Growth 4. Bone size Answer: 3 Explanation: Growth refers to physical change and increase in size. Indicators include height, weight, bone size, and dentition. Page Ref: 410 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Differentiate between the terms growth and development. MNL Learning Outcome: 1. Recognize the factors that influence growth and development and the characteristics and nursing implications for each stage of growth and development. 2) During a wellness visit, the nurse notes that a 16-month-old child is unable to move from a sitting to a standing position. In which process should the nurse identify that this child is lagging? 1. Growth 2. Development 3. Height 4. Behavior Answer: 2 Explanation: Development is an increase in the complexity of function and skill progression. It is the behavioral aspect of growth–the person's ability to walk, talk, and run, for example. Page Ref: 411 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Differentiate between the terms growth and development. MNL Learning Outcome: 1. Recognize the factors that influence growth and development and the characteristics and nursing implications for each stage of growth and development. 1
3) A child is starting school and is being screened for certain developmental milestones. What is the nurse assessing when determining how the child interacts with other children? 1. Temperament 2. Physical characteristics 3. Environment 4. Culture Answer: 1 Explanation: Temperament is the way individuals respond to their external and internal environment and sets the stage for the interactive dynamics of growth and development. Page Ref: 411-412 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Explain the concept of temperament. MNL Learning Outcome: 1. Recognize the factors that influence growth and development and the characteristics and nursing implications for each stage of growth and development. 4) The nurse explains that development is based on in-born timetables and a child will be most likely able to meet this milestone at a specific time. Which theory is the nurse explaining? 1. Havighurst's theory 2. Task theory 3. Psychosocial theory 4. Maturational theory Answer: 4 Explanation: The maturational theory (Arnold Gesell) postulates that child development is a maturational process based on an in-born timetable. Although children benefit from experience, they will achieve maturational milestones such as rolling over, sitting, and walking at specific times. Page Ref: 412 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Describe the stages of growth and development according to various theorists. MNL Learning Outcome: 3. Recognize growth and development milestones through the different phases of the lifespan by the various theorists. 2
5) A toddler shows fear and begins to cry when left at day care. According to Havighurst, which developmental task should the nurse recognize this child is exhibiting? 1. Building wholesome attitudes toward oneself 2. Learning to get along with age-mates 3. Learning to relate emotionally 4. Achieving personal independence Answer: 3 Explanation: A toddler would be in the infancy and early childhood age period, in which learning to relate emotionally to parents, siblings, and other people is a developmental task. Page Ref: 416 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation Learning Outcome: 8. Identify developmental tasks associated with Havighurst's six age periods. MNL Learning Outcome: 3. Recognize growth and development milestones through the different phases of the lifespan by the various theorists.
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6) A parent is concerned that a 5-year-old is beginning to masturbate. How should the nurse, familiar with Freud's stages of development, respond? 1. "All children are curious, but make sure the child knows that this behavior might be offensive to others." 2. "You should probably consult a child psychologist if you're this concerned." 3. "Let's make sure to ask your physician at the next appointment." 4. "This behavior is a normal part of your child's development." Answer: 4 Explanation: In the phallic stage, as described by Freud, which occurs from age 4 to 6 years, the child's genitals are the center of pleasure. Masturbation offers pleasure, and questions about sexual topics from parents are normal. Assuring the parent that this is a normal part of development is the best response. Page Ref: 413-414 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation Learning Outcome: 6. Describe characteristics and implications of Freud's five stages of development. MNL Learning Outcome: 3. Recognize growth and development milestones through the different phases of the lifespan by the various theorists.
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7) A young adult has never lived away from home. According to Freud's theory of development, the nurse should suspect that this person would be fixated at which stage of development? 1. Phallic 2. Latency 3. Genital 4. Anal Answer: 3 Explanation: Freud's genital stage is characterized by energy that is directed toward full sexual maturity and function and development of skills needed to cope with the environment. It occurs during puberty and extends beyond. Implications of this stage include separation from parents, achievement of independence, and decision making. Fixation occurs at any stage and is the immobilization or the inability of the personality to proceed to the next stage because of anxiety. Page Ref: 414 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 6. Describe characteristics and implications of Freud's five stages of development. MNL Learning Outcome: 3. Recognize growth and development milestones through the different phases of the lifespan by the various theorists.
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8) A client is being seen in the mental health clinic for antisocial behavior. According to Erikson's stages of development, the nurse realizes that this client is experiencing which task of development? 1. Initiative versus guilt 2. Industry versus inferiority 3. Intimacy versus isolation 4. Identity versus role confusion Answer: 4 Explanation: According to Erik Erikson, the adolescent stage is from 12 to 20 years and the central task is identity versus role confusion. Positive resolution indicates sense of self with plans to actualize one's abilities. Negative resolution indicates feelings of confusion, indecisiveness, and possible antisocial behavior. Page Ref: 414 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 7. Identify Erikson's eight stages of development. MNL Learning Outcome: 3. Recognize growth and development milestones through the different phases of the lifespan by the various theorists.
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9) A client with a terminal diagnosis collects pictures for a scrapbook and wrote a journal of favorite memories for family members to read after the client dies. According to Peck, the nurse realizes that this client is working through which developmental task? 1. Body transcendence versus body preoccupation 2. Ego transcendence versus ego preoccupation 3. Ego differentiation versus work-role preoccupation 4. Integrity versus despair Answer: 2 Explanation: Ego transcendence is the acceptance without fear of one's death as inevitable. This acceptance includes being actively involved in one's own future beyond death. Peck proposes that there are three developmental tasks during old age, in contrast to Erikson's one–integrity versus despair. Page Ref: 415-416 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 9. Compare Peck's and Gould's stages of adult development. MNL Learning Outcome: 4. Consider the nursing implications related to caring for patients at various stages of growth and development. 10) A college-age client is struggling with feelings of both independence and dependence. The nurse recognizes this as which stage of development, according to Roger Gould? 1. Stage 2 2. Stage 3 3. Stage 4 4. Stage 5 Answer: 1 Explanation: Roger Gould studied adult development and described seven stages. Stage 2 (ages 18-22) is where individuals have established autonomy, feel it is in jeopardy, and feel they could be pulled back into their families. Page Ref: 416-417 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 9. Compare Peck's and Gould's stages of adult development. MNL Learning Outcome: 4. Consider the nursing implications related to caring for patients at various stages of growth and development. 7
11) A child is learning new words faster than he can write them in the baby book. According to Piaget, the nurse realizes that this child is in which phase? 1. Intuitive thought phase 2. Preconceptual phase 3. Concrete operations phase 4. Formal operations phase Answer: 2 Explanation: Ages 2-4 years, according to Piaget, is the preconceptual phase where the child uses an egocentric approach to accommodate the demands of an environment. Language development is rapid and the child associates words with objects. Page Ref: 419 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 11. Explain Piaget's theory of cognitive development. MNL Learning Outcome: 4. Consider the nursing implications related to caring for patients at various stages of growth and development. 12) The nurse notes that a 20-month-old child is lagging in stage 6 of Piaget's phases of cognitive development. Which activity did the nurse observe that indicates that this child is struggling at this stage? 1. The child wants the same toy to sleep with during naptime and bedtime. 2. The child merely watches as the other children pretend-play. 3. The child cries when the parents leave the unit. 4. The child does not cooperate with some of the treatments. Answer: 2 Explanation: In this stage of development, inventions of new means, children interpret the environment by mental images. They use make-believe and pretend-play. A child who is unable to do this would not be demonstrating the behavior that is significant at this stage. Page Ref: 419 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 11. Explain Piaget's theory of cognitive development. MNL Learning Outcome: 4. Consider the nursing implications related to caring for patients at various stages of growth and development. 8
13) The nurse is exploring the behavior of children and how they interpret right from wrong or bad from good. Which theorist should the nurse study to learn this information? 1. Vygotsky 2. Skinner 3. Kohlberg 4. Piaget Answer: 3 Explanation: Lawrence Kohlberg's theory specifically addresses the moral development of children and adults. Page Ref: 420 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Planning Learning Outcome: 12. Compare Kohlberg's and Gilligan's theories of moral development. MNL Learning Outcome: 4. Consider the nursing implications related to caring for patients at various stages of growth and development. 14) The nurse is planning to go to the gym after work three days a week and stop eating foods with extra sugar. In which stage of Gilligan's theory is the nurse functioning? 1. Stage 1 2. Stage 2 3. Stage 3 4. Stage 4 Answer: 1 Explanation: Gilligan's stage 1 is concerned about caring for self. Page Ref: 422 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation Learning Outcome: 12. Compare Kohlberg's and Gilligan's theories of moral development. MNL Learning Outcome: 3. Recognize growth and development milestones through the different phases of the lifespan by the various theorists.
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15) The nurse is completing a spiritual assessment with an adult client. In which stage of Fowler's theory of development should the nurse expect for this client? 1. Mythic-lyrical 2. Intuitive-projective 3. Universalizing 4. Individuating-reflexive Answer: 4 Explanation: After the age of 18, adults build their own spiritual systems. This is known as the individuating-reflexive stage. Page Ref: 424 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 13. Compare Fowler's and Westerhoff's stages of spiritual development. MNL Learning Outcome: 4. Consider the nursing implications related to caring for patients at various stages of growth and development. 16) A client with an acute, serious illness is observed praying. With which theorist should the nurse associate this client's behavior? 1. Fowler 2. Westerhoff 3. Gilligan 4. Kohlberg Answer: 2 Explanation: Westerhoff describes faith as a way of being and behaving that evolves from an experienced faith guided by parents and others during a person's infancy and childhood to an owned faith that is internalized in adulthood. For the client who is ill, faith provides strength and trust. Page Ref: 423 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 13. Compare Fowler's and Westerhoff's stages of spiritual development. MNL Learning Outcome: 4. Consider the nursing implications related to caring for patients at various stages of growth and development.
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17) The nurse is reviewing the four stages of development in Westerhoff's spiritual theory. In which order should the nurse review these stages to match the life cycle? 1. Owned faith 2. Affiliative faith 3. Experienced faith 4. Searching faith Answer: 4, 2, 1, 3 Explanation: 1. Puts faith into personal and social action and is willing to stand up for what the individual believes even against the nurturing community is Stage 4. 2. Actively participates in activities that characterize a particular faith tradition; experiences awe and wonderment; feels a sense of belonging is Stage 2. 3. Experiences faith through interaction with others who are living a particular faith tradition is Stage 1. 4. Through a process of questioning and doubting own faith, acquires a cognitive as well as an affective faith is Stage 3. Page Ref: 423 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation Learning Outcome: 13. Compare Fowler's and Westerhoff's stages of spiritual development. MNL Learning Outcome: 4. Consider the nursing implications related to caring for patients at various stages of growth and development.
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18) A school-age client is learning how to use a peak flow meter to monitor asthma but really does not want to do it. What should the nurse say to this client? 1. "You should feel very proud for understanding and using your meter." 2. "Think of using the meter as one of your daily chores." 3. "Maybe you could make a game out of the daily use of your meter." 4. "It's too bad if you don't want to use the meter, it's just something you'll have to do." Answer: 1 Explanation: School-age children (6-12 years) are in the preadolescent period, where the peer group begins to increasingly influence behavior. The nurse must allow time and energy for the school-age child to pursue hobbies and school activities and should recognize and support the child's achievement. Play and social activity are more important in the preschool-age child as new experiences and social roles are tried during play. Page Ref: 413 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation Learning Outcome: 2. Describe essential principles related to growth and development. MNL Learning Outcome: 2. Examine the characteristics of the various theories of growth and development. 19) The nurse is working with the residents of an assisted living complex. When planning care for the old-old stage, the nurse realizes that what action will be important? 1. Provide as much care to the residents as possible. 2. Allow as much independence for the residents as possible. 3. Make sure to provide safety measures as needed. 4. Make sure the residents maintain peer interactions and social groups. Answer: 2 Explanation: The old-old stage, age 85 and older, is characterized by increasing physical problems. The nursing implication for this age group is to assist with self-care as required but maintain as much independence as possible. Page Ref: 413 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation Learning Outcome: 2. Describe essential principles related to growth and development. MNL Learning Outcome: 2. Examine the characteristics of the various theories of growth and development. 12
20) A community health nurse is planning adult health education classes. According to Erikson's stages of development, the nurse should address which task with this age group? 1. Industry versus inferiority 2. Identity versus role confusion 3. Intimacy versus isolation 4. Generativity versus stagnation Answer: 4 Explanation: Adulthood, age 25-65 years, is characterized by the central task of generativity versus stagnation. Positive resolution is indicated by creativity, productivity, and concern for others. Negative resolution is characterized by self-indulgence, self-concern, and lack of interests and communication. Page Ref: 414 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Planning Learning Outcome: 7. Identify Erikson's eight stages of development. MNL Learning Outcome: 2. Examine the characteristics of the various theories of growth and development. 21) A baby is having brought in for a well-child checkup. Which action of the child should the nurse identify as an indicator of positive resolution of the central task of this age? 1. The child does not cry when the parent allows the nurse to hold the child. 2. The child shows mistrust when strangers approach. 3. The child becomes willful when disciplined. 4. The child does not play with other children. Answer: 1 Explanation: In the infancy years (birth to 18 months), the child's central task is to form trust or mistrust with people. Positive resolution would indicate a safe feeling when the parents leave the child with someone they are familiar with and can trust. Page Ref: 413 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Describe essential principles related to growth and development. MNL Learning Outcome: 2. Examine the characteristics of the various theories of growth and development. 13
22) A child is described as being creative and learning how to pretend with "almost anything in the house." According to Piaget, the nurse realizes this child is demonstrating which stage/phase? 1. Tertiary circular reaction: stage 5 2. Inventions of new means: stage 6 3. Preconceptual phase 4. Concrete operations phase Answer: 2 Explanation: Stage 6, inventions of new means, is from 18 to 24 months. The significant behavior is identified by interpretation of the environment by mental image. Make-believe and pretend-play are in use during this stage. Page Ref: 419 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 11. Explain Piaget's theory of cognitive development. MNL Learning Outcome: 3. Recognize growth and development milestones through the different phases of the lifespan by the various theorists.
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23) The nurse concludes that a young adult client is completing developmental tasks within Havighurst's early adulthood age period. What did the nurse assess to come to this conclusion? (Select all that apply.) 1. Taking on civic responsibility 2. Developing adult leisure-time activities 3. Getting started in an occupation 4. Relating oneself to one's spouse as a person 5. Managing a home Answer: 1, 3 Explanation: Taking on civic responsibilities and getting started in an occupation are two of Havighurst's early adulthood tasks. Page Ref: 416 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 8. Identify developmental tasks associated with Havighurst's six age periods. MNL Learning Outcome: 3. Recognize growth and development milestones through the different phases of the lifespan by the various theorists.
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24) The nurse is discussing human growth and development with the parents of a newborn. What should the nurse include in this discussion? (Select all that apply.) 1. Growth involves physical change and increase in size. 2. Skills and function increase with growth. 3. Most humans experience a similar pattern of growth. 4. Being able to adapt to one's environment is an indicator of growth. 5. Children's growth is monitored by height, weight, bone size, and dentition. Answer: 1, 3, 5 Explanation: Growth is physical change and increase in size. The pattern of physiologic growth is similar for all people. Growth can be measured quantitatively. Indicators of growth include height, weight, bone size, and dentition. Page Ref: 411 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation Learning Outcome: 2. Describe essential principles related to growth and development. MNL Learning Outcome: 1. Recognize the factors that influence growth and development and the characteristics and nursing implications for each stage of growth and development.
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25) The nurse is assessing a child's growth and development. What questions should the nurse ask the parents that demonstrate an understanding of the factors that affect growth and development processes? (Select all that apply.) 1. How tall the parents are 2. Whether noises seem to bother their child 3. How many ounces of formula their child drinks daily 4. What their yearly income is 5. Whether their child will receive day-care services Answer: 1, 2, 3 Explanation: The genetic inheritance of an individual is established at conception. It remains unchanged throughout life and determines such characteristics as sex and other physical characteristics (e.g., eye color, potential height). Temperament sets the stage for the interactive dynamics of growth and development. Adequate nutrition is an essential component of growth and development. Page Ref: 411-412 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation Learning Outcome: 3. List factors that influence growth and development. MNL Learning Outcome: 1. Recognize the factors that influence growth and development and the characteristics and nursing implications for each stage of growth and development.
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26) The nurse is preparing a teaching session for a group of parents with newborn children. What should the nurse include about Bowlby's attachment theory during this presentation? (Select all that apply.) 1. Use the attachment figure as security 2. Desire to be near the attachment figure 3. Plan to separate from the attachment figure 4. Return to the attachment figure when threatened 5. Express anxiety when the attachment figure is absent Answer: 1, 2, 4, 5 Explanation: Bowlby believed that attachment served as a protective or survival mechanism for the infant. Characteristics of Bowlby's attachment theory include using the attachment figure as a security base, the desire to be near the attachment figure, returning to the attachment figure when threatened, and expressing anxiety (separation anxiety) when the attachment figure is absent. Page Ref: 417 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Planning Learning Outcome: 10. State the four characteristics of Bowlby's attachment theory. MNL Learning Outcome: 4. Consider the nursing implications related to caring for patients at various stages of growth and development.
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27) After analyzing behavior, the nurse determines that a client is demonstrating defense mechanisms. According to Freud, what should the nurse realize as being the cause of this behavior? (Select all that apply.) 1. Anxiety created by conflicts 2. Activation of the conscience 3. Conflict between the id's impulses 4. Immediate pleasure and gratification 5. Underlying motivation for development Answer: 1, 3 Explanation: Defense mechanisms or adaptive mechanisms are the result of anxiety created by the conflicts due to social and environmental restrictions. Defense mechanisms or adaptive mechanisms are the result of conflicts between the id's impulses. Page Ref: 414 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge: Evidence and best practices for nursing | Nursing/Integrated Concepts: Evaluation Learning Outcome: 6. Describe characteristics and implications of Freud's five stages of development. MNL Learning Outcome: 2. Examine the characteristics of the various theories of growth and development.
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28) A parent states that a school-age child has the same behavior as a relative who was unsuccessful in life. Which should the nurse keep in mind when responding to the parent? 1. Genetics can be changed 2. Caution must be taken to not label or categorize a child 3. Efforts must be taken to alter the child's personality now 4. Money should not be used to try to improve this child's behavior Answer: 2 Explanation: Regarding temperament, caution must be taken not to label or categorize a child. Genetics cannot be changed. Efforts to change personality would not be effective. The family should most likely do whatever is required to support the child's growth and development. Page Ref: 411-412 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Planning Learning Outcome: 3. List factors that influence growth and development. MNL Learning Outcome: 1. Recognize the factors that influence growth and development and the characteristics and nursing implications for each stage of growth and development. 29) A child is observed walking over to a group of children and askings to play with them. Which should the nurse conclude about this child's temperament? 1. The child will be fearful. 2. The child will be outgoing. 3. The child will dislike being alone. 4. The child will view life as a playground. Answer: 2 Explanation: Temperament is the way a person responds to the external and internal environment. Approaching others to participate indicates an outgoing temperament. This child's behavior does not indicate being fearful, dislike being alone, or viewing life as a playground. Page Ref: 411-412 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Evaluation Learning Outcome: 4. Explain the concept of temperament. MNL Learning Outcome: 1. Recognize the factors that influence growth and development and the characteristics and nursing implications for each stage of growth and development.
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30) A middle-aged client says that the youngest child is starting college in a few months. Which should the nurse do to support this client's growth and development? 1. Offer suggestions to deal with stress and conflict 2. Encourage ways to reduce dependence upon others 3. Outline ways to help the client deal with physical losses 4. Assist the client to prepare for the change after the child leaves home Answer: 4 Explanation: A client in middle adulthood may face lifestyle changes when a child leaves home. The nurse should assist the client to prepare for the change. Stress and conflict issues are characteristic of an adolescent. Physical losses and dependency upon others are characteristics of middle-old and old-old adults. Page Ref: 413 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Describe the stages of growth and development according to various theorists. MNL Learning Outcome: 3. Recognize growth and development milestones through the different phases of the lifespan by the various theorists. 31) A hospitalized toddler runs out of the room after a parent who is going to make a telephone call. Which characteristic of Bowlby's theory is this client demonstrating? 1. Self-reflection 2. Self-regulation 3. Transformation 4. Separation anxiety Answer: 4 Explanation: Expression of anxiety or separation anxiety occurs when the attachment figure is absent. Running after a parent demonstrates separation anxiety. The client's behavior does not demonstrate self-reflection, self-regulation, or transformation. Page Ref: 417 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 10. State the four characteristics of Bowlby's attachment theory. MNL Learning Outcome: 4. Consider the nursing implications related to caring for patients at various stages of growth and development. 21
Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 24 Promoting Health from Conception Through Adolescence 1) A client with a positive home pregnancy test states that the last menstrual cycle was 2 months ago. According to this time frame, the nurse determines that the client is in which stage of pregnancy? 1. Fetal phase 2. Second trimester 3. Third trimester 4. Embryonic phase Answer: 4 Explanation: Traditionally, pregnancy has been divided into three periods called trimesters, each of which lasts 3 months. The embryonic phase is the period during which the fertilized ovum develops into an organism with most of the features of a human. This period is considered to encompass the first 8 weeks of pregnancy. Page Ref: 428 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Describe usual physical development from infancy through adolescence. MNL Learning Outcome: 1. Recognize the physical development and characteristics of the different stages of development from infancy through adolescence.
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2) The parents of a baby born prematurely during the sixth month of pregnancy question the nurse about the hair all over their baby. What is the nurse's best response? 1. "All babies are hairy. It is more noticeable on preemies." 2. "Fine downy hair helps keep the baby insulated in utero." 3. "You should be more concerned with the baby's respiratory function." 4. "Don't worry about how the baby looks. All preemies look funny." Answer: 2 Explanation: Lanugo, a fine downy hair, covers the body of the baby and usually disappears by the time gestation is full term. Because this baby was born early, the lanugo is more noticeable and will disappear as the baby nears full term. Page Ref: 429 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 1. Describe usual physical development from infancy through adolescence. MNL Learning Outcome: 1. Recognize the physical development and characteristics of the different stages of development from infancy through adolescence. 3) The nurse is preparing to instruct a client about nutritional needs before and during pregnancy. What should the nurse encourage the patient to consume in order to meet the requirements for folic acid? 1. Meats, fish, and poultry 2. A mix of vegetables and fiber 3. Oranges and green leafy vegetables 4. Low-fat and high-protein foods Answer: 3 Explanation: Folic acid is important to prevent neural tube defects in the fetus. Neural tube defects occur in the first few weeks of fetal development. Folic acid-rich foods include green leafy vegetables, oranges, and dried beans. Page Ref: 429 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 8. Identify essential activities of health promotion and protection to meet the needs of infants, toddlers, preschoolers, school-age children, and adolescents. MNL Learning Outcome: 1. Recognize the physical development and characteristics of the different stages of development from infancy through adolescence. 2
4) The nurse is completing a health history with a client who is 10 weeks pregnant. Which factor should the nurse identify as increasing this client's risk for a spontaneous abortion? 1. Having taken a medication that is a known teratogen 2. Smoking 3. Having low levels of folic acid 4. Genetic history Answer: 2 Explanation: Exposure to environmental tobacco smoke has been associated with preterm births, stillbirth, miscarriage, and low-birth-weight infants. Page Ref: 430 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Describe usual physical development from infancy through adolescence. MNL Learning Outcome: 1. Recognize the physical development and characteristics of the different stages of development from infancy through adolescence. 5) The school nurse determines that a 14-year-old student has reached an expected level of cognitive development. What did the nurse assess to come to this conclusion? (Select all that apply.) 1. Thinks logically 2. Thinks about the future 3. Makes rational statements 4. Uses a trial-and-error process 5. States things as they could be Answer: 1, 2, 3, 5 Page Ref: 449 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Explain cognitive development according to Piaget from infancy through adolescence. MNL Learning Outcome: 2. Explore psychological, cognitive, moral, and spiritual development according to key theorists from infancy through adolescence.
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6) At birth a baby weighed 8 lb. What should the nurse expect this baby to weigh at the age of 1? 1. 32 lb 2. 16 lb 3. 20 lb 4. 24 lb Answer: 4 Explanation: Normal growth patterns dictate that infants usually reach three times their birth weight by 12 months and twice their birth weight at 6 months. They typically gain weight at a rate of 5-7 ounces weekly for 6 months. Page Ref: 431 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Describe usual physical development from infancy through adolescence. MNL Learning Outcome: 1. Recognize the physical development and characteristics of the different stages of development from infancy through adolescence. 7) Parents of a newborn ask why the newborn's head seems lopsided and not round, as they thought it should be. How should the nurse respond? 1. "I don't think it looks unusual; actually, the head is beautifully shaped." 2. "Your baby's head had to shape itself to the birth canal. It will look round in a few days." 3. "You're right. We'll make sure your doctor checks this out." 4. "Babies' heads always look funny. Once his hair grows out, you'll hardly notice it." Answer: 2 Explanation: Molding of the head is made possible by the fontanels and occurs during vaginal deliveries as the head comes through the birth canal. Within a week, the newborn's head usually regains its symmetry. It is normal with vaginal deliveries. Babies born via cesarean section do not experience molding. Molding is not permanent–a fact that makes parents feel more reassured. Page Ref: 431 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 1. Describe usual physical development from infancy through adolescence. MNL Learning Outcome: 1. Recognize the physical development and characteristics of the different stages of development from infancy through adolescence. 4
8) The parents of a newborn ask what their baby can see. What should the nurse respond to these parents? 1. "Babies aren't able to see until they are around 4 months old." 2. "Babies won't track moving objects until about 5 months." 3. "Newborns blink in response to bright lights and sound and will follow large objects." 4. "Newborns aren't able to focus, so everything looks blurry to them." Answer: 3 Explanation: Newborns can follow large, moving objects and blink in response to bright lights and sound. Their pupils respond slowly, and the eyes cannot focus on close objects. We don't know what they "see" or how it looks to them. Page Ref: 431 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 1. Describe usual physical development from infancy through adolescence. MNL Learning Outcome: 1. Recognize the physical development and characteristics of the different stages of development from infancy through adolescence.
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9) The parents of a newborn male ask the nurse about pain during circumcision. How should the nurse respond? 1. "Newborns can't feel pain, so don't worry about it." 2. "We'll make sure to bring your baby to you right after the procedure, so you can comfort him." 3. "I'll have the pediatrician speak to you about it." 4. "Newborns' pain experience is real. We'll use some medication to help your baby feel more comfortable." Answer: 4 Explanation: Young babies react diffusely to pain and cannot isolate the discomfort. The pain of circumcision is not isolated in the genital region, but may be felt more diffusely, throughout the body. Page Ref: 432 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 1. Describe usual physical development from infancy through adolescence. MNL Learning Outcome: 1. Recognize the physical development and characteristics of the different stages of development from infancy through adolescence. 10) An expectant parent asks the nurse about health problems of newborns. On what should the nurse provide information to this client? (Select all that apply.) 1. Infant colic 2. Respiratory tract infections 3. Failure to thrive 4. Injuries 5. SIDS Answer: 1, 3, 5 Page Ref: 435 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 1. Describe usual physical development from infancy through adolescence. MNL Learning Outcome: 1. Recognize the physical development and characteristics of the different stages of development from infancy through adolescence.
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11) New parents ask if their 8-month-old baby is performing activities that are expected at this age. What should the nurse suggest to screen this baby's developmental level? 1. The Denver Developmental Screening Test (DDST-II) 2. Growth and development charts from the Centers for Disease Control and Prevention (CDC) 3. Assessment tools utilized by the state education department 4. The Apgar scoring system Answer: 1 Explanation: The Denver Developmental Screening Test (DDST-II) can be used to assess the infant's behavior and can be used from birth to 6 years. It is intended to estimate the abilities of a child compared to those of an average group of children of the same age. Page Ref: 436 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Identify tasks characteristic of different stages of development from infancy through adolescence. MNL Learning Outcome: 2. Explore psychological, cognitive, moral, and spiritual development according to key theorists from infancy through adolescence.
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12) The parents of a toddler are concerned that the child is messy during eating and feed the child instead. What should the nurse respond to the parents? 1. "That's probably best. I'm sure it makes your mealtime more pleasant." 2. "At least you're sharing meals as a family. That's the most important." 3. "Motor skills keep improving with age. Try not to get frustrated with the mess." 4. "Your child will never learn if you don't let him experience." Answer: 3 Explanation: Fine muscle coordination and gross motor skills improve during toddlerhood. At 2 years, the toddler should be able to hold a spoon and put it into the mouth correctly, albeit with some messes while he is learning. Assuring the parents that this will improve may help them with their patience during the messy times. Page Ref: 437 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 2. Identify tasks characteristic of different stages of development from infancy through adolescence. MNL Learning Outcome: 2. Explore psychological, cognitive, moral, and spiritual development according to key theorists from infancy through adolescence.
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13) A toilet-trained 4-year-old hospitalized for several days with an acute illness has been wetting the bed at night and is having incontinent accidents during the day. How should the nurse address the parent's concern about this behavior? 1. "Maybe your child should be seen by a specialist, just to make sure there are no physical problems." 2. "It is normal for some children to go through a stage of regression after separation from their family or after an acute illness. Try not to be too discouraged." 3. "You'll have to be very strict with discipline, so your child knows this behavior is not acceptable." 4. "I'd be upset too. It must be hard to go back to using diapers." Answer: 2 Explanation: Regression is reverting to an earlier development stage (bedwetting, using baby talk, etc.) as part of the child's experiences with separation anxiety. Nurses can assist parents by helping them understand that this behavior is normal and will pass as the child reestablishes herself as part of the family and works through her own frustration with the situation. Page Ref: 438 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 2. Identify tasks characteristic of different stages of development from infancy through adolescence. MNL Learning Outcome: 2. Explore psychological, cognitive, moral, and spiritual development according to key theorists from infancy through adolescence.
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14) The school nurse learns that students in a kindergarten class have 20/20, 20/30, or 20/40 vision. What should the nurse say about these findings? 1. "These children have normal vision abilities." 2. "The diets of these children are lacking in essential vitamins because they all have poor eyesight." 3. "These kids will all be wearing glasses in a year." 4. "A different eye chart should be used." Answer: 1 Explanation: Preschool children are generally farsighted and not able to focus on near objects. By the end of the preschool years, visual ability has improved. Normal vision for the 5-year-old is 20/30. Page Ref: 440 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 1. Describe usual physical development from infancy through adolescence. MNL Learning Outcome: 1. Recognize the physical development and characteristics of the different stages of development from infancy through adolescence.
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15) During an auditory screening of third graders, the school nurse identifies a hearing deficit for one of the students. When asked about the findings, how should the nurse respond? 1. "Hearing acuity is not fully developed in your child. Let's recheck next year." 2. "I'd like to recheck at the clinic. Then we may need to have your child be seen by an auditory specialist." 3. "It was too noisy when we were testing, so I wouldn't be concerned if I were you." 4. "Your child will probably need a hearing aid." Answer: 2 Explanation: Auditory perception is fully developed in school-age children, who are able to identify fine differences in voices, both in sound and pitch. Rechecking the results with a possible referral would be appropriate at this level. Page Ref: 444 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 1. Describe usual physical development from infancy through adolescence. MNL Learning Outcome: 1. Recognize the physical development and characteristics of the different stages of development from infancy through adolescence.
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16) The nurse is addressing the developmental needs of grade school students according to Erikson's theory of industry versus inferiority. Which activities should the nurse suggest? 1. Providing time for running and playing sports, such as basketball, to increase gross motor skills 2. Allowing "pretend" time during their classes, such as for dress-up or role-playing activities 3. Presenting diversity in culture and practices as part of classroom study 4. Helping them develop skills needed in the adult world, such as allowance budgeting Answer: 4 Explanation: School-age children are motivated by activities that provide a sense of worth. They concentrate on mastering skills that will help them function in the adult world. Page Ref: 444 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 3. Trace psychosocial development according to Erikson from infancy through adolescence. MNL Learning Outcome: 2. Explore psychological, cognitive, moral, and spiritual development according to key theorists from infancy through adolescence.
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17) The parents of a school-age child are concerned about the child learning right from wrong. In which order should the nurse explain that moral development will develop in the child? 1. Punishment and obedience 2. Law-and-order orientation 3. Instrumental—relativist orientation 4. "Good boy—nice girl" stage Answer: 1, 4, 2, 3 Explanation: 1. School-age children are in Kohlberg's stage 1 of the preconventional level (punishment and obedience); that is, they act to avoid being punished. 2. Stage 4 is the law-and-order orientation. The motivation for moral action at this stage is to live up to what significant others think of the child. 3. Stage 2 is the instrumental—relativist orientation. These children do things to benefit themselves. Fairness, in which everyone gets a fair share or chance, becomes important. 4. Stage 3 is the "good boy—nice girl" stage. The child shifts from the concrete interests of individuals to the interests of groups. Page Ref: 445 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Describe moral development according to Kohlberg from childhood through adolescence. MNL Learning Outcome: 2. Explore psychological, cognitive, moral, and spiritual development according to key theorists from infancy through adolescence.
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18) The school health nurse is identifying education programs for high school students besides the dangers of unprotected sex or drug and alcohol abuse. Which class topic should the nurse present to these students? 1. Warning signs of depression for peers to identify among their classmates 2. Injury prevention 3. Early signs of cancer and heart disease 4. Normal physiological changes of this age group Answer: 1 Explanation: The rate of attempted suicide in female adolescents is higher than for males. There has been a linear decline in the prevalence of adolescents who have seriously considered suicide. Suicide by an adolescent may be reported as an accidental death. Motor vehicle crashes, drug and alcohol overdoses, firearm injuries, and even homicides can be disguised suicides. Psychological, social, and physiological stressors are apparent causes for many suicides. Students would benefit from understanding what to look for in their peers. Page Ref: 450 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 8. Identify essential activities of health promotion and protection to meet the needs of infants, toddlers, preschoolers, school-age children, and adolescents. MNL Learning Outcome: 4. Recognize essential activities of health promotion and protection to meet the needs of infants, toddlers, preschoolers, school-age children, and adolescents.
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19) While the nurse is teaching a group of parents and their teenage sons about puberty and sexual growth, a parent asks if fertility coincides with ejaculation. What should the nurse respond to this question? 1. "Yes, if your son is ejaculating, he also possesses fertility." 2. "Sexual maturity does not occur until age 18, so don't worry about anything until then." 3. "Fertility follows several months after the first ejaculation." 4. "You'll have to ask your physician about this because it is a sensitive subject." Answer: 3 Explanation: The milestone of male puberty is considered to be the first ejaculation, which commonly occurs at about 14 years of age. Fertility follows several months later, with sexual maturity achieved by age 18. Page Ref: 447 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 1. Describe usual physical development from infancy through adolescence. MNL Learning Outcome: 1. Recognize the physical development and characteristics of the different stages of development from infancy through adolescence. 20) The nurse suspects that an adolescent is working through the stages of spiritual development. What observations did the nurse make to come to this conclusion? (Select all that apply.) 1. Imitated behavior demonstrated by parents 2. Conceptualized angels and devils with the use of imagination 3. Compartmentalized differences between spiritual beliefs with friends 4. Determined differences between spiritual beliefs as being right or wrong 5. Met with the church priest to talk about the differences in spiritual beliefs Answer: 3, 4, 5 Page Ref: 449 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Evaluation Learning Outcome: 6. Describe spiritual development according to Fowler throughout adulthood. MNL Learning Outcome: 2. Explore psychological, cognitive, moral, and spiritual development according to key theorists from infancy through adolescence.
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21) An adolescent spends large amounts of time with friends, causing the parents to have concern. What should the nurse respond to the parents? 1. "You should really keep better track of your child. It's hard to tell what kinds of trouble she may be getting into." 2. "Independence is really important for this age group. Try to be extra attentive when your child does spend time at home." 3. "Use stricter guidelines for curfew and punishment if curfew is broken." 4. "Is it possible that your child might be taking drugs?" Answer: 2 Explanation: Many adolescents gradually draw away from the family and gain independence. This sometimes creates conflict within the family. The young person may appear hostile or depressed. It is not uncommon for adolescents to prefer to be with their peers rather than their families. Page Ref: 448 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 2. Identify tasks characteristic of different stages of development from infancy through adolescence. MNL Learning Outcome: 2. Explore psychological, cognitive, moral, and spiritual development according to key theorists from infancy through adolescence.
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22) An adolescent reports feels pressure to participate in activities such as drinking parties and sexual explorations. What should the nurse do? 1. Tell the adolescent to stay away from "friends like that." 2. Be open to the concerns and provide accurate information about any questions. 3. Encourage the adolescent to accept psychosocial counseling. 4. Give the adolescent pamphlets on sexually transmitted diseases. Answer: 2 Explanation: The nurse must present an open, accepting attitude to the adolescent's questions while encouraging the adolescent to find relationships that promote discussion of feelings, concerns, and fears. Page Ref: 451 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 8. Identify essential activities of health promotion and protection to meet the needs of infants, toddlers, preschoolers, school-age children, and adolescents. MNL Learning Outcome: 4. Recognize essential activities of health promotion and protection to meet the needs of infants, toddlers, preschoolers, school-age children, and adolescents. 23) Parents ask what to do when their child throws a temper tantrum. How should the nurse respond to this parent? 1. "Try to be more attentive to the behaviors that lead into a tantrum. Then you can avoid them." 2. "Put the child in a room alone and ignore the tantrum." 3. "Make sure the child is safe then walk away." 4. "Hold the child tightly until he stops crying." Answer: 3 Explanation: Making sure of safety, then walking away is part of fostering the toddler's psychosocial development. Page Ref: 438 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 8. Identify essential activities of health promotion and protection to meet the needs of infants, toddlers, preschoolers, school-age children, and adolescents. MNL Learning Outcome: 2. Explore psychological, cognitive, moral, and spiritual development according to key theorists from infancy through adolescence. 17
24) The school nurse is implementing a program to promote psychosocial development among adolescent teens at a high school. Which activity should the nurse include? 1. Career planning 2. Establishing peer groups 3. Playing musical instruments 4. Determining a value system Answer: 4 Explanation: Appropriate psychosocial activities for the adolescent include activities to help establish an appropriate value system. Page Ref: 451 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Planning Learning Outcome: 8. Identify essential activities of health promotion and protection to meet the needs of infants, toddlers, preschoolers, school-age children, and adolescents. MNL Learning Outcome: 4. Recognize essential activities of health promotion and protection to meet the needs of infants, toddlers, preschoolers, school-age children, and adolescents. 25) A baby was born with flaccid muscle tone, regular respirations with crying, a heart rate of 85, and blue extremities. What would the Apgar score be? 1. 6 2. 7 3. 5 4. 8 Answer: 1 Explanation: Flaccid muscle tone = 0. Regular respirations = 2. Crying = 2. Heart rate of 85 = 1. Blue extremities = 1. Total = 6. Page Ref: 435 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Describe usual physical development from infancy through adolescence. MNL Learning Outcome: 1. Recognize the physical development and characteristics of the different stages of development from infancy through adolescence.
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26) The nurse is preparing a teaching session for pregnant clients that reviews the fetal growth and development that occurs in the first 3 weeks post-conception. What should the nurse include in this teaching? (Select all that apply.) 1. How the embryo has attached to the wall of the uterus 2. Development of the fetal membranes and the amniotic sac 3. How the embryo will be covered with a protective substance called vernix caseosa 4. How development of the fetal placenta has begun 5. How the embryo is covered with a soft, downy hair Answer: 1, 2, 4 Page Ref: 429 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Planning/Teaching and Learning Learning Outcome: 1. Describe usual physical development from infancy through adolescence. MNL Learning Outcome: 1. Recognize the physical development and characteristics of the different stages of development from infancy through adolescence.
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27) The nurse is confident that a client has met the developmental guidelines for a preschooler. What did the nurse assess to make this clinical decision? (Select all that apply.) 1. Can print her own name. 2. Proudly announces, "I put my own toys away." 3. Shares that, "I know I shouldn't hit, even when I'm mad." 4. Effectively brushes her own teeth. 5. Washes her hands after toileting without prompting. Answer: 1, 2, 4 Explanation: Development is assessed when the child is able to print letters and numbers by 5 years of age. Development is assessed when the child is able to cooperate in doing simple chores by 5 years of age. Development is assessed when the child is able to perform simple hygiene measures by 5 years of age. Page Ref: 443 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 7. Identify assessment activities and expected characteristics from birth through late childhood. MNL Learning Outcome: 3. Recognize assessment activities and expected characteristics from birth through late childhood.
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28) The nurse is assessing a preschool-age child. Which behavior indicates that the client is successfully in the stage of initiative versus guilt? 1. Becomes upset with failure 2. Imitates a parent's behavior 3. Cries when the mother leaves the room 4. Argues about spending time with friends Answer: 2 Explanation: Behavior that a client is in the initiative versus guilt stage is imitating behavior. A preschool-age child would not be upset with failure, crying when the mother leaves the room, or arguing about spending time with friends. Page Ref: 441 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Trace psychosocial development according to Erikson from infancy through adolescence. MNL Learning Outcome: 2. Explore psychological, cognitive, moral, and spiritual development according to key theorists from infancy through adolescence.
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29) The nurse is assessing the cognitive development of an adolescent. Which finding indicates that the client is in the formal operations stage of cognitive development? 1. Thinks abstractly 2. Spends times with peers 3. Engages in organized sports 4. Decides differences are wrong Answer: 1 Explanation: In social interactions, adolescents often practice the ability to think abstractly. Spending time with peers, engaging in organized sports, and deciding that differences are wrong do not demonstrate that the client is in the formal operations stage of cognitive development. Page Ref: 449 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Explain cognitive development according to Piaget from infancy through adolescence. MNL Learning Outcome: 2. Explore psychological, cognitive, moral, and spiritual development according to key theorists from infancy through adolescence.
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30) The nurse observes a child ask a parent a "why" question about a social issue. For which age should the nurse plan teaching for the parent? 1. Toddler 2. School-age 3. Adolescent 4. Preschool-age Answer: 4 Explanation: Preschool-age children will ask "why" questions that should be answered in order to help the child develop values. This behavior would not occur in a toddler, school-age child, or adolescent. Page Ref: 442 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Planning/Teaching and Learning Learning Outcome: 5. Describe moral development according to Kohlberg from childhood through adolescence. MNL Learning Outcome: 2. Explore psychological, cognitive, moral, and spiritual development according to key theorists from infancy through adolescence.
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31) A parent asks if a preschool child should be enrolled in Sunday school. Which response should the nurse make? 1. "Only if you attend with the child." 2. "Wait until the child starts attending school." 3. "The child will enjoy the social interaction." 4. "It might cause the child to have nightmares." Answer: 3 Explanation: Many preschoolers enroll in Sunday school or faith-oriented classes. The preschooler usually enjoys the social interaction of these classes. The parent does not need to attend with the child. The child does not need to wait until attending school. These classes are not identified as causing nightmares. Page Ref: 442 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 6. Describe spiritual development according to Fowler throughout adulthood. MNL Learning Outcome: 2. Explore psychological, cognitive, moral, and spiritual development according to key theorists from infancy through adolescence.
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32) The parent of an adolescent female client is concerned about the client's height and weight. Which information should the nurse include in response to the parent? (Select all that apply.) 1. The fastest rate of growth in females is at age 12 2. A female achieves maximum height at about age 15 or 16 3. An average female doubles body weight from ages 10 to 18 4. An average female gains about 55 lbs. between ages 10 to 18 5. An average female will grow an additional 1 to 2 cm in their 20s Answer: 1, 2, 4 Explanation: The fastest rate of growth in females is at age 12. A female does achieve maximum height at about age 15 or 16. An average female will gain about 55 lbs. between the ages of 10 to 18. Page Ref: 447 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Identify assessment activities and expected characteristics from birth through late childhood. MNL Learning Outcome: 3. Recognize assessment activities and expected characteristics from birth through late childhood.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 25 Promoting Health in Young and Middle-Aged Adults 1) The nurse is providing pre-employment physicals to a group of adults, age 30-40. In which generation should the nurse categorize these adults? 1. Baby Boomers 2. Generation X 3. Generation Y 4. Millennials Answer: 2 Explanation: Generation X includes individuals born in the years 1965 to 1980. Page Ref: 455 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Compare and contrast the following generational groups: Baby Boomers, Generation X, Generation Y, and the iGeneration. MNL Learning Outcome: 1. Recognize the physical development occurring in young and middle-aged adults.
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2) A client reports that an adult child has moved back home, which is causing issues in the family. Which factor should the nurse identify that is least likely contributing to this trend? 1. Maladaptive behavior 2. High unemployment rate 3. High housing costs 4. High incidence of chronic disease Answer: 4 Explanation: These young adults, known as "boomerang kids," have moved back into their parents' homes after an initial period of independent living. Chronic disease is not a factor that has contributed to this trend. Page Ref: 456 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Compare and contrast the following generational groups: Baby Boomers, Generation X, Generation Y, and the iGeneration. MNL Learning Outcome: 1. Recognize the physical development occurring in young and middle-aged adults.
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3) The nurse is observing a group of young adults engaged in a discussion regarding work schedules over the holidays. What should the nurse realize that these adults will use to balance the emotional as well as logical side of the discussion? 1. Formal operational stage 2. Postformal thought process 3. Kohlberg's theory of moral development 4. Fowler's spiritual development theory Answer: 2 Explanation: Postformal thought, sometimes called the problem-finding stage, is characterized by creative thought, realistic thinking, problem forming, and problem solving. Postformal thinkers are able to comprehend and balance arguments created by both logic and emotion. Page Ref: 457 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify characteristic tasks of psychosocial development during young and middle adulthood. MNL Learning Outcome: 2. Explore psychological, cognitive, moral, and spiritual development according to key theorists for young and middle-aged adults.
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4) The nurse working in a community health office that is often frequented by young adults is assessing clients for suicide. Which factors should the nurse identify as indicating a problem in this area? (Select all that apply.) 1. Decreased interest in work 2. Weight loss 3. Depression 4. Brain dysfunction, including tumors 5. Sleep disturbances Answer: 1, 2, 3, 5 Explanation: The nurse's role in the prevention of suicide includes identifying behaviors that may indicate potential problems, including decreased interest in work roles, weight loss, depression, and sleep disturbances. Page Ref: 458-459 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 7. Identify selected health risks associated with young and middle-aged adults. MNL Learning Outcome: 4. Recognize essential activities of health promotion and protection to meet the needs of young and middle-aged adults.
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5) An occupational health nurse is providing a hypertension screening at a local manufacturing plant. Among the employees, the nurse should focus on which population? 1. Males and females equally 2. African American males 3. Asian American females 4. Caucasian females Answer: 2 Explanation: Hypertension is a major problem for young African American adults, particularly men. The causes for this are unknown. Page Ref: 459 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 7. Identify selected health risks associated with young and middle-aged adults. MNL Learning Outcome: 4. Recognize essential activities of health promotion and protection to meet the needs of young and middle-aged adults.
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6) A nurse is working in a community of factory workers and is planning an educational session for wellness, targeting the young adult group. In order to address one of the health problems of this group, which should the nurse plan to do? 1. Help the group become more aware of marketing efforts by tobacco companies. 2. Tell this group that smoking is unacceptable. 3. Make sure the group is aware of the increased risk of liver disease and cancer of the esophagus. 4. Counsel the group regarding addiction. Answer: 1 Explanation: Smoking is a type of drug abuse prevalent in this age group, which can lead to lung cancer and cardiovascular disease. The nurse's role regarding smoking is to serve as a role model by not smoking, provide educational information regarding the dangers of smoking (not just "tell" or "counsel" about it), help make smoking socially unacceptable, suggest resources such as hypnosis, and assist with lifestyle training and behavior modification to clients who desire to stop smoking. Page Ref: 459 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Planning Learning Outcome: 7. Identify selected health risks associated with young and middle-aged adults. MNL Learning Outcome: 4. Recognize essential activities of health promotion and protection to meet the needs of young and middle-aged adults.
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7) During an educational session regarding physical changes of the middle-aged adult, a participant asks about typical weight changes. How should the nurse respond? 1. "Weight loss is no different during this time than at any other time of your life." 2. "Metabolism slows during middle age, which may result in weight gain." 3. "As long as you exercise appropriately, weight loss will be ensured." 4. "Weight loss is always a good idea, regardless of your age." Answer: 2 Explanation: The nurse should educate clients regarding physical changes occurring in their bodies. Age does make a difference in how the body responds to diet and exercise, and it is important for nurses to be well informed and educated regarding age-related changes. Page Ref: 461-462 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 9. List examples of health promotion topics for young and middle adulthood. MNL Learning Outcome: 4. Recognize essential activities of health promotion and protection to meet the needs of young and middle-aged adults.
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8) A client comes to the clinic with a history of pain in his testicle. During the interview assessment, what information should be of concern to the nurse? 1. The client works as an auto-detailer. 2. He smokes half a pack of cigarettes per week. 3. He has not had a yearly exam for 5 years. 4. He does not perform testicular self-exams. Answer: 3 Explanation: Testicular cancer is the most common neoplasm in men between the ages of 20 and 34. Monthly testicular self-examination, a means of early identification of malignancy, used to be recommended for all men. More recent recommendations from the American Cancer Society (ACS) are that men should have a testicular exam as part of a yearly physical exam. Page Ref: 463-464 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 8. Identify developmental assessment guidelines for young and middle-aged adults. MNL Learning Outcome: 3. Recognize assessment activities and expected characteristics for young and middle-aged adults.
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9) A young female client comes into the emergency department with vague physical symptoms and does not make eye contact with the nurse during the interview. In order to best assess the client, what should the nurse ask? 1. "Can you tell me what's been going on in your life lately?" 2. "What kind of problems are you having?" 3. "Is someone hurting you?" 4. "Can you explain what your family life is like?" Answer: 3 Explanation: The nurse who works with women should explicitly ask if the young adult is frightened or hurt by someone she knows. It is essential that nurses make assessment for domestic violence part of their routine. Page Ref: 458 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 7. Identify selected health risks associated with young and middle-aged adults. MNL Learning Outcome: 4. Recognize essential activities of health promotion and protection to meet the needs of young and middle-aged adults. 10) The nurse is providing education regarding early detection of breast cancer to a group of women between the ages of 30 and 40. According to recommendations from the American Cancer Society, which should the nurse instruct the clients to do? 1. Monthly breast self-exams 2. Yearly mammogram 3. See a physician if there is a strong family history of breast cancer 4. Have an annual breast exam performed by a healthcare provider Answer: 1 Explanation: Breast self-exam (BSE) is an option for women starting in their 20s. Page Ref: 460 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 9. List examples of health promotion topics for young and middle adulthood. MNL Learning Outcome: 4. Recognize essential activities of health promotion and protection to meet the needs of young and middle-aged adults. 9
11) A community health nurse is doing a screening for cervical cancer at a women's health fair. Which client should the nurse identify as having the highest risk factor for cervical cancer? 1. The client who had a difficult vaginal delivery 2 years ago 2. The client who has a history of genital herpes 3. The client who was married at age 27 4. The client who has a sister with breast cancer Answer: 2 Explanation: High risk factors for cervical cancer include sexual activity at an early age, multiple sexual partners, and a history of syphilis, herpes genitalis, or trichomonas vaginitis. Page Ref: 460 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 8. Identify developmental assessment guidelines for young and middle-aged adults. MNL Learning Outcome: 3. Recognize assessment activities and expected characteristics for young and middle-aged adults. 12) A 30-year-old client who plans to travel extensively within the United States asks the nurse about appropriate immunizations. What should the nurse recommend to this client? 1. The client should have a tetanus booster if the client has not had one within the last 5 years. 2. The client should have the hepatitis B immunization series. 3. The client should receive a meningococcal vaccine if the client did not receive one as a teen. 4. The client should not worry about immunizations, as they are not recommended for this age group. Answer: 3 Explanation: Recommended immunizations for this age group include the meningococcal vaccine if not given in early adolescence. Page Ref: 461 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 8. Identify developmental assessment guidelines for young and middle-aged adults. MNL Learning Outcome: 3. Recognize assessment activities and expected characteristics for young and middle-aged adults. 10
13) A nurse is presenting an educational session regarding psychosocial development to a group of middle-aged adults. According to Erikson's theory, what activity should the nurse select to best meet the needs of this stage? 1. Providing opportunities to mentor school-age children 2. Giving the group handouts regarding peer socialization 3. Helping the members of this group find appropriate civic responsibility 4. Assisting the group members to look at their life accomplishments Answer: 1 Explanation: Erikson viewed the developmental choice of the middle-aged adult as generativity versus stagnation. Generativity is defined as concern for establishing and guiding the next generation. This could be accomplished through a mentor program with school-age children. Page Ref: 462 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 3. Identify characteristic tasks of psychosocial development during young and middle adulthood. MNL Learning Outcome: 2. Explore psychological, cognitive, moral, and spiritual development according to key theorists for young and middle-aged adults.
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14) While assisting in a community health project for middle-aged adults, the nurse attempts to identify members of the community who have been successful in the tasks identified by Erikson. What characteristic should the nurse identify in the community members? 1. Ability to have satisfaction in their volunteer activities 2. Ability to find an acceptable social group 3. Satisfaction with rearing children 4. Ability to manage a home Answer: 1 Explanation: Erikson identifies this stage as generativity versus stagnation. Generative middleaged persons are able to feel a sense of comfort in their lifestyle and receive gratification from charitable endeavors. Page Ref: 462 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify characteristic tasks of psychosocial development during young and middle adulthood. MNL Learning Outcome: 2. Explore psychological, cognitive, moral, and spiritual development according to key theorists for young and middle-aged adults.
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15) The nurse is providing assistance at a community health fair for middle-aged clients. Which information should the nurse use when working with this group of clients? 1. The middle-aged person has decreased intellectual and cognitive abilities as a result of the normal aging process. 2. Adults make the transition into this stage easily and without problems. 3. Physical capabilities and functions decrease with age, but mental and social capacities tend to increase in the latter part of life. 4. Cognitive and intellectual abilities are somewhat decreased due to slower reaction time, loss of memory, and changes in perception and problem solving. Answer: 3 Explanation: Physical capabilities and functions do decrease with age, but mental and social capacities actually increase in the latter part of life. Page Ref: 461-462 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Planning/Teaching and Learning Learning Outcome: 8. Identify developmental assessment guidelines for young and middle-aged adults. MNL Learning Outcome: 2. Explore psychological, cognitive, moral, and spiritual development according to key theorists for young and middle-aged adults.
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16) The nurse can identify movement into Kohlberg's postconventional level when the client, after being asked about work, makes which statement? 1. "Oh, the work isn't so bad anymore. I'm getting close to retirement." 2. "Work is fine, but my family and friends are so much more important to me." 3. "I've done a good job for the company. I'm proud of my years there." 4. "I don't like to talk about work when I'm not there." Answer: 2 Explanation: According to Kohlberg, the extensive experience of personal moral choice and responsibility is required to move into the postconventional level. Movement from a law-andorder orientation to a social contract orientation requires that the individual move to a stage in which rights of others take precedence–as in the statement that work is OK, but family and friends are more important. Page Ref: 463 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Describe moral development according to Kohlberg throughout adulthood. MNL Learning Outcome: 2. Explore psychological, cognitive, moral, and spiritual development according to key theorists for young and middle-aged adults.
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17) The nurse is preparing information for a community health education seminar. Which statement should the nurse include regarding disease for the middle-aged adult? 1. Cancer is the leading cause of death in the age group from 25 to 64 years. 2. Coronary heart disease is the leading cause of death. 3. Leading causes of death include suicide and motor-vehicle crashes. 4. Injuries and chronic disease are the leading causes of death in this age group. Answer: 4 Explanation: Motor-vehicle crashes as well as occupational injuries along with chronic disease such as cancer and cardiovascular disease combined make up the leading causes of death in the middle-aged adult group. Page Ref: 463-464 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 5. Describe moral development according to Kohlberg throughout adulthood. MNL Learning Outcome: 2. Explore psychological, cognitive, moral, and spiritual development according to key theorists for young and middle-aged adults.
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18) A middle-aged client is struggling with life changes, including menopause. What is the best response by the nurse to this client? 1. "Don't worry–menopause can't last forever." 2. "There are some very good antidepressants you can take." 3. "What did your mother do to get through menopause?" 4. "There is a menopause support group that meets every 2 weeks." Answer: 4 Explanation: Clients experiencing developmental stressors like menopause, the climacteric, aging, impending retirement, or any other situational stressors may experience anxiety and depression. These clients may benefit from support groups or individual therapy to help them cope with specific crises. Page Ref: 461-462 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 9. List examples of health promotion topics for young and middle adulthood. MNL Learning Outcome: 4. Recognize essential activities of health promotion and protection to meet the needs of young and middle-aged adults.
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19) A group of middle-aged clients is inquiring about nutrition-related health problems inherent in their age group. In order to best address these concerns of this specific age group, the nurse should take which action? 1. Provide information, including a website, regarding age-specific diet plans. 2. Give all clients a handout on diets recommended by the ADA. 3. Tell the clients to check with their physician before dieting. 4. Have them write to the U.S. Department of Agriculture for more information. Answer: 1 Explanation: Decreased metabolic activity and decreased physical activity mean a decrease in caloric needs. This particular age group must be educated regarding nutrition, exercise, and the relationship of nutrition and exercise to chronic diseases such as diabetes mellitus and heart problems. Page Ref: 464 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 7. Identify selected health risks associated with young and middle-aged adults. MNL Learning Outcome: 4. Recognize essential activities of health promotion and protection to meet the needs of young and middle-aged adults.
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20) The nurse is working with young adults in the community. What should the nurse realize as being the psychosocial developmental tasks of this population? (Select all that apply.) 1. Selecting a mate 2. Rearing children 3. Achieving civic responsibility 4. Finding a congenial social group 5. Developing adult leisure-time activities Answer: 1, 2, 4 Explanation: Selecting a mate, rearing children, and finding a congenial social group are tasks appropriate for this age group. Page Ref: 456 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify characteristic tasks of psychosocial development during young and middle adulthood. MNL Learning Outcome: 2. Explore psychological, cognitive, moral, and spiritual development according to key theorists for young and middle-aged adults. 21) A client approaching middle age asks for information to keep mentally sharp. What should the nurse explain about the cognitive abilities of the middle-aged client? (Select all that apply.) 1. Reaction time stays much the same. 2. Memory is maintained during this time. 3. Learning declines and cannot be completed. 4. Problem-solving ability is maintained during this time. 5. Cognitive and intellectual abilities change very little at this time. Answer: 1, 2, 4, 5 Explanation: The middle-aged adult's reaction time, memory, problem-solving ability, and cognitive and intellectual abilities are maintained during the middle years. Page Ref: 463 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 4. Explain changes in cognitive development throughout adulthood. MNL Learning Outcome: 2. Explore psychological, cognitive, moral, and spiritual development according to key theorists for young and middle-aged adults. 18
22) The nurse is confident that a young adult has successfully achieved psychosocial development. What observations about the client did the nurse make to come to this conclusion? (Select all that apply.) 1. Discusses plans to expand his exercise routine to include running 2. Is optimistic about finding a new job 3. Volunteers weekly at the local senior center 4. Recognizes that professional sports may be enjoyed but does not aspire to participating 5. May be "too bald" to play Santa Claus Answer: 1, 2, 4 Explanation: The psychosocial development of a young adult would include keeping good health habits. The ability to cope with stressors appropriately, and having a realistic self-concept. Page Ref: 456 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify characteristic tasks of psychosocial development during young and middle adulthood. MNL Learning Outcome: 2. Explore psychological, cognitive, moral, and spiritual development according to key theorists for young and middle-aged adults.
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23) The nurse is completing a spiritual assessment with a middle-aged client. What should the nurse recognize as expected characteristics of moral development in this client? (Select all that apply.) 1. Uses religion for comfort 2. Seeks religious explanations for death 3. Compares characteristics of various religions 4. Questions the purpose of religion in one's life 5. Relies upon spiritual beliefs to help with illness Answer: 1, 2, 5 Explanation: In middle age, people tend to be less dogmatic about religious beliefs, and religion often offers more comfort to the middle-aged person than it did previously. People in this age group often rely on spiritual beliefs to help them deal with death. People in this age group often rely on spiritual beliefs to help them deal with illness. Page Ref: 463 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Development Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 6. Describe spiritual development according to Fowler throughout adulthood. MNL Learning Outcome: 2. Explore psychological, cognitive, moral, and spiritual development according to key theorists for young and middle-aged adults.
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24) The nurse assesses a 25-year-old male client. Which should the nurse expect when completing this assessment? 1. Heart problems 2. Decline in height 3. Unexpected weight gain 4. Peak muscle development Answer: 4 Explanation: The human body is at its most efficient functioning at about age 25 years. The musculoskeletal system is well developed and coordinated. Heart problems, decline in height, and unexpected weight gain are more associated with an older adult. Page Ref: 456 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Describe the usual physical development occurring during young and middle adulthood. MNL Learning Outcome: 1. Recognize the physical development occurring in young and middle-aged adults. 25) An older client is concerned about an unplanned weight gain. Which response should the nurse make to this client? 1. "Retaining water with aging causes a weight gain." 2. "It is likely caused by an undiagnosed chronic illness." 3. "Muscle changes to adipose tissue, causing a weight gain." 4. "The metabolism slows with aging, which may result in weight gain." Answer: 4 Explanation: Weight gain in an older adult can occur because of metabolism slowing. The older person does not gain weight because of water retention, an undiagnosed chronic illness, or muscle changing to adipose tissue. Page Ref: 462 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 2. Describe the usual physical development occurring during young and middle adulthood. MNL Learning Outcome: 1. Recognize the physical development occurring in young and middle-aged adults. 21
26) A young adult client reports meditating every day before going to work. Which should the nurse expect to be affected by the client's practice? 1. Reduction in caloric intake 2. Improved postformal thinking 3. Change in attitude about religion 4. Enhanced postconventional level of moral development Answer: 2 Explanation: Meditation and other insight-oriented practices facilitate becoming a postformal thinker. Meditation does not impact caloric intake, attitude about religion, or enhance the postconventional level of moral development. Page Ref: 457 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Explain changes in cognitive development throughout adulthood. MNL Learning Outcome: 2. Explore psychological, cognitive, moral, and spiritual development according to key theorists for young and middle-aged adults. 27) A young adult client believes that there are many ways to express belief in a "higher power." In which way should the nurse describe the client's statement? 1. Questioning the purpose of religion 2. Spiritual but not necessarily religious 3. Religious but not necessarily spiritual 4. Using religion when faced with challenges Answer: 2 Explanation: Individuals who are young adults are noted as being spiritual but not necessarily religious. The young adult client is not questioning the purpose of religion. The client is not demonstrating being religious or using religion when faced with challenges. Page Ref: 457 Cognitive Level: Applying Client Need/Sub: Psychosocial Development Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 6. Describe spiritual development according to Fowler throughout adulthood. MNL Learning Outcome: 2. Explore psychological, cognitive, moral, and spiritual development according to key theorists for young and middle-aged adults. 22
Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 26 Promoting Health in Older Adults 1) A nurse is working with a group of clients in a community center, all over the age of 85. How should the nurse classify this group of clients? 1. Young-old 2. Middle-old 3. Old-old 4. Elite-old Answer: 3 Explanation: Those of age 85 to 100 are old-old. Page Ref: 469 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Identify the different categories of older adults as they range from 65 to 100 years of age. MNL Learning Outcome: 1. Explain characteristics of, attitudes towards, and care settings for older adults. 2) The nurse is planning care for an older adult client. On what should the nurse focus if following the Functional Consequences Theory on aging? (Select all that apply.) 1. Promote safety. 2. Promote mental health. 3. Improve quality of life. 4. Promote spiritual health. 5. Promote growth and development. Answer: 1, 3 Page Ref: 472 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. List the common biological theories of aging. MNL Learning Outcome: 2. Recognize the theories of aging and the effects of physiological changes associated with aging.
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3) The nurse is presenting a health education program to a group of older adults at a senior citizens center. Considering the physiological changes of this age group, how should the nurse set the temperature of the room? 1. It should be set at a temperature that is comfortable for the nurse. 2. It should be set cooler than what is comfortable for the nurse. 3. It should be set warmer than the nurse's preference. 4. The temperature of the room is not one of the nurse's concerns. Answer: 3 Explanation: Because elderly persons have a loss of subcutaneous fat, their tolerance of cold is decreased and they typically enjoy warmer temperatures. Page Ref: 474 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 1. Describe the demographic, socioeconomic, ethnicity, and health characteristics of older adults in the United States. MNL Learning Outcome: 2. Recognize the theories of aging and the effects of physiological changes associated with aging.
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4) In the review of an older client's chart, the nurse reads that the client has sarcopenia. What should the nurse expect the client to report? 1. Weight loss and nausea 2. Hair loss and thin skin 3. Bleeding and bruising tendencies 4. Lack of strength and tiring easily Answer: 4 Explanation: Sarcopenia is defined as a steady decrease in muscle fibers, a normal physiological change of aging. The age-related mechanism appears to be related to denervation of the muscle and causes older adults to often complain about their lack of strength and how quickly they tire. Page Ref: 476 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 8. Describe the usual physical changes that occur during older adulthood. MNL Learning Outcome: 4. Examine the health problems, and health promotion needs of older adults. 5) An elderly client comes to the clinic for follow-up after a long hospitalization. When the client asks about increasing strength and endurance, what should the nurse respond? 1. "Your muscles can be strengthened, which might help you function better." 2. "It won't matter if you exercise. At your age, there's little room for improvement." 3. "Once muscle mass is decreased, there's nothing that can be done for strength improvement." 4. "Maybe you should think about going to a nursing home. At least the people there will be able to help with your needs." Answer: 1 Explanation: There is evidence that an older adult's muscles can be strengthened through exercise and training, with concomitant improvements in functional status. Page Ref: 474 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 8. Describe the usual physical changes that occur during older adulthood. MNL Learning Outcome: 4. Examine the health problems, and health promotion needs of older adults. 3
6) A group of elderly women come to the community center for exercise classes taught by the community health nurse. This activity will help lead to which outcome for these clients? 1. Reverse the effects of aging and cure pain. 2. Slow bone density loss and decrease muscle atrophy. 3. Eliminate the risk for osteoporosis. 4. Prevent pathologic fractures. Answer: 2 Explanation: Programs of physical activity and proper nutrition will slow bone density loss and decrease muscle atrophy and stiffness that occur with aging. Page Ref: 476 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 8. Describe the usual physical changes that occur during older adulthood. MNL Learning Outcome: 4. Examine the health problems, and health promotion needs of older adults. 7) The nurse is teaching a wellness class for older adults. In order to address the sensory loss that accompanies the aging process, the nurse should recommend that these clients take which action? 1. Use hearing aids and glasses. 2. Wear shaded glasses indoors to reduce glare. 3. Switch to brighter lighting in their home. 4. Exercise more and increase calcium intake. Answer: 3 Explanation: Changes in vision associated with aging include loss of visual acuity, less power of adaptation to darkness and dim light, decrease in accommodation to near and far objects, loss of peripheral vision, and difficulty in discriminating similar colors. Having brighter lighting in their home may help with some of these vision changes. Page Ref: 478 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 15. Describe selected health problems associated with older adults. MNL Learning Outcome: 4. Examine the health problems, and health promotion needs of older adults. 8) The school nurse is bringing a group of students to a nursing home for a social exchange 4
project. Before the students arrive, the nurse reminds them to do what when speaking to the residents? 1. Speak as loud as they can. 2. Speak into the residents' ears. 3. Write out what they want to say on a piece of paper. 4. Speak distinctly, while facing the residents. Answer: 4 Explanation: Hearing loss in older adults is greater in the higher frequencies than the lower ones. Older adults with hearing loss usually hear speakers with low, distinct voices best, and it is always appropriate to speak while facing a target. Page Ref: 478 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 8. Describe the usual physical changes that occur during older adulthood. MNL Learning Outcome: 4. Examine the health problems, and health promotion needs of older adults. 9) The nurse is preparing an education program on safety concerns for elderly adults living in their own homes. To address the sensory changes in this age group, what should the nurse recommend? 1. Have carbon monoxide detectors that are checked on a scheduled basis. 2. Place a list of emergency numbers near the phone. 3. Install telephones that use a blinking light instead of a ringer. 4. Ask someone to do their cooking for them. Answer: 1 Explanation: A decreased or absent sense of smell adds to the safety issues of this age group. Because of this, and if the elderly person's home has natural gas appliances or furnace, a carbon monoxide detector would alert the person of any gas leaks or problems present. Page Ref: 489 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 16. List examples of health promotion topics for older adulthood. MNL Learning Outcome: 4. Examine the health problems, and health promotion needs of older adults. 5
10) An older client has a blood pressure measurement of 146/80 mm Hg. What should the nurse say to this client? 1. "Having blood pressure a little high is normal at your age. Yours is fine." 2. "I'll recheck this in a while, but your systolic pressure is too high." 3. "We'll wait and see what the doctor says, but I doubt he will be concerned." 4. "You should be on medicine for high blood pressure." Answer: 2 Explanation: Isolated systolic hypertension was considered to be "normal" in older adults and was frequently not treated. Now, evidence indicates that a systolic pressure of greater than 140 mm Hg is as problematic in older adults as in younger ones and should be treated. Page Ref: 475 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 15. Describe selected health problems associated with older adults. MNL Learning Outcome: 4. Examine the health problems, and health promotion needs of older adults. 11) An older client comes to the clinic reporting gastrointestinal problems, including frequent constipation and indigestion, but denies any recent weight loss. What should these symptoms indicate to the nurse? 1. Could be caused by cancer 2. The need for an upper and lower GI x-ray series 3. Normal changes in muscle tone and activity 4. A gastric ulcer or colitis Answer: 3 Explanation: With the normal aging process, there is a decrease in muscle tone, digestive juices, and intestinal activity. These together may lead to indigestion and constipation in the older adult. Page Ref: 476 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 8. Describe the usual physical changes that occur during older adulthood. MNL Learning Outcome: 4. Examine the health problems, and health promotion needs of older adults. 12) An older client reports having urinary incontinence. In which way should the nurse respond? 6
1. "You shouldn't feel badly. Lots of people have this trouble." 2. "You'll probably have to start wearing incontinence briefs. Then you won't be worried about accidents." 3. "Getting old isn't much fun, is it?" 4. "There could be a number of causes for this. I need to ask you some more questions about it." Answer: 4 Explanation: Older clients may be susceptible to urinary incontinence (UI) because of changes in the kidneys and bladder. UI is never normal and the nurse must promptly investigate the cause, onset, and any other symptoms. Page Ref: 476 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 15. Describe selected health problems associated with older adults. MNL Learning Outcome: 4. Examine the health problems, and health promotion needs of older adults. 13) An older male client is upset because of a lack interest in sexual intercourse. What should the nurse explain about decreased sexual interest in older clients? 1. It does decrease and gradually disappears. 2. It should not be taken as seriously as it would be if the client were a younger person. 3. It is caused by decreased hormone activity and there is little that can be done about it. 4. It decreases but does not disappear. Answer: 4 Explanation: The major age-related change in sexual response is timing. It takes longer to become sexually aroused, longer to complete intercourse, and longer before sexual arousal can occur again. Page Ref: 480 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 8. Describe the usual physical changes that occur during older adulthood. MNL Learning Outcome: 4. Examine the health problems, and health promotion needs of older adults.
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14) The nurse is planning a health program for older adults. Which should the nurse expect the participants to demonstrate if successfully achieving the developmental task of ego integrity versus despair? 1. Have a feeling of satisfaction from past accomplishments 2. Make connections with the younger generation 3. Desire to live life over again 4. Live out last years in physical health Answer: 1 Explanation: Erikson's task of this developmental stage is integrity versus despair. People who develop integrity accept their lives with a sense of wholeness and satisfaction with their past accomplishments. Page Ref: 481 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation Learning Outcome: 10. Describe developmental tasks of the older adult. MNL Learning Outcome: 2. Recognize the theories of aging and the effects of physiological changes associated with aging. 15) When consulting Erikson's developmental theory, the nurse determines that which older adult will have the least difficulty being successful with the task of this stage? 1. A client who felt success through her children's accomplishments 2. A client who held his job and work status as the defining feature of his life 3. A client who maintained a balance between work and home 4. A client who planned to really enjoy life once she retired Answer: 3 Explanation: People who learned early in life to live well-balanced and fulfilling lives are generally more successful in retirement. Page Ref: 481 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 9. List the common psychosocial theories about aging. MNL Learning Outcome: 2. Recognize the theories of aging and the effects of physiological changes associated with aging.
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16) A gerontological nurse is helping a potential home health client acquire the supplies that will be needed once the client is discharged from acute care. When considering these supplies, what should the nurse recall? 1. Medicare will cover supplies, but only with a physician's written order. 2. Between insurance supplements and Medicare, the older client shouldn't have any difficulty with coverage. 3. Most clients in this age group live on a fixed income, and supplies used should be as economical as possible. 4. Clients have to be responsible for their own supplies. Answer: 3 Explanation: The financial needs of this age group vary considerably, and problems with income are related to low retirement benefits, lack of pension plans, and increasing length of retirement years. Nurses should be aware of the costs of healthcare and use supplies that are as economical as possible. Page Ref: 482 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 1. Describe the demographic, socioeconomic, ethnicity, and health characteristics of older adults in the United States. MNL Learning Outcome: 3. Recognize the sociological, psychological, economic, and cognitive changes associated with aging.
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17) A group of older clients is interested in living options available in the community when they may need some assistance with their daily needs. What should the nurse suggest as possibilities to meet these needs? (Select all that apply.) 1. Adult foster care 2. Group homes 3. Retirement villages 4. Long-term care facilities 5. Adult day-care centers Answer: 1, 2, 5 Explanation: Adult foster care offers services to individuals who can care for themselves but require some form of supervision for safety purposes. Group homes offer services to individuals who can care for themselves but require some form of supervision for safety purposes. The older adult who lives at home can attend a day-care center that provides health and social services to the older person. While the older adult is at day-care, the caregiver has a respite from the daily care. Page Ref: 483 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 6. Describe the different care settings for older adults. MNL Learning Outcome: 1. Explain characteristics of, attitudes towards, and care settings for older adults.
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18) An older client who has had a stroke is ready for hospital discharge. How should the gerontological nurse case manager support this client's independence? 1. Allow the client to be actively involved in all decisions made. 2. Make arrangements based on what the nurse feels is in the best interest of the client. 3. Work closely with the social worker and physician to make the decisions necessary for the client. 4. Set up a meeting with the family members so decisions can be made. Answer: 1 Explanation: Nurses need to acknowledge the older client's ability to think, reason, and make decisions. Most elders are willing to listen to suggestions and advice, but they do not want to be ordered around. It would be quite appropriate to include the physician or primary care provider, social worker, as well as the family in the decision-making process, but always and foremost, to include the client. Page Ref: 484 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered-care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Describe the development of gerontological nursing and the roles of the gerontological nurse. MNL Learning Outcome: 3. Recognize the sociological, psychological, economic, and cognitive changes associated with aging.
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19) Some nursing students are doing their first clinical rotation in a long-term care facility. What should the nurse educator remind the students to do to meet the needs of this particular client group? 1. Do all care for the clients, as they're unable to do it independently. 2. Always remember that the clients' self-respect must be maintained in all interactions of the students. 3. Make sure the clients' care is done in a timely manner, and sometimes that means doing things for the client. 4. Treat this group of clients with a greater level of respect than younger clients. Answer: 2 Explanation: Older people appreciate the same thoughtfulness, consideration, and acceptance of their abilities as younger people do. Page Ref: 483 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 3. Describe ageism and its contribution to the development of negative stereotypes about older adults. MNL Learning Outcome: 1. Explain characteristics of, attitudes towards, and care settings for older adults.
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20) The nurse is working with clients in an assisted living facility. In the past month, there have been several deaths among the residents and their spouses. In helping the remaining residents deal with these deaths, the nurse understands that adjustment may be easier for which resident? 1. A resident who spent most of her days attending to her partner who is now deceased 2. A resident who had a wide circle of friends, besides her spouse 3. A resident who was not inclined to participate in any activities offered at the facility 4. A resident who started to become more dependent on the nursing staff at the facility Answer: 2 Explanation: Independence established prior to the loss of a mate makes adjustment easier. A person who had meaningful relationships and friendships or economic security, ongoing interests in the community or private hobbies, and a peaceful philosophy of life copes more easily with bereavement. Page Ref: 483-484 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 11. Describe psychosocial changes to which the older adult adjusts during the aging process. MNL Learning Outcome: 3. Recognize the sociological, psychological, economic, and cognitive changes associated with aging.
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21) The nurse who works in a long-term care facility has noticed that one of the residents has been showing signs of impaired cognitive and self-care abilities over the last 2 weeks. Which should the nurse do? 1. Remember that memory loss is a normal, age-related change 2. Investigate for possible physiological problems 3. Instruct the staff to be extra attentive, as this person needs more assistance 4. Inform the resident's family that the resident probably has some form of dementia Answer: 2 Explanation: Cognitive impairment that interferes with normal life is not considered part of normal aging. A decline in intellectual abilities that interferes with social or occupational functions should always be regarded as abnormal and be investigated. Page Ref: 484 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 12. Explain changes in cognitive abilities that occur during the aging process. MNL Learning Outcome: 4. Examine the health problems, and health promotion needs of older adults.
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22) A client has been diagnosed with dementia. The family wants to know how to plan for the future. What is the best response by the nurse? 1. "Your family member's symptoms will get worse, but there are medications to stop the progress." 2. "You should plan right now on which long-term care facility you will want to utilize when the time comes." 3. "Dementia is a progressive deterioration. It's important for you to clearly understand what to look for in symptoms." 4. "Dementia can be treated once the cause is known." Answer: 3 Explanation: Dementia is a progressive loss of cognitive function. The most common type is Alzheimer's disease. The cause is unknown. The most prominent symptoms are cognitive dysfunctions, including decline in memory, learning, attention, judgment, orientation, and language skills. Family members must be educated on the course of dementia and be encouraged to learn as much about coping skills as possible. Page Ref: 486 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 12. Explain changes in cognitive abilities that occur during the aging process. MNL Learning Outcome: 4. Examine the health problems, and health promotion needs of older adults.
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23) A client has had Alzheimer's dementia for a period of time and continues to live at home with the spouse. What would be one of the gerontological nurse's responsibilities? 1. Make sure the client is being prescribed appropriate medication. 2. Provide support for the spouse. 3. Assess the client early to ensure proper care. 4. Find a suitable long-term care facility for the client. Answer: 2 Explanation: The nurse's responsibility is to provide supportive nursing care, accurate information, and referral assistance, if necessary, to the caregiver. Caregivers may experience physical and emotional exhaustion while they render continuous care. Page Ref: 487 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Describe the development of gerontological nursing and the roles of the gerontological nurse. MNL Learning Outcome: 4. Examine the health problems, and health promotion needs of older adults. 24) The nurse is explaining the difference between dementia and delirium to the spouse of a client with Alzheimer's disease. What should the nurse say to make this distinction? 1. "Delirium is easily distinguished from dementia." 2. "Dementia is reversible and treatable." 3. "Delirium is an acute and reversible syndrome." 4. "Dementia is the only condition that is characterized by changes in memory, judgment, language, mathematic calculation, abstract reasoning, and problem-solving ability." Answer: 3 Explanation: Once the underlying pathology is treated, the delirium disappears. Page Ref: 487 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 15. Describe selected health problems associated with older adults. MNL Learning Outcome: 4. Examine the health problems, and health promotion needs of older adults.
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25) An older client being discharged has questions about medications and care at home. Which should the gerontological nurse do? 1. Inform the physician that the client needs to go to a nursing home 2. Assess the client's independence and ability to function in his own home before discharge 3. Tell the client not to worry about going home 4. Invite the client's family to come to the hospital so the nurse can explain the client's care to them Answer: 2 Explanation: Older adults often perceive that being in the hospital could change their ability to be autonomous and independent. As a result, the nurse needs to assess the older adult's stage or perception of need for control and autonomy during the hospitalization and fears and hopes about being discharged from the hospital setting. Page Ref: 488 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Describe the development of gerontological nursing and the roles of the gerontological nurse. MNL Learning Outcome: 4. Examine the health problems, and health promotion needs of older adults.
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26) The nurse is completing an assessment to determine an older patient's development of moral reasoning. Which observation indicates that the client has developed moral reasoning as anticipated? 1. Considers relationships as well as justice in moral decisions 2. Approaches moral decisions based on the consequences to self 3. Follows society's rules of conduct in response to the expectations of others 4. Bases moral judgments on connectedness to others and the value of relationships Answer: 1 Explanation: Older adults begin to make moral decisions that are consistent with the theories of both Kohlberg and Gilligan. Older men consider relationships, as well as justice, in moral decisions, and older women add justice to the factors they consider in moral situations. Page Ref: 485 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 13. Compare and contrast Kohlberg's and Gilligan's theories of moral reasoning in older adults. MNL Learning Outcome: 2. Recognize the theories of aging and the effects of physiological changes associated with aging. 27) The nurse is identifying health promotion needs for an older adult client. What should the nurse consider for this client? (Select all that apply.) 1. Offering to arrange a pneumococcal vaccine for a client turning 60 years old 2. Assessing the 62-year-old client for situational depression 3. Discussing smoking-cessation classes with a 64-year-old 4. Asking a 78-year-old client whether he had his cholesterol tested within the last 3 years 5. Measuring the 79-year-old client's height and weight Answer: 2, 3, 5 Page Ref: 489 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 16. List examples of health promotion topics for older adulthood. MNL Learning Outcome: 4. Examine the health problems, and health promotion needs of older adults.
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28) The nurse is caring for an older client living in the community. Which nurse actions demonstrate an understanding of the prevalent health concerns specific to the older adult client? (Select all that apply.) 1. Discusses the need for proper lighting–especially at night–to minimize the risk of falls 2. Assesses amount and frequency of the client's alcohol consumption patterns 3. Assesses the client's orientation to time, place, and person as well as short-term memory 4. Discusses the client's views on long-term residential care if the need arises 5. Asks the client to name and provide the reason for each medication he is currently taking Answer: 1, 2, 3, 5 Page Ref: 485-487 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 15. Describe selected health problems associated with older adults. MNL Learning Outcome: 4. Examine the health problems, and health promotion needs of older adults. 29) The nurse has accepted a position to provide care to clients on a geriatric unit. Which should the nurse expect when caring for these clients? 1. Advocate for the health of the clients 2. Study the effects of aging on the body 3. Provide direct care to treat medical problems 4. Address psychological problems associated with aging Answer: 3 Explanation: Geriatrics is associated with medical care. Gerontology includes advocacy, the study of aging, and includes the psychological impact of aging. Page Ref: 471 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 4. Compare and contrast gerontology and geriatrics. MNL Learning Outcome: 1. Explain characteristics of, attitudes towards, and care settings for older adults.
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30) An older client is unable to attend religious services during the winter months. Which should the nurse suggest to this client? 1. Take a nap 2. Call a friend 3. Engage in a social activity 4. Spend quiet time in prayer Answer: 4 Explanation: The "old-old" individual who cannot attend formal services often continues religious participation in a more private manner. Assisting the older adult to participate in religious and spiritual practices is an important nursing responsibility. Napping, talking to friends, or engaging in a social activity would not support the client's spiritual needs. Page Ref: 485 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 14. Describe how spirituality and aging interact. MNL Learning Outcome: 3. Recognize the sociological, psychological, economic, and cognitive changes associated with aging.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 27 Promoting Family Health 1) A client includes parents, siblings, grandparents, aunts, uncles, and cousins as family members. Which type of family should the nurse document for this client? 1. Nuclear 2. Extended 3. Traditional 4. Blended Answer: 2 Explanation: The extended family includes parents and offspring (nuclear) along with relatives such as grandparents, aunts, and uncles. Page Ref: 494 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: II. C. 4. Respect the centrality of the patient/family as core members of any healthcare team | AACN Essentials Competencies: IX. 2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Describe different types of families. MNL Learning Outcome: 1. Examine the functions and types of family and theoretical frameworks that affect families.
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2) The nurse cares for clients within a particular cultural group in which it is not uncommon for grandparents to live with their married children and to assist with childrearing and discipline issues. For which type of family should the nurse plan care for these clients? 1. Two-career family 2. Blended family 3. Intragenerational family 4. Traditional family Answer: 3 Explanation: In some cultures and as people live longer, more than two generations may live together in an intragenerational setting, as described. Page Ref: 495 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: II. C. 4. Respect the centrality of the patient/family as core members of any healthcare team | AACN Essentials Competencies: IX. 2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Describe different types of families. MNL Learning Outcome: 1. Examine the functions and types of family and theoretical frameworks that affect families. 3) A client who is unmarried and has one child reports living with another single person who has two children. Which type of living arrangement does this client have? 1. Cohabiting family 2. Blended family 3. Foster family 4. Intragenerational family Answer: 1 Explanation: Cohabiting (or communal) families consist of unrelated individuals or families that live under one roof. Reasons for cohabiting may be a need for companionship, a desire to achieve a sense of family, sharing expenses, and household management. Page Ref: 495 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: II. C. 4. Respect the centrality of the patient/family as core members of any healthcare team | AACN Essentials Competencies: IX. 2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Describe different types of families. MNL Learning Outcome: 1. Examine the functions and types of family and theoretical frameworks that affect families. 2
4) The nurse is planning to complete a family assessment. For which reasons is the nurse completing this assessment? (Select all that apply.) 1. Determine the level of family functioning. 2. Identify family strengths and weaknesses. 3. Provide legal guidelines for consent to healthcare. 4. Clarify family interaction patterns. 5. Describe the health status of individual members. Answer: 1, 2, 4, 5 Page Ref: 496 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: II. C. 4. Respect the centrality of the patient/family as core members of any healthcare team | AACN Essentials Competencies: IX. 2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Identify the components of a family health assessment. MNL Learning Outcome: 2. Recognize the components of a family health assessment. 5) The nurse is conducting a family assessment as part of the process for services provided through the community. Which part of the assessment should provide the nurse with the best information in identifying existing or potential health problems? 1. Ecomap 2. Genogram 3. Cultural assessment 4. Family communication patterns Answer: 2 Explanation: The health history is one of the most effective ways of identifying existing or potential health problems. A genogram will help the nurse to visualize how all family members are genetically related to each other and how patterns of chronic conditions are present within the family unit. Page Ref: 497 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: II. C. 4. Respect the centrality of the patient/family as core members of any healthcare team | AACN Essentials Competencies: IX. 2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Identify the components of a family health assessment. MNL Learning Outcome: 2. Recognize the components of a family health assessment. 3
6) A family struggles with clear communication, and members of the family often seek the help of other systems for personal validation and gratification. What should the nurse identify as an appropriate nursing diagnosis for this family? 1. Altered Family Processes related to communication patterns 2. Impaired Verbal Communication related to inability to communicate 3. Ineffective Family Coping evidenced by assistance from outside sources 4. Knowledge Deficiency (communication patterns) related to dysfunctional patterns of communication Answer: 1 Explanation: This describes a state in which a family with previous normal functioning experiences a dysfunction. The communication patterns have affected how the family works as a unit. Page Ref: 500 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: II. C. 4. Respect the centrality of the patient/family as core members of any healthcare team | AACN Essentials Competencies: IX. 2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Diagnosis Learning Outcome: 6. Develop nursing diagnoses, outcomes, and interventions pertaining to family functioning. MNL Learning Outcome: 4. Utilize the nursing process in the care of families.
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7) The nurse is conducting a family assessment and is focusing, for the moment, on the family members' communication patterns. Which observation indicates that there are existing or potential problems with family communication? 1. All members are participating in the discussion equally, some quite vocally. 2. The verbal communication is congruent with the nonverbal messages. 3. A few of the members just sit and listen. 4. Disagreements are not addressed among members; rather, they are ignored by the person who does the most talking. Answer: 4 Explanation: This option describes an authoritarian setting where other members may be cautious in expressing their feelings because of power struggles, hostility, or anger. Nurses should pay special attention to who does the talking for the family, which members are silent, how disagreements are handled, and how well the members listen to one another and encourage the participation of others. Page Ref: 498 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: II. A. 5. Analyze differences in communication style preferences among patients and families, nurses, and other members of the health team | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship Centered Care; Knowledge; Effective communication | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Identify the components of a family health assessment. MNL Learning Outcome: 2. Recognize the components of a family health assessment.
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8) The nurse has been caring for a family at the community health office and is concerned about signs of family violence. Which finding should the nurse identify as most concerning? 1. The baby always seems to have a cold. 2. One of the children never speaks and seems "on guard" when in the presence of a parent. 3. The family's clothes are relatively clean, but the children usually have some kind of dirt stain on their shirts or pants. 4. The family does not have a regular physician. Answer: 2 Explanation: A child who does not speak and is watchful when parents are near would be a significant indicator of a possible abuse situation. Page Ref: 498-499 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Relationship Centered Care; Knowledge; Threats to the integrity of relationships and the potential for conflict and abuse | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Identify common risk factors for family health problems. MNL Learning Outcome: 3. Recognize common risk factors for family health problems. 9) The nurse is performing a family risk assessment. Which factor should the nurse identify that indicates this family is at risk of developing health problems? 1. The family is an elderly couple who are active in their retirement community. 2. The family is a teenage mother and child. The mother is enrolled in parenting classes at the high school. 3. The family belongs to the local synagogue and has family members still living in Germany. 4. The family depends on two incomes with a limit on their health insurance spending. Answer: 3 Explanation: Tay-Sachs is a neurodegenerative disease that occurs primarily in individuals of Eastern European Jewish descent. Simply because of this family's ethnicity, they are at risk for developing this health problem. Page Ref: 500-501 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Identify common risk factors for family health problems. MNL Learning Outcome: 3. Recognize common risk factors for family health problems. 6
10) During a previous family assessment, the nurse realized that the mother did most of the talking and was quick to make decisions, which appeared to be acceptable to the father. Which action should the nurse take if one of the children is hospitalized? 1. Make sure that both parents are involved in all decision making 2. Allow the mother to make the decisions 3. Include both parents in the decision making but be accepting if the mother retains control 4. Make sure that the physician understands the family dynamics so parental consent comes from the mother Answer: 3 Explanation: The nurse uses information gained from the assessment to help diagnose, plan, and implement care. Understanding that the mother assumes the authority role in this particular family, the nurse may find it easier to address things with both present but should not be surprised if this pattern continues during the child's hospitalization. However, the nurse should not assume that family processes will be the same in a crisis situation or during stress and will want to make sure that the father is present during the process. Page Ref: 498 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Identify the components of a family health assessment. MNL Learning Outcome: 2. Recognize the components of a family health assessment.
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11) A family member is hospitalized with an illness. What should the nurse assess to determine the impact this illness will have on the family? (Select all that apply.) 1. Nature of the illness 2. Duration of the illness 3. Cause of the illness 4. Financial impact of the illness 5. Effect of the illness on future family functioning Answer: 1, 2, 4, 5 Explanation: Factors that determine the impact of illness on the family include the nature of the illness, duration of the illness, financial impact of the illness, and effect of the illness on future family functioning. Effect of the illness on future family functioning is a factor that determines the impact of illness on the family. Page Ref: 500 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Identify common risk factors for family health problems. MNL Learning Outcome: 3. Recognize common risk factors for family health problems. 12) A father of a family was killed in a motor-vehicle crash. What should the nurse consider a "normal" reaction to this event? 1. Family disorganization may occur. 2. Family members become detached from extended family. 3. The family feels that their place in the community has been eliminated. 4. The family withdraws into seclusion during the grief process. Answer: 1 Explanation: The death of a family member often has a profound effect on the whole family— especially if the deceased, as in this situation, was the head of the family. Family disorganization would be common, but as the family begins to recover, a new sense of normalcy develops and the family reintegrates its roles and functions. Page Ref: 501 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Identify common risk factors for family health problems. MNL Learning Outcome: 3. Recognize common risk factors for family health problems.
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13) During a family assessment, the nurse asks, "How, as a family, do you deal with disappointments or stressful changes that occur and affect the members of your family?" What is the nurse attempting to identify? 1. Family coping mechanisms 2. Whether the family experiences stress 3. Which family members are most stressed 4. Family dynamics Answer: 1 Explanation: Family coping mechanisms are behaviors that families use to deal with stress or changes imposed from either within or without. The coping mechanisms families and individuals develop reflect their individual resourcefulness. The assessment of coping mechanisms is a way to determine how families relate to stress. Page Ref: 498 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Identify the components of a family health assessment. MNL Learning Outcome: 2. Recognize the components of a family health assessment.
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14) The nurse has identified a coping problem in a family that recently lost their house and all of their belongings in a fire. What should the nurse identify as this family's external support systems? (Select all that apply.) 1. Grandparents 2. The parent's siblings 3. Local social services agencies 4. The family's religious leader 5. The family's communication skills Answer: 1, 2, 3, 4 Explanation: External support includes extended family members, social services, and religious organizations. Page Ref: 498 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Describe the functions of the family. MNL Learning Outcome: 1. Examine the functions and types of family and theoretical frameworks that affect families.
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15) The nurse is confident that a family is functioning appropriately. What findings did the nurse use to make this determination? (Select all that apply.) 1. The teenage son keeps the money earned from cutting grass for a "car fund." 2. All the children are expected to excel in the sport of their choice. 3. A parent reads the preschool child a bedtime story each night. 4. All the children have household chores once they reach school age. 5. A young adult child moves back home after losing his job. Answer: 1, 3, 4, 5 Explanation: An appropriately functioning family has the economic resources needed by the family secured by adult members. An appropriately functioning family creates an atmosphere that influences the cognitive and psychosocial growth of its members. In an appropriately functioning family, the members support each other and the family unit. An appropriately functioning family provides support, understanding, and encouragement to all members as they progress through predictable developmental stages, as they move in or out of the family unit, and as they establish new family units. Page Ref: 493 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation Learning Outcome: 1. Describe the functions of the family. MNL Learning Outcome: 1. Examine the functions and types of family and theoretical frameworks that affect families.
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16) The nurse is preparing to assess a family regarding the impact of one of its members being diagnosed with diabetes. What should the nurse include in this assessment? (Select all that apply.) 1. The seriousness of the disorder 2. Whether the family has ever dealt with a chronic illness before 3. The age of the affected member 4. The financial impact the illness will have on the family 5. The number of members of the family Answer: 1, 2, 4 Explanation: It is appropriate to consider the seriousness of the disorder, as the impact on the family will be in proportion to the degree of seriousness; The effect of the illness on future family functioning; and the financial impact of the illness, which is influenced by factors such as insurance and the ability of the ill member to return to work. Page Ref: 500 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Identify the components of a family health assessment. MNL Learning Outcome: 2. Recognize the components of a family health assessment.
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17) During a family assessment, the nurse determines that a family functions according to the systems theory. What did the nurse assess to make this clinical decision? (Select all that apply.) 1. Family members work together toward goals. 2. Family members seek out and use community resources. 3. Family members interact with other community systems. 4. Healthy boundaries are used to regulate influence by other systems. 5. Family members are encouraged to hold fast to beliefs and practices. Answer: 1, 2, 3, 4 Explanation: In systems theory, family members work together to achieve specific purposes and goals. Seek out healthcare information and use community resources. Interact with and are influenced by other systems in the community. Boundaries regulate the input from other systems that interact with the family system. Page Ref: 496 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify theoretical frameworks used in family health promotion. MNL Learning Outcome: 1. Examine the functions and types of family and theoretical frameworks that affect families.
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18) The nurse is planning to use the structural-functional theory when assessing a family new to a community. What should the nurse include when conducting this assessment? (Select all that apply.) 1. Individuals in the family 2. The family's sense of purpose 3. Relationships among family members 4. Strategies to restrict outside influences on the family 5. The approach the family uses to socialize new family members Answer: 1, 2, 3, 5 Explanation: The structural-functional theory focuses on family structure and function. The structural component of the theory addresses the membership of the family. The functional aspect of the theory examines the effects of intrafamily relationships on the family system. Some of the main functions of the family include developing a sense of family purpose. The structural-functional theory focuses on family structure and function. The structural component of the theory addresses the relationships among family members. The functional aspect of the theory examines the effects of intrafamily relationships on the family system. Some of the main functions of the family include socializing new members. Page Ref: 496 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify theoretical frameworks used in family health promotion. MNL Learning Outcome: 1. Examine the functions and types of family and theoretical frameworks that affect families.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 28 Vital Signs 1) An older client has an oral temperature reading of 97.2°F. The nurse realizes that this client's low temperature could be due to which observation? 1. The anxiety level of the client has increased. 2. Hormones have fluctuated in this client. 3. Muscle activity has increased during the client's therapy session. 4. Loss of subcutaneous fat is noted. Answer: 4 Explanation: This client is older and research shows that older people are at risk for hypothermia. When one ages, subcutaneous fat is lost. Page Ref: 507 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation Learning Outcome: 2. Identify the variations in normal body temperature, pulse, respirations, and blood pressure that occur from infancy to old age. MNL Learning Outcome: 2. Examine the factors that influence the measured results of vital signs. 2) The nurse is preparing to measure a client's temperature. What is the first thing that the nurse should do to ensure an accurate temperature reading? 1. Assess that the equipment used is working properly. 2. Place the client in a position that is most comfortable for the healthcare provider. 3. Take the temperature with a chemical disposable thermometer when the client is perspiring. 4. Wait at least 10 minutes before taking the temperature after a client has been smoking. Answer: 1 Explanation: If the equipment is not working properly, no accuracy will be obtained in the readings. Page Ref: 514 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Verbalize the steps used in: a. Assessing body temperature. MNL Learning Outcome: 3. Apply the principles of assessing vital signs in patient care. 1
3) The nurse needs to measure the temperature of a client who has a history of heart disease and has eaten a bowl of vegetable soup 45 minutes ago. Which site should the nurse use? 1. Axilla 2. Oral 3. Popliteal 4. Rectal Answer: 2 Explanation: Body temperature is frequently measured orally even if the client has eaten or drank something cold or hot. One only needs to wait 30 minutes, and then this site can be used. Page Ref: 511 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Verbalize the steps used in: a. Assessing body temperature. MNL Learning Outcome: 3. Apply the principles of assessing vital signs in patient care. 4) While waiting for the physician to respond regarding a client's elevated temperature, what can the nurse do to assist the client? 1. Bathe the client with ice water. 2. Give the client an antipyretic. 3. Increase fluid intake. 4. Lower the room temperature. Answer: 3 Explanation: Elevated body temperature contributes to dehydration, which leads to body tissues drying out and malfunctioning. Rehydrating the client's tissues will allow the temperature to return to normal. Page Ref: 510 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 4. Describe appropriate nursing care for alterations in vital signs. MNL Learning Outcome: 4. Utilize the nursing process for patients with alterations in vital signs across the lifespan.
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5) While assessing the dorsalis pedis pulse of a client, the nurse determines that the pulse is absent. However, the extremity is warm and pink with nail beds blanching at 2-3 seconds of capillary refilling time. How would the nurse explain these findings? 1. A change in the client's health status has occurred. 2. The client has thrown a blood clot in that extremity. 3. The RN's watch has stopped working. 4. Too much pressure was applied over the pulse site. Answer: 4 Explanation: Too firm of pressure on a pulse site will obliterate that pulse because assessing the dorsalis pedis pulse requires one to apply some pressure over the dorsalis pedis artery. Page Ref: 519 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Verbalize the steps used in: b. Assessing a peripheral pulse. MNL Learning Outcome: 3. Apply the principles of assessing vital signs in patient care. 6) The nurse assesses a client who is recovering from femoral popliteal bypass surgery and discovers that it is difficult to assess the dorsalis pedis pulses. Which nursing intervention would be most appropriate for the nurse to use? 1. Ask another nurse to assess the pulses. 2. Document the findings. 3. Obtain a Doppler ultrasound stethoscope. 4. Wait and try again later. Answer: 3 Explanation: Obtaining a Doppler ultrasound stethoscope is the appropriate action to take. The Doppler will ensure accuracy by helping to exclude environmental sounds. Page Ref: 518-519 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Verbalize the steps used in: b. Assessing a peripheral pulse. MNL Learning Outcome: 3. Apply the principles of assessing vital signs in patient care.
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7) The nurse is assessing a client's peripheral pulse. Which characteristic should the nurse also assess at this time? 1. Depth 2. Rhythm 3. Sound 4. Stress Answer: 2 Explanation: When assessing peripheral pulses, one of the characteristics being assessed is rhythm, along with rate, volume, and equality. Page Ref: 519 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 6. List the characteristics that should be included when assessing pulses. MNL Learning Outcome: 3. Apply the principles of assessing vital signs in patient care. 8) The nurse is going to assess the apical-radial pulse of a client with a cardiovascular disorder. Which rationale did the nurse use to make this decision? 1. A forceful radial pulse is much too difficult to count correctly. 2. Both arteriole and venous sounds were heard simultaneously. 3. The pulse was bounding and easily obliterated. 4. The thrust of blood from the heart is too feeble for the wave to be felt at the peripheral pulse site. Answer: 4 Explanation: Knowing there is a history of a cardiovascular disorder would alert the nurse to the importance of the utmost accuracy for the client's pulse assessment. The apical-radial pulse is used to assess this type of client due to the feebleness of the wave of blood flow felt at the peripheral sites. Page Ref: 525 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Identify nine sites used to assess the pulse and state the reasons for their use. MNL Learning Outcome: 3. Apply the principles of assessing vital signs in patient care.
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9) A client is unconscious and in respiratory distress after being in a motor-vehicle crash. Which should the nurse realize as being a factor that caused a change in this client's respiratory rate? 1. Exercise 2. Increased intracranial pressure 3. Increased environmental temperature 4. Stress Answer: 2 Explanation: Factors that decrease respirations include increased intracranial pressure. Page Ref: 528 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 7. Describe the mechanics of breathing and the mechanisms that control respirations. MNL Learning Outcome: 3. Apply the principles of assessing vital signs in patient care. 10) The nurse needs to assess a client's respiratory status. Which client position would be the best for this assessment? 1. Prone 2. Semi-Fowler 3. Side-lying 4. Supine Answer: 2 Explanation: Persons in a semi-Fowler position will better aid themselves and the nurse to assess their respiratory status. People in a supine position experience two physiologic processes that suppress respiration: an increase in the volume of blood inside the thoracic cavity and compression of the chest. Consequently, clients lying on their back have poorer lung aeration, which predisposes them to the stasis of fluids and subsequent infection. Page Ref: 528 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Verbalize the steps used in: d. Assessing respirations. MNL Learning Outcome: 3. Apply the principles of assessing vital signs in patient care.
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11) A client is being treated for congestive heart failure. Which physical finding would lead the nurse to believe the client's condition has not improved? 1. Temperature of 98.6°F (37°C) 2. Moderate amount of clear thin mucus 3. Pulse oximetry reading of 96% 4. Wheezing of breath sounds in all lobes Answer: 4 Explanation: Wheezing heard when assessing breath sounds is indicative of abnormal breath sounds, which are characteristic of congestive heart failure. Page Ref: 528 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 7. Describe the mechanics of breathing and the mechanisms that control respirations. MNL Learning Outcome: 4. Utilize the nursing process for patients with alterations in vital signs across the lifespan. 12) Which determinant of blood pressure would explain a client's blood pressure reading of 120/100 mm Hg? 1. Blood viscosity 2. Blood volume 3. Pumping action of the heart 4. Peripheral vascular resistance Answer: 4 Explanation: Peripheral vascular resistance especially affects diastolic blood pressure readings. A reading of 120/100 mm Hg would be indicative of peripheral vascular resistance. Page Ref: 530 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation Learning Outcome: 2. Identify the variations in normal body temperature, pulse, respirations, and blood pressure that occur from infancy to old age. MNL Learning Outcome: 4. Utilize the nursing process for patients with alterations in vital signs across the lifespan.
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13) The nurse is assessing a client's blood pressure. What should the nurse hear during phase 2 of Korotkoff's sounds? 1. A muffled, whooshing, or swishing sound 2. Disappearance of sound 3. Faint, clear tapping sound 4. Increased intensity of sound Answer: 1 Explanation: Phase 2 produces a muffled, whooshing, or swishing sound. Page Ref: 534 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Verbalize the steps used in: e. Assessing blood pressure. MNL Learning Outcome: 3. Apply the principles of assessing vital signs in patient care. 14) The nurse is preparing to assess a client's blood pressure. Which artery will the nurse use for this assessment? 1. Brachial 2. Femoral 3. Radial 4. Ulnar Answer: 1 Explanation: The brachial is the most common artery used to assess a blood pressure reading because it is the most accessible. Page Ref: 535 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Verbalize the steps used in: e. Assessing blood pressure. MNL Learning Outcome: 3. Apply the principles of assessing vital signs in patient care.
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15) In the palpatory method of blood pressure determination, instead of listening for the blood flow sounds, light to moderate pressure is used over the artery as the pressure in the cuff is released. When will the nurse read the pressure from the sphygmomanometer? 1. When the cuff is applied 2. When the cuff is being deflated 3. When the first pulsation is felt 4. When the second pulsation is felt Answer: 3 Explanation: The first pulsation that is felt after the cuff is slowly deflated is the blood pressure reading that is recorded if the palpatory method is used to assess a client's blood pressure. Page Ref: 536 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 3. Verbalize the steps used in: e. Assessing blood pressure. MNL Learning Outcome: 3. Apply the principles of assessing vital signs in patient care. 16) The nurse is assessing a client. For which health problem should the nurse choose the dorsalis pedis pulse as the site for further assessing the client's status? 1. Altered level of consciousness 2. Decreased urine output 3. Irregular radial pulse 4. Toes cool to touch Answer: 4 Explanation: The dorsalis pedis pulse site is in the foot, so this is the ideal site to assess the pulse for toes that are cool to touch. Page Ref: 518 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Identify nine sites used to assess the pulse and state the reasons for their use. MNL Learning Outcome: 3. Apply the principles of assessing vital signs in patient care.
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17) The nurse is preparing to assess a client's oxygen saturation level. Which should the nurse realize that will affect this measurement? 1. Activity 2. Environmental conditions 3. Nutrition 4. Skin color Answer: 1 Explanation: Factors affecting oxygen saturation readings are hemoglobin, circulation, and activity. If there is shivering or excessive movement of the sensor site, this will interfere with an accurate reading. Page Ref: 539 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 3. Verbalize the steps used in: f. Assessing blood oxygenation using pulse oximetry. MNL Learning Outcome: 3. Apply the principles of assessing vital signs in patient care.
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18) As the nurse is suctioning a client, the pulse oximetry reading drops to 83%. What should the nurse do? 1. Allow the client to take some extra deep breaths. 2. Continue to suction but only intermittently. 3. Keep the catheter in place and wait a few minutes. 4. Stop suctioning and give supplemental oxygen. Answer: 4 Explanation: Not only does suctioning remove secretions, but it also removes the client's air. By stopping suctioning, the nurse stops removing both. This allows the client to recoup from the procedure and giving oxygen will also increase the saturation ability back to a normal range. Page Ref: 539-540 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 3. Verbalize the steps used in: f. Assessing blood oxygenation using pulse oximetry. MNL Learning Outcome: 4. Utilize the nursing process for patients with alterations in vital signs across the lifespan.
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19) The nurse needs vital signs assessed for four clients. Which client should the nurse address and not assign to the UAP? 1. Cardiac catheterization client returning to the nursing unit 2. COPD client on 2 Lpm oxygen via nasal cannula 3. Pneumonia client nearing discharge 4. Post-op client 2 days from gallbladder surgery Answer: 1 Explanation: The cardiac catheterization client will need a thorough assessment because of just returning to the nursing unit. Invasive procedures, such as a catheterization, will need to be closely assessed. More than likely a Doppler will be needed to ensure the pedal pulse is present and stable in the extremity used during the procedure. Unlicensed personnel are not usually delegated Doppler ultrasound device use. Page Ref: 507 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the health care team | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 8. Recognize when it is appropriate to assign or delegate measurement of vital signs to unlicensed assistive personnel. MNL Learning Outcome: 4. Utilize the nursing process for patients with alterations in vital signs across the lifespan.
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20) Prior to assessing a client's blood pressure, the nurse reviews factors that could affect the reading. Which factors could impact blood pressure? (Select all that apply.) 1. Stress 2. Race 3. Obesity 4. Medications 5. Employment Answer: 1, 2, 3, 4 Explanation: Stimulation of the sympathetic nervous system increases cardiac output and vasoconstriction of the arterioles, increasing the blood pressure reading. African Americans over 35 years of age tend to have higher blood pressures than do Caucasian Americans of the same age. Both childhood and adult obesity predispose to hypertension. Many medications, including caffeine, can increase or decrease the blood pressure. Page Ref: 531 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Describe factors that affect the vital signs and accurate measurement of them. MNL Learning Outcome: 3. Apply the principles of assessing vital signs in patient care.
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21) The nurse is planning to assess a client's pulse. What characteristics should the nurse include in this assessment? (Select all that apply.) 1. Rate 2. Rhythm 3. Volume 4. Tone 5. Viscosity Answer: 1, 2, 3 Explanation: When assessing the pulse, the nurse collects data about the rate, rhythm, and volume. Page Ref: 519 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 6. List the characteristics that should be included when assessing pulses. MNL Learning Outcome: 3. Apply the principles of assessing vital signs in patient care. 22) When assessing a client's respirations, the nurse realizes that the respiratory centers and chemoreceptors respond to changes in which factors? (Select all that apply.) 1. Oxygen concentration 2. Carbon dioxide concentration 3. Hydrogen ions 4. Potassium level 5. Serum calcium level Answer: 1, 2, 3 Explanation: The respiratory centers and chemoreceptors respond to changes in the concentration of oxygen, carbon dioxide, and hydrogen ions. Page Ref: 527 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 7. Describe the mechanics of breathing and the mechanisms that control respirations. MNL Learning Outcome: 3. Apply the principles of assessing vital signs in patient care.
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23) Even though an unlicensed assistive personnel (UAP) is available to assist with vital sign assessment, the nurse is going to conduct these assessments independently in which situations? (Select all that apply.) 1. Client who complains of chest pain 2. Client returning from surgery 3. Prior to administering a medication that affects blood pressure 4. Client who complains of dizziness after ambulating 5. Client being admitted to the care area Answer: 1, 2, 3, 4 Explanation: The nurse should conduct the assessment when a client reports symptoms such as chest pain. Client returns from surgery. Is prescribed a medication that could affect the vital signs. Reports symptoms such as dizziness after ambulation. Page Ref: 507 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the health care team | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 8. Recognize when it is appropriate to assign or delegate measurement of vital signs to unlicensed assistive personnel. MNL Learning Outcome: 3. Apply the principles of assessing vital signs in patient care. 24) When documenting a client's axillary temperature on the graphic sheet, how should the nurse identify the method of assessing the temperature? 1. AX 2. O 3. R 4. SL Answer: 1 Explanation: When documenting the temperature in the client record, an axillary temperature should be recorded with an AX. Page Ref: 515 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 9. Demonstrate appropriate documentation and reporting of vital signs. MNL Learning Outcome: 3. Apply the principles of assessing vital signs in patient care. 14
25) The nurse assesses phase 1 Korotkoff's sound occurring at 136 and phase 5 Korotkoff's sound occurring at 72. How should the nurse document this client's blood pressure reading? 1. 136/72 2. 72/136 3. 136-72 4. 72-136 Answer: 1 Explanation: The first tapping phase 1 Korotkoff's sound is the systolic blood pressure. The last sound heard during phase 5 Korotkoff's sound is the diastolic blood pressure. The nurse would document the blood pressure as being 136/72. Page Ref: 534 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 9. Demonstrate appropriate documentation and reporting of vital signs. MNL Learning Outcome: 3. Apply the principles of assessing vital signs in patient care. 26) A client comes to the emergency department with a temperature of 104°F. Which assessment findings should the nurse use to determine if this client is experiencing heat stroke? (Select all that apply.) 1. Delirious 2. Pale and dizzy 3. Skin warm and flushed 4. No evidence of sweating 5. Had been playing tennis in the sun Answer: 1, 3, 4, 5 Explanation: Persons experiencing heat stroke may be delirious; have warm, flushed skin; often do not sweat; and have generally been exercising in hot weather. Page Ref: 509 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Describe appropriate nursing care for alterations in vital signs. MNL Learning Outcome: 4. Utilize the nursing process for patients with alterations in vital signs across the lifespan.
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27) The nurse determines that unlicensed assistive personnel (UAP) are not to be delegated client blood pressure measurements. What did the nurse observe to make this clinical decision? (Select all that apply.) 1. The valve on the bulb was closed. 2. The client was sitting with the legs crossed. 3. The arm was below the level of the heart. 4. The UAP waited 2 minutes before remeasuring. 5. The cuff bladder was placed over the brachial artery. Answer: 2, 3 Explanation: The adult client should be sitting with both feet on the floor. Crossed legs can cause elevations in systolic and diastolic blood pressures. The elbow should be slightly flexed with the palm of the hand facing up and the arm supported at heart level. The blood pressure increases when the arm is below heart level. Page Ref: 536 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the health care team | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation Learning Outcome: 8. Recognize when it is appropriate to assign or delegate measurement of vital signs to unlicensed assistive personnel. MNL Learning Outcome: 3. Apply the principles of assessing vital signs in patient care.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 29 Health Assessment 1) The nurse is preparing to perform a health assessment of the abdomen. In which order should the nurse perform the assessment? 1. Auscultate, percuss, palpate, inspect 2. Inspect, auscultate, palpate, percuss 3. Inspect, auscultate, percuss, palpate 4. Palpate, percuss, auscultate, inspect Answer: 3 Explanation: Inspection should occur first. Palpation should always be performed last when performing an abdominal health assessment. Auscultation is done before palpation and percussion because palpation and percussion cause movement or stimulation of the bowel, which can increase bowel motility and thus heighten bowel sounds, creating false results. Page Ref: 601-602 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: o. Assessing the abdomen. MNL Learning Outcome: 1. Apply the four techniques used in physical assessment and the general survey to patient care.
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2) The nurse is performing a health assessment and notes a yellow tinge to the sclera of the eye. In which way should the nurse document this finding? 1. Cyanosis 2. Jaundice 3. Pallor 4. Erythema Answer: 2 Explanation: Jaundice is a yellow tinge that is abnormal and is often noticed in the sclera of the eye. Page Ref: 554 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment/Communication and Documentation Learning Outcome: 8. Demonstrate appropriate documentation and reporting of health assessment. MNL Learning Outcome: 4. Recognize deviations from normal findings obtained from the physical assessment of each body system across the lifespan. 3) While performing an assessment of the integument system, the nurse notes the client's eyeballs are protruding and the upper eyelids are elevated. What term should the nurse use to document this finding? 1. Erythema 2. Cyanosis 3. Exophthalmos 4. Normocephalic Answer: 3 Explanation: Hyperthyroidism can cause exophthalmos, a protrusion of the eyeballs with elevation of the upper eyelids, resulting in a startled or staring expression. Page Ref: 562 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment/Communication and Documentation Learning Outcome: 8. Demonstrate appropriate documentation and reporting of health assessment. MNL Learning Outcome: 4. Recognize deviations from normal findings obtained from the physical assessment of each body system across the lifespan. 2
4) The nurse is preparing for morning rounds. What should the nurse avoid delegating to unlicensed assistive personnel? 1. Vital signs 2. Filling of water pitchers 3. Skull and face assessment 4. Ambulation of surgical clients Answer: 3 Explanation: Assessment of the skull and face may not be delegated to unlicensed assistive personnel. Page Ref: 562 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the health care team| NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 7. Recognize when it is appropriate to assign data collection skills to unlicensed assistive personnel. MNL Learning Outcome: 2. Apply the techniques used for physical assessment of each body system across the lifespan. 5) The nurse is performing a lung assessment on a client with suspected pneumonia. Which finding should the nurse report to the physician immediately? 1. Chest symmetrical 2. Breath sounds equal bilaterally 3. Asymmetrical chest expansion 4. Bilateral symmetric vocal fremitus Answer: 3 Explanation: Chest expansion should be symmetrical. Page Ref: 585 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: k. Assessing the thorax and lungs. MNL Learning Outcome: 4. Recognize deviations from normal findings obtained from the physical assessment of each body system across the lifespan.
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6) While performing a health assessment, in which position should the nurse place the client for inspection of the jugular veins? 1. 90-degree angle 2. 30- to 45-degree angle 3. 15-degree angle 4. 60-degree angle Answer: 2 Explanation: The nurse should place the client in the semi-Fowler position (30- to 45-degree angle) while inspecting the jugular veins for distention. Page Ref: 548 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: l. Assessing the heart and central vessels. MNL Learning Outcome: 2. Apply the techniques used for physical assessment of each body system across the lifespan. 7) The nurse is assessing peripheral pulses on a client with suspected peripheral vascular disease. Which finding should the nurse report to the physician immediately? 1. Pulses equal bilaterally 2. Full pulsations 3. Thready pulses 4. Pulses present bilaterally Answer: 3 Explanation: Thready, weak, or decreased pulses are abnormal and should be reported to the physician. Page Ref: 594 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: m. Assessing the peripheral vascular system. MNL Learning Outcome: 4. Recognize deviations from normal findings obtained from the physical assessment of each body system across the lifespan.
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8) During the assessment of a client's breasts, the nurse finds both breasts rounded, slightly unequal in size, skin smooth and intact, and nipples without discharge. What should the nurse do next? 1. Notify the charge nurse. 2. Notify the physician. 3. Document the findings in the nurse's notes as normal. 4. Document the findings in the nurse's notes as abnormal. Answer: 3 Explanation: The findings are all normal, so the nurse would document the assessment in the nurse's notes as normal. Page Ref: 597 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify expected findings during health assessment. MNL Learning Outcome: 3. Recognize normal findings obtained from the physical assessment of each body system across the lifespan. 9) The nurse is preparing a client for an abdominal examination. What should the nurse do before beginning the examination? 1. Ask the client to urinate. 2. Ask the client to drink 8 ounces of water. 3. Assess vital signs. 4. Assess heart rate. Answer: 1 Explanation: The nurse should ask the client to urinate because an empty bladder makes the assessment more comfortable. Page Ref: 601 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: o. Assessing the abdomen. MNL Learning Outcome: 2. Apply the techniques used for physical assessment of each body system across the lifespan.
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10) The nurse is performing a musculoskeletal assessment on a client admitted with a possible stroke. When testing for muscle grip strength, the nurse should ask the client to perform which action? 1. Grasp the nurse's index and middle fingers while the nurse tries to pull the fingers out. 2. Hold an arm up and resist while the nurse tries to push it down. 3. Flex each arm and then try to extend it against the nurse's attempt to keep the arm in flexion. 4. Shrug the shoulders against the resistance of the nurse's hands. Answer: 1 Explanation: This is the technique to assess muscle grip strength. Page Ref: 606 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: p. Assessing the musculoskeletal system. MNL Learning Outcome: 2. Apply the techniques used for physical assessment of each body system across the lifespan. 11) The nurse is preparing to conduct a mental status assessment. What should the nurse include in this assessment? 1. Cognitive and affective functions 2. Cognitive and effective functions 3. Affective and memory functions 4. Affective and knowledge functions Answer: 1 Explanation: Cognitive (intellectual) and affective (emotional) functions are assessed. Page Ref: 607 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: a. Assessing appearance and mental status. MNL Learning Outcome: 2. Apply the techniques used for physical assessment of each body system across the lifespan.
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12) A client recovering from a stroke is able to comprehend what is being said but is unable to respond by speech or writing. What type of aphasia should the nurse realize this patient is demonstrating? 1. Auditory aphasia 2. Acoustic aphasia 3. Sensory aphasia 4. Expressive aphasia Answer: 4 Explanation: Motor or expressive aphasia involves loss of the power to express oneself by writing, making signs, or speaking. Clients may find that even though they can recall words, they have lost the ability to combine speech sounds into words. Page Ref: 607 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: q. Assessing the neurologic system. MNL Learning Outcome: 4. Recognize deviations from normal findings obtained from the physical assessment of each body system across the lifespan. 13) The nurse is preparing to assess a client's reflexes. What equipment should the nurse gather before entering the room? 1. Sterile gloves 2. Clean gloves 3. Percussion hammer 4. Penlight Answer: 3 Explanation: A percussion hammer is used to test reflexes. Page Ref: 549 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: q. Assessing the neurologic system. MNL Learning Outcome: 2. Apply the techniques used for physical assessment of each body system across the lifespan. 7
14) The nurse is assisting the physician who is preparing to test a sexually active female client for cervical cancer. What should the nurse expect the healthcare provider to perform? 1. Pap test 2. Breast exam 3. Rectal exam 4. Abdominal exam Answer: 1 Explanation: For sexually active adolescent and adult women, a Papanicolaou test (Pap test) is used to detect cancer of the cervix. Page Ref: 616 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: r. Assessing the female genitals and inguinal area. MNL Learning Outcome: 2. Apply the techniques used for physical assessment of each body system across the lifespan. 15) The nurse is preparing the morning assignments. Which assessment could the nurse delegate to unlicensed assistive personnel? 1. Neurological assessment 2. Musculoskeletal assessment 3. Vital signs assessment 4. Female genital assessment Answer: 3 Explanation: The nursing assistant can only assess vital signs. Page Ref: 551, 553 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the health care team | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 7. Recognize when it is appropriate to assign data collection skills to unlicensed assistive personnel. MNL Learning Outcome: 2. Apply the techniques used for physical assessment of each body system across the lifespan.
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16) The nurse is preparing to administer a cardiotonic drug to a client. Which assessment should the nurse perform before administering the medication? 1. Respiratory rate 2. Apical pulse 3. Popliteal pulse 4. Capillary blanch test Answer: 2 Explanation: The apical pulse should be assessed before administering any cardiotonic medication. Page Ref: 545 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: l. Assessing the heart and central vessels. MNL Learning Outcome: 2. Apply the techniques used for physical assessment of each body system across the lifespan. 17) The nurse is preparing to complete a physical examination on a client. What should the nurse realize as being the purpose for this examination? (Select all that apply.) 1. Obtain baseline data. 2. Obtain data to help determine nursing diagnoses. 3. Identify areas for disease prevention. 4. Identify the client's employment status. 5. Obtain data about the client's leisure activities. Answer: 1, 2, 3 Page Ref: 545 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 1. Identify the purposes of the physical examination. MNL Learning Outcome: 2. Apply the techniques used for physical assessment of each body system across the lifespan.
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18) A client has been receiving a new medication to address specific symptoms. The nurse will perform a physical examination to determine which of the following? (Select all that apply.) 1. Progress of the client's health problem 2. Physiological impact of the prescribed medication 3. Baseline data 4. Data to support nursing diagnoses 5. Areas for health promotion Answer: 1, 2 Page Ref: 545 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Identify the purposes of the physical examination. MNL Learning Outcome: 2. Apply the techniques used for physical assessment of each body system across the lifespan. 19) The nurse is utilizing the technique of inspection during a physical examination with a client. When using this technique, the nurse will take which actions? (Select all that apply.) 1. Visually observe a body area. 2. Obtain information through the sense of smell. 3. Obtain information through the sense of hearing. 4. Examine the body through the use of touch. 5. Strike the body to elicit a sound from a body part. Answer: 1, 2, 3 Explanation: When using inspection, the nurse will visually observe a body area. In addition to visual observation, olfactory cues are noted. In addition to visual observation, auditory cues are noted. Page Ref: 547 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Explain the four techniques used in physical examination: inspection, palpation, percussion, and auscultation. MNL Learning Outcome: 1. Apply the four techniques used in physical assessment and the general survey to patient care.
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20) The nurse is planning to perform indirect percussion on an area of a client's body during a physical examination. Which actions should the nurse take to use this assessment technique? (Select all that apply.) 1. Place the middle finger of the nondominant hand on the client's skin. 2. Use the tip of the flexed middle finger of the other hand to strike the middle finger of the nondominant hand. 3. Perform a striking motion by moving the wrist. 4. Perform short, rapid, firm blows. 5. Use a stethoscope to transmit sounds to the ears. Answer: 1, 2, 3, 4 Explanation: Placing the middle finger of the nondominant hand on the client's skin is the first step when performing indirect percussion. Using the tip of the flexed middle finger of the other hand to strike the middle finger of the nondominant hand is the second step when performing indirect percussion. The nurse should perform a striking motion by moving the wrist. The nurse should perform short, rapid, firm blows. Page Ref: 550 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Explain the four techniques used in physical examination: inspection, palpation, percussion, and auscultation. MNL Learning Outcome: 1. Apply the four techniques used in physical assessment and the general survey to patient care.
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21) The nurse is assessing the nose and sinuses of a client. Which findings should the nurse identify as being within normal limits? (Select all that apply.) 1. Nose straight 2. Nares symmetrical 3. No tenderness over the bridge 4. Air movement restricted in one nare 5. Clear drainage from one nare Answer: 1, 2, 3 Page Ref: 573 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: h. Assessing the nose and sinuses. MNL Learning Outcome: 3. Recognize normal findings obtained from the physical assessment of each body system across the lifespan. 22) The nurse is planning a physical examination of a client following a head-to-toe format. In which order should the nurse conduct this assessment? 1. Head, upper extremities, abdomen, and lower extremities 2. Neck, head, vital signs, chest, and back 3. Lower extremities, abdomen, upper extremities, chest, and back 4. Head, neck, lower extremities, and abdomen Answer: 1 Explanation: When conducting a physical examination from head to toe, the nurse would start with the head, move down to the upper extremities, then to the abdomen, and finally to the lower extremities. Page Ref: 545 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Describe suggested sequencing to conduct a physical health examination in an orderly fashion. MNL Learning Outcome: 2. Apply the techniques used for physical assessment of each body system across the lifespan.
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23) The nurse is assessing the peripheral vascular status of an older client. Which finding should the nurse consider as being normal for this client? 1. Easy to palpate upper-extremity arteries 2. Easy to palpate lower-extremity arteries 3. Reduction in the number of varicosities 4. Increase in diastolic blood pressure Answer: 1 Explanation: In some older clients, arteries may be palpated more easily because of the loss of supportive surrounding tissues. Page Ref: 596 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: l. Assessing the heart and central vessels. MNL Learning Outcome: 3. Recognize normal findings obtained from the physical assessment of each body system across the lifespan. 24) The nurse is preparing to perform an eye assessment. What equipment should the nurse have available to complete this assessment? (Select all that apply.) 1. Penlight 2. Snellen's chart 3. Sterile gloves 4. Gauze square 5. Millimeter ruler Answer: 1, 2, 4, 5 Page Ref: 565 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: f. Assessing the eye structures and visual acuity. MNL Learning Outcome: 2. Apply the techniques used for physical assessment of each body system across the lifespan.
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25) The nurse is preparing to conduct an assessment of the heart. Where should the nurse place the stethoscope to auscultate heart sounds? (Select all that apply.) 1. Aortic region 2. Pulmonic region 3. Tricuspid valve region 4. Abdomen 5. Mitral valve region Answer: 1, 2, 3, 5 Page Ref: 589 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: l. Assessing the heart and central vessels. MNL Learning Outcome: 2. Apply the techniques used for physical assessment of each body system across the lifespan. 26) The nurse is preparing to assess a client with the Glasgow Coma Scale. Which areas is the nurse assessing in this patient? (Select all that apply.) 1. Eye response 2. Motor response 3. Verbal response 4. Orientation 5. Musculoskeletal response Answer: 1, 2, 3 Page Ref: 608 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: q. Assessing the neurologic system. MNL Learning Outcome: 2. Apply the techniques used for physical assessment of each body system across the lifespan.
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27) A client is experiencing abdominal pain. What assessments should the nurse perform to assess this complaint? (Select all that apply.) 1. Inspect the abdomen. 2. Auscultate the abdomen. 3. Palpate the abdomen. 4. Assess vital signs. 5. Assess peripheral pulses. Answer: 1, 2, 3, 4 Page Ref: 601 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Verbalize the steps used in performing selected examination procedures: o. Assessing the abdomen. MNL Learning Outcome: 2. Apply the techniques used for physical assessment of each body system across the lifespan. 28) The nurse is assessing the musculoskeletal status of a 4-year-old child. What findings should the nurse consider as being expected in this client? (Select all that apply.) 1. Lordosis 2. Genu valgus 3. Genu varum 4. Pronation of the feet 5. Asymmetric leg abduction Answer: 1, 2 Explanation: Lordosis (swayback) is common in children before age 5. Genu valgus (knock-knee) is normal in preschool and early-school-age children. Page Ref: 607 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation Learning Outcome: 6. Discuss variations in examination techniques appropriate for clients of different ages. MNL Learning Outcome: 4. Recognize deviations from normal findings obtained from the physical assessment of each body system across the lifespan.
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29) The nurse is concerned that an older client has nutritional deficiencies. What did the nurse find when assessing this client's nails to make this clinical decision? (Select all that apply.) 1. White spots 2. Curved nails 3. Deep purple areas 4. Spoon-shaped nails 5. Bands across the nails Answer: 1, 4, 5 Explanation: White spots may indicate zinc deficiency. Spoon-shaped nails may indicate iron deficiency. Bands across the nails may indicate protein deficiency. Page Ref: 562 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation Learning Outcome: 6. Discuss variations in examination techniques appropriate for clients of different ages. MNL Learning Outcome: 4. Recognize deviations from normal findings obtained from the physical assessment of each body system across the lifespan.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 30 Pain Assessment and Management 1) The nurse is caring for an 8-month-old infant. What is the best tool the nurse should use for evaluating pain in this infant? 1. FLACC scale 2. Wong-Baker FACES 3. Visual analog scale 4. Numeric rating scale Answer: 1 Explanation: The FLACC scale has been validated in children from 2 months to 7 years old. Page Ref: 636 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Identify subjective and objective data to collect and analyze when assessing pain. MNL Learning Outcome: 2. Perform nursing assessment for pain for patients across the lifespan. 2) The nurse is preparing to discharge a client home with a prescription for ibuprofen (Motrin). What should the nurse instruct as a common side effect of this medication? 1. Gastrointestinal (GI) distress 2. Shakiness 3. Tremors 4. Rash Answer: 1 Explanation: The most common side effect of NSAIDs, including ibuprofen, is gastrointestinal distress, such as heartburn or indigestion. Page Ref: 646 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 10. Describe pharmacologic interventions for pain. MNL Learning Outcome: 4. Integrate collaborative interventions in the care of a patient with pain. 1
3) Which objective assessment data should the nurse obtain before administering a prescribed opioid medication to a client? 1. Pain level as stated by client 2. Any nausea the client may be feeling 3. Respiratory rate 4. Color of skin Answer: 3 Explanation: Opioids may depress the respiratory system, so the nurse should assess the respiratory rate before administering opioids. Page Ref: 647 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Identify subjective and objective data to collect and analyze when assessing pain. MNL Learning Outcome: 2. Perform nursing assessment for pain for patients across the lifespan. 4) The nurse is to administer acetaminophen (Tylenol) prn to a client for a headache; however, the client has been vomiting all day. Which route should be used to administer the medication? 1. Oral 2. Vaginal 3. Rectal 4. Intravenous Answer: 3 Explanation: The rectal route is often used if the client has nausea or vomiting. The nurse should administer an acetaminophen suppository to the client. Page Ref: 650 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 12. Identify risks and benefits of patient-controlled analgesia. MNL Learning Outcome: 4. Integrate collaborative interventions in the care of a patient with pain.
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5) A client recovering from a left below-the-knee amputation is experiencing left foot pain. The nurse realizes the client is experiencing which type of pain? 1. Phantom limb pain 2. Acute pain 3. Chronic pain 4. Narcotic-induced pain Answer: 1 Explanation: Phantom sensations, the feeling that a lost body part is present, occur in most people after amputation. It is important for the nurse to remember to explain the reasons for phantom limb pain, as clients may have difficulty understanding why they have pain when the limb is gone. Page Ref: 628 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Describe factors that can affect a client's perception of and reaction to pain. MNL Learning Outcome: 1. Recognize the nature and physiology of pain. 6) The nurse is providing discharge instructions to a client prescribed an opioid medication. What should the nurse suggest to decrease the risk of constipation with this medication? 1. Take an antihistamine three times per day. 2. Drink six to eight glasses of water per day. 3. Assess respiratory rate before taking medication. 4. Assess heart rate before taking medication. Answer: 2 Explanation: Increasing fluid intake can help prevent constipation. Page Ref: 648 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 6. Individualize a pain treatment plan based on clinical and personal goals, while setting objective outcome criteria by which to evaluate a client's response to interventions for pain. MNL Learning Outcome: 3. Determine appropriate independent nursing interventions in the care of a patient with pain.
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7) The nurse is caring for a client who is using morphine through patient-controlled analgesia. What medication should the nurse have readily available? 1. Naloxone hydrochloride (Narcan) 2. Acetaminophen (Tylenol) 3. Diphenhydramine hydrochloride (Benadryl) 4. Normal saline Answer: 1 Explanation: Narcan is an opioid antagonist and should be readily available when a client is receiving an opioid. Page Ref: 651 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Planning Learning Outcome: 10. Describe pharmacologic interventions for pain. MNL Learning Outcome: 4. Integrate collaborative interventions in the care of a patient with pain. 8) The client taking an opioid is experiencing pruritus. Which medication should the nurse expect the physician to prescribe? 1. Naloxone hydrochloride (Narcan) 2. Acetaminophen (Tylenol) 3. Diphenhydramine hydrochloride (Benadryl) 4. Normal saline Answer: 3 Explanation: When clients experience pruritus, an antihistamine, such as Benadryl, is ordered. Page Ref: 648 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Planning Learning Outcome: 10. Describe pharmacologic interventions for pain. MNL Learning Outcome: 4. Integrate collaborative interventions in the care of a patient with pain.
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9) A client seeks medical attention for severe abdominal pain. What is the nurse's first action? 1. Administer IV pain medication as ordered. 2. Start an IV line of lactated Ringer's. 3. Assess pain using a scale of 1 to 10. 4. Place a Foley catheter to bedside drainage. Answer: 3 Explanation: Assessment should always occur before implementation. Page Ref: 634 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Assessment Learning Outcome: 6. Individualize a pain treatment plan based on clinical and personal goals, while setting objective outcome criteria by which to evaluate a client's response to interventions for pain. MNL Learning Outcome: 2. Perform nursing assessment for pain for patients across the lifespan. 10) A client is surprised to learn of the diagnosis of a heart attack when there was no chest pain experienced but only some left shoulder pain. The nurse should explain that the client experienced which type of pain? 1. Phantom pain 2. Referred pain 3. Visceral pain 4. Chronic pain Answer: 2 Explanation: Referred pain appears to arise in different areas of the body, as may occur with cardiac pain. Page Ref: 626 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 1. Discriminate between nociceptive and neuropathic pain categories. MNL Learning Outcome: 1. Recognize the nature and physiology of pain.
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11) A client rates pain as being 7 on a scale from 0 to 10. What should the nurse document as this client's pain intensity? 1. Mild pain 2. Moderate pain 3. Severe pain 4. Physiological pain Answer: 3 Explanation: Severe pain is rated as being from 7 to 10 on a scale of 0 to 10. Page Ref: 636 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Assessment/Communication and Documentation Learning Outcome: 4. Identify subjective and objective data to collect and analyze when assessing pain. MNL Learning Outcome: 2. Perform nursing assessment for pain for patients across the lifespan. 12) A client is experiencing pain after spraining an ankle. The nurse realizes that the client is most likely experiencing which type of pain? 1. Mild pain 2. Severe pain 3. Somatic pain 4. Visceral pain Answer: 3 Explanation: Somatic pain originates in the skin, muscles, bone, or connective tissue. The sharp sensation of a paper cut or aching of a sprained ankle are common examples of somatic pain. Page Ref: 627 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Discriminate between nociceptive and neuropathic pain categories. MNL Learning Outcome: 1. Recognize the nature and physiology of pain.
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13) The client scheduled to undergo minor surgery states, "The physician will not give me pain medication after surgery because my surgery is only minor." What is the best response by the nurse? 1. "You can experience pain after minor surgery, so you can have pain medication." 2. "You are correct. The physician will not order any pain medication." 3. "You are correct. I will need to teach you nonpharmacologic pain relief measures." 4. "You can only have about half the dose because your surgery is minor." Answer: 1 Explanation: Clients can experience intense pain after minor surgery, so pain medication may be ordered. Page Ref: 641 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 6. Individualize a pain treatment plan based on clinical and personal goals, while setting objective outcome criteria by which to evaluate a client's response to interventions for pain. MNL Learning Outcome: 4. Integrate collaborative interventions in the care of a patient with pain. 14) The nurse is caring for a postpartum client receiving pain medication through an epidural catheter. Which assessment finding should the nurse report immediately to the physician? 1. Pulse rate: 80 2. Respiratory rate: 8 3. Blood pressure: 120/80 4. Pain rating of 4 on scale of 1 to 10 Answer: 2 Explanation: A respiratory rate below 8 should be reported immediately. Page Ref: 652 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Assessment Learning Outcome: 12. Identify risks and benefits of patient-controlled analgesia. MNL Learning Outcome: 3. Determine appropriate independent nursing interventions in the care of a patient with pain.
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15) A client states that a cramping pain started 2 hours ago and is not accompanied by any nausea or vomiting. Which type of pain is this client most likely experiencing? 1. Chronic pain 2. Phantom pain 3. Visceral pain 4. Acute pain Answer: 4 Explanation: Acute pain is pain that is directly related to tissue injury and resolves when tissue heals. Page Ref: 627 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Discriminate between nociceptive and neuropathic pain categories. MNL Learning Outcome: 1. Recognize the nature and physiology of pain. 16) The nurse is preparing to conduct a pain assessment. What should the nurse include in this assessment? (Select all that apply.) 1. Duration 2. Location 3. Intensity 4. Etiology 5. Neurology Answer: 1, 2, 3, 4 Page Ref: 637-638 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Identify subjective and objective data to collect and analyze when assessing pain. MNL Learning Outcome: 2. Perform nursing assessment for pain for patients across the lifespan.
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17) A client experiencing pain has been prescribed aspirin. The nurse realizes that this medication will affect which pain process? 1. Transduction 2. Transmission 3. Perception 4. Modulation Answer: 1 Explanation: During the transduction phase, noxious stimuli trigger the release of biochemical mediators, such as prostaglandins, bradykinin, serotonin, histamine, and substance P, that sensitize nociceptors. Noxious or painful stimulation also causes movement of ions across cell membranes, which excites nociceptors. Pain medications such as aspirin can work during this phase by blocking the production of prostaglandin or by decreasing the movement of ions across the cell membrane. Page Ref: 629 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Planning Learning Outcome: 2. Describe the four processes involved in nociception and how pain interventions can work during each process. MNL Learning Outcome: 1. Recognize the nature and physiology of pain.
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18) A client is complaining of having the same type of pain prior to being diagnosed with cancer. The nurse realizes that which process will influence this client's perception of pain? 1. Transmission 2. Modulation 3. Perception 4. Transduction Answer: 3 Explanation: Perception is when the client becomes conscious of the pain. Pain perception is the sum of complex activities in the central nervous system that can shape the character and intensity of pain perceived and ascribes meaning to the pain. The psychosocial context of the situation and the meaning of the pain based on past experiences and future hopes and dreams help to shape the behavioral response that follows. Page Ref: 629 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Describe the four processes involved in nociception and how pain interventions can work during each process. MNL Learning Outcome: 1. Recognize the nature and physiology of pain. 19) The nurse is caring for an adolescent client who is experiencing postoperative pain. What interventions should the nurse use to help this client? (Select all that apply.) 1. Talk with the client about pain. 2. Provide privacy. 3. Present choices for dealing with pain. 4. Encourage distraction with music or television. 5. Allay fears and anxiety. Answer: 1, 2, 3, 4 Page Ref: 632 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 3. Describe factors that can affect a client's perception of and reaction to pain. MNL Learning Outcome: 3. Determine appropriate independent nursing interventions in the care of a patient with pain.
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20) An older client who refuses medication for pain is irritable and unable to sleep. What should the nurse explain to the client to encourage the use of pain medication? (Select all that apply.) 1. There are high-dose medications that will eradicate the pain. 2. The lack of pain control is causing the inability to sleep. 3. The lack of pain control is causing irritability. 4. The risks of taking pain medication are low in the older population. 5. The lack of pain control will affect mobility and activity tolerance. Answer: 2, 3, 5 Explanation: If pain is not effectively controlled in the older client, the ability to sleep will be affected. If pain is not effectively controlled in the older client, irritability can occur. If pain is not effectively controlled in the older client, mobility and activity tolerance will be affected. Page Ref: 633 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 3. Describe factors that can affect a client's perception of and reaction to pain. MNL Learning Outcome: 3. Determine appropriate independent nursing interventions in the care of a patient with pain.
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21) A client with pain has had previous episodes of uncontrolled pain in the past and is worried about the current pain pattern. Which diagnosis would be appropriate for the nurse to include for this client? 1. Anxiety 2. Ineffective Coping 3. Deficient Knowledge 4. Hopelessness Answer: 1 Explanation: The diagnosis of Anxiety would be appropriate for the client, as the client has past experiences of poor pain control and is anticipating pain. Page Ref: 639-640 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Diagnosis Learning Outcome: 5. Identify examples of nursing diagnoses for clients with pain. MNL Learning Outcome: 3. Determine appropriate independent nursing interventions in the care of a patient with pain.
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22) From an assessment, the nurse learns that the client is having difficulty sleeping because of pain in the hips and knees due to arthritis. The client is weak and fatigued. Which diagnoses would be applicable to the client at this time? (Select all that apply.) 1. Anxiety 2. Hopelessness 3. Ineffective Health Maintenance 4. Insomnia 5. Impaired Physical Mobility Answer: 3, 4, 5 Explanation: The diagnosis of Ineffective Health Maintenance would be applicable, as the client is experiencing chronic arthritic pain and is fatigued. The diagnosis of Insomnia would be applicable, as the client is experiencing increased pain perception at night, affecting sleep. The diagnosis of Impaired Physical Mobility would be applicable, as the client is experiencing arthritic pain in the hips and knees. Page Ref: 639-640 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Diagnosis Learning Outcome: 5. Identify examples of nursing diagnoses for clients with pain. MNL Learning Outcome: 3. Determine appropriate independent nursing interventions in the care of a patient with pain.
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23) A client experiencing chronic pain is not getting relief with pain medication. What should the nurse do to help this client? 1. Ask the physician to change the prescribed pain medication. 2. Reassess the pain and consider another pain relief measure. 3. Limit interaction with the client. 4. Stop using alternative pain relief measures, if not effective. Answer: 2 Explanation: Keep trying. Do not ignore a client because pain persists despite failed attempts to alleviate the discomfort. In these circumstances, reassess the pain and consider other relief measures. Page Ref: 641 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 6. Individualize a pain treatment plan based on clinical and personal goals, while setting objective outcome criteria by which to evaluate a client's response to interventions for pain. MNL Learning Outcome: 2. Perform nursing assessment for pain for patients across the lifespan. 24) A client's pain level is assessed as being severe. Which intervention would be the most applicable for the client at this time? 1. Provide NSAID medication as prescribed. 2. Coach the client with guided imagery. 3. Suggest the client read or watch television until the pain subsides. 4. Provide opioid analgesic as prescribed. Answer: 4 Explanation: The selection of pain relief measures should be aligned with the client's report of the severity of the pain. If a client reports severe pain, a more potent pain relief measure is indicated. Page Ref: 646 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 6. Individualize a pain treatment plan based on clinical and personal goals, while setting objective outcome criteria by which to evaluate a client's response to interventions for pain. MNL Learning Outcome: 4. Integrate collaborative interventions in the care of a patient with pain. 14
25) A client recovering from back surgery is refusing pain medication for fear of becoming addicted. What should the nurse say to the client? 1. "I understand." 2. "There are ways to treat addictions to pain medications." 3. "If the medication is taken to treat pain, you will not become addicted to it." 4. "All pain medication causes addiction. There is nothing that can be done to prevent it." Answer: 3 Explanation: Clients are unlikely to become addicted to an analgesic provided to treat pain. Page Ref: 642 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 8. Differentiate tolerance, physical dependence, and addiction. MNL Learning Outcome: 3. Determine appropriate independent nursing interventions in the care of a patient with pain. 26) A client experiencing pain after surgery believes something is wrong because the pain is so severe. What is the best response for the nurse to make to the client? 1. "The amount of tissue disrupted from the surgery is not related to the degree of pain you feel." 2. "That could be so." 3. "Taking pain medication for many years has made the medication ineffective now." 4. "Are you sure the pain is as bad as you are saying it is?" Answer: 1 Explanation: Pain is a subjective experience, and the intensity and duration of pain vary considerably among individuals. The amount of tissue damaged or disrupted is not related to the amount of pain experienced. Page Ref: 634, 662 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 2. Describe the four processes involved in nociception and how pain interventions can work during each process. MNL Learning Outcome: 1. Recognize the nature and physiology of pain.
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27) A client has been taking medication for back pain for several months and has seen several different healthcare providers in efforts to receive pain medication. Which should the nurse suspect the client is exhibiting? 1. Tolerance 2. Addiction 3. Physical dependence 4. Pseudoaddiction Answer: 2 Explanation: Addiction is characterized by the behaviors of compulsive use of pain medication, continued use despite harm, and craving. Page Ref: 643 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Assessment Learning Outcome: 8. Differentiate tolerance, physical dependence, and addiction. MNL Learning Outcome: 2. Perform nursing assessment for pain for patients across the lifespan. 28) A client reports pain as being a 2 on a scale from 0 to 10. Which pain medications should the nurse consider for the client at this time? (Select all that apply.) 1. Acetaminophen (Tylenol) 2. Ibuprofen (Motrin) 3. Naproxen (Naprosyn) 4. Hydrocodone (Vicodin) 5. Methadone (Dolophine) Answer: 1, 2, 3 Page Ref: 649-650 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Assessment Learning Outcome: 11. Describe the World Health Organization's ladder step approach developed for cancer pain control. MNL Learning Outcome: 4. Integrate collaborative interventions in the care of a patient with pain.
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29) After receiving medication for mild pain, the client states that the pain is getting worse. What should the nurse plan to do for this client? 1. Administer another dose of a nonopioid medication. 2. Administer an opioid for severe pain. 3. Administer an opioid for moderate pain. 4. Administer two doses of an opioid for moderate pain. Answer: 3 Explanation: If the client has mild pain that persists or increases despite using full doses of step 1 medications, or if the pain is moderate, then a step 2 regimen is appropriate. At the second step, an opioid for moderate pain or a combination of opioid and nonopioid medicine is provided with or without adjuvant medications. Page Ref: 350 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 11. Describe the World Health Organization's ladder step approach developed for cancer pain control. MNL Learning Outcome: 4. Integrate collaborative interventions in the care of a patient with pain. 30) A client tells the nurse that at home, the dog helps distract the client from chronic hip pain. The nurse realizes that the client is utilizing which form of nonpharmacologic pain control? 1. Body 2. Mind 3. Social interactions 4. Spirit Answer: 3 Explanation: Social interactions that are used as nonpharmacologic pain control methods include pet therapy. Page Ref: 653 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Assessment Learning Outcome: 17. List three nonpharmacologic interventions directed at each of the following: the body, the mind, the spirit, and social interactions. MNL Learning Outcome: 3. Determine appropriate independent nursing interventions in the care of a patient with pain. 17
31) The nurse is preparing to instruct a client on nonpharmacologic interventions that target the body for pain control. What should the nurse include in these instructions? (Select all that apply.) 1. Massage 2. Acupressure 3. Self-hypnosis 4. Exercise 5. Nutritional supplements Answer: 1, 2, 4, 5 Page Ref: 653 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Planning/Teaching and Learning Learning Outcome: 17. List three nonpharmacologic interventions directed at each of the following: the body, the mind, the spirit, and social interactions. MNL Learning Outcome: 3. Determine appropriate independent nursing interventions in the care of a patient with pain. 32) The nurse is preparing to massage a client's back. Place in order the steps the nurse will follow, after conducting hand hygiene and preparing the client, to perform the back massage. 1. Move the hands down the sides of the back. 2. Pour lotion into the palms of the hands to warm the lotion. 3. Massage the areas over the right and left iliac crests. 4. Move the hands up the center of the back. 5. With the palms, massage the sacral area with smooth, circular strokes. 6. Move the hands to the scapulae and massage this region using circular strokes. Answer: 2, 5, 4, 6,1, 3 Explanation: To perform a back massage, the nurse should: (1) pour a small amount of lotion into the palms of the hands and hold for a minute to warm; (2) with the palms, begin in the sacral area using smooth, circular strokes; (3) move the hands up the center of the back; (4) move the hands to the scapulae and massage this region using circular strokes; (5) move the hands down the sides of the back; and (6) massage the areas over the right and left iliac crests. Page Ref: 654-655 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 14. Verbalize the steps used in performing a back massage. MNL Learning Outcome: 3. Determine appropriate independent nursing interventions in the care of a patient with pain. 18
33) The nurse is preparing a client for a back massage. Which positions would be the best for the client to receive this massage? (Select all that apply.) 1. Supine 2. Fowler 3. Trendelenburg 4. Prone 5. Side-lying Answer: 4, 5 Explanation: The prone position is recommended for a back rub. The side-lying position can be used if a client cannot assume the prone position for a back rub. Page Ref: 655 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 14. Verbalize the steps used in performing a back massage. MNL Learning Outcome: 3. Determine appropriate independent nursing interventions in the care of a patient with pain. 34) A client who is on postoperative day 1 after abdominal surgery is requesting a back rub. Who should provide this massage? 1. The Registered nurse 2. Assistive personnel (AP) 3. No one, because the client cannot assume the prone position 4. The Physician Answer: 1 Explanation: Because the client is on day 1 in recovery from abdominal surgery, the client's condition might not be stable enough to have AP perform the skill. Page Ref: 654 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the health care team | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Planning Learning Outcome: 15. Recognize when it is appropriate to assign aspects of back massage to assistive personnel. MNL Learning Outcome: 3. Determine appropriate independent nursing interventions in the care of a patient with pain.
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35) The nurse wants to assign back rubs to assistive personnel (AP). Which should the nurse determine before making the assignments? (Select all that apply.) 1. Whether unlicensed assistive personnel know how to perform a back rub 2. Whether there any clients who have intravenous fluids infusing 3. Whether there any clients who should not have a back rub performed 4. Whether there any clients who are prescribed to take nothing by mouth 5. Whether there any clients who do not want a back rub done by unlicensed assistive personnel Answer: 1, 3, 5 Explanation: The nurse can delegate this skill to AP; however, the nurse first should assess for the AP's comfort and ability. The nurse can delegate this skill to AP; however, the nurse first should assess for client contraindications. The nurse can delegate this skill to AP; however, the nurse first should assess for client willingness to participate. Page Ref: 654 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the health care team | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Assessment Learning Outcome: 15. Recognize when it is appropriate to assign aspects of back massage to assistive personnel. MNL Learning Outcome: 3. Determine appropriate independent nursing interventions in the care of a patient with pain.
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36) The nurse has completed a back massage for a client. What should the nurse document about this procedure? (Select all that apply.) 1. Effectiveness of pain medication using a rating scale from 0 to 10 2. Position to perform the massage 3. Content of communication that occurred during the back massage 4. Amount of lotion used during the back massage 5. Client response Answer: 2, 5 Explanation: The nurse should document the position in which the massage was performed on the client. The nurse should document the client's response to the massage. Page Ref: 655 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 16. Demonstrate appropriate documentation and reporting of back massage. MNL Learning Outcome: 3. Determine appropriate independent nursing interventions in the care of a patient with pain. 37) A client with a long leg cast is complaining of knee discomfort. Which nonpharmacologic intervention can the nurse use to help this client? 1. Apply ice to the knee over the cast. 2. Rub the knee of the noncasted leg. 3. Apply heat to the knee over the cast. 4. Rub the foot of the casted extremity. Answer: 2 Explanation: The nurse can use contralateral stimulation, which is accomplished by stimulating the skin in an area opposite to the painful area, such as stimulating the left knee if the pain is in the right knee. The nurse should explain the rationale to the client in that nerves are crossed in the spinal cord, and that is why this technique works contralaterally. Page Ref: 655 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 13. Describe nonpharmacologic pain control interventions. MNL Learning Outcome: 3. Determine appropriate independent nursing interventions in the care of a patient with pain. 21
38) A client watching a comedy on television is laughing. When asked about the amount of pain on a scale from 0 to 10, the client reports a level that is 2 below the previous assessment. The nurse realizes the client's pain was influenced by which type of distraction? 1. Visual 2. Tactile 3. Intellectual 4. Behavioral Answer: 1 Explanation: Visual distraction includes watching television. Page Ref: 656 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Assessment Learning Outcome: 13. Describe nonpharmacologic pain control interventions. MNL Learning Outcome: 3. Determine appropriate independent nursing interventions in the care of a patient with pain. 39) The healthcare provider is writing medication orders for a client recovering from spinal fusion surgery. When the client reports pain as a 9 on a scale from 0 to 10, which medications should the nurse consider providing to the client? (Select all that apply.) 1. Oxymorphone (Opana) 2. Hydrocodone (Vicodin) 3. Oxycodone (OxyContin) 4. Morphine sulfate (morphine) 5. Hydromorphone hydrochloride (Dilaudid) Answer: 1, 3, 4, 5 Page Ref: 647 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Assessment Learning Outcome: 10. Describe pharmacologic interventions for pain. MNL Learning Outcome: 4. Integrate collaborative interventions in the care of a patient with pain.
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40) The nurse is caring for a client receiving pain medication through an epidural catheter. What should the nurse include to ensure safety when caring for this client? (Select all that apply.) 1. Secure all tubing connections with gauze. 2. Apply tape over all injection ports on the tubing. 3. Cleanse the insertion site with alcohol swabs once a day. 4. Label the tubing, infusion bag, and pump with the word "epidural." 5. Post a sign above the client's bed indicating that an epidural is being used. Answer: 2, 4, 5 Explanation: Apply tape over all injection ports on the epidural line to avoid the injection of substances intended for IV administration into the epidural catheter. Label the tubing, the infusion bag, and the front of the pump with tape marked "epidural" to prevent confusion with similar-looking IV lines. Post a sign above the client's bed indicating that an epidural is in place. Page Ref: 651-652 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 13. Describe nonpharmacologic pain control interventions. MNL Learning Outcome: 4. Integrate collaborative interventions in the care of a patient with pain. 41) A client with severe pain is prescribed two medications from different classes to be given orally and topically. Which is an advantage of this approach to pain management? 1. Lostess costly to the client 2. Less time-consuming to provide 3. Eliminating the need for opioids 4. Reduces the development of chronic pain Answer: 3 Explanation: Multimodal analgesia combines analgesics from two or more drug classes and a variety of delivery approaches for the analgesics that result in reducing, and often eliminating, the need for opioids. This approach does not reduce cost, reduce time, or reduce the development of chronic pain. Page Ref: 645 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 9. Describe the benefits of multimodal pain management. MNL Learning Outcome: 4. Integrate collaborative interventions in the care of a patient with pain. 23
42) A client is receiving opioid-sparing pain management. Which should the nurse consider to enhance the effectiveness for the client? 1. Massage 2. Turning and repositioning 3. Range-of-motion exercises 4. Deep breathing and coughing Answer: 1 Explanation: Multimodal pain therapies include therapies that are independent of or in addition to pharmacologic therapy and include nonpharmacologic therapies such as yoga, massage, biofeedback, acupuncture, mind—body therapies, and physical therapies. Turning and repositioning, range-of-motion exercises, and deep breathing and coughing will not enhance opioid-sparing pain management. Page Ref: 645 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 9. Describe the benefits of multimodal pain management. MNL Learning Outcome: 4. Integrate collaborative interventions in the care of a patient with pain. 43) The nurse is assigning tasks for evening care. Which client should the nurse assign assistive personnel (AP) to provide a back massage? 1. Client with spontaneous fractures 2. Client receiving high-dose heparin 3. Client recovering from back surgery 4. Client with moderate pain asking for help Answer: 4 Explanation: The client with moderate pain asking for help would be the best client to assign AP to provide a back massage. Back massage is contraindicated in clients with a risk of fractures, coagulation issues, or recovering from back surgery. Page Ref: 654 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the health care team | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Planning Learning Outcome: 15. Recognize when it is appropriate to assign aspects of back massage to assistive personnel. MNL Learning Outcome: 3. Determine appropriate independent nursing interventions in the care of a patient with pain. 24
44) The nurse provides a client with a back massage. Which information should the nurse omit when documenting the care provided to this client? 1. Client fell asleep 2. Client reports feeling relaxed 3. Client reports pain level 3 on a scale from 1 to 10 4. Client talked with family on the telephone during the massage Answer: 4 Explanation: Although the client should not have been talking on the phone during the massage, this information does not need to be documented. Falling sleep, feeling relaxed, and reporting a lower pain level should all be documented after a back massage. Page Ref: 655 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 16. Demonstrate appropriate documentation and reporting of back massage. MNL Learning Outcome: 3. Determine appropriate independent nursing interventions in the care of a patient with pain.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 31 Asepsis and Infection Prevention 1) The nurse is setting up a sterile field. Which action by the nurse best exhibits surgical asepsis? 1. Disinfecting an item before adding it to a sterile field 2. Allowing sterile gloved hands to fall below the waist 3. Suctioning the oral cavity of an unconscious client 4. Touching only the inside surface of the first glove while pulling it onto the hand Answer: 4 Explanation: Touching only the inside surface of the first glove while pulling it onto the hand is the correct technique when applying sterile gloves. This prevents contamination of the outside of the glove, which must remain sterile. Page Ref: 696-697 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Implementation Learning Outcome: 1. Explain the concepts of medical and surgical asepsis. MNL Learning Outcome: 3. Apply the principles of surgical asepsis to patient care. 2) The nurse is using medical asepsis when providing client care. Which action did the nurse demonstrate? 1. Administering parenteral medications 2. Changing a dressing 3. Performing a urinary catheterization 4. Using personal protective equipment Answer: 4 Explanation: Using personal protective equipment demonstrates medical asepsis. Page Ref: 668 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Implementation Learning Outcome: 1. Explain the concepts of medical and surgical asepsis. MNL Learning Outcome: 2. Apply the principles of medical asepsis to patient care.
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3) The nurse is reviewing the care needs for a group of assigned clients. Which client should the nurse recognize as being most at risk for a nosocomial infection? 1. A client in the emergency department with abdominal pain 2. A 19-year-old woman in her first trimester of pregnancy 3. A 72-year-old male client with COPD 4. An 86-year-old female client on steroid therapy Answer: 4 Explanation: The client most at risk for a nosocomial infection is the client who is 86 years old and on steroid therapy. The very old and very young are most susceptible to infections. The 86year-old client is also on steroid therapy, which compromises the immune system. Page Ref: 672 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify risks for nosocomial and healthcare-associated infections. MNL Learning Outcome: 4. Apply the nursing process to the care of the patient to prevent the spread of infection. 4) The nurse is preparing discharge teaching for a client recovering from surgery. What instruction is the most important for the nurse to give this client who has a surgical wound? 1. Adjust the diet so it contains more fruits and vegetables. 2. Apply lubricating lotion to the edges of the wound. 3. Notify the physician of any edema, heat, or tenderness at the wound site. 4. Thoroughly irrigate the wound with hydrogen peroxide. Answer: 3 Explanation: A client being discharged with an open surgical wound has to be instructed on the detection of infection because the skin is the first line of defense. Signs such as edema, heat, and tenderness would indicate a local infection. Page Ref: 671, 673 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 2. Identify signs of localized and systemic infections and inflammation. MNL Learning Outcome: 1. Examine the types of infections, transmission of disease, body defenses to disease, and use of precautions in patient care.
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5) A patient is diagnosed with a systemic infection. What will the nurse most likely assess in this client? 1. Edema, rubor, heat, and pain 2. Fever, malaise, anorexia, and nausea and vomiting 3. Palpitations, irritability, and heat intolerance 4. Tingling, numbness, and cramping of the extremities Answer: 2 Explanation: Fever, malaise, anorexia, and nausea and vomiting are symptoms of a systemic infection. Page Ref: 675 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Identify signs of localized and systemic infections and inflammation. MNL Learning Outcome: 1. Examine the types of infections, transmission of disease, body defenses to disease, and use of precautions in patient care. 6) An older client with gallbladder disease has had a cholecystectomy. Which factor should the nurse realize would influence the development of an infection in this client? 1. Active bowel sounds 2. Dry intact skin 3. Intact mucous membranes 4. Susceptibility of the client Answer: 4 Explanation: How susceptible the client is for an infection is one of the factors that influences microorganism growth. This client is 80 years old and has a surgical incision, so the first line of defense, the skin, is not intact. Page Ref: 670 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Identify factors influencing a microorganism's capability to produce an infectious process. MNL Learning Outcome: 1. Examine the types of infections, transmission of disease, body defenses to disease, and use of precautions in patient care.
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7) The nurse is reviewing collected data from a client. Which information should the nurse identify as a physiological barrier to defend the client's body from microorganisms? 1. Heavy smoking 2. Moisturizing the skin 3. Breakdown of skin 4. Voiding quantity sufficient Answer: 4 Explanation: Voiding quantity sufficient is a barrier that helps the body defend itself against microorganisms. The act of voiding flushes those organisms that might try to enter the body through the urinary meatus. Page Ref: 673 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Identify anatomic and physiological barriers that defend the body against microorganisms. MNL Learning Outcome: 1. Examine the types of infections, transmission of disease, body defenses to disease, and use of precautions in patient care. 8) The nurse determines that a client has active immunity to a microorganism. What did the nurse assess that caused the client to develop this type of immunity? 1. Becoming ill with tetanus and receiving tetanus toxoid 2. Having chickenpox 3. Receiving a rabies shot after being bitten by a rabid dog 4. Receiving an injection of gamma globulin Answer: 2 Explanation: When the client has the disease, the body stimulates the process of acquired active immunity. Page Ref: 674 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Assessment Learning Outcome: 6. Differentiate active from passive immunity. MNL Learning Outcome: 1. Examine the types of infections, transmission of disease, body defenses to disease, and use of precautions in patient care.
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9) A client was bitten by a rabid raccoon. What care should the nurse prepare to provide to this client? 1. A tetanus toxoid injection 2. An immunization for rabies 3. An injection of immunoglobulin 4. Mother's breast milk with antibodies in it Answer: 2 Explanation: Receiving an immunization for rabies is an example of artificially acquired passive immunity. Page Ref: 678 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Implementation Learning Outcome: 6. Differentiate active from passive immunity. MNL Learning Outcome: 1. Examine the types of infections, transmission of disease, body defenses to disease, and use of precautions in patient care. 10) The nurse is planning care for a client. Which intervention would be appropriate to reduce the risk of infection? 1. Assess vital signs only once daily. 2. Raise the temperature in the client's room. 3. Wash hands. 4. Wear a mask for all client care. Answer: 3 Explanation: Washing hands is always the first and best way to stop the spread of microorganisms, which cause infections. Page Ref: 678 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Planning Learning Outcome: 8. Identify interventions to reduce risks for infections. MNL Learning Outcome: 1. Examine the types of infections, transmission of disease, body defenses to disease, and use of precautions in patient care.
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11) The nurse wants to protect a client from developing an infection. Which action should the nurse take to break a link in the chain of infection? 1. Cover the mouth and nose when sneezing. 2. Place contaminated linens in a paper bag. 3. Use personal protective equipment sparingly. 4. Wear gloves at all times. Answer: 1 Explanation: Covering the mouth and nose when sneezing prevents airborne droplets from escaping into the air for others to contract in the chain of infection. Page Ref: 677 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Implementation Learning Outcome: 9. Identify measures that break each link in the chain of infection. MNL Learning Outcome: 1. Examine the types of infections, transmission of disease, body defenses to disease, and use of precautions in patient care. 12) The nurse is caring for a client with hepatitis A. Which technique should the nurse use to promote proper handwashing technique with this client? 1. Allow the water to splatter forcibly when it is turned on. 2. Clean the faucet after use. 3. Hold the hands upward under the faucet. 4. Use approximately a teaspoon of soap. Answer: 4 Explanation: Approximately 1 teaspoon of soap should be used when performing proper handwashing technique. Page Ref: 681 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Implementation Learning Outcome: 11. Verbalize the steps used in: a. Performing hand hygiene. MNL Learning Outcome: 2. Apply the principles of medical asepsis to patient care.
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13) The nurse is removing personal protective equipment. Which nursing action demonstrates the appropriate technique for removing a mask? 1. Bend the strip at the top of the mask. 2. Loop the ties over the ears. 3. Tie the strings in a bow. 4. Touch the mask by the strings only. Answer: 4 Explanation: Touching the mask by the strings is the appropriate intervention because the mask is considered contaminated. Page Ref: 687 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Implementation Learning Outcome: 11. Verbalize the steps used in: b. Applying and removing a gown, face mask, eyewear, and clean gloves. MNL Learning Outcome: 2. Apply the principles of medical asepsis to patient care. 14) The nurse is preparing to remove soiled gloves. What action should the nurse take first? 1. Drop the gloves into the appropriate waste receptacle. 2. Ease the fingers into the gloves. 3. Grasp the outside of the nondominant glove. 4. Hook the bare thumb inside the other glove. Answer: 3 Explanation: In order to remove gloves after use, one must grasp the outside of the nondominant glove. Page Ref: 687 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Implementation Learning Outcome: 11. Verbalize the steps used in: b. Applying and removing a gown, face mask, eyewear, and clean gloves. MNL Learning Outcome: 2. Apply the principles of medical asepsis to patient care.
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15) The nurse is concerned that a break occurred in a sterile field. Which action occurred that caused this break? 1. Grasping the edge of the outermost flap and opening it away from oneself 2. Keeping objects on the field 1 inch from the edge 3. Keeping the sterile field in eyesight 4. Transferring a sterile object to a sterile field with a clean gloved hand Answer: 4 Explanation: Transferring a sterile object onto a sterile field with a gloved hand would render the field unsterile only if the gloves are not sterile. Page Ref: 692 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Evaluation Learning Outcome: 11. Verbalize the steps used in: c. Establishing and maintaining a sterile field. MNL Learning Outcome: 3. Apply the principles of surgical asepsis to patient care. 16) A client needs to be placed in contact isolation. What items should the nurse ensure are included in this client's room? 1. Cabinet stocked with gloves and gowns 2. Cards and records 3. Paper towels, sink, and blood pressure cuff 4. Sign on the door Answer: 3 Explanation: Paper towels and a sink for handwashing should be in the client's room so they can be used before the staff leaves the room. A blood pressure cuff needs to stay in the client's room to prevent cross contamination. Page Ref: 684 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Implementation Learning Outcome: 10. Compare and contrast category-specific, disease-specific, standard, and transmission-based isolation precaution systems. MNL Learning Outcome: 4. Apply the nursing process to the care of the patient to prevent the spread of infection. 17) The nurse has just been stuck with a syringe while dropping it into a sharps container that was too full in a client's room. What action should the nurse take first for this puncture wound? 1. Complete an injury report. 8
2. Encourage bleeding. 3. Initiate first aid. 4. Wash the area with soap and water. Answer: 2 Explanation: Encouraging bleeding is the first step. Page Ref: 697 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Implementation Learning Outcome: 13. Describe the steps to take in the event of a bloodborne pathogen exposure. MNL Learning Outcome: 1. Examine the types of infections, transmission of disease, body defenses to disease, and use of precautions in patient care. 18) The nurse is preparing to leave a client's isolation room. Which action should the nurse take first when removing a grossly soiled gown? 1. Grasp the sleeve of the dominant arm and remove it with a gloved hand. 2. Release the neck ties of the gown and allow the gown to fall forward. 3. Untie the strings at the neck first. 4. Untie the strings at the waist first. Answer: 4 Explanation: To leave an isolation room where a gown has been worn, one must untie the gown at the waist first, not at the neck. After the neck ties are untied, the gown is allowed to fall forward. Page Ref: 687 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Implementation Learning Outcome: 11. Verbalize the steps used in: b. Applying and removing a gown, face mask, eyewear, and clean gloves. MNL Learning Outcome: 4. Apply the nursing process to the care of the patient to prevent the spread of infection. 19) The nurse is preparing a presentation on standard precautions. Which statement should the nurse include in the presentation? 1. Cut the needle off a syringe after using it to give a client an injection. 2. Dispose of blood-contaminated materials in a biohazard container. 3. Gloves should not be worn for client care unless body fluids are seen. 4. Wear a mask when in direct contact with all clients. 9
Answer: 2 Explanation: Disposal of blood-contaminated materials in a biohazard container is a standard precaution. Page Ref: 688 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 10. Compare and contrast category-specific, disease-specific, standard, and transmission-based isolation precaution systems. MNL Learning Outcome: 1. Examine the types of infections, transmission of disease, body defenses to disease, and use of precautions in patient care. 20) A client diagnosed with tuberculosis is being admitted to a care area. Which nursing action prevents the transmission of the disease? 1. Have the client wear a mask when coming from admission. 2. Stock the supply cart at the beginning of each shift. 3. Wash the hands only after leaving the room. 4. Wear a mask when exiting the room. Answer: 1 Explanation: When a client has an airborne disease and must go elsewhere in the hospital, the client must wear a mask. Page Ref: 684 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Evaluation Learning Outcome: 9. Identify measures that break each link in the chain of infection. MNL Learning Outcome: 1. Examine the types of infections, transmission of disease, body defenses to disease, and use of precautions in patient care.
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21) The nurse is concerned that a client is at risk for a nosocomial infection. What did the nurse assess to make this clinical decision? (Select all that apply.) 1. Client is receiving intravenous fluids. 2. Client has an indwelling urinary catheter. 3. Client is recovering from surgery. 4. Client is receiving pain medication. 5. Client is ambulating twice a day with assistance. Answer: 1, 2, 3 Explanation: Bacteremia can occur from an intravascular line. The client could develop an infection from an invasive procedure or device such as an indwelling urinary catheter. After surgery, the client's health status is compromised, lowering the client's defenses to fight infection. Page Ref: 669 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify risks for nosocomial and healthcare-associated infections. MNL Learning Outcome: 1. Examine the types of infections, transmission of disease, body defenses to disease, and use of precautions in patient care.
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22) A client diagnosed with an infectious disease asks the nurse how the infection "got inside" her body. Which responses would be appropriate for the nurse to make? (Select all that apply.) 1. "It depends on the number of organisms present to cause a disease." 2. "It depends on how aggressive the organisms are to cause a disease." 3. "It depends on how the organisms get inside the body to cause a disease." 4. "It depends on where the person is at the time the disease is present." 5. "It depends on where the person works." Answer: 1, 2, 3, 4 Explanation: This response addresses the number of microorganisms present. This response addresses the virulence and potency of the microorganisms. This response addresses the ability of the microorganisms to enter the body. This response addresses the susceptibility of the host and the ability of the microorganisms to live in the host's body. Page Ref: 671 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Implementation Learning Outcome: 4. Identify factors influencing a microorganism's capability to produce an infectious process. MNL Learning Outcome: 1. Examine the types of infections, transmission of disease, body defenses to disease, and use of precautions in patient care.
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23) The nurse determines that a client has adequate physiological barriers to defend the body against infection. What did the nurse assess in this client? (Select all that apply.) 1. Intact and dry skin 2. Intact oral mucous membranes 3. Bowel sounds present in all four quadrants 4. Nasal congestion 5. Urinary retention Answer: 1, 2, 3 Explanation: Intact skin is the body's first line of defense against microorganisms. Intact mucous membranes are the body's first line of defense against microorganisms. Peristalsis tends to move microbes out of the body. Page Ref: 672-673 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Identify anatomic and physiological barriers that defend the body against microorganisms. MNL Learning Outcome: 1. Examine the types of infections, transmission of disease, body defenses to disease, and use of precautions in patient care. 24) A client is diagnosed with a communicable disease and must be placed in isolation. The nurse should identify which diagnosis as a priority for this client? 1. Social Isolation 2. Anxiety 3. Acute Pain 4. Imbalanced Nutrition: Less Than Body Requirements Answer: 1 Explanation: Social Isolation would be appropriate for the client who needs to be separated from others during a contagious episode. Page Ref: 677 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Diagnosis Learning Outcome: 7. Identify relevant nursing diagnoses and contributing factors for clients at risk for infection and who have an infection. MNL Learning Outcome: 4. Apply the nursing process to the care of the patient to prevent the spread of infection. 13
25) A client tells the nurse that the newly diagnosed communicable disease is negatively impacting employment and causing a stressful situation at home. What diagnosis should the nurse select as a priority for this client? 1. Anxiety 2. Acute Pain 3. Social Isolation 4. Low Self-Esteem Answer: 1 Explanation: Anxiety is appropriate because the client is discussing the impact of the communicable disease on work and home life. Page Ref: 677 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Diagnosis Learning Outcome: 7. Identify relevant nursing diagnoses and contributing factors for clients at risk for infection and who have an infection. MNL Learning Outcome: 4. Apply the nursing process to the care of the patient to prevent the spread of infection. 26) A client is being discharged after a surgical procedure. On what should the nurse instruct the client to reduce the risk of infection? (Select all that apply.) 1. Handwashing technique 2. The importance of adequate nutrition 3. Covering the mouth and nose when coughing or sneezing 4. Increasing contact with others 5. Restricting rest period Answer: 1, 2, 3 Page Ref: 677 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Implementation Learning Outcome: 8. Identify interventions to reduce risks for infections. MNL Learning Outcome: 4. Apply the nursing process to the care of the patient to prevent the spread of infection.
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27) A client in isolation ambulates with assistance to the bathroom. After toileting, what should the unlicensed assistive personnel do? 1. Assist the client with handwashing. 2. Assist the client back to bed. 3. Change the client's bed. 4. Leave the client's room. Answer: 1 Explanation: The client should utilize good handwashing after going to the bathroom. The unlicensed assistive personnel should assist the client with handwashing. Page Ref: 677 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Implementation Learning Outcome: 8. Identify interventions to reduce risks for infections. MNL Learning Outcome: 4. Apply the nursing process to the care of the patient to prevent the spread of infection. 28) While irrigating a client's abdominal wound, the irrigate splashes into the nurse's nose and eyes. What should the nurse do? 1. Flush the nose and eyes for 5-10 minutes with water or normal saline. 2. Begin HIV high-risk exposure prophylaxis within 24 hours. 3. Wash the areas with soap and water. 4. Have blood drawn for hepatitis B antibodies. Answer: 1 Explanation: After an exposure to the mucous membranes, the area should be flushed for 5-10 minutes with saline or water. Page Ref: 698 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Implementation Learning Outcome: 13. Describe the steps to take in the event of a bloodborne pathogen exposure. MNL Learning Outcome: 1. Examine the types of infections, transmission of disease, body defenses to disease, and use of precautions in patient care.
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29) The nurse is reviewing the agents available to disinfect the hands after providing client care. Which agents should the nurse consider using? (Select all that apply.) 1. Triclosan 2. Chlorine (bleach) 3. Isopropyl alcohol 4. Hydrogen peroxide 5. Chlorhexidine gluconate Answer: 3, 5 Explanation: Isopropyl alcohol is an agent that can be used on the hands as a disinfectant. Chlorhexidine gluconate is an agent that can be used on the hands as a disinfectant. Page Ref: 682 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Planning Learning Outcome: 8. Identify interventions to reduce risks for infections. MNL Learning Outcome: 1. Examine the types of infections, transmission of disease, body defenses to disease, and use of precautions in patient care.
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30) The nurse needs to apply personal protective equipment before entering a client's room. In which order should the nurse perform the following actions? Place the steps in the order in which they should be performed. 1. Apply gloves. 2. Apply eyewear. 3. Apply the gown. 4. Apply the face mask. 5. Perform hand hygiene. Answer: 5, 3, 4, 2, 1 Explanation: 1. Gloves are applied last. 2. Protective eyewear is applied after the face mask. 3. The gown is applied after hand hygiene. 4. The face mask is applied after the gown. 5. Before applying personal protective equipment, hand hygiene should be performed. Page Ref: 686-687 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Implementation Learning Outcome: 11. Verbalize the steps used in: b. Applying and removing a gown, face mask, eyewear, and clean gloves. MNL Learning Outcome: 1. Examine the types of infections, transmission of disease, body defenses to disease, and use of precautions in patient care.
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31) The nurse asks unlicensed assistive personnel (UAP) to help a client off of a bedpan. Which action should the UAP take first? 1. Wash hands 2. Apply gloves 3. Apply a gown 4. Apply a face mask Answer: 1 Explanation: Before providing any type of client care, the hands should be washed. Gloves are to then be applied. There is no reason for the UAP to apply a gown or face mask. Page Ref: 680 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the health care team | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Implementation Learning Outcome: 12. Recognize when it is appropriate to assign infection prevention skills to unlicensed assistive personnel. MNL Learning Outcome: 1. Examine the types of infections, transmission of disease, body defenses to disease, and use of precautions in patient care. 32) A client is having a lumbar puncture at the bedside. Which action should the nurse assign to unlicensed assistive personnel (UAP) to complete? 1. Apply sterile gloves 2. Clean a work surface 3. Open the sterile package 4. Transport samples to the lab Answer: 4 Explanation: UAP are not responsible for setting up a sterile field. UAP can transport the samples to the lab. The UAP will not apply sterile gloves, clean a work surface, or open the sterile package. Page Ref: 692 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the health care team | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Implementation Learning Outcome: 12. Recognize when it is appropriate to assign infection prevention skills to unlicensed assistive personnel. MNL Learning Outcome: 1. Examine the types of infections, transmission of disease, body defenses to disease, and use of precautions in patient care.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 32 Safety 1) The nurse is planning care for an older client. Which safety hazard should the nurse take into consideration when planning this care? 1. Burns 2. Drowning 3. Poisoning 4. Suffocation Answer: 1 Explanation: Falls, burns, and pedestrian and motor-vehicle crashes are safety hazards in older adults. Page Ref: 702 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Planning Learning Outcome: 4. Identify common potential hazards throughout the lifespan. MNL Learning Outcome: 2. Recognize lifespan considerations when developing strategies for preventing injury in patients. 2) The nurse is preparing materials to instruct the parents of a newborn. What should the nurse identify as a safety hazard in an infant? 1. Exposure to alcohol consumption 2. Drowning 3. Pedestrian accidents 4. Suffocation in the crib Answer: 4 Explanation: Suffocation in the crib is a safety hazard for both newborns and infants. Page Ref: 702 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Planning/Teaching and Learning Learning Outcome: 4. Identify common potential hazards throughout the lifespan. MNL Learning Outcome: 2. Recognize lifespan considerations when developing strategies for preventing injury in patients.
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3) The nurse is reviewing safety hazards with a pregnant client. What should the nurse include when instructing this client about safety and the developing fetus? 1. Banging into objects 2. Bicycle rides 3. Recreational activities 4. X-rays Answer: 4 Explanation: Exposure to x-rays in the first trimester could cause harm to the developing fetus. Page Ref: 641 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 4. Identify common potential hazards throughout the lifespan. MNL Learning Outcome: 2. Recognize lifespan considerations when developing strategies for preventing injury in patients. 4) The nurse would like to improve communication among caregivers. How should the nurse use the Joint Commission 2019 National Patient Safety Goals to achieve this objective? 1. Review a list of look-alike/sound-alike drugs used in the organization. 2. Use a verification process to confirm the correct procedure. 3. Report critical results of tests and diagnostic procedures on a timely basis. 4. Use the client's room number as an identifier. Answer: 3 Explanation: Reporting critical results of tests and diagnostic procedures on a timely basis is one way the National Patient Safety Goals improve communication among caregivers. Page Ref: 705 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Implementation Learning Outcome: 3. Discuss the National Patient Safety Goals. MNL Learning Outcome: 3. Implement interventions to provide quality safety and best patient outcomes.
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5) As a member of the safety committee, the nurse's task is to identify actions to prevent falls within the organization. Which intervention should the nurse emphasize as important to prevent falls? 1. Display the phone number to the nurses' station. 2. Keep electrical cords under the bed. 3. Keep the environment tidy. 4. Read label directions. Answer: 3 Explanation: Keeping the environment tidy and free of clutter will go a long way in preventing falls. Page Ref: 711 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Planning Learning Outcome: 5. Plan strategies to maintain safety in the healthcare setting, home, and community, including prevention strategies across the lifespan for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism. MNL Learning Outcome: 1. Recognize factors that affect patient safety in the home, healthcare facility, and community.
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6) The home care nurse wants to ensure the safety of an older client who lives at home alone. Which intervention should the nurse identify as a way to prevent this client from falling? 1. Check vision every 5 years. 2. Exercise regularly. 3. Place socks on feet. 4. Turn the light on after getting out of bed. Answer: 2 Explanation: The client needs to exercise regularly to maintain strength, flexibility, mobility, and balance, which prevents falls. Page Ref: 711 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Plan strategies to maintain safety in the healthcare setting, home, and community, including prevention strategies across the lifespan for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism. MNL Learning Outcome: 2. Recognize lifespan considerations when developing strategies for preventing injury in patients.
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7) The mother of a 2-year-old expresses concern to the nurse that her child continually climbs out of the crib at home. What should the nurse advise the mother to do? 1. Omit the afternoon nap. 2. Place a crib net over the top of the crib. 3. Remove all objects from around the crib. 4. Restrain the child if he gets up more than once. Answer: 2 Explanation: A crib net will prevent an active child from climbing out of the crib but will allow him freedom to move about in the crib. Page Ref: 726 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Plan strategies to maintain safety in the healthcare setting, home, and community, including prevention strategies across the lifespan for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism. MNL Learning Outcome: 2. Recognize lifespan considerations when developing strategies for preventing injury in patients. 8) While the nurse is performing morning care, a client begins to have a seizure. What should the nurse do to help this client? 1. Insert a tongue blade into the client's mouth. 2. Loosen any clothing around the neck and chest. 3. Restrain the client. 4. Turn the client to the supine position, if possible. Answer: 2 Explanation: Loosening any clothing around the neck and chest prevents constriction that might occur during the seizure that could compromise the airway. Page Ref: 715 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Discuss implementation of seizure precautions. MNL Learning Outcome: 4. Utilize the nursing process in caring for patients to maintain safe and effective client care across the lifespan. 9) The nurse is considering the use of restraints for a client. In which situation can the nurse apply restraints to a client? 5
1. Client wanders around the care area. 2. Client is picking at the access site for intravenous infusion of chemotherapy. 3. Client needed to use the bathroom and waited for help but didn't want to soil the bed and fell while attempting to walk to the bathroom. 4. Client does not want to stay in bed but wants to sit in the lounge with others. Answer: 2 Explanation: In this situation, the client's actions could be harmful to health and a restraint would be indicated. Page Ref: 720 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Assessment Learning Outcome: 8. Discuss the use and legal implications of restraints. MNL Learning Outcome: 4. Utilize the nursing process in caring for patients to maintain safe and effective client care across the lifespan. 10) The nurse is applying restraints to a client. After securing a healthcare provider's order, what should the nurse do? 1. Assess the restraints every 10 minutes. 2. Pad bony prominences. 3. Secure the restraint to the side rail. 4. Tie the restraint with a square knot. Answer: 2 Explanation: Padding bony prominences will prevent possible skin breakdown. Page Ref: 722 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Implementation Learning Outcome: 11. Verbalize the steps for: c. Applying restraints. MNL Learning Outcome: 4. Utilize the nursing process in caring for patients to maintain safe and effective client care across the lifespan.
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11) An older client diagnosed with Alzheimer disease continually tries to get out of bed at night. Which safety measure should the nurse consider using with this client? 1. Explain all procedures and treatments. 2. Place a bed safety monitoring device on the bed. 3. Orient the client to surroundings. 4. Use relaxation techniques. Answer: 2 Explanation: Alzheimer disease causes impaired intellectual functioning, so a safety device that is weight sensitive would alert the nurse when the client is trying to get out of bed. Page Ref: 713-714 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Implementation Learning Outcome: 9. Describe alternatives to restraints. MNL Learning Outcome: 4. Utilize the nursing process in caring for patients to maintain safe and effective client care across the lifespan. 12) The nurse is caring for a client who is confused and wanders. Which alternative to a restraint can the nurse use for this client? 1. Assign this client to the farthest room from the nurses' station. 2. Place a rocking chair in the client's room. 3. Pull up all of the side rails on the bed. 4. Wedge pillows against the side rails on the bed. Answer: 2 Explanation: Placing a rocking chair in the client's room will help her to expend some of her energy so that she will be less inclined to walk and wander. Page Ref: 721 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Implementation Learning Outcome: 9. Describe alternatives to restraints. MNL Learning Outcome: 4. Utilize the nursing process in caring for patients to maintain safe and effective client care across the lifespan.
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13) The nurse is identifying outcomes for an older client prone to injuries. Which outcome should the nurse identify as appropriate for this client? 1. The client will demonstrate an understanding of all limitations. 2. The client will establish a buddy system. 3. The client will make uninformed choices when addressing health issues. 4. The client will take his medication as desired. Answer: 2 Explanation: Establishing a buddy system provides social contact, safeguards against abuse, and offers respite for caregivers. It also provides a way for elders to be checked up on daily. Page Ref: 709-710, 726 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Planning Learning Outcome: 5. Plan strategies to maintain safety in the healthcare setting, home, and community, including prevention strategies across the lifespan for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism. MNL Learning Outcome: 2. Recognize lifespan considerations when developing strategies for preventing injury in patients.
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14) The nurse is reviewing safety with a home-care client. What should the nurse include in this teaching? 1. Always pull a plug at the plug-in from the wall outlet. 2. Keep plants in the home. 3. Use overloaded outlets when necessary. 4. Remove labels from containers and refill for recycling. Answer: 1 Explanation: Always pull a plug at the plug-in from the wall outlet. Pulling a plug by its cord can damage the cord and plug unit, creating a dangerous situation. Page Ref: 719 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 5. Plan strategies to maintain safety in the healthcare setting, home, and community, including prevention strategies across the lifespan for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism. MNL Learning Outcome: 1. Recognize factors that affect patient safety in the home, healthcare facility, and community.
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15) The nurse is attending a seminar on disaster planning. What should the nurse identify as being the highest concern for homeland security? 1. Cancer 2. Seasonal flu 3. Tuberculosis 4. Zika virus Answer: 4 Explanation: All institutions are either required or encouraged to have emergency operations plans, and personnel with a direct role in emergency preparedness are required by the Homeland Security Presidential Directive. The Zika virus is one heath situation that should be addressed with disaster planning. Page Ref: 703 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Plan strategies to maintain safety in the healthcare setting, home, and community, including prevention strategies across the lifespan for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism. MNL Learning Outcome: 1. Recognize factors that affect patient safety in the home, healthcare facility, and community.
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16) While eating in a restaurant, a nurse notices that a customer at the next table begins to clutch his throat while eating a steak. What should the nurse do first? 1. Ask the customer if he is choking. 2. Attempt to give five back blows. 3. Perform the Heimlich maneuver. 4. Start chest compressions. Answer: 1 Explanation: The first step is to ask if the person is choking. Page Ref: 717 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Plan strategies to maintain safety in the healthcare setting, home, and community, including prevention strategies across the lifespan for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism. MNL Learning Outcome: 1. Recognize factors that affect patient safety in the home, healthcare facility, and community. 17) The nurse is admitting an older client to the care area. What can the nurse do to promote a safe environment for the client? 1. Keep clutter to a minimum in the client's room. 2. Have the client wear terry-cloth slippers. 3. Provide adequate lighting. 4. Turn off alarms to reduce noise. Answer: 3 Explanation: Providing adequate lighting will help prevent the client from falling. Page Ref: 702 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Plan strategies to maintain safety in the healthcare setting, home, and community, including prevention strategies across the lifespan for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism. MNL Learning Outcome: 2. Recognize lifespan considerations when developing strategies for preventing injury in patients. 18) The nurse is determining a client's risk for injury. What should the nurse assess in this client? 11
(Select all that apply.) 1. Age 2. Mobility 3. Hearing 4. Vision 5. Dietary intake Answer: 1, 2, 3, 4 Page Ref: 701-702 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Describe methods to assess a client's risk for injury. MNL Learning Outcome: 1. Recognize factors that affect patient safety in the home, healthcare facility, and community.
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19) An older client is observed having difficulty moving from a sitting to a standing position and has an unsteady gait. What should the nurse assess in this client to promote home safety? (Select all that apply.) 1. Presence of grab bars in the bathroom 2. Absence of scatter rugs on the floors 3. Correct use of cane to ambulate 4. Ability to stand in place for a minute before ambulating 5. Alcohol use with prescribed medications Answer: 1, 2, 3 Explanation: For home safety, it would be beneficial for the client with difficulty moving from a sitting to a standing position to have grab bars in the bathroom. For home safety, it would be beneficial for the client with an unsteady gait not to have scatter rugs on the floor. For home safety, it would be beneficial for the client with an unsteady gait to be able to use a cane correctly. Page Ref: 702 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Assessment Learning Outcome: 6. Explain interventions to prevent falls. MNL Learning Outcome: 1. Recognize factors that affect patient safety in the home, healthcare facility, and community.
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20) A client is being transferred from an acute care facility to a long-term care facility. What information should the nurse provide to the long-term care facility about the client's medications? 1. Nothing, as the medications all need to be reordered at the long-term care facility. 2. Have the client's medication prescriptions filled before going to the long-term care facility. 3. Instruct the client to tell the nurses at the long-term care facility what medications are prescribed. 4. Inform the nurse at the long-term care facility what medications the client is prescribed, and document that this information was provided. Answer: 4 Explanation: The nurse should communicate the client's medications to the nurses at the longterm care facility and document that this communication occurred. Page Ref: 707 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Plan strategies to maintain safety in the healthcare setting, home, and community, including prevention strategies across the lifespan for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism. MNL Learning Outcome: 4. Utilize the nursing process in caring for patients to maintain safe and effective client care across the lifespan.
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21) A client is prescribed seizure precautions. The nurse places functioning oral suction equipment in the client's room for what reason? 1. Suctioning might be needed to prevent the aspiration of oral secretions. 2. The client has difficulty swallowing liquids. 3. There was a spare oral suction set up, and the nurse did not want to return it to the engineering department. 4. It helps when the client is brushing her teeth. Answer: 1 Explanation: When implementing seizure precautions, the nurse should place oral suction equipment in the client's room because suctioning might be needed to prevent aspiration of oral secretions. Page Ref: 715 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Planning Learning Outcome: 7. Discuss implementation of seizure precautions. MNL Learning Outcome: 3. Implement interventions to provide quality safety and best patient outcomes. 22) The nurse is evaluating teaching provided to a client about home safety. Which observation indicates that teaching has been effective? 1. Smoke alarm functioning with new batteries installed 2. Scatter rugs located in the kitchen and bathroom only 3. Cord for a space heater stretched across a hallway 4. Light bulbs burned out in the bathroom and living room Answer: 1 Explanation: The installation and use of a smoke alarm in the home would indicate that home safety instruction has been effective. Page Ref: 716 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Evaluation/Teaching and Learning Learning Outcome: 5. Plan strategies to maintain safety in the healthcare setting, home, and community, including prevention strategies across the lifespan for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism. MNL Learning Outcome: 1. Recognize factors that affect patient safety in the home, healthcare facility, and community. 15
23) The nurse is installing a bed safety-monitoring device for a client. What should the nurse do after testing the device and alarm sound? 1. Place the leg band on the client with the leg in a straight horizontal position. 2. Place the sensor under the mattress near the shoulder region. 3. Set a time delay for 30 seconds. 4. Connect the sensor pad to the control unit. Answer: 1 Explanation: After testing the device and alarm sound, the nurse should place the leg band on the client with the leg in a straight horizontal position. Page Ref: 713 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Implementation Learning Outcome: 11. Verbalize the steps for: a. Using a bed or chair exit safety monitoring device. MNL Learning Outcome: 3. Implement interventions to provide quality safety and best patient outcomes.
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24) A client is prescribed to have wrist restraints applied. Place in order the steps the nurse will take to apply these restraints. 1. Pad bony prominences on the wrist. 2. Apply the padded portion of the restraint around the wrist. 3. Pull the tie of the restraint through the slit in the wrist restraint and ensure that it is not too tight. 4. Attach the other end of the restraint to the movable portion of the bed frame using a half-bow knot. Answer: 1, 2, 3, 4 Explanation: 1. Prior to applying the wrist restraint, the client's bony prominences should be padded. 2. The nurse should apply the padded portion of the restraint around the wrist. 3. The nurse should then pull the tie of the restraint through the slit in the wrist restraint and ensure that it is not too tight. 4. The nurse should then attach the other end of the restraint to the movable portion of the bed frame using a half-bow knot. Page Ref: 724-725 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Implementation Learning Outcome: 11. Verbalize the steps for: c. Applying restraints. MNL Learning Outcome: 3. Implement interventions to provide quality safety and best patient outcomes.
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25) The nurse is identifying activities and skills to assign to assistive personnel (AP). Which action can the nurse safely delegate? 1. Provide oral fluids to a newly extubated client. 2. Irrigate the indwelling urinary catheter of a client recovering from prostate surgery. 3. Apply a wrist restraint to a client. 4. Administer oral pain medication to a client before the client attends physical therapy. Answer: 3 Explanation: Application of ordered restraints and their temporary removal for skin monitoring and care may be delegated to UAP who have been trained in their use. Page Ref: 724 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the health care team | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Planning Learning Outcome: 12. Recognize when it is appropriate to delegate using a bed or chair exit safety monitoring device, implementing seizure precautions, and applying restraints of clients to assistive personnel. MNL Learning Outcome: 3. Implement interventions to provide quality safety and best patient outcomes. 26) A client is prescribed seizure precautions. What can the nurse safely assign to assistive personnel (AP) to complete when implementing the precautions? 1. Placing a tongue blade at the head of the bed 2. Padding the client's bed 3. Installing oxygen 4. Checking the oral suction apparatus Answer: 2 Explanation: The nurse can safely delegate the padding of the bed to AP. Page Ref: 715 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Planning Learning Outcome: 12. Recognize when it is appropriate to delegate using a bed or chair exit safety monitoring device, implementing seizure precautions, and applying restraints of clients to unlicensed assistive personnel. MNL Learning Outcome: 3. Implement interventions to provide quality safety and best patient outcomes.
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27) After ambulating a client to the bathroom, the assistive personnel did not reattach the client's bed safety-monitoring device, and the client fell out of bed. What should the nurse document? 1. Client fell out of bed; bed safety-monitoring device malfunctioning. 2. Client fell out of bed; client removed leg band of bed safety-monitoring device. 3. Client fell out of bed; no observable injuries. 4. Client fell out of bed; bed safety-monitoring device not activated. Answer: 4 Explanation: The nurse needs to document what occurred with the client and why. Page Ref: 714 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 13. Demonstrate appropriate documentation and reporting of using a bed or chair exit safety monitoring device, seizure precautions, and applying restraints. MNL Learning Outcome: 4. Utilize the nursing process in caring for patients to maintain safe and effective client care across the lifespan. 28) A client who is on seizure precautions experiences a seizure while ambulating in the room. What should the nurse include in this client's documentation? (Select all that apply.) 1. Who assisted the client back to bed 2. Location of the seizure 3. Duration of the seizure 4. Status of airway and use of oxygen 5. Who discovered the client Answer: 2, 3, 4 Page Ref: 715 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Implementation Learning Outcome: 13. Demonstrate appropriate documentation and reporting of using a bed or chair exit safety monitoring device, seizure precautions, and applying restraints. MNL Learning Outcome: 4. Utilize the nursing process in caring for patients to maintain safe and effective client care across the lifespan.
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29) The nurse is preparing to assess a client who has a history of falls. Which methods should the nurse use to assess this client's risk for injury? (Select all that apply.) 1. Cognitive awareness 2. Mobility 3. Nursing history 4. Physical examination 5. Marital status Answer: 1, 2, 3, 4 Explanation: Cognitive awareness is essential to assess. Mobility status is essential to assess. A nursing history and physical examination are methods to assess a client at risk for injury. A nursing history and physical examination are methods to assess a client at risk for injury. Page Ref: 704 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Plan strategies to maintain safety in the healthcare setting, home, and community, including prevention strategies across the lifespan for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism. MNL Learning Outcome: 1. Recognize factors that affect patient safety in the home, healthcare facility, and community.
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30) The nurse is appointed to be a member of a committee whose focus is to identify and address workplace safety issues. Which issues should the nurse recommend for analysis by this committee? (Select all that apply.) 1. Lifting clients 2. Inadequate lighting 3. Bending and walking 4. Exposure to infectious agents 5. Exposure to hazardous medications Answer: 1, 3, 4, 5 Page Ref: 703 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Plan strategies to maintain safety in the healthcare setting, home, and community, including prevention strategies across the lifespan for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism. MNL Learning Outcome: 1. Recognize factors that affect patient safety in the home, healthcare facility, and community.
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31) During a home visit, the nurse determines that a toddler is at risk for injury. What did the nurse assess to identify this client's risk? (Select all that apply.) 1. Unscreened windows 2. Electrical outlets uncovered 3. Yard with a built-in pool unfenced 4. Storing a cleaning solution in a bottom cabinet 5. Pots on stove with handles turned inward Answer: 1, 2, 3, 4 Explanation: Unscreened windows, uncovered electrical outlets, having a backyard pool without a fence, and a cleaning solution stored in a bottom cabinet would be safety hazards for a toddler. Page Ref: 706 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Plan strategies to maintain safety in the healthcare setting, home, and community, including prevention strategies across the lifespan for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism. MNL Learning Outcome: 1. Recognize factors that affect patient safety in the home, healthcare facility, and community.
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32) The nurse is assessing a client's risk for injury. Which finding should the nurse categorize as a lifestyle factor? 1. Language barrier 2. Chronic insomnia 3. Diminished balance 4. Access to illicit drugs Answer: 4 Explanation: Access to illicit drugs is a lifestyle factor. A language barrier affects the ability to communicate. Chronic insomnia affects cognitive awareness. Diminished balance affects mobility. Page Ref: 701-702 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Discuss factors that affect individuals' ability to protect themselves. MNL Learning Outcome: 1. Recognize factors that affect patient safety in the home, healthcare facility, and community. 33) The nurse visits the home of a client recently hospitalized. Which finding indicates to the nurse that the client is at risk for injury in the home environment? 1. Handrails on all stairs 2. Nonskid shower surface 3. Outdoor lightbulbs burned out 4. Smoke alarms throughout the home Answer: 3 Explanation: Outdoor lightbulbs being burned out indicates inadequate lighting and increases the client's risk for injury. Handrails, nonskid shower surface, and smoke alarms all decrease the risk for injury in the home environment. Page Ref: 701-702 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Discuss factors that affect individuals' ability to protect themselves. MNL Learning Outcome: 1. Recognize factors that affect patient safety in the home, healthcare facility, and community.
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34) The nurse is assessing an older client. Which finding should cause the nurse to be concerned about the client's safety? 1. Alteration in olfactory status 2. Blood pressure 138/88 mm Hg 3. Applies medication for a skin rash 4. Ambulates without assistive devices Answer: 1 Explanation: A change in the ability to smell could be a safety hazard since the client may not be able to smell a gas leak or smoke from a fire in the home. A normal blood pressure, topical medication, and ambulating without assistive devices do not increase this client's risk for injury. Page Ref: 701-702 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Describe methods to assess a client's risk for injury. MNL Learning Outcome: 1. Recognize factors that affect patient safety in the home, healthcare facility, and community. 35) The nurse is creating a teaching poster about the most recent National Patient Safety Goals. Which information should be included to reduce the risk of healthcare-associated infections? 1. Post the guidelines for hand hygiene 2. List the chemicals used to clean the floors 3. Identify when the client rooms are cleaned each day 4. Explain the different types of transmission-based precautions Answer: 1 Explanation: One action to prevent the development of healthcare-associated infections is to perform thorough hand hygiene. Chemicals used to clean the floors and room cleaning schedule will not prevent the development of healthcare-associated infections. The different types of transmission-based precautions would be applicable after an infection occurs. Page Ref: 705 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 3. Discuss the National Patient Safety Goals. MNL Learning Outcome: 3. Implement interventions to provide quality safety and best patient outcomes. 24
36) The nurse is planning care for a client with urinary frequency. Which action should be taken to reduce the client's risk of falling when walking to the bathroom? 1. Provide a bedside commode 2. Raise one side rail on the bed 3. Assess for activity intolerance 4. Provide slippers with nonskid soles Answer: 1 Explanation: For urinary frequency, one measure to prevent falls is to provide the client with a bedside commode. Raising one side rail would be appropriate if the client were taking medication that alters sensorium. Assessing for activity intolerance would be appropriate if the client is experiencing weakness. Slippers with nonskid soles is appropriate if the client has impaired gait or balance. Page Ref: 711 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Planning Learning Outcome: 6. Explain interventions to prevent falls. MNL Learning Outcome: 1. Recognize factors that affect patient safety in the home, healthcare facility, and community.
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37) An older client is agitated and confused after relocating to a new facility. Which action should the nurse take to ensure for this client's safety? 1. Apply a vest restraint 2. Medicate with a sedative 3. Take the client for a walk 4. Place in a chair with a locked tray Answer: 3 Explanation: One action to address a psychological cause of potential unsafe behavior is to take the client for a walk. Restraining the client with a vest, sedatives, or a locked tray over a chair all require a healthcare provider's prescription and could cause the client's agitation to worsen. Page Ref: 721 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Assessment Learning Outcome: 8. Discuss the use and legal implications of restraints. MNL Learning Outcome: 4. Utilize the nursing process in caring for patients to maintain safe and effective client care across the lifespan.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 33 Hygiene 1) The nurse is preparing to provide morning care to a client. What should the nurse explain to the client as the reason for a daily bath? 1. Assess skin integrity 2. Develop a nurse-client relationship 3. Moisturize the skin 4. Stimulate circulation Answer: 4 Explanation: The three major reasons for a bath are to remove waste products such as perspiration, stimulate circulation, and refresh the client. Page Ref: 736 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Identify the purposes of bathing. MNL Learning Outcome: 1. Perform assessment for patients related to hygienic needs and practices. 2) The nurse is preparing to bathe a client on the first postoperative day. Which nursing intervention should take priority? 1. Apply lotion to the extremities. 2. Change the water when it becomes cold. 3. Raise side rails when gathering supplies. 4. Remove the soiled dressing during the bath. Answer: 3 Explanation: Raising the side rails would take priority when planning care. This is a safety issue, and safety is second on Maslow's hierarchy of needs. The client is only 1 day postop and may still be sedated, posing a risk for a potential fall. Page Ref: 740 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Compare and contrast the task-centered approach and the client-centered approach to bathing. MNL Learning Outcome: 3. Implement the steps for procedures used to meet the hygienic needs of patients. 1
3) A client who is ambulatory is able to get out of bed for morning care. What should the nurse assess before assisting the client out of the bed to change the linens? (Select all that apply.) 1. Pulse 2. Respirations 3. Urine output 4. Blood pressure 5. Mobility status Answer: 1, 2, 4, 5 Page Ref: 71 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 13. Verbalize the steps used in: h. Changing an unoccupied bed. MNL Learning Outcome: 1. Perform assessment for patients related to hygienic needs and practices. 4) The nurse is shampooing a client's hair. Which assessment finding should the nurse consider as expected? 1. Dry, dark, thin 2. Smooth, taut, shiny 3. Smooth texture and not oily or dry 4. Tender, warm scalp Answer: 3 Explanation: The hair should be smooth in texture and neither oily nor dry. Page Ref: 762-763 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify normal and abnormal assessment findings while providing hygiene care. MNL Learning Outcome: 3. Implement the steps for procedures used to meet the hygienic needs of patients.
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5) The nurse identifies the diagnosis Self-Care Deficit related to cognitive impairment as appropriate for a client. What should the nurse select as an expected outcome for this client? 1. The client will be able to name the staff that works on the day shift. 2. The client will eliminate safety hazards in her environment. 3. The client, with supervision, will brush the teeth. 4. The nurse will stress the importance of adequate fluid intake. Answer: 3 Explanation: A client with cognitive impairment would be able to brush the teeth but only with supervision. The client would not voluntarily brush teeth without prompting from the staff. Page Ref: 733, 752 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 4. Apply the nursing process to common problems related to hygienic care of the skin, feet, nails, mouth, hair, eyes, and ears. MNL Learning Outcome: 3. Implement the steps for procedures used to meet the hygienic needs of patients. 6) The nurse is reviewing assigned clients for morning care needs. Which situation could pose a threat to one client's personal hygiene? 1. A client has a newly formed ileostomy. 2. A client performs meticulous foot care. 3. A German client refuses to bathe every day. 4. The room temperature is set at 72°F. Answer: 1 Explanation: Some of the factors that influence one's personal hygiene are social practices, body image, knowledge of physical condition, and cultural variables. A client who has had an ileostomy has had a body image change, which can greatly influence whether the client will care for it or rely on others. This can pose a threat if the client chooses not to care for it. Page Ref: 760 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Identify factors influencing personal hygiene. MNL Learning Outcome: 2. Plan nursing care for patients related to hygienic needs, practices, and delegation.
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7) The nurse is preparing to provide hygienic care to a client. On what will the nurse focus this care? 1. Clothes 2. Family 3. Hair 4. Nutritional Answer: 3 Explanation: Hygiene care consists of skin, hair, hands, feet, eyes, nose, mouth, back, and perineum. Page Ref: 730 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 1. Describe hygienic care that nurses provide to clients. MNL Learning Outcome: 2. Plan nursing care for patients related to hygienic needs, practices, and delegation. 8) A client is removing soft contact lenses. Which should the nurse do to support the client's lenses? 1. Provide disposable tissues 2. Obtain a bottle of sterile normal saline 3. Remind to place each lens in the correct side of the container 4. Prepare to irrigate the client's eyes after removal Answer: 3 Explanation: All users should have a special container for their lenses. Some contain a solution so that the lenses are stored wet; in others, the lenses are dry. Each lens container has a slot or cup with a label indicating whether it is for the right or left lens. It is essential the correct lens be stored in the appropriate slot so that it will be placed in the correct eye. The lenses are not stored in tissues. There is not enough information to determine if the client needs sterile normal saline. There is no reason to irrigate the client's eyes after removal of the lenses. Page Ref: 765 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 9. Discuss the different types of contact lenses. MNL Learning Outcome: 3. Implement the steps for procedures used to meet the hygienic needs of patients.
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9) The nurse is caring for a client with diabetes. What should the nurse include as foot care for this client? 1. Cut toenails in a rounded shape and file. 2. Dry toes thoroughly. 3. Wash feet with water at a temperature of 90-98.6°F. 4. Inspect feet thoroughly once a week. Answer: 2 Explanation: Toes should be dried thoroughly after being washed to impede fungal growth and prevent maceration. Page Ref: 747 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 13. Verbalize the steps used in: c. Providing foot care. MNL Learning Outcome: 3. Implement the steps for procedures used to meet the hygienic needs of patients. 10) A client has the nursing diagnosis Risk for Impaired Skin Integrity related to immobility. Which nursing intervention should be identified for this client's problem? 1. Encourage the client to eat at least 40% of meals. 2. Keep linens dry and wrinkle-free. 3. Restrict fluid intake. 4. Turn client every 3 hours. Answer: 2 Explanation: Keeping linens dry and wrinkle-free will prevent pressure areas. Page Ref: 772 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 4. Apply the nursing process to common problems related to hygienic care of the skin, feet, nails, mouth, hair, eyes, and ears. MNL Learning Outcome: 3. Implement the steps for procedures used to meet the hygienic needs of patients.
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11) Assistive personnel are caring for a client's ears. What information should be reported to the nurse? 1. Excessive earwax 2. Loud talking 3. Presence of a hearing aid 4. Presence of any drainage Answer: 4 Explanation: The healthcare provider should report any drainage from the ears to the nurse. Page Ref: 767 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the health care team | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 16. Recognize when it is appropriate to delegate hygiene skills for clients to unlicensed assistive personnel. MNL Learning Outcome: 4. Implement the evaluation, documentation, and reporting of care of patients related to hygienic needs and practices. 12) A client's hearing aid needs to be removed. What action should the nurse perform? 1. Assist the client with removal when necessary. 2. Instruct the client to remove the aid in the sunroom. 3. Leave the aid in place when bathing. 4. Send the aid home with the family. Answer: 1 Explanation: The small size of hearing aids may make it difficult for older adults to manipulate, so they may need assistance in the aid's removal. Page Ref: 767-768 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 13. Verbalize the steps used in: g. Removing, cleaning, and inserting a hearing aid. MNL Learning Outcome: 3. Implement the steps for procedures used to meet the hygienic needs of patients.
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13) A client's hearing aid needs to be cleaned. What action should the nurse take to complete this task? 1. Clean with a dry, soft cloth. 2. Leave the battery in place when not in use. 3. Store the aid in the bathroom cabinet. 4. Use alcohol to remove any earwax. Answer: 1 Explanation: It is recommended by the manufacturers to clean the aid with a dry, soft cloth to prevent any damage to the aid. Page Ref: 767-768 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 13. Verbalize the steps used in: g. Removing, cleaning, and inserting a hearing aid. MNL Learning Outcome: 3. Implement the steps for procedures used to meet the hygienic needs of patients. 14) The nurse is making a client's bed. What safety measure should the nurse implement at this time? 1. Begin at the head and move toward the foot, loosening the bottom linen. 2. Miter corners at the head of the bed. 3. Place the soiled sheet in a laundry bag. 4. Prepare the client. Answer: 3 Explanation: Placing the soiled sheet in the laundry bag reduces the spread of microorganisms, which is a safety measure for both the nurse and client. Page Ref: 771 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 12. Identify safety and comfort measures underlying bedmaking procedures. MNL Learning Outcome: 3. Implement the steps for procedures used to meet the hygienic needs of patients.
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15) The nurse is preparing to remove a tick from a client's scalp. Which actions should the nurse perform to safely remove them from the client? (Select all that apply.) 1. Grasp the tick with blunt tweezers. 2. Apply heat to the tick with a match. 3. Wash the area with antibacterial soap. 4. Pull the tick away in a perpendicular movement. 5. Apply petroleum jelly to the surface of the tick. Answer: 1, 3, 4 Explanation: To remove a tick, grasp the tick as close to the skin as possible with blunt tweezers. After the tick is removed, wash the area with antibacterial soap. Gently pull the tick away using a perpendicular motion. Page Ref: 759 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 4. Apply the nursing process to common problems related to hygienic care of the skin, feet, nails, mouth, hair, eyes, and ears. MNL Learning Outcome: 3. Implement the steps for procedures used to meet the hygienic needs of patients. 16) The nurse is making an occupied bed. Which step will provide comfort for the client during this linen change? 1. Loosen the covers around the foot of the bed. 2. Place a bath blanket over the client. 3. Slide the mattress to the head of the bed. 4. Raise the side rail. Answer: 1 Explanation: Loosen the top covers around the foot of the bed to provide space for the client's feet. Page Ref: 772 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 12. Identify safety and comfort measures underlying bedmaking procedures. MNL Learning Outcome: 3. Implement the steps for procedures used to meet the hygienic needs of patients. 17) The nurse is preparing to shave a client. Which action step should the nurse consider when 8
providing this care? 1. Assist the client to a prone position. 2. Pull the skin taut with the dominant hand. 3. Wear gloves during the procedure. 4. Use long strokes. Answer: 3 Explanation: Wear gloves in case facial nicks occur and you come in contact with blood. Page Ref: 763 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 4. Apply the nursing process to common problems related to hygienic care of the skin, feet, nails, mouth, hair, eyes, and ears. MNL Learning Outcome: 3. Implement the steps for procedures used to meet the hygienic needs of patients. 18) The nurse is preparing to provide a client with mouth care. What should the nurse do to ensure safe handling of the client's dentures? 1. Clean biting surfaces. 2. Place a washcloth in the bowl of the sink. 3. Replace the upper dentures first. 4. Rinse dentures thoroughly with hot water. Answer: 2 Explanation: Placing a washcloth in the bowl of the sink serves as a cushion for the dentures if accidentally dropped. Page Ref: 756 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 13. Verbalize the steps used in: e. Providing special oral care. MNL Learning Outcome: 3. Implement the steps for procedures used to meet the hygienic needs of patients.
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19) A connection on a client's intravenous solution was dislodged and solution saturated the client's gown and bed linens. The nurse will provide which type of hygienic care to the client? 1. Hour-of-sleep care 2. As-needed care 3. Early-morning care 4. Morning care Answer: 2 Explanation: As-needed care is provided as required by the client. Because the intravenous solution has saturated the gown and bed linens, this is the type of care the client needs at this time. Page Ref: 730-731 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 1. Describe hygienic care that nurses provide to clients. MNL Learning Outcome: 3. Implement the steps for procedures used to meet the hygienic needs of patients. 20) A client tells the nurse that bathing is done at the sink in the bathroom at home because it is difficult to physically lift the legs to get into the shower. The nurse identifies which factor as influencing this client's hygienic practice? 1. Religion 2. Personal preference 3. Culture 4. Health and energy Answer: 4 Explanation: Ill people or those with neuromuscular disorders may not be able to perform hygienic care. Page Ref: 731 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Identify factors influencing personal hygiene. MNL Learning Outcome: 1. Perform assessment for patients related to hygienic needs and practices.
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21) During the morning bath of a client, the nurse identifies areas of erythema below the client's breasts. What should the nurse do to enhance comfort and healing for the client? 1. Wash the skin carefully. 2. Apply alcohol-free lotion. 3. Wash the area without soap. 4. Remove hair in the area. Answer: 1 Explanation: For areas of erythema, the nurse should wash the area carefully to remove microorganisms. Page Ref: 732 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 4. Apply the nursing process to common problems related to hygienic care of the skin, feet, nails, mouth, hair, eyes, and ears. MNL Learning Outcome: 3. Implement the steps for procedures used to meet the hygienic needs of patients. 22) While providing a complete bed bath to a client, the nurse discovers abrasions along the client's back and upper buttock area. What should the nurse do to help this client? 1. Apply antiseptic spray to the abrasions. 2. Do not wash the client with soap. 3. Find assistance to help with the remainder of the bath. 4. Apply alcohol-free lotion to the abrasions. Answer: 3 Explanation: Because the client has abrasions over the back and upper buttock area, the nurse should lift and not pull or slide the client. The nurse needs to find assistance to help with the remainder of the bath. Page Ref: 738 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 4. Apply the nursing process to common problems related to hygienic care of the skin, feet, nails, mouth, hair, eyes, and ears. MNL Learning Outcome: 3. Implement the steps for procedures used to meet the hygienic needs of patients.
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23) The nurse wants to assess a client during the morning bath. What will the nurse be able to assess during this time? (Select all that apply.) 1. Skin status 2. Financial status 3. Psychosocial needs 4. Learning needs 5. Physical conditions Answer: 1, 3, 4, 5 Explanation: Assessment of the skin can be done during the morning bath. The client's psychosocial needs can be assessed during the morning bath. The client's learning needs regarding hygienic care can be assessed during the morning bath. Assessing the client's physical conditions can be done during the morning bath. Page Ref: 737 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify normal and abnormal assessment findings while providing hygiene care. MNL Learning Outcome: 1. Perform assessment for patients related to hygienic needs and practices.
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24) A client is prescribed bed rest with bathroom privileges. Which types of bath would be appropriate for this client? (Select all that apply.) 1. Shower 2. Tub bath 3. Self-help bed bath 4. Therapeutic bath 5. Partial bath Answer: 3, 5 Explanation: Because the client is prescribed bed rest with bathroom privileges, the self-help bed bath would be appropriate because the client can independently wash with some help from the nurse. Because the client is prescribed bed rest with bathroom privileges, the partial bath would be appropriate because the client can independently wash with some help from the nurse to wash the back area. Page Ref: 736-737 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 6. Describe various types of baths. MNL Learning Outcome: 3. Implement the steps for procedures used to meet the hygienic needs of patients.
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25) A client with a skin rash is prescribed a bath in which medication is added to the bath water. The nurse should plan for the client to receive which type of bath? 1. Shower 2. Tub 3. Partial 4. Complete Answer: 2 Explanation: Therapeutic baths are given for physical effects, such as to soothe irritated skin or to treat an area. Medications may be placed in the water. A therapeutic bath is generally taken in a tub one-third or one-half full. The client remains in the bath for a designated time, often 20-30 minutes. If the client's back, chest, and arms are to be treated, these areas need to be immersed in the solution. Page Ref: 737 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 4. Apply the nursing process to common problems related to hygienic care of the skin, feet, nails, mouth, hair, eyes, and ears. MNL Learning Outcome: 3. Implement the steps for procedures used to meet the hygienic needs of patients. 26) A client who has not been bathed for several days does not want to get into the tub for a morning bath. What should the nurse do? 1. Assign assistive personnel the task of giving the client a bath. 2. Skip the client's bath and document "refused" in the medical record. 3. Ask the client the usual way bathing occurs at home. 4. Tell the client that a bath is needed and ignore the client's comment. Answer: 3 Explanation: To provide a person-centered approach to bathing, the nurse should ask the client to describe the usual way bathing occurs at home. Page Ref: 741 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Compare and contrast the task-centered approach and the client-centered approach to bathing. MNL Learning Outcome: 1. Perform assessment for patients related to hygienic needs and practices. 14
27) An older client tells the nurse that showers are not taken because of a previous fall. What can the nurse do to support the client's bathing needs? 1. Obtain a shower chair and assist the client in the shower. 2. Document that the client "refused" a morning bath in the medical record. 3. Tell the client that shower shoes can be worn to prevent falls. 4. Hold the client during the shower. Answer: 1 Explanation: To provide person-centered care with bathing, the nurse should obtain a shower chair. This should eliminate the client's fear of falling when in the shower. Page Ref: 736 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 11. Discuss factors that support a positive and safe environment for the client. MNL Learning Outcome: 2. Plan nursing care for patients related to hygienic needs, practices, and delegation. 28) The nurse is preparing to provide a morning bath to a client diagnosed with dementia. What can the nurse do to ensure a positive bathing experience for the client? (Select all that apply.) 1. Move slowly. 2. Be flexible. 3. Help the client feel in control. 4. Avoid stopping once the bath is started. 5. Be prepared. Answer: 1, 2, 3, 5 Page Ref: 742 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 8. Describe guidelines for bathing persons with dementia. MNL Learning Outcome: 3. Implement the steps for procedures used to meet the hygienic needs of patients.
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29) A client has hard contact lenses. What should the nurse do to assist the client in the care of the lenses? 1. Pinch the lenses out of the client's eyes to remove. 2. Remove both of the client's lenses before storing in the appropriate storage cup. 3. Document when the lenses need to be removed and cleaned every 2 weeks. 4. Ask the client how many hours the lenses are worn each day. Answer: 4 Explanation: Hard contact lenses should only be worn for 12-14 hours. Page Ref: 765 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 9. Discuss the different types of contact lenses. MNL Learning Outcome: 1. Perform assessment for patients related to hygienic needs and practices. 30) During an assessment, the nurse learns a client has soft contact lenses that have not been removed or cleaned for weeks. What should the nurse do? 1. Nothing, because these types of lenses can be worn for months. 2. Remove the client's lenses, wrap in tissue, and place in the bedside table. 3. Assist the client to remove and clean the contacts. 4. Ask the physician for an ophthalmology consult because the client will need help removing the lenses. Answer: 3 Explanation: Most eye specialists recommend that soft contact lenses be removed and cleaned every week. The nurse should assist the client to remove and clean the contacts. Page Ref: 765 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 9. Discuss the different types of contact lenses. MNL Learning Outcome: 3. Implement the steps for procedures used to meet the hygienic needs of patients.
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31) A client has a hearing aid with an earpiece that is almost invisible to an observer. The nurse would document this as which type of hearing aid? 1. Body hearing aid 2. In-the-canal aid 3. Completely-in-the-canal aid 4. Eyeglasses aid Answer: 3 Explanation: A completely-in-the-canal (CIC) aid is almost invisible to an observer. It has to be custom designed to fit the individual's ear. Page Ref: 766 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 10. Discuss the different types of hearing aids. MNL Learning Outcome: 4. Implement the evaluation, documentation, and reporting of care of patients related to hygienic needs and practices. 32) The nurse has assigned the making of unoccupied beds to assistive personnel. What should the nurse assess regarding client safety once the beds are completed? 1. Folding of the top sheet 2. Direction of the pillow 3. Call light being readily available 4. Presence of mitered corners Answer: 3 Explanation: The nurse should assess for the call light being readily available. Page Ref: 773 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 12. Identify safety and comfort measures underlying bedmaking procedures. MNL Learning Outcome: 3. Implement the steps for procedures used to meet the hygienic needs of patients.
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33) A client recovering from acute illness has just received a tub bath. When documenting the bath, what should the nurse include? (Select all that apply.) 1. Client's ability to maintain a conversation during the procedure 2. Client's tolerance of the procedure 3. Condition and integrity of the skin 4. Client strength 5. Percentage of bath done without assistance Answer: 2, 3, 4, 5 Page Ref: 740 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation Learning Outcome: 15. Demonstrate appropriate documentation and reporting of hygiene skills. MNL Learning Outcome: 4. Implement the evaluation, documentation, and reporting of care of patients related to hygienic needs and practices. 34) The nurse has completed foot care for a client as part of routine morning care. What should the nurse document about the procedure? 1. The condition of the skin and nails 2. Nothing unless a problem is noted 3. The amount of time taken on foot care 4. The client's comments about the foot care Answer: 2 Explanation: Foot care is not generally recorded unless problems are noted. Page Ref: 748 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation Learning Outcome: 15. Demonstrate appropriate documentation and reporting of hygiene skills. MNL Learning Outcome: 4. Implement the evaluation, documentation, and reporting of care of patients related to hygienic needs and practices.
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35) During a home visit, a client reports feeling sad and upset about personal appearance. For which reason should the nurse assist the client with a bath? 1. Improve circulation 2. Establish trust with the client 3. Improve morale and self-concept 4. Remove dead skin cells and bacteria Answer: 3 Explanation: Bathing produces a sense of well-being. It is refreshing and relaxing and frequently improves morale, appearance, and self-concept. The purpose of the bath for this client is not to improve circulation, establish trust, or remove dead skin cells and bacteria. Page Ref: 736 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Identify the purposes of bathing. MNL Learning Outcome: 3. Implement the steps for procedures used to meet the hygienic needs of patients. 36) A client is in the critical care unit for an acute illness. Which type of bath should this client receive? 1. Bag 2. Towel 3. Self-help 4. Complete Answer: 1 Explanation: A bag bath is often a desirable form for bathing clients in critical care. A towel bath would be appropriate for a client with dementia. The client is in critical care and should not expend any energy needed for bathing. A complete bath would be too strenuous for the client. Page Ref: 736 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 6. Describe various types of baths. MNL Learning Outcome: 3. Implement the steps for procedures used to meet the hygienic needs of patients.
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37) The nurse is bathing a client with Alzheimer disease. Which should the nurse remember to do during this bath? 1. Help the client into a bathtub 2. Place the client in the shower 3. Complete the bath as quickly as possible 4. Keep the body covered and wash one area at a time Answer: 4 Explanation: Providing personal hygiene to a client with dementia should include keeping parts of the body covered while washing one area at a time. The client should not be given a tub bath or shower. The bath should proceed slowly and methodically to prevent agitation. Page Ref: 742 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 8. Describe guidelines for bathing persons with dementia. MNL Learning Outcome: 3. Implement the steps for procedures used to meet the hygienic needs of patients. 38) The nurse is surprised to learn that a client has a hearing deficit. Which type of hearing aid should the nurse suspect the client is using? 1. In-the-ear 2. In-the-canal 3. Behind-the-ear 4. Completely-in-the-canal Answer: 4 Explanation: A completely-in-the-canal hearing aid is not visible. The other types of hearing aids are visible to some degree. Page Ref: 766 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 10. Discuss the different types of hearing aids. MNL Learning Outcome: 1. Perform assessment for patients related to hygienic needs and practices.
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39) The nurse plans to provide foot care to a client. Which action should be taken to ensure for the client's safety? 1. Cut off any calluses 2. Soak the feet for 30 minutes 3. Apply lotion between the toes 4. Use water at 106-110°F Answer: 4 Explanation: For safety, the temperature of the water for foot care should be between 106110°F. Calluses should not be cut. The feet should not be oversoaked as this could remove essential skin oils and encourage drying and skin breakdown. Lotion should not be applied between the toes. Page Ref: 748 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 11. Discuss factors that support a positive and safe environment for the client. MNL Learning Outcome: 3. Implement the steps for procedures used to meet the hygienic needs of patients. 40) The nurse assigns assistive personnel (AP) to provide morning care to a client. Which information is essential for the nurse to provide to the AP? 1. Blood test results 2. Any precautions to take 3. Reason for a chest x-ray 4. Marital status of the client Answer: 2 Explanation: When delegating care to AP, the nurse should provide information about any special precautions that should be taken. There is no reason to provide the AP with the client's blood test results, reason for a chest x-ray, or the client's marital status. Page Ref: 738 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the health care team | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 14. Recognize when it is appropriate to assign hygiene skills for clients to assistive personnel. MNL Learning Outcome: 2. Plan nursing care for patients related to hygienic needs, practices, and delegation. 21
41) The nurse is assigning assistive personnel (AP) to provide care to a group of clients. For which client reason should the AP provide mouth care more frequently? 1. Has a nasogastric tube 2. Treatments for diabetes 3. Medications for osteoarthritis 4. Receives intravenous antibiotics Answer: 1 Explanation: Clients with nasogastric tubes are likely to develop dry oral mucous membranes, especially if they breathe through their mouths. More frequent oral hygiene will be needed. There is no reason to provide more frequent mouth care for the client being treated for diabetes, receiving medication for osteoarthritis, or receiving intravenous antibiotics. Page Ref: 756 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the health care team | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 14. Recognize when it is appropriate to assign hygiene skills for clients to assistive personnel. MNL Learning Outcome: 2. Plan nursing care for patients related to hygienic needs, practices, and delegation.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 34 Diagnostic Testing 1) The nurse is assisting a client with a diagnostic test. Which role should the nurse expect to perform in the intratest phase? 1. Assess the data. 2. Collect the specimen. 3. Observe the client. 4. Prepare the client. Answer: 2 Explanation: Collecting the specimen comes during the intratest phase. Page Ref: 779 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 1. Describe the nurse's role for each of the phases involved in diagnostic testing. MNL Learning Outcome: 1. Examine the nurse's role related to diagnostic testing, specimen collection, and reporting of results. 2) The nurse is teaching a client with heart failure about diagnostic tests. Which test should the nurse emphasize in this teaching? 1. BNP 2. CBC 3. LDH 4. PKU Answer: 1 Explanation: The specific blood test to detect and guide treatment for heart failure is the BNP test. B-type natriuretic peptide is secreted primarily by the left ventricle in response to increased ventricular volume and pressure. Page Ref: 782 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 2. List common blood tests. MNL Learning Outcome: 1. Examine the nurse's role related to diagnostic testing, specimen collection, and reporting of results. 1
3) The nurse is reviewing laboratory results for a client. Which diagnostic study determines how well blood glucose levels have been controlled in the client? 1. Blood chemistry 2. Capillary blood glucose 3. Hemoglobin A1c 4. Serum electrolytes Answer: 3 Explanation: The glycosylated hemoglobin or hemoglobin A1c (HbA1c) is a measurement of blood glucose that is bound to hemoglobin. Hemoglobin A1c is a reflection of how well blood glucose levels have been controlled. Page Ref: 782 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. List common blood tests. MNL Learning Outcome: 1. Examine the nurse's role related to diagnostic testing, specimen collection, and reporting of results. 4) Which return demonstration by a client indicates that teaching about performing a blood glucose monitoring test has been effective? 1. The client punctures the fingertip. 2. The client puts on gloves. 3. The client smears the blood on the reagent strip. 4. The client washes the hands. Answer: 4 Explanation: One of the first steps the client would perform is handwashing for infection control. Page Ref: 786 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation/Teaching and Learning Learning Outcome: 11. Verbalize the steps used in: a. Obtaining a capillary blood specimen to measure blood glucose. MNL Learning Outcome: 2. Apply the nursing process to patients prescribed serum laboratory studies.
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5) A client asks why blood glucose levels have to be monitored. Which response should the nurse make? 1. "Because your doctor ordered it." 2. "If I were you, I would monitor the blood glucose when I didn't feel good." 3. "Monitoring your blood glucose better enables you to manage your diabetes." 4. "You can eat anything you want." Answer: 3 Explanation: Blood glucose monitoring improves diabetes management. By testing one's blood, one can change the insulin regimen to maintain a normal glycemic range. Page Ref: 786 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 4. Explain the rationale for the collection of each type of specimen. MNL Learning Outcome: 2. Apply the nursing process to patients prescribed serum laboratory studies. 6) What is the responsibility of the nurse when collecting a specimen from a client? 1. Accompany the client to collect a specimen. 2. Handle the specimen discreetly. 3. Clean technique should be used with all specimen collection. 4. Use day-old specimens. Answer: 2 Explanation: The nurse should handle the specimen discreetly to avoid embarrassing the client. Page Ref: 788 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 5. Deliver compassionate, patientcentered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 3. Discuss the nursing responsibilities for specimen collection. MNL Learning Outcome: 1. Examine the nurse's role related to diagnostic testing, specimen collection, and reporting of results.
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7) A client is prescribed a diagnostic test requiring a 24-hour stool specimen. What should this test indicate to the nurse? 1. Dietary products and digestive secretions. 2. Presence of bacteria or viruses. 3. Presence of ova and parasites. 4. Presence of occult blood. Answer: 1 Explanation: The nurse needs to collect and send the total quantity of stool expelled at one time instead of a small sample so that the specimen can be analyzed for dietary products and digestive secretions. Page Ref: 788 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 5. Deliver compassionate, patientcentered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Explain the rationale for the collection of each type of specimen. MNL Learning Outcome: 3. Apply the nursing process to patients prescribed urine, stool, sputum, and throat specimens. 8) A client being treated for tuberculosis needs to provide a sputum specimen. What is the reason for this specimen? 1. Test for acid-fast bacillus 2. Assess the effectiveness of therapy 3. Identify origin, structure, function, and pathology of cells 4. Identify the specific organism Answer: 2 Explanation: Sputum specimens are usually collected to assess the effectiveness of treatment for tuberculosis. Page Ref: 796 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Explain the rationale for the collection of each type of specimen. MNL Learning Outcome: 3. Apply the nursing process to patients prescribed urine, stool, sputum, and throat specimens.
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9) The nurse is collecting a sputum specimen from a client. Which action should the nurse take during the collection of this specimen? 1. Collect at least 30 mL of sputum. 2. Offer mouth care. 3. Take shallow breaths. 4. Wear a mask. Answer: 2 Explanation: Offer mouth care so that the specimen will not be contaminated with microorganisms from the mouth. Page Ref: 796 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Describe how to collect sputum and throat specimens. MNL Learning Outcome: 3. Apply the nursing process to patients prescribed urine, stool, sputum, and throat specimens. 10) Which instruction should the nurse give to the client when a stool specimen is to be collected? 1. Defecate in the toilet. 2. Follow sterile technique. 3. Send at least 60 mL of specimen. 4. Void before the specimen is collected. Answer: 4 Explanation: To avoid contaminating the specimen, the client should void before the specimen is collected. Page Ref: 789 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Describe how to collect and test stool specimens. MNL Learning Outcome: 3. Apply the nursing process to patients prescribed urine, stool, sputum, and throat specimens.
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11) What should the nurse instruct a client for obtaining a clean voided urine specimen? 1. Collect at least 5 mL of urine. 2. Collect the first voided specimen in the morning. 3. Keep the specimen on ice. 4. Void in a sterile cup. Answer: 2 Explanation: Routine urine examination is usually performed on the first voided specimen in the morning because it tends to have a higher, more uniform concentration and a more acidic pH than specimens later in the day. Page Ref: 790 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 11. Verbalize the steps used in: b. Collecting a urine specimen for culture and sensitivity by clean catch. MNL Learning Outcome: 3. Apply the nursing process to patients prescribed urine, stool, sputum, and throat specimens. 12) The nurse needs to obtain a sputum specimen from a client. What should the nurse have the client do? 1. Apply sterile gloves. 2. Clear the throat. 3. Cough to bring up secretions. 4. Rinse the mouth with mouthwash prior to the collection. Answer: 3 Explanation: Clients need to cough to bring sputum up from the lungs, bronchi, and trachea into the mouth in order to expectorate the specimen into a collecting container. Page Ref: 796 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 7. Describe how to collect sputum and throat specimens. MNL Learning Outcome: 3. Apply the nursing process to patients prescribed urine, stool, sputum, and throat specimens.
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13) The nurse is preparing to collect a throat culture from a client. What client response indicates to the nurse that teaching about this test has been ineffective? 1. "I need to hyperextend my neck." 2. "I need to say 'ah'." 3. "I will need to sit up." 4. "The nurse will use a light." Answer: 1 Explanation: The client should extend the tongue when a throat culture is to be taken, not hyperextend the neck. Page Ref: 797 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation/Teaching and Learning Learning Outcome: 7. Describe how to collect sputum and throat specimens. MNL Learning Outcome: 3. Apply the nursing process to patients prescribed urine, stool, sputum, and throat specimens. 14) A client is scheduled for a barium enema. What is the nursing priority for this client? 1. Assess bowel sounds. 2. Assess for allergies. 3. Cleanse the bowel. 4. Keep the client NPO. Answer: 3 Explanation: For visualization of the colon, the bowel has to be cleansed, otherwise the test cannot be performed. Therefore, that is the first priority the nurse must keep in mind. Page Ref: 797-798 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 5. Deliver compassionate, patientcentered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 8. Describe visualization procedures that may be used for the client with gastrointestinal, urinary, and cardiopulmonary alterations. MNL Learning Outcome: 4. Examine the nurse's role in relation to visualization and biopsy/aspiration procedures.
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15) A client is to have an echocardiogram. Which statement by the client indicates the teaching about the test has been effective? 1. "I'm told this test causes no discomfort." 2. "I will have to walk on a treadmill." 3. "I will need to remain NPO." 4. "I will need to take my pulse prior to the test." Answer: 1 Explanation: An echocardiogram causes no discomfort, although conductive gel is used and it may be cold. Page Ref: 798 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning/Teaching and Learning Learning Outcome: 8. Describe visualization procedures that may be used for the client with gastrointestinal, urinary, and cardiopulmonary alterations. MNL Learning Outcome: 4. Examine the nurse's role in relation to visualization and biopsy/aspiration procedures. 16) The nurse is reviewing instructions provided to a client about an upcoming cystoscopy. Which client response indicates that no further teaching is required? 1. "During the procedure the physician will take x-rays." 2. "I will be awake for this procedure." 3. "The doctor will be able to see my kidneys." 4. "The scope is a lighted instrument inserted through the urethra." Answer: 4 Explanation: The cystoscope is a lighted instrument inserted through the urethra. Page Ref: 798 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation/Teaching and Learning Learning Outcome: 8. Describe visualization procedures that may be used for the client with gastrointestinal, urinary, and cardiopulmonary alterations. MNL Learning Outcome: 4. Examine the nurse's role in relation to visualization and biopsy/aspiration procedures.
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17) A client with tattooed eyeliner is scheduled for an MRI. What should the nurse instruct the client about this diagnostic test? 1. Earplugs will be provided. 2. Lie very still. 3. Report any burning sensation. 4. Wear goggles. Answer: 4 Explanation: Recent reports have shown that, in very few instances, people with tattoos or permanent cosmetics experience edema or burning in the tattoo during an MRI. Any potential problems can be avoided by wearing goggles to cover permanent cosmetics around the eyes. Page Ref: 799 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 9. Compare and contrast CT, MRI, and nuclear imaging studies. MNL Learning Outcome: 4. Examine the nurse's role in relation to visualization and biopsy/aspiration procedures. 18) A client is having a lumbar puncture. In which position should the nurse place the client? 1. Lateral with head bent toward the chest and knees flexed onto the abdomen 2. Lying prone, with the knees drawn up toward the abdomen 3. Sitting bent over from the waist with legs extended 4. Supine with knees pulled toward the chest Answer: 1 Explanation: Lying in the lateral position with the head bent toward the chest and knees flexed onto the abdomen is the correct position for a lumbar puncture. In this position the back is arched, increasing the spaces between the vertebrae so that the spinal needle can be readily inserted. Page Ref: 801 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 10. Describe the nurse's role in caring for clients undergoing aspiration and biopsy procedures. MNL Learning Outcome: 4. Examine the nurse's role in relation to visualization and biopsy/aspiration procedures. 9
19) A client is scheduled to have abdominal ascites fluid removed. What should the nurse instruct the client about this procedure? 1. A catheter will be inserted into the bladder. 2. A liver biopsy will be done. 3. An abdominal paracentesis will be done. 4. A thoracentesis will be done. Answer: 3 Explanation: An abdominal paracentesis is performed to remove ascites, which relieves pressure on the abdominal organs. Page Ref: 801 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 10. Describe the nurse's role in caring for clients undergoing aspiration and biopsy procedures. MNL Learning Outcome: 4. Examine the nurse's role in relation to visualization and biopsy/aspiration procedures. 20) The nurse is providing care to a client during the posttest phase of diagnostic testing. What will the nurse do during this phase? (Select all that apply.) 1. Provide emotional and physical support to the client. 2. Compare the previous and current test results. 3. Prepare the client for the test. 4. Modify nursing interventions as necessary. 5. Report the results to appropriate health team members. Answer: 2, 4, 5 Page Ref: 779 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 10. Describe the nurse's role in caring for clients undergoing aspiration and biopsy procedures. MNL Learning Outcome: 4. Examine the nurse's role in relation to visualization and biopsy/aspiration procedures.
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21) The nurse needs to collect a specimen from a client but has never collected this type of specimen. Which action should the nurse take? 1. Notify the physician. 2. Ask another nurse to collect the specimen. 3. Consult the nursing procedure manual. 4. Delegate the collection of the specimen to unlicensed assistive personnel. Answer: 3 Explanation: A nursing procedure or laboratory manual is often available if the nurse is unfamiliar with the procedure. If there is any question about the procedure, the nurse should call the laboratory for directions before collecting the specimen. Page Ref: 779 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 3. Discuss the nursing responsibilities for specimen collection. MNL Learning Outcome: 1. Examine the nurse's role related to diagnostic testing, specimen collection, and reporting of results. 22) An older client is having difficulty handling the specimen cup for a clean catch urine specimen. What can the nurse do to help this client? 1. Provide a clean funnel to pour the urine into the specimen cup. 2. Document that the specimen could not be obtained. 3. Catheterize the client for the specimen. 4. Ask the physician to obtain the specimen. Answer: 1 Explanation: If an older client is having difficulty with a specimen cup for a clean catch urine specimen, the nurse should provide a clean funnel to pour the urine into the container. Page Ref: 794 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 11. Verbalize the steps used in: b. Collecting a urine specimen for culture and sensitivity by clean catch. MNL Learning Outcome: 3. Apply the nursing process to patients prescribed urine, stool, sputum, and throat specimens.
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23) A client is scheduled for a nuclear imaging test. What should the nurse instruct the client about this test? 1. It is the use of a magnetic field to produce an image of a body part or organ. 2. A radioisotope will be injected to determine organ functioning as being either hot or cold. 3. It produces a three-dimensional image of an organ. 4. It is more sensitive than an x-ray image. Answer: 2 Explanation: In nuclear imaging studies, a radioisotope is injected, and the body organ is determined as functioning as either hot or cold. Page Ref: 799-800 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 9. Compare and contrast CT, MRI, and nuclear imaging studies. MNL Learning Outcome: 4. Examine the nurse's role in relation to visualization and biopsy/aspiration procedures.
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24) The nurse is instructing a female client on how to cleanse the perineum before collecting a clean catch urine specimen for culture and sensitivity. What should the nurse instruct this client to do? Select all that apply. 1. Clean the perineal area using a circular motion. 2. Use all towelettes provided. 3. Use each towelette once, and discard. 4. Clean the perineal area from back to front. 5. Clean the perineal area from front to back. Answer: 2, 3, 5 Explanation: To cleanse the perineum before collecting a clean catch urine specimen for culture and sensitivity for a female client, the client should be instructed to use all towelettes provided. To cleanse the perineum before collecting a clean catch urine specimen for culture and sensitivity for a female client, the client should be instructed to use each towelette once and discard. To cleanse the perineum before collecting a clean catch urine specimen for culture and sensitivity for a female client, the client should be instructed to clean the perineal area from front to back. Page Ref: 793 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 11. Verbalize the steps used in: b. Collecting a urine specimen for culture and sensitivity by clean catch. MNL Learning Outcome: 3. Apply the nursing process to patients prescribed urine, stool, sputum, and throat specimens.
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25) Assistive personnel (AP) will be conducting a test on a client's urine. What should the nurse instruct the AP about the test? (Select all that apply.) 1. Nothing, because the AP can perform urine testing. 2. Remind the AP to tell the client the results of the test. 3. Notify the physician with the results of the test. 4. Report the results of the test to the nurse. 5. Save the urine, in case the nurse wants to repeat the test. Answer: 4, 5 Explanation: The nurse should instruct the AP to report the results of the test to the nurse. The nurse should instruct the AP to save the urine in case the nurse wants to repeat the test. Page Ref: 795 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the health care team | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 12. Recognize when it is appropriate to assign diagnostic testing skills to assistive personnel. MNL Learning Outcome: 3. Apply the nursing process to patients prescribed urine, stool, sputum, and throat specimens. 26) A client is having a timed urine collection done however but one specimen is not saved. What should the nurse do? 1. Continue with the test, and document that one specimen is missing. 2. End the test immediately and send what is collected to the laboratory. 3. Document that the test cannot be completed. 4. Start the test over. Answer: 4 Explanation: If the client or staff forgets and discards the client's urine during a timed collection, the procedure must be restarted from the beginning. Page Ref: 794 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 6. Compare and contrast the different types of urine specimens. MNL Learning Outcome: 3. Apply the nursing process to patients prescribed urine, stool, sputum, and throat specimens.
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27) The nurse is caring for a client who has just had a lumbar puncture. What should the nurse document about this client's procedure? (Select all that apply.) 1. Date and time performed 2. The physician's name 3. The client's ability to void after the procedure 4. The color, character, and amount of cerebrospinal fluid withdrawn 5. The client's status after the procedure Answer: 1, 2, 4, 5 Page Ref: 805 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 13. Demonstrate appropriate documentation and reporting of diagnostic testing information. MNL Learning Outcome: 4. Examine the nurse's role in relation to visualization and biopsy/aspiration procedures.
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28) A client has just completed a bone marrow biopsy. What should the nurse document about the client at this time? (Select all that apply.) 1. Client's tolerance of the procedure 2. Bowel sounds 3. The site for bleeding 4. Status of deep tendon reflexes 5. Presence of pain and any pain medication received Answer: 1, 3, 5 Explanation: The nurse should document how well the client tolerated the procedure, as it can cause considerable discomfort. The nurse should document the bone marrow biopsy site for bleeding, as this can occur. The nurse should document whether the client is experiencing any pain, and whether any pain medication was provided. Page Ref: 806 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 13. Demonstrate appropriate documentation and reporting of diagnostic testing information. MNL Learning Outcome: 4. Examine the nurse's role in relation to visualization and biopsy/aspiration procedures.
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29) A client is scheduled for a bronchoscopy. What should the nurse instruct the client about this procedure? (Select all that apply.) 1. Tissue samples may be taken for biopsy. 2. Eating will not be permitted for 12 hours. 3. A local anesthetic is sprayed on the throat. 4. Bed rest for 8 hours is necessary after the test. 5. Informed consent is required for this procedure. Answer: 1, 3, 5 Explanation: A bronchoscopy is a sterile procedure. Tissue samples may also be taken for biopsy. A local anesthetic is sprayed on the client's pharynx to prevent gagging. Informed consent is required for this procedure. Page Ref: 798 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 10. Describe the nurse's role in caring for clients undergoing aspiration and biopsy procedures. MNL Learning Outcome: 4. Examine the nurse's role in relation to visualization and biopsy/aspiration procedures. 30) The nurse needs to obtain a urine specimen from a client with an indwelling urinary catheter. What should the nurse do when collecting this specimen? (Select all that apply.) 1. Withdraw 30 mL of urine for a routine urinalysis. 2. Perform catheter care before obtaining the specimen. 3. Apply sterile gloves before retrieving the urine specimen. 4. Send the specimen immediately or refrigerate it for later pickup. 5. Clamp the drainage tubing for 30 minutes if there is no urine in the catheter. Answer: 1, 4, 5 Page Ref: 794-795 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 6. Compare and contrast the different types of urine specimens. MNL Learning Outcome: 3. Apply the nursing process to patients prescribed urine, stool, sputum, and throat specimens. 17
Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 35 Medication Administration 1) The nurse is preparing to administer a medication that the agency designates as "high alert." What action should the nurse take? 1. Ask another registered nurse to verify the medication. 2. Call the pharmacist to check the efficacy of the medication. 3. Decline to administer the medication unless there is a physician present. 4. Request that the nursing supervisor administer the medication. Answer: 1 Explanation: Most healthcare agencies maintain a list of high-alert medications, including controlled substances, which require the verification of two registered nurses. Page Ref: 855 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 1. Define selected terms related to the administration of medications. MNL Learning Outcome: 1. Consider the factors that affect the role of the nurse in administering medications, drug forms and routes of administration, how drugs affect the body, how the body affects drugs, and factors that affect medication action. 2) The nurse is reviewing medications prescribed for a client. Why is the nurse writing out the name of the drug morphine sulfate instead of using the abbreviation MS? 1. The hospital has placed MS on its list of do-not-use abbreviations. 2. The Joint Commission (TJC) requires that the abbreviation MS not be used. 3. Using the abbreviation MS puts the client at risk of medication error. 4. Computerized charting systems will not accept the abbreviation MS. Answer: 3 Explanation: The best answer is that using the abbreviation MS puts the client at risk of medication error. TJC publishes a list of unacceptable abbreviations. Computerized charting systems accept abbreviations. Page Ref: 819 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 2. Describe legal aspects of administering medications. MNL Learning Outcome: 3. Apply the correct principles and procedures for safe administration of medications to patients. 1
3) A hospitalized client is prescribed acetaminophen 325 mg 2 tablets every 4 hours prn temperature over 101°F. The client complains of a headache. Can the nurse legally administer the medication to treat the headache? 1. Yes, as acetaminophen is used both for fever and headache. 2. No, not unless the client also has a temperature over 101°F. 3. Yes, but the nurse should document the reason why the medication was administered as a temperature elevation. 4. Yes, because the medication is available over the counter, an order is not required. Answer: 2 Explanation: In the hospital setting, the nurse can only administer medications that are prescribed for the client and can only administer those medications according to the specifics of the prescription. In this case, the medication was ordered for temperature elevation, not pain, so the nurse cannot legally administer the acetaminophen to treat the client's headache. Page Ref: 832 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 2. Describe legal aspects of administering medications. MNL Learning Outcome: 3. Apply the correct principles and procedures for safe administration of medications to patients. 4) The nurse identifies that the ordered dose for a medication is twice the amount generally administered. What action should the nurse take? 1. Administer the medication as it was ordered. 2. Check to see if previous shift nurses gave the medication. 3. Collaborate with the prescriber about the order. 4. Administer only the standard dose of the medication. Answer: 3 Explanation: When the nurse has doubts about the correctness of a medication or medication dose for a specific client, collaboration with the prescriber is necessary. The nurse is legally and ethically responsible for all actions taken, including medication administration. Page Ref: 832 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 11. State the "rights" to accurate medication administration. MNL Learning Outcome: 3. Apply the correct principles and procedures for safe administration of medications to patients. 2
5) The nurse is preparing to administer a medication to a 6-year-old client. What is the nurse's priority action? 1. Administer the exact dosage as ordered. 2. Give the dosage supplied by the pharmacy. 3. Verify that the dosage is within the safe range for this child. 4. Administer no more than one-half of the safe adult dosage. Answer: 3 Explanation: The priority action is to verify that the dosage is within the safe range for this child. This verification can be done by figuring the dose per kilogram of body weight or by use of a nomogram. Page Ref: 825 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 9. Describe four formulas for calculating drug dosages. MNL Learning Outcome: 2. Calculate medication dosages based on prescribed and available dosages. 6) During the process of administering medications, the nurse checks the name band for the client's name. What should be this nurse's next action? 1. Administer the medication as ordered. 2. Initial the MAR that the medication will be given. 3. Double-check the client's identification using a second method. 4. Educate the client regarding the medication to be given. Answer: 3 Explanation: The Joint Commission's National Safety Goals require a two-step check of client identification prior to the administration of medications. This nurse should employ a second method to verify the client's identification. Page Ref: 834 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 10. List six essential steps to follow when administering medication. MNL Learning Outcome: 3. Apply the correct principles and procedures for safe administration of medications to patients.
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7) The nurse is planning to administer a bitter-tasting oral medication to a 4-year-old client. What strategy should this nurse plan? 1. Give the medication in orange juice or milk to mask the taste. 2. Tell the child that the medication tastes good. 3. Ask the parents how they give medications at home. 4. Get another nurse to assist by holding the client down. Answer: 3 Explanation: Parents are a very good source of ideas for caring for their child, and their input should be sought when performing tasks such as medication administration. Page Ref: 836 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 10. List six essential steps to follow when administering medication. MNL Learning Outcome: 3. Apply the correct principles and procedures for safe administration of medications to patients. 8) The nurse is caring for a client who has just received a new cardiac medication. How should the nurse instruct the unlicensed assistive personnel (UAP) who is also caring for this client? 1. Have the UAP assess for any unexpected effects from the medication. 2. Tell the UAP to teach the client's family what to expect from the medication. 3. Have the UAP look the medication up in a drug reference book to read about drug actions and possible side effects. 4. Give the UAP specific instructions regarding what drug actions or side effects to report to the nurse. Answer: 4 Explanation: The nurse should give the UAP specific instructions about what drug actions or side effects should be reported to the nurse. The UAP does not have the skills or legal responsibility to assess the client but can collect data to report to the nurse. Page Ref: 838 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the health care team | NLN Competencies: Quality and Safety; Knowledge; Current best practices | Nursing/Integrated Concepts: Planning Learning Outcome: 21. Recognize when it is appropriate to assign medication administration to unlicensed assistive personnel. MNL Learning Outcome: 3. Apply the correct principles and procedures for safe administration of medications to patients.
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9) The nurse is to administer four oral medications to the client via a nasogastric tube. One of the medications is a tablet that has been crushed, one is a capsule that has been opened and the powder removed, and two are supplied in liquid form. How should the nurse administer these medications? 1. Flush the tube, mix the crushed tablet and the capsule powder into the two liquids for administration, and follow by flushing the tube. 2. Mix the crushed tablet and capsule powder in warm water and administer. Flush the tube and administer the mixed liquids. 3. Flush the tube with the mixed liquids first, then administer the crushed tablet and capsule powder mixed in cold water. 4. Mix the crushed tablet and capsule powder individually in warm water. Administer each medication separately, flushing the tube before and after each administration. Answer: 4 Explanation: When giving medication via a nasogastric or gastric tube, the nurse should individually prepare and administer the medications, flushing the tube before and after each administration. Failure to flush the tube adequately is the leading cause of tube occlusion. Page Ref: 842-843 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 14. Outline the steps required for nasogastric and gastrostomy tube medication administration. MNL Learning Outcome: 3. Apply the correct principles and procedures for safe administration of medications to patients.
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10) At which point of preparing medication from an ampule does the nurse anticipate using a filter needle? 1. Filter needles are not used for this preparation. 2. When drawing the medication from the ampule. 3. When administering the medication to the client. 4. Both for drawing up the medication and for administering the medication. Answer: 2 Explanation: The nurse uses a filter needle to draw medication up from an ampule to remove any possible shards of glass from the liquid. Page Ref: 849 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 16. Verbalize the steps used in: a. Preparing medications from ampules. MNL Learning Outcome: 3. Apply the correct principles and procedures for safe administration of medications to patients. 11) The client is to receive an intramuscular injection of a medication that is supplied in a 2-mL cartridge and a second medication that is supplied in a vial. The total amount to be administered of these medications exceeds the volume of the cartridge by 0.5 mL. How should the nurse proceed? 1. Administer the cartridge medication in one injection and the vial medication in a separate injection. 2. Call the pharmacy for advice on administering these medications. 3. Draw both of the medications up into a syringe for administration. 4. Add as much of the vial medication to the cartridge as possible prior to injection, giving the balance in a separate injection. Answer: 3 Explanation: When the total amount of medication to administer exceeds the volume of the cartridge, the medication is drawn up into a syringe and is administered. Page Ref: 855 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 16. Verbalize the steps used in: c. Mixing medications in one syringe. MNL Learning Outcome: 3. Apply the correct principles and procedures for safe administration of medications to patients.
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12) During administration of an intradermal injection, the nurse notices that the outline of the needle bevel is visible under the client's skin. How should the nurse proceed? 1. Recognize that this is an expected finding in a properly administered intradermal injection. 2. Withdraw the needle, prepare a new injection, and start again. 3. Insert the needle further into the skin at a deeper angle. 4. Turn the needle so that the bevel is down and inject the medication slowly, looking for development of a bleb. Answer: 1 Explanation: Intradermal injections are given at a very shallow angle so that the medication is delivered into the area between the dermal layers. When properly given, the outline of the needle bevel will be visible prior to injection of the fluid. Page Ref: 856 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 18. Verbalize the steps used in administering parenteral medications by the following routes: a. Intradermal. MNL Learning Outcome: 3. Apply the correct principles and procedures for safe administration of medications to patients. 13) The nurse has just injected insulin subcutaneously into the client's abdomen. What action should the nurse take at this point? 1. Massage the site to encourage absorption. 2. Leave the needle embedded in the client's skin for 5 seconds after administration. 3. Remove the needle rapidly by pulling it quickly from the skin. 4. Cover the injection site with a pressure dressing for at least 15 minutes or until the bleb disappears. Answer: 2 Explanation: The American Diabetes Association recommends leaving the needle embedded in the client's skin for 5 seconds after injection of medication, particularly insulin. This allows for complete delivery of the dose. Page Ref: 859 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 18. Verbalize the steps used in administering parenteral medications by the following routes: b. Subcutaneous. MNL Learning Outcome: 3. Apply the correct principles and procedures for safe administration of medications to patients. 7
14) The nurse who is to administer 2.5 mL of intramuscular pain medication to an adult client notes that the previous injection was administered in the right ventrogluteal site. In which site should the nurse plan to administer this injection? 1. The same site 2. The deltoid 3. The left ventrogluteal 4. The rectus femoris Answer: 3 Explanation: Of the options given, the best choice is the left ventrogluteal. This is a site that will accept 2.5 mL of medication and using the opposite site from the last injection will allow the first site time for recovery. Page Ref: 861 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 17. Identify the sites used for: c. Intramuscular injection. MNL Learning Outcome: 3. Apply the correct principles and procedures for safe administration of medications to patients. 15) While administering an intramuscular injection, the nurse notes blood return in the syringe barrel after aspirating. What action should the nurse take? 1. Pull the needle out
inch and inject the medication.
2. Inject the medication as planned. 3. Notify the physician immediately. 4. Discard the medication and start over. Answer: 4 Explanation: The nurse should discard the medication and start over with new medication and a new syringe. Page Ref: 866 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 18. Verbalize the steps used in administering parenteral medications by the following routes: c. Intramuscular. MNL Learning Outcome: 3. Apply the correct principles and procedures for safe administration of medications to patients. 8
16) Upon aspirating a saline lock prior to administering intravenous medication, the nurse notes that there is no blood return. What nursing action should be taken? 1. Discontinue this infiltrated lock and restart another site for medication administration. 2. Slowly infuse 1 mL of saline into the lock, assessing for infiltration. 3. Reinsert the needle into the lock and aspirate using more pressure. 4. Pull the intravenous catheter out
inch and attempt aspiration.
Answer: 2 Explanation: Although the presence of blood upon aspiration confirms that the catheter is in a vein, the absence of blood does not rule out correct placement. If no blood returns, the nurse should slowly infuse 1 mL of saline into the lock while assessing the site for infiltration. If there is no infiltration present, the nurse should administer the medication. Page Ref: 871 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 19. Verbalize the steps used in administering intravenous medications using IV push. MNL Learning Outcome: 3. Apply the correct principles and procedures for safe administration of medications to patients. 17) While preparing to administer an eye ointment, the nurse inadvertently squeezes the tube, discarding the first bead of medication. What action should the nurse take at this point? 1. Administer the eye ointment as ordered, as the first bead of ointment should be discarded anyway. 2. Notify the pharmacy and request a new, unopened tube of ointment. 3. Have a second licensed nurse witness the waste and sign the chart. 4. Continue to squeeze the tube until a clear line of ointment has been discarded from the tip. Answer: 1 Explanation: The nurse should administer the eye ointment as ordered, as the first bead of ointment is considered contaminated and should always be discarded. Page Ref: 875 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 20. Verbalize the steps used in administering the following topical medications: b. Ophthalmic. MNL Learning Outcome: 3. Apply the correct principles and procedures for safe administration of medications to patients. 9
18) The nurse is preparing to administer eardrops to a 6-year-old client. What nursing action is correct? 1. Pull the earlobe down and back to straighten the ear canal. 2. Insert the tip of the applicator into the ear canal. 3. Put the eardrops in the refrigerator for 10 minutes prior to administration. 4. Press gently on the tragus of the ear a few times after administration. Answer: 4 Explanation: The nurse should press gently but firmly on the tragus of the ear after eardrops are administered in order to direct the drops into the ear canal. Page Ref: 877 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 20. Verbalize the steps used in administering the following topical medications: c. Otic. MNL Learning Outcome: 4. Utilize the nursing process for the administration of medications to patients across the lifespan. 19) While preparing to administer a transdermal estrogen patch, the nurse finds the previously applied patch in the client's bed linens. How can the nurse avoid this situation with the patch now being applied? 1. Shave the area where the patch is being applied. 2. Place a heating pad over the area where the patch is applied for 10 minutes after application. 3. Run a finger around the adhesive edges of the new patch before placing it on the client's skin. 4. Press firmly over the patch with the palm of the hand for about 10 seconds after applying it to the skin. Answer: 4 Explanation: In order to affix the patch firmly to the client's skin, press firmly over the patch with the palm of the hand for about 10 seconds after application. Page Ref: 874 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 20. Verbalize the steps used in administering the following topical medications: a. Dermatologic. MNL Learning Outcome: 4. Utilize the nursing process for the administration of medications to patients across the lifespan. 10
20) The nurse is preparing a small amount of medication for oral administration. Which nursing action is essential? 1. Draw up the medication in a syringe with a large-gauge needle. 2. Measure the medication at the top of the meniscus. 3. Label the syringe with the medication name, amount, and route. 4. Dilute the medication with water before measuring. Answer: 3 Explanation: When measuring medication in a syringe, a label must be attached indicating the name of the medication, the amount, and the route. This labeling is essential to prevent the medication from being given via the wrong route. Page Ref: 839 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 13. Verbalize the steps used in administering oral medications safely. MNL Learning Outcome: 3. Apply the correct principles and procedures for safe administration of medications to patients. 21) The client who regularly uses a metered-dose inhaler four times a day tells the nurse that it is difficult to tell when the canister is empty. What instruction should the nurse give this client? 1. Place the canister in a bowl of water. If the canister floats, it is not empty. 2. When you get a new canister, divide the number of puffs that is listed on the label by four. That will tell you how many days the canister will last. 3. You can tell that the canister is empty when you can no longer smell the medication when you activate the plunger. 4. When you feel like you are no longer getting maximum effect from the medication, your canister is empty. Answer: 2 Explanation: The best way to track the number of puffs left in a canister is to start with the new canister, dividing the number of puffs listed on the label by the number of puffs taken each day. Page Ref: 883 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 20. Verbalize the steps used in administering the following topical medications: g. Respiratory inhalation. MNL Learning Outcome: 4. Utilize the nursing process for the administration of medications to patients across the lifespan. 11
22) The nurse is providing discharge teaching for a client who is prescribed a bronchodilator inhaler and a corticosteroid inhaler. What information should the nurse provide regarding the dosage schedule for these two medications? 1. Always use the corticosteroid inhaler first. 2. Use the bronchodilator first. 3. It makes no difference which inhaler is used first. 4. Use the inhalers on alternate days, not on the same day. Answer: 2 Explanation: These two types of inhalers are frequently prescribed to be used together. The bronchodilator should be used first in order to open the airways so the corticosteroid medication can move deeply into the lungs. Page Ref: 884 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 20. Verbalize the steps used in administering the following topical medications: g. Respiratory inhalation. MNL Learning Outcome: 4. Utilize the nursing process for the administration of medications to patients across the lifespan. 23) The nurse is planning to administer medications to a new client. What is the nurse's greatest priority in administering these medications? 1. Be certain the medications are given within 15 minutes of the time they are scheduled. 2. Before giving the medications, know what the intended effects are for this client. 3. Assess the client's knowledge of the action of the medications. 4. Document the administration accurately so the reimbursement is correct. Answer: 2 Explanation: The greatest priority is to understand the intended effects of the medication for this client. The nurse should never do anything to or for a client without knowing the intended effect. Page Ref: 830-831 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Planning Learning Outcome: 3. Describe actions of drugs on the body. MNL Learning Outcome: 1. Consider the factors that affect the role of the nurse in administering medications, drug forms and routes of administration, how drugs affect the body, how the body affects drugs, and factors that affect medication action. 12
24) A client who has been prescribed a narcotic for chronic back pain is demonstrating signs of withdrawal. In which way should the nurse categorize the client's symptoms? 1. Physiological dependence 2. Psychological dependence 3. Plateau 4. Drug allergy Answer: 1 Explanation: Physiological dependence is due to biochemical changes in body tissues, especially the nervous system. These tissues come to require the substance for normal functioning. A dependent person who stops using the drug experiences withdrawal symptoms. Page Ref: 814 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Describe actions of drugs on the body. MNL Learning Outcome: 1. Consider the factors that affect the role of the nurse in administering medications, drug forms and routes of administration, how drugs affect the body, how the body affects drugs, and factors that affect medication action.
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25) A client is diagnosed with liver disease. The nurse realizes that which element of pharmacokinetics will be affected in this client? 1. Absorption 2. Distribution 3. Biotransformation 4. Excretion Answer: 3 Explanation: Biotransformation, also called detoxification or metabolism, is a process by which a drug is converted to a less active form. Most biotransformation takes place in the liver. Biotransformation can be altered if a person has an unhealthy liver. Page Ref: 816 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Identify factors affecting medication action. MNL Learning Outcome: 1. Consider the factors that affect the role of the nurse in administering medications, drug forms and routes of administration, how drugs affect the body, how the body affects drugs, and factors that affect medication action. 26) The nurse is administering a medication to a client as prescribed in order to maintain a specific amount of the medication in the client's bloodstream at all times. The nurse is ensuring that which action is being maintained for this client? 1. Peak plasma level 2. Drug half-life 3. Onset of action 4. Plateau Answer: 4 Explanation: Plateau is when a concentration of a drug is maintained in the client's plasma through a series of scheduled doses. Page Ref: 815 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Identify factors affecting medication action. MNL Learning Outcome: 1. Consider the factors that affect the role of the nurse in administering medications, drug forms and routes of administration, how drugs affect the body, how the body affects drugs, and factors that affect medication action. 14
27) The nurse determines that the effectiveness of a medication is not as great when provided to female clients as it is with male clients. The nurse suspects that this difference in effectiveness is because of which factor? (Select all that apply.) 1. Occupation 2. Hormones 3. Fat amount 4. Physical activity status 5. Fluid level Answer: 2, 3, 5 Page Ref: 816 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Identify factors affecting medication action. MNL Learning Outcome: 1. Consider the factors that affect the role of the nurse in administering medications, drug forms and routes of administration, how drugs affect the body, how the body affects drugs, and factors that affect medication action. 28) A client is prescribed an oral medication. When reviewing this medication, the nurse realizes it might not be the route of choice for this client because the client is experiencing which of the following? (Select all that apply.) 1. Nausea 2. Anxiety 3. Vomiting 4. Pain from cuts and abrasions 5. Irritated gastric mucosa Answer: 1, 3, 5 Page Ref: 826 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Describe actions of drugs on the body. MNL Learning Outcome: 1. Consider the factors that affect the role of the nurse in administering medications, drug forms and routes of administration, how drugs affect the body, how the body affects drugs, and factors that affect medication action. 15
29) A client is prescribed a medication to be administered through the parenteral route. The nurse would expect that this medication will be provided through which method? (Select all that apply.) 1. Subcutaneous injection 2. Intramuscular injection 3. The oral route 4. Intradermal injection 5. Intravenous infusion Answer: 1, 2, 4, 5 Page Ref: 827-828 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Planning Learning Outcome: 15. Identify equipment required for parenteral medications. MNL Learning Outcome: 4. Utilize the nursing process for the administration of medications to patients across the lifespan. 30) The nurse is reviewing a new medication order for a client and determines that the order is incomplete when which element is missing? (Select all that apply.) 1. Client's address 2. Dispensing instructions for the pharmacist 3. Name of the medication 4. Dosage 5. Route of administration Answer: 3, 4, 5 Page Ref: 820 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Assessment Learning Outcome: 6. Identify essential parts of a medication order. MNL Learning Outcome: 4. Utilize the nursing process for the administration of medications to patients across the lifespan.
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31) A client tells the nurse that the pharmacy will not fill a prescription that was written by the physician. Upon closer examination, what should the nurse determine is missing from the prescription? (Select all that apply.) 1. Rx symbol 2. Client's diagnosis 3. Client's Social Security number 4. Dispensing instructions for the pharmacist 5. Number of refills Answer: 1, 4, 5 Explanation: The Rx symbol is to be written on a prescription. The dispensing instructions for the pharmacist are part of a prescription. The number of refills must be provided on a prescription. Page Ref: 820 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Assessment Learning Outcome: 6. Identify essential parts of a medication order. MNL Learning Outcome: 4. Utilize the nursing process for the administration of medications to patients across the lifespan. 32) A client has a new order for a medication that does not have a termination date. The nurse would place this medication order under which classification on the client's medication administration record? 1. Standing 2. PRN 3. STAT 4. Single Answer: 1 Explanation: A standing order might not have a termination date. This medication may be provided to the client indefinitely. Page Ref: 819 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. List examples of various types of medication orders. MNL Learning Outcome: 4. Utilize the nursing process for the administration of medications to patients across the lifespan. 17
33) A client's status is deteriorating, and the physician prescribes a medication to be administered immediately one time. The nurse would contact the pharmacy and identify this medication order as being of which type? 1. Standing 2. PRN 3. STAT 4. Single order Answer: 3 Explanation: A STAT order indicates that the medication is to be provided immediately and only once. Page Ref: 819 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. List examples of various types of medication orders. MNL Learning Outcome: 4. Utilize the nursing process for the administration of medications to patients across the lifespan. 34) While hospitalized, a client was receiving 15 mL of an oral medication three times a day. When providing discharge instructions, the nurse should teach the client to take how much of this medication for each dose at home? 1. 2 teaspoons 2. 1 teaspoon 3. 2 tablespoons 4. 1 tablespoon Answer: 4 Explanation: In the metric system, 15 mL is equal to 1 tablespoon in the household measurement system. Page Ref: 822 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 9. Describe four formulas for calculating drug dosages. MNL Learning Outcome: 2. Calculate medication dosages based on prescribed and available dosages.
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35) While reviewing a medication order, the nurse determines that it is written using the metric system. What did the nurse observe to come to this conclusion about the medication order? (Select all that apply.) 1. Number of ounces 2. Number of teaspoons 3. Number of milligrams of the medication 4. Number of drops 5. Number of milliliters of the solution Answer: 3, 5 Page Ref: 822 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Assessment Learning Outcome: 8. State systems of measurement that are used in the administration of medications. MNL Learning Outcome: 4. Utilize the nursing process for the administration of medications to patients across the lifespan. 36) The nurse is providing medications to a client. After identifying the client, the nurse should take which action? 1. Inform the client as to the intended action of the medication. 2. Administer the drug. 3. Document that the drug was provided. 4. Evaluate the effectiveness of the drug. Answer: 1 Explanation: After identifying the client, the nurse should next instruct the client as to the intended action of the medication. Page Ref: 834 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 11. State the "rights" to accurate medication administration. MNL Learning Outcome: 3. Apply the correct principles and procedures for safe administration of medications to patients.
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37) Before administering a medication to a client, the nurse checks the client's pulse, blood pressure, and laboratory values. The nurse is performing which "right" of medication administration? 1. Medication 2. Assessment 3. Route 4. Dose Answer: 2 Explanation: Some medications require specific assessments prior to administration, such as blood pressure, pulse, or laboratory values. Medication orders can include specific parameters for administration, so these assessments must be done before administering. Page Ref: 836 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 10. List six essential steps to follow when administering medication. MNL Learning Outcome: 3. Apply the correct principles and procedures for safe administration of medications to patients. 38) The nurse is preparing medications for a client. What should the nurse do to ensure that the correct medication is provided to the client? (Select all that apply.) 1. Make sure it is the right client. 2. Make sure it is the right medication. 3. Make sure it is the right dose. 4. Make sure it is the right route. 5. Make sure it is for the right diagnosis. Answer: 1, 2, 3, 4 Page Ref: 836 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 11. State the "rights" to accurate medication administration. MNL Learning Outcome: 3. Apply the correct principles and procedures for safe administration of medications to patients.
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39) The nurse is concerned that an older client is experiencing an adverse effect from a prescribed medication. What did the nurse assess to make this clinical decision? 1. Altered memory 2. Altered organ responsiveness 3. Decreased manual dexterity 4. Decreased visual acuity Answer: 2 Explanation: Altered quality of organ responsiveness, resulting in adverse effects becoming pronounced before therapeutic effects are achieved, is one effect of medications on the older client. Page Ref: 837 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Assessment Learning Outcome: 12. Describe the physiologic changes in older adults that alter medication administration and effectiveness. MNL Learning Outcome: 1. Consider the factors that affect the role of the nurse in administering medications, drug forms and routes of administration, how drugs affect the body, how the body affects drugs, and factors that affect medication action. 40) The nurse is concerned that an older client will have difficulty self-administering medications. What did the nurse assess that caused this concern? (Select all that apply.) 1. Eats several servings of fruits and vegetables each day 2. Altered memory 3. Decreased visual acuity 4. Decreased manual dexterity 5. Limits red meat in the diet Answer: 2, 3, 4 Page Ref: 837 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Assessment Learning Outcome: 12. Describe the physiologic changes in older adults that alter medication administration and effectiveness. MNL Learning Outcome: 3. Apply the correct principles and procedures for safe administration of medications to patients.
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41) The nurse is preparing to administer a subcutaneous injection to a client. Which should the nurse consider when selecting the needle for the injection? 1. Small gauge number 2. Long shaft 3. Long bevel 4. Short bevel Answer: 3 Explanation: Longer bevels provide the sharpest needles and cause less discomfort. They are commonly used for subcutaneous and intramuscular injections. Page Ref: 847 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 17. Identify the sites used for: b. Subcutaneous. MNL Learning Outcome: 3. Apply the correct principles and procedures for safe administration of medications to patients. 42) An adult client is prescribed the hepatitis B vaccination. The nurse will administer this medication through which site? 1. Dorsogluteal 2. Rectus femoris 3. Vastus lateralis 4. Deltoid Answer: 4 Explanation: The deltoid muscle is not used often for intramuscular injections because it is a relatively small muscle and is very close to the radial nerve and radial artery. It is sometimes considered for use in adults because of rapid absorption from the deltoid area, but no more than 1 mL of solution can be administered. This site is recommended for the administration of immunizations and vaccines in adults because these medications are usually small in volume. Page Ref: 863 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 17. Identify the sites used for: c. Intramuscular injection. MNL Learning Outcome: 3. Apply the correct principles and procedures for safe administration of medications to patients.
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43) The nurse has provided an otic medication to a client. What should the nurse document about this medication's administration? (Select all that apply.) 1. Name of the drug 2. The strength 3. The appetite of the client 4. The number of drops 5. The response of the client Answer: 1, 2, 4, 5 Page Ref: 878 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 22. Demonstrate appropriate documentation and reporting of medication administration skills. MNL Learning Outcome: 4. Utilize the nursing process for the administration of medications to patients across the lifespan. 44) A client is prescribed a new medication. The pharmacy notifies the nurse that the dosage is outside of route prescribing limits. The nurse is unable to reach the prescribing physician about the order. What should the nurse do? 1. Give the medication to the client as prescribed. 2. Withhold the medication. 3. Give one-half of the medication dose prescribed. 4. Administer the medication through the oral route. Answer: 2 Explanation: If the primary care provider cannot be reached, document all attempts to contact the primary care provider and the reason for withholding the medication. Page Ref: 821 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 2. Describe legal aspects of administering medications. MNL Learning Outcome: 3. Apply the correct principles and procedures for safe administration of medications to patients.
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45) A client weighing 220 lbs. is prescribed to receive 25 mg/kg of a medication, divided over four equal doses. How many mg of the medication should the nurse provide for each dose? (Round to the nearest whole number.) Answer: 625 mg Explanation: First determine the client's weight in kg by dividing the weight in lbs. by 2.2, or 220/2.2 = 100 kg. Then multiply the prescribed dose of 25 mg × 100 kg = 2500 mg. Then divide the total mg dose by 4, or 2500/4 = 625 mg. The nurse should provide 625 mg of the medication for each dose. Page Ref: 824-825 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 9. Describe four formulas for calculating drug dosages. MNL Learning Outcome: 2. Calculate medication dosages based on prescribed and available dosages. 46) The nurse is instructing a new mother on the method to provide a newly prescribed medication to her 2-month-old infant. What should the nurse include in this teaching? (Select all that apply.) 1. Mix the medication into the baby's formula. 2. Use a nipple so the baby can suck the medication. 3. Use a syringe or dropper to provide the medication. 4. Place a small amount of the medication along the side of the baby's cheek. 5. Prepare twice the amount of medication prescribed because the baby will spit out half of it. Answer: 2, 3, 4 Explanation: Oral medications can be provided to a baby with the use of a nipple so that the baby sucks the medication. Oral medications can be provided to a baby with a syringe or dropper. Oral medications can be provided to a baby by placing a small amount of liquid medication along the inside of the baby's cheek and waiting for the infant to swallow. Page Ref: 841 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 5. Describe various routes of administration, including opioids. MNL Learning Outcome: 3. Apply the correct principles and procedures for safe administration of medications to patients. 24
47) A client with dysphagia is experiencing severe ureteral spasms. Which route for an opioid medication should the nurse expect to be prescribed for this client? 1. Oral 2. Rectal 3. Transnasal 4. Transmucosal Answer: 2 Explanation: The rectal route is particularly useful for clients who have dysphagia (difficulty swallowing). One medication, belladonna and opium suppositories, are used to relieve moderate to severe pain caused by ureteral spasm. Oral medication would be contraindicated because the client has dysphagia. The transnasal and transmucosal routes would not be as effective as the rectal route. Page Ref: 828 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Planning Learning Outcome: 5. Describe various routes of administration, including opioids. MNL Learning Outcome: 3. Apply the correct principles and procedures for safe administration of medications to patients.
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48) A client who weighs 176 lbs. is prescribed 4 mg/kg of a medication. Which action should the nurse take before administering the client with the medication? 1. Convert the weight in lbs. to kg 2. Move the decimal three spaces to the left 3. Ask the pharmacist to send the prescribed medication 4. Ask the provider to change the order to be based upon weight in lbs. Answer: 1 Explanation: The client's weight in lbs. should be converted to kg. by dividing the weight in lbs. by 2.2. The decimal point is not moved three spaces to the left. The pharmacist should not be asked to send the prescribed medication. The provider does not need to change the order to be based upon weight in lbs. Page Ref: 822 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Planning Learning Outcome: 8. State systems of measurement that are used in the administration of medications. MNL Learning Outcome: 4. Utilize the nursing process for the administration of medications to patients across the lifespan. 49) The nurse is preparing oral medications for a client. At which time should the packaged unitdose of a medication be opened? 1. At the client's bedside 2. Immediately before entering the client's room 3. When checking the medication against the MAR 4. When taking the dose out of the unit-dose drawer Answer: 1 Explanation: The wrapper keeps the medication clean. Not removing the medication facilitates identification of the medication in the event the client refuses the drug or assessment data indicate to hold the medication. Unopened unit-dose packages can usually be returned to the medication cart. Page Ref: 839 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 13. Verbalize the steps used in administering oral medications safely. MNL Learning Outcome: 3. Apply the correct principles and procedures for safe administration of medications to patients. 26
50) The nurse needs to provide medications to a client with a nasogastric tube attached to suction. At which time should the suction be reapplied after giving the medications? 1. An hour after giving the medications 2. Two hours after giving the medications 3. Immediately after giving the medications 4. Twenty to 30 minutes after giving the medications Answer: 4 Explanation: If the tube is connected to suction, disconnect the suction and keep the tube clamped for 20 to 30 minutes after giving the medication to enhance absorption. The suction should not be immediately applied. It is not appropriate to wait one to two hours before reapplying the suction. Page Ref: 843 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 14. Outline the steps required for nasogastric and gastrostomy tube medication administration. MNL Learning Outcome: 3. Apply the correct principles and procedures for safe administration of medications to patients. 51) A client with a body mass index of 40 requires a subcutaneous medication. Which needle should the nurse use for this injection? 1. 22 gauge 1 inch 2. 24 gauge 5/8 inch 3. 26 gauge 3/8 inch 4. 22 gauge 5/8 inch Answer: 1 Explanation: An obese adult client may require a 1-inch needle. The needles that are 3/8 or 5/8 inches would be too short to administer the medication appropriately Page Ref: 847 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Planning Learning Outcome: 15. Identify equipment required for parenteral medications. MNL Learning Outcome: 4. Utilize the nursing process for the administration of medications to patients across the lifespan. 27
52) A client is prescribed an intradermal injection for allergy skin testing. Which aspect of this injection should the nurse assign to unlicensed assistive personnel (UAP)? 1. Preparing the medication 2. Providing the medication 3. Reporting symptoms of a reaction 4. Identifying the location for the injection Answer: 3 Explanation: The UAP is not trained or qualified to prepare, provide, or identify the location for an intradermal injection. The UAP should be assigned to report any symptoms that might indicate a reaction. Page Ref: 856 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the health care team | NLN Competencies: Quality and Safety; Knowledge; Current best practices | Nursing/Integrated Concepts: Planning Learning Outcome: 21. Recognize when it is appropriate to assign medication administration to unlicensed assistive personnel. MNL Learning Outcome: 3. Apply the correct principles and procedures for safe administration of medications to patients. 53) A client who received a routine medication develops an adverse reaction. Where should the nurse document the client's response to the medication? 1. Kardex 2. Flow sheet 3. Nurse's notes 4. Medication administration record Answer: 3 Explanation: Many agencies prefer that medication administration be recorded on the medication record however but the nurse's notes are used when there is a special problem with a medication, such as the development of an adverse reaction. Medication administration is not documented on a flow sheet or Kardex. Page Ref: 860 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Current best practices | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 22. Demonstrate appropriate documentation and reporting of medication administration skills. MNL Learning Outcome: 4. Utilize the nursing process for the administration of medications to patients across the lifespan. 28
Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 36 Skin Integrity and Wound Care 1) The continuous quality improvement team is monitoring the nursing care of cleancontaminated wounds. Which operative wound would be excluded from this study? 1. Gastric resection 2. Uncomplicated abdominal hysterectomy 3. Breast biopsy 4. Lung resection Answer: 3 Explanation: A breast biopsy is considered a clean wound. Clean wounds are uninfected wounds in which there is minimal inflammation and the respiratory, gastrointestinal, genital, and urinary tracts are not entered. Clean wounds are primarily closed wounds. Page Ref: 890 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 7. Identify the main complications of and factors that affect wound healing. MNL Learning Outcome: 1. Assess patients for risk, pressure sites, wounds, and problems with wound healing.
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2) The surgical report of a newly transferred client indicates that there was a great deal of intestinal spillage into the abdominal cavity during the client's bowel resection. For which category of wound should the receiving nurse plan care for this client? 1. Clean-contaminated 2. Contaminated 3. Dirty 4. Infected Answer: 2 Explanation: A surgical wound in which there is a large amount of spillage from the gastrointestinal tract is considered a contaminated wound. Page Ref: 890 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 7. Identify the main complications of and factors that affect wound healing. MNL Learning Outcome: 2. Plan care of patients to maintain skin integrity, promote wound healing, and determine delegation. 3) A client has sustained multiple contusions from a motor-vehicle accident. What should the nurse do to prepare for this client's care? 1. Obtain ice packs to apply to the wounds. 2. Request gauze to pack the wounds. 3. Organize suture material to close the wounds. 4. Notify the surgical staff that a surgical client will soon be arriving. Answer: 1 Explanation: Contusions are closed wounds in which the skin is ecchymotic or bruised due to damage of blood vessels. These wounds are treated with ice pack application for the first 24 hours. Page Ref: 890, 900 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 14. Identify physiological responses to and purposes of heat and cold. MNL Learning Outcome: 2. Plan care of patients to maintain skin integrity, promote wound healing, and determine delegation.
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4) A client has a reddened area over the coccyx that disappears after an hour. In which way should the nurse document this area? 1. Reactive hyperemia 2. Stage 1 pressure injury 3. Stage 2 pressure injury 4. Stage 3 pressure injury Answer: 1 Explanation: If the reddened area blanches with thumb pressure and disappears in one-half to three-quarters of the time pressure was on the area, the condition is reactive hyperemia and no damage to the skin and tissues has occurred. Page Ref: 891 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation Learning Outcome: 3. Describe the four stages of pressure injury development. MNL Learning Outcome: 1. Assess patients for risk, pressure sites, wounds, and problems with wound healing. 5) A client has a wound that is approximately 10 cm in diameter, surrounded by edematous and boggy tissue, with the edges curling towards the center. Which additional finding would indicate to the nurse that this is a stage 4 pressure injury? 1. There is undermining of adjacent tissues. 2. The crater extends into the subcutaneous tissue. 3. The joint capsule of the hip is visible. 4. The ulcer has thick dark eschar over the top. Answer: 3 Explanation: Stage 4 injuries demonstrate damage to muscle, bone, tendons, or the joint capsule. Page Ref: 893 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Describe the four stages of pressure injury development. MNL Learning Outcome: 3. Implement the steps for nursing procedures used to treat pressure ulcers, promote wound healing, and prevent complications of wound healing.
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6) Assistive personnel (AP) reports a small skin tear on the client's forearm that occurred during a routine turn. After assessing the wound the nurse should take which action? 1. Obtain a transparent dressing for the AP to place on the wound. 2. Request a consult with the wound care nurse. 3. Cleanse the wound and apply a dressing. 4. Tell the AP to reevaluate the wound in 20 minutes. Answer: 3 Explanation: The nurse should go to the room, assess the wound, cleanse the wound, and apply a dressing. Page Ref: 913 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 10. Identify essential aspects of planning care to maintain skin integrity and promote wound healing. MNL Learning Outcome: 3. Implement the steps for nursing procedures used to treat pressure ulcers, promote wound healing, and prevent complications of wound healing. 7) The new nurse learns that the facility uses the Braden Scale for Predicting Pressure Sore Risk to assess all new admissions. What should be done before the nurse uses the scale? 1. Receive specific training 2. Be certified 3. Ask the client's permission 4. Obtain special assessment equipment Answer: 1 Explanation: The nurse should receive specific training in the use of the Braden scale in order for assessment to be accurate. Page Ref: 894 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 8. Identify assessment data pertinent to skin integrity, pressure sites, and wounds. MNL Learning Outcome: 1. Assess patients for risk, pressure sites, wounds, and problems with wound healing.
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8) A client has had Braden scores of 18 and 19 and Norton scores of 15 and 17 over the last 2 months. What does the nurse determine as the significance of the trending of these scores? 1. Trending can only be accurate if the same scale is used. 2. There is a definite trend of low risk for pressure injury development. 3. Trending would be more accurate if the same scale was used. 4. The scores indicate opposite risks for pressure ulcer development. Answer: 3 Explanation: All of these scores indicate risk for development of a pressure injury, so some trending is possible, but it would be more accurate if the same scale was always used. Page Ref: 894 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 8. Identify assessment data pertinent to skin integrity, pressure sites, and wounds. MNL Learning Outcome: 1. Assess patients for risk, pressure sites, wounds, and problems with wound healing. 9) A client's laceration has been closed with tissue adhesive. What instruction should the nurse provide the client about wound healing? 1. Primary intention 2. Open approximation 3. Secondary healing 4. Delayed closure Answer: 1 Explanation: The nurse should instruct the client regarding primary intention wound healing. The edges of these wounds are approximated and held together with sutures, bandages, or tissue adhesive. Scarring is minimal with these wounds. Page Ref: 897 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 4. Differentiate primary and secondary wound healing. MNL Learning Outcome: 3. Implement the steps for nursing procedures used to treat pressure ulcers, promote wound healing, and prevent complications of wound healing.
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10) A client is prescribed steroid medication. For which reason should the nurse instruct the client about infection control because of this medication? 1. Decreases oxygen supply to tissues 2. Suppresses the inflammatory process necessary for healing 3. Decreases the amount of nutrients such as glucose in the blood 4. Constricts blood vessels, which impairs waste product removal Answer: 2 Explanation: Steroids suppress the inflammatory process, which is a normal part of the healing process. Page Ref: 899 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 11. Describe nursing strategies to treat pressure injuries, promote wound healing, and prevent complications of wound healing. MNL Learning Outcome: 3. Implement the steps for nursing procedures used to treat pressure ulcers, promote wound healing, and prevent complications of wound healing. 11) On the fourth postoperative day, a client has a sudden coughing episode and reports that "something popped" in the abdominal incision. Upon inspection, the nurse finds that evisceration has occurred. What nursing action should be taken first? 1. Notify the client's surgeon. 2. Cover the area with a large saline-soaked dressing. 3. Position the client in bed with knees bent. 4. Pack the wound with nonadherent gauze. Answer: 2 Explanation: Evisceration occurs when an abdominal wound opens and there is protrusion of the internal viscera through the incision. The first action should be to cover the area with a large saline-soaked dressing to keep the viscera moist. Page Ref: 899 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 11. Describe nursing strategies to treat pressure injuries, promote wound healing, and prevent complications of wound healing. MNL Learning Outcome: 3. Implement the steps for nursing procedures used to treat pressure ulcers, promote wound healing, and prevent complications of wound healing. 6
12) A client is prescribed antiembolic stockings. How should the nurse assess the skin on the client's legs? 1. Defer the assessment because the stockings are in place. 2. Remove the stockings for this assessment. 3. Review the morning assessment, but don't repeat it unless a problem occurs. 4. Assess the skin when the client removes the stockings at bedtime. Answer: 2 Explanation: The stockings should be removed to do this assessment. Page Ref: 899 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 7. Identify the main complications of and factors that affect wound healing. MNL Learning Outcome: 1. Assess patients for risk, pressure sites, wounds, and problems with wound healing. 13) A trauma victim's leg wound dressing has a 4-cm by 6-cm blood spot that has soaked through the bandage. The client is otherwise stable. What action should the nurse take? 1. Place a tourniquet above the wound. 2. Remove the dressing and place direct pressure on the wound. 3. Add an additional dressing to the wound without removing the original. 4. Remove the dressing and replace it with a new sterile dressing. Answer: 3 Explanation: Because the client is stable, the correct nursing action is to add an additional dressing to the wound without removing the original. Page Ref: 913 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 10. Identify essential aspects of planning care to maintain skin integrity and promote wound healing. MNL Learning Outcome: 3. Implement the steps for nursing procedures used to treat pressure ulcers, promote wound healing, and prevent complications of wound healing.
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14) The nurse is collecting a specimen from an infected wound. From which portion of the wound should the specimen be collected? 1. Clean areas of granulation tissue 2. Exudate in the bottom of the wound 3. A pus-coated area on the side of the wound 4. Intact skin at the edge of the wound Answer: 1 Explanation: Microorganisms that are most likely to be responsible for wound infections live in viable tissue such as granulation tissue. Page Ref: 916 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 13. Verbalize the steps used in: b. Obtaining wound specimens. MNL Learning Outcome: 3. Implement the steps for nursing procedures used to treat pressure ulcers, promote wound healing, and prevent complications of wound healing. 15) A client has a documented stage 3 pressure injury on the right hip. What nursing diagnosis problem statement is most appropriate for use with this client? 1. Altered Tissue Perfusion 2. Impaired Skin Integrity 3. Impaired Tissue Integrity 4. Risk for Injury Answer: 3 Explanation: Because a stage 3 pressure injury involves tissues, not just skin, this client has criteria for using the problem statement Impaired Tissue Integrity. Page Ref: 902 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Diagnosis Learning Outcome: 9. Identify nursing diagnoses associated with impaired skin integrity. MNL Learning Outcome: 2. Plan care of patients to maintain skin integrity, promote wound healing, and determine delegation.
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16) The nurse is selecting dressings for a clean abdominal incision that will be allowed to heal by secondary intention. What principles should the nurse use in choosing this dressing? 1. Materials used in dressing this wound should keep the wound bed moist. 2. The dressing should allow good air circulation through the wound. 3. Dressings should be simple as they will be changed at least every 4 hours. 4. Absorbent material to wick exudates away and support drying should be used. Answer: 1 Explanation: Wounds that are expected to heal by secondary intention heal by "granulating in." In order to support the growth of granulation tissue, the wound bed should be kept moist and oxygen should be kept out of the wound. Page Ref: 906 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 12. Identify purposes of commonly used wound dressing materials and binders. MNL Learning Outcome: 3. Implement the steps for nursing procedures used to treat pressure ulcers, promote wound healing, and prevent complications of wound healing. 17) An older client who is incontinent and wears incontinence briefs develops an irritated rash in the perianal area. What care should the nurse provide? 1. Wash the area with soap and hot water at every brief change. 2. Apply a petroleum-based cream to the area after cleaning. 3. Wipe the skin with an alcohol-free barrier film agent after cleaning. 4. Keep the client in bed on absorbent pads until the area clears. Answer: 3 Explanation: The care should include wiping the skin with an alcohol-free barrier film agent after cleaning. Page Ref: 904 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 2. Identify clients at risk for pressure injuries. MNL Learning Outcome: 3. Implement the steps for nursing procedures used to treat pressure ulcers, promote wound healing, and prevent complications of wound healing.
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18) The nurse is writing the plan of care for a client who is confined to bed. Which intervention should be included to help reduce the effects of shearing forces on the client's skin? 1. Keep the head of the client's bed at 30°F. 2. Coat the client's back and buttocks with baby powder after bathing. 3. Use a turn sheet lifted by two staff members to move the client in bed. 4. Dust the linens with cornstarch each morning to allow for easier movement. Answer: 3 Explanation: The nurse should plan to use a turn sheet lifted by two staff members to move the client up in bed. Page Ref: 904 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 10. Identify essential aspects of planning care to maintain skin integrity and promote wound healing. MNL Learning Outcome: 2. Plan care of patients to maintain skin integrity, promote wound healing, and determine delegation. 19) Upon assessing a pressure injury, the nurse notes the presence of red, yellow, and black tissue. Using the RYB color code, which wound care should the nurse plan? 1. Red 2. Yellow 3. Black 4. A combination of all three Answer: 3 Explanation: When using the RYB color code to guide wound care for a wound that contains more than one of the colors, the nurse plans care for the most serious color, in this case black. Page Ref: 906 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 8. Identify assessment data pertinent to skin integrity, pressure sites, and wounds. MNL Learning Outcome: 2. Plan care of patients to maintain skin integrity, promote wound healing, and determine delegation.
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20) The nurse has established an expected outcome that the client will demonstrate healing of a stage 2 pressure injury over the coccyx. Which finding, discovered by the nurse during evaluation, might be implicated in the failure to achieve this outcome? 1. The rubber doughnut pressure relief device was not delivered by central supply. 2. The client's serum albumin increased over the last month. 3. Nurses did not document disinfection of the wound with alcohol with each dressing change. 4. AAP followed a right side—back—left side—back turning schedule. Answer: 4 Explanation: Because this expected outcome was not met, the nurse looks for problems in the provision of care or changes in the client's condition. Of the options listed, the only one that would result in poor healing is the right side—back—left side—back turning schedule. This schedule places the client on the back for 50% of the time. The schedule should be right side— back—left side—right side. Page Ref: 926-927 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation Learning Outcome: 10. Identify essential aspects of planning care to maintain skin integrity and promote wound healing. MNL Learning Outcome: 4. Implement the evaluation, documentation, and reporting of care of patients related to skin integrity, wound care, and wound healing.
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21) A client with an aquathermia pad reports that the pad is not warm after 15 minutes and wants the temperature increased. How should the nurse evaluate this request? 1. Because this client's thermal tolerance is higher than normal, increasing the temperature is necessary. 2. This client may be experiencing a rebound effect from the application of moist heat. 3. Adaptation of the thermal receptors often results in the decreased sensation of warmth. 4. The aquathermia pad should be replaced with a standard hot pack. Answer: 3 Explanation: After about 15 minutes of heat application, the thermal receptors adapt to the temperature increase and the sensation of warmth is diminished. Clients often request that the temperature be increased because they do not feel the same amount of heat. This can lead to burns. Page Ref: 923 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation Learning Outcome: 14. Identify physiological responses to and purposes of heat and cold. MNL Learning Outcome: 3. Implement the steps for nursing procedures used to treat pressure ulcers, promote wound healing, and prevent complications of wound healing. 22) The nurse identifies an older client as being at risk for impaired skin integrity. What did the nurse assess in this client? (Select all that apply.) 1. Poor skin turgor 2. Elevated body temperature 3. Diminished pain sensation 4. Thin epidermis 5. Dry skin Answer: 1, 3, 4, 5 Page Ref: 899 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Describe factors affecting skin integrity. MNL Learning Outcome: 1. Assess patients for risk, pressure sites, wounds, and problems with wound healing.
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23) A client has a wound that is going to heal through secondary intention. When instructing the client about this wound, the nurse would include which statements? (Select all that apply.) 1. Minimal tissue loss. 2. Closure of the wound will occur within 5 days. 3. Healing time will be longer. 4. Potential for scarring is greater. 5. Susceptibility to infection is greater. Answer: 3, 4, 5 Explanation: In secondary intention healing, the repair time is longer. In secondary intention healing, the scarring is greater. In secondary intention healing, the susceptibility to infection is greater. Page Ref: 897 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 4. Differentiate primary and secondary wound healing. MNL Learning Outcome: 3. Implement the steps for nursing procedures used to treat pressure ulcers, promote wound healing, and prevent complications of wound healing. 24) A client's leg wounds appear red and edematous a day after a traumatic injury. Which stage of healing should the nurse identify for this client? 1. Inflammatory 2. Proliferative 3. Maturation 4. Remodeling Answer: 1 Explanation: The inflammatory phase is initiated immediately after injury and lasts 3— to 6 days. Page Ref: 897 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Describe the three phases of wound healing. MNL Learning Outcome: 1. Assess patients for risk, pressure sites, wounds, and problems with wound healing.
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25) A client has several dark, thick scars on body locations from previous surgeries and injuries. The nurse realizes this occurs during which phase of wound healing? 1. Exudative 2. Proliferative 3. Inflammatory 4. Maturation Answer: 4 Explanation: Dark, thick scars, or keloids, are caused by an abnormal amount of collagen during the maturation phase of healing. Page Ref: 898 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Describe the three phases of wound healing. MNL Learning Outcome: 1. Assess patients for risk, pressure sites, wounds, and problems with wound healing. 26) While changing a client's dressing, the nurse notes thick yellow-green drainage on the gauze. How should the nurse document this wound's drainage? 1. Purulent 2. Serous 3. Sanguineous 4. Serosanguinous Answer: 1 Explanation: Purulent exudate is thick and can vary in color, including green and yellow. Page Ref: 898 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 6. Identify three major types of wound exudate. MNL Learning Outcome: 1. Assess patients for risk, pressure sites, wounds, and problems with wound healing.
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27) The nurse documents that a client's postoperative wound is purosanguinous. What did the nurse assess in this client's wound? 1. Water and red blood cells 2. Pus and red blood cells 3. Watery drainage 4. Pus Answer: 2 Explanation: Purosanguinous drainage consists of purulent drainage and red blood cells. Page Ref: 898 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 6. Identify three major types of wound exudate. MNL Learning Outcome: 1. Assess patients for risk, pressure sites, wounds, and problems with wound healing. 28) The nurse is assessing a client's pressure ulcer. To determine the depth of the ulcer, the nurse should take which action? 1. Measure the width. 2. Measure the length. 3. Insert a sterile swab into the deepest part of the wound. 4. Identify where on the face of a clock the ulcer is located. Answer: 3 Explanation: To measure the depth of a wound, the nurse should insert a sterile swab into the deepest part of the wound and then measure the length of the swab that was inserted. Page Ref: 900 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Describe the four stages of pressure injury development. MNL Learning Outcome: 1. Assess patients for risk, pressure sites, wounds, and problems with wound healing.
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29) A client has episodes of bowel and bladder incontinence. When planning care for this client, the nurse would identify which nursing diagnosis as being appropriate? 1. Impaired Skin Integrity 2. Risk for Impaired Skin Integrity 3. Impaired Tissue Integrity 4. Risk for Infection Answer: 2 Explanation: Because the client is experiencing episodes of incontinence without any current changes in skin integrity, the client is at Risk for Impaired Skin Integrity. Page Ref: 902 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Diagnosis Learning Outcome: 9. Identify nursing diagnoses associated with impaired skin integrity. MNL Learning Outcome: 2. Plan care of patients to maintain skin integrity, promote wound healing, and determine delegation. 30) A client has a yellow wound with purulent drainage. The nurse identifies what type of wound care as appropriate for this client's wound? (Select all that apply.) 1. Cover it with transparent film. 2. Apply a damp-to-damp normal saline dressing. 3. Cover it with a dry dressing. 4. Irrigate the wound. 5. Apply impregnated hydrogel. Answer: 2, 4, 5 Explanation: A damp-to-damp normal saline dressing will remove nonviable tissue from the wound and is appropriate for a yellow wound. Irrigating the wound is appropriate for a yellow wound. Applying impregnated hydrogel is appropriate for a yellow wound. Page Ref: 913 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 12. Identify purposes of commonly used wound dressing materials and binders. MNL Learning Outcome: 3. Implement the steps for nursing procedures used to treat pressure ulcers, promote wound healing, and prevent complications of wound healing. 16
31) The nurse is preparing to irrigate a client's abdominal wound. In which order should the nurse perform this irrigation? 1. Dry the area around the wound. 2. Insert the catheter into the wound until resistance is met. 3. Remove and discard clean gloves. 4. Apply clean gloves. 5. Irrigate until the solution flows clear. 6. Select a syringe with a catheter attached or with an irrigating tip. Answer: 4, 6, 2, 5, 1, 3 Explanation: 1. After irrigating, the nurse should dry the area around the wound. 2. The nurse should then insert the catheter into the wound until resistance is met. 3. The nurse should then remove and discard the clean gloves. 4. The nurse first should apply clean gloves. 5. The nurse should then irrigate the wound until the solution flows clear. 6. The nurse should then select a syringe with a catheter attached or with an irrigating tip. Page Ref: 910-911 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 13. Verbalize the steps used in: c. Irrigating a wound. MNL Learning Outcome: 3. Implement the steps for nursing procedures used to treat pressure ulcers, promote wound healing, and prevent complications of wound healing.
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32) A client asks why a cold pack has been prescribed for an arm injury. What should the nurse explain to the client? (Select all that apply.) 1. The application of cold dilates blood vessels. 2. The application of cold constricts blood vessels. 3. The application of cold decreases inflammation. 4. The application of cold reduces localized pain. 5. The application of cold provides a calming, sedative effect. Answer: 2, 3, 4 Page Ref: 923 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 14. Identify physiological responses to and purposes of heat and cold. MNL Learning Outcome: 3. Implement the steps for nursing procedures used to treat pressure ulcers, promote wound healing, and prevent complications of wound healing. 33) During morning care, (AP) observe a client's abdominal wound dressing become saturated with bright red blood. What should the AP do? 1. Reinforce the wound with supplies on the client's bedside table. 2. Document that the bath was completed and the condition of the dressing. 3. Complete the bath, then report the change to the nurse. 4. Report the dressing changes to the nurse immediately. Answer: 4 Explanation: When delegating the care of the client to the AP, the nurse should have provided direction to the AP to report any changes to the nurse. AP should report the dressing changes to the nurse immediately. Page Ref: 908 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the health care team | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 15. Recognize when it is appropriate to assign aspects of skin and wound care to assistive personnel. MNL Learning Outcome: 2. Plan care of patients to maintain skin integrity, promote wound healing, and determine delegation.
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34) The nurse is preparing to apply a bandage to a client using the spiral reverse turn. For which body parts should the nurse use this technique when bandaging? (Select all that apply.) 1. Finger 2. Forearm 3. Upper leg 4. Lower leg 5. Upper arm Answer: 2, 4 Page Ref: 920 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 13. Verbalize the steps used in: d. Applying dressings. MNL Learning Outcome: 3. Implement the steps for nursing procedures used to treat pressure ulcers, promote wound healing, and prevent complications of wound healing.
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35) The nurse is preparing to apply a moist aquathermia pack to a client's left upper leg. In which order should the nurse prepare and apply this treatment? 1. Use tape or gauze ties to hold the pad in place. 2. Set the desired temperature according to the manufacturer's instructions. 3. Apply the pad to the body part. The treatment is usually continued for 30 minutes. 4. Fill the reservoir of the unit two-thirds full of water as specified by the manufacturer. 5. Cover the pad and plug in the unit. Check for any leaks or malfunctions of the pad before use. Answer: 4, 2, 5, 3, 1 Explanation: 1. The last step is to apply tape or gauze to hold the pad in place. 2. Second, set the temperature according to the manufacturer's instructions. 3. The fourth step is to apply the pad to the body part being treated and expect to keep the pad in place for 30 minutes. 4. First, the reservoir of the unit should be filled two-thirds full with water. 5. The third step is to cover the pad and plug in the unit, making sure the pad is checked for leaks or malfunctions before use. Page Ref: 924 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 13. Verbalize the steps used in: f. Applying dry and moist heat and cold. MNL Learning Outcome: 3. Implement the steps for nursing procedures used to treat pressure ulcers, promote wound healing, and prevent complications of wound healing.
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36) A client reports having a severe sunburn after being outdoors for a short period of time. For which potential cause should the nurse assess the client? 1. Takes an antibiotic 2. Eats fresh fruit everyday 3. Sleeps 7 hours each night 4. Exercises 5 days a week Answer: 1 Explanation: Many medications increase sensitivity to sunlight and can predispose a client to severe sunburns. Some of the most common medications that cause this damage are certain antibiotics. Fresh fruit, sleep, and exercise do not increase the risk of severe sunburns. Page Ref: 890 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Describe factors affecting skin integrity. MNL Learning Outcome: 1. Assess patients for risk, pressure sites, wounds, and problems with wound healing. 37) A client reports following a vegan eating plan. For which finding should the nurse suspect the client has a protein deficiency? 1. Slow heart rate 2. Slow respiratory rate 3. Lower-extremity edema 4. Hyperactive bowel sounds Answer: 3 Explanation: Hypoproteinemia predisposes the client to dependent edema. Edema makes skin more prone to injury by decreasing its elasticity, resilience, and vitality. A protein deficiency does not cause a slow heart rate, a slow respiratory rate, or hyperactive bowel sounds. Page Ref: 892 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Identify clients at risk for pressure injuries. MNL Learning Outcome: 3. Implement the steps for nursing procedures used to treat pressure ulcers, promote wound healing, and prevent complications of wound healing.
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38) During morning care, assistive personnel (AP) note that a client's wound is seeping a large amount of drainage. Which should the AP do? 1. Notify the nurse. 2. Remove the dressing. 3. Apply a new dressing. 4. Reinforce the dressing. Answer: 1 Explanation: The nurse should have directed the AP to report any changes with a dressing. The AP should not remove, change, or reinforce the dressing. Page Ref: 910 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the health care team | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 15. Recognize when it is appropriate to assign aspects of skin and wound care to assistive personnel. MNL Learning Outcome: 3. Implement the steps for nursing procedures used to treat pressure ulcers, promote wound healing, and prevent complications of wound healing. 39) The nurse changes the dressing around a client's drain. Which information can be omitted from the documentation of this care? 1. Condition of the skin 2. Condition of the drain 3. Name of the surgeon who inserted the drain 4. Estimated amount of drainage on the dressing Answer: 3 Explanation: The name of the surgeon who placed the drain does not need to be documented. The nurse should document the condition of the skin, condition of the drain, and estimated amount of drainage on the dressing. Page Ref: 909 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 16. Demonstrate appropriate documentation and reporting of skin integrity and wound care. MNL Learning Outcome: 4. Implement the evaluation, documentation, and reporting of care of patients related to skin integrity, wound care, and wound healing. 22
40) The nurse irrigates a client's infected abdominal wound. On which part of the electronic medical record should the nurse document that this care was provided? 1. Kardex 2. Care plan 3. Nurse's notes 4. Wound and skin care documentation sheet Answer: 4 Explanation: Electronic health records will use a designated wound and skin documentation sheet. Wound irrigation is not documented on the Kardex, care plan, or nurse's notes. Page Ref: 911 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 16. Demonstrate appropriate documentation and reporting of skin integrity and wound care. MNL Learning Outcome: 4. Implement the evaluation, documentation, and reporting of care of patients related to skin integrity, wound care, and wound healing.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 37 Perioperative Nursing 1) The nurse is caring for a client who is having surgery and is currently being transported to the operating room suite. The nurse should document that the client is in which operative phase? 1. Preoperative phase 2. Intraoperative phase 3. Postoperative phase 4. Perioperative phase Answer: 1 Explanation: The preoperative phase begins when the decision to have surgery is made and ends when the client is transferred to the operating table. Page Ref: 931 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health—illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 2. Describe the phases of the perioperative period. MNL Learning Outcome: 2. Plan care of patients during preoperative, operative, and postoperative phases, and determine delegation appropriate to each phase. 2) The nurse is caring for an 80-year-old client preparing for surgery. The nurse realizes this client is at increased risk for which reason? 1. The physiological deficits of aging increase the surgical risk for older adults. 2. The older adult has increased kidney function. 3. The older adult has an increase in sensory function. 4. The older adult will turn, cough, and deep-breathe more effectively. Answer: 1 Explanation: The older adult has more physiological deficits, such as decreased kidney function and decreased thirst, and is at greater risk for fluid and electrolyte imbalances. Page Ref: 932 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify essential aspects of preoperative assessment. MNL Learning Outcome: 2. Plan care of patients during preoperative, operative, and postoperative phases, and determine delegation appropriate to each phase. 1
3) The nurse is preparing to complete a physical assessment before surgery. Which assessments should the nurse obtain? (Select all that apply.) 1. Mini mental status 2. Assessment of hearing 3. Assessment of the respiratory system 4. Gastrointestinal assessment 5. Maintain NPO status Answer: 1, 2, 3, 4 Explanation: A brief or "mini" mental status examination provides valuable baseline data for evaluating the client's mental status and alertness after surgery. It is also important to evaluate the client's ability to understand what is happening. Assessment of hearing helps guide the effectiveness of perioperative teaching. Respiratory assessment not only provides baseline data for evaluating the client's postoperative status but may alert care providers to a problem that may affect the client's response to surgery and anesthesia. Gastrointestinal status provides baseline data. Page Ref: 935 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify essential aspects of preoperative assessment. MNL Learning Outcome: 1. Assess patients during preoperative, operative, and post-operative phases.
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4) The nurse is preparing to conduct preoperative teaching. What should be included in this teaching? 1. Information related to what will happen to the client 2. Referral of the client to the physician for any misconceptions the client may have 3. The role of the nurse during surgery 4. How to perform activities of daily living (ADLs) following surgery Answer: 1 Explanation: The nurse should provide information related to what will happen to the client, when, and what the client will experience. Page Ref: 936 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 6. Describe essential preoperative teaching, including pain assessment and management, moving, leg exercises, and deep-breathing and coughing exercises. MNL Learning Outcome: 3. Implement the steps for nursing procedures used in the care of patients during the preoperative, operative, and postoperative phases. 5) The nurse is preparing a care plan for a client about to undergo surgery. Which nursing diagnosis would take priority during the intraoperative phase of surgery? 1. Ineffective Protection 2. Risk for Aspiration 3. Impaired Skin Integrity 4. Risk for Falls Answer: 2 Explanation: This is the priority nursing diagnosis for the client having surgery. The risk for aspiration would impact the client's airway and breathing. Page Ref: 935-936 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Diagnosis Learning Outcome: 4. Give examples of pertinent nursing diagnoses for surgical clients. MNL Learning Outcome: 2. Plan care of patients during preoperative, operative, and postoperative phases, and determine delegation appropriate to each phase.
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6) The nurse is preparing the skin of a client for surgery. For which reason should this preparation be done? 1. Sterilize the skin 2. Assess the surgical site before surgery 3. Reduce the risk of postoperative wound infection 4. Clean any moles the client may have Answer: 3 Explanation: The purpose of a surgical skin preparation is to reduce the risk of postoperative wound infection. Page Ref: 942 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Describe essential aspects of preparing a client for surgery. MNL Learning Outcome: 3. Implement the steps for nursing procedures used in the care of patients during the preoperative, operative, and postoperative phases. 7) The nurse is preparing a client for an upper GI endoscopy. For which type of anesthesia should the nurse prepare the client to receive? 1. Local anesthesia 2. Spinal anesthesia 3. Epidural anesthesia 4. Conscious sedation Answer: 4 Explanation: Conscious sedation is often used for procedures such as endoscopies and incision and drainage of abscesses. Page Ref: 946 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 8. Compare various types of anesthesia. MNL Learning Outcome: 3. Implement the steps for nursing procedures used in the care of patients during the preoperative, operative, and postoperative phases.
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8) The nurse is caring for a client in the recovery area. In which position should the nurse place the unconscious client during the immediate postanesthesia phase? 1. Supine 2. Prone 3. Side-lying 4. Supine with a pillow under the head Answer: 3 Explanation: The unconscious client should be positioned on the side, with the face slightly down. Page Ref: 949 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 9. Identify essential nursing assessments and interventions during the immediate postanesthetic phase. MNL Learning Outcome: 3. Implement the steps for nursing procedures used in the care of patients during the preoperative, operative, and postoperative phases. 9) The nurse is admitting a client to the medical-surgical unit following a cholecystectomy. Which assessment should the nurse perform first? 1. Level of consciousness 2. Dressing 3. Drains 4. Skin color Answer: 1 Explanation: The nurse should assess the client's level of consciousness first. Page Ref: 950 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 9. Identify essential nursing assessments and interventions during the immediate postanesthetic phase. MNL Learning Outcome: 3. Implement the steps for nursing procedures used in the care of patients during the preoperative, operative, and postoperative phases.
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10) The nurse is caring for a client on the postoperative unit. Which nursing diagnosis is the priority for this client? 1. Self-Care Deficit 2. Disturbed Body Image 3. Ineffective Airway Clearance 4. Risk for Falls Answer: 3 Explanation: When prioritizing, the nurse should remember the ABCs. Airway should always be the priority. Page Ref: 953 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Diagnosis Learning Outcome: 4. Give examples of pertinent nursing diagnoses for surgical clients. MNL Learning Outcome: 2. Plan care of patients during preoperative, operative, and postoperative phases, and determine delegation appropriate to each phase. 11) A client recovering from surgery asks the nurse why turning, deep-breathing, and coughing exercises need to be done. What should the nurse respond? 1. "These exercises help prevent pneumonia." 2. "The doctor ordered the exercises." 3. "All surgical clients must do these exercises." 4. "These exercises prevent thrombophlebitis." Answer: 1 Explanation: By increasing lung expansion and preventing accumulation of secretions, deep breathing helps prevent pneumonia and atelectasis. Page Ref: 939 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 6. Describe essential preoperative teaching, including pain assessment and management, moving, leg exercises, and deep-breathing and coughing exercises. MNL Learning Outcome: 3. Implement the steps for nursing procedures used in the care of patients during the preoperative, operative, and postoperative phases.
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12) The nurse is assessing an abdominal wound in the postoperative period. Which sign should indicate to the nurse that an infection is present? 1. Absence of bleeding 2. Edges warm to the touch 3. Edges well approximated 4. Sutures in place Answer: 2 Explanation: If the wound becomes warm, red, and edematous, the nurse should suspect an infection and notify the physician. Page Ref: 952 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 11. Identify potential postoperative complications and describe nursing interventions to prevent them. MNL Learning Outcome: 1. Assess patients during preoperative, operative, and post-operative phases. 13) The nurse is preparing a 23-year-old female client for surgery. The nurse should anticipate which diagnostic test to be prescribed for this client? 1. Pregnancy test 2. EEG 3. EKG 4. Pulmonary function tests Answer: 1 Explanation: A pregnancy test is done on all female clients of childbearing age. Page Ref: 935 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Identify nursing responsibilities in planning perioperative nursing care. MNL Learning Outcome: 1. Assess patients during preoperative, operative, and post-operative phases.
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14) The nurse wants to ensure that a client recovering from surgery does not develop thrombophlebitis. Which action should the nurse take to reduce the client's risk of this postoperative complication? 1. Administer an anticoagulant. 2. Assist the client to cough every 2 hours. 3. Monitor intake and output every 2 hours. 4. Provide for early ambulation. Answer: 4 Explanation: Early ambulation, leg exercises, antiembolic stockings, SCDs, and adequate fluid intake are all interventions to reduce the risk for thrombophlebitis. Page Ref: 951 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 11. Identify potential postoperative complications and describe nursing interventions to prevent them. MNL Learning Outcome: 3. Implement the steps for nursing procedures used in the care of patients during the preoperative, operative, and postoperative phases. 15) A client is scheduled for a cholecystectomy. Which should the nurse identify as the purpose of this surgical procedure? 1. Diagnostic 2. Palliative 3. Ablative 4. Constructive Answer: 3 Explanation: When the purpose of surgery is ablative, the diseased body part is removed. Page Ref: 932 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Discuss various types of surgery according to the purpose, degree of urgency, and degree of risk. MNL Learning Outcome: 2. Plan care of patients during preoperative, operative, and postoperative phases, and determine delegation appropriate to each phase.
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16) The nurse is obtaining preoperative assessment data. What should be included in this assessment? (Select all that apply.) 1. Current health status 2. Allergies 3. Current medications 4. Mental status 5. Mother's maiden name Answer: 1, 2, 3, 4 Page Ref: 935 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify essential aspects of preoperative assessment. MNL Learning Outcome: 1. Assess patients during preoperative, operative, and post-operative phases. 17) The nurse is caring for a client in the immediate postoperative period (PACU). Which intervention should the nurse implement to reduce the risk of thrombophlebitis? 1. Leg exercises 2. Coughing every 2 hours 3. Ambulating every 2 hours 4. Oxygen by mask Answer: 1 Explanation: Leg exercises may be implemented in the PACU to help prevent thrombophlebitis. Page Ref: 950 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 11. Identify potential postoperative complications and describe nursing interventions to prevent them. MNL Learning Outcome: 3. Implement the steps for nursing procedures used in the care of patients during the preoperative, operative, and postoperative phases.
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18) The nurse is preparing to apply antiembolic stockings to a postoperative client. What should be done first, before applying the stockings? 1. Measure the calf. 2. Assess for circulatory problems. 3. Assess the client's blood pressure. 4. Clean the stockings. Answer: 2 Explanation: Before applying antiembolic stockings, determine any potential or present circulatory problems and the surgeon's orders involving the lower extremities. Page Ref: 943 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 12. Verbalize the steps used in: b. Applying antiemboli stockings. MNL Learning Outcome: 3. Implement the steps for nursing procedures used in the care of patients during the preoperative, operative, and postoperative phases. 19) The nurse has just inserted a nasogastric tube for gastric suction. What is the most reliable test for confirming tube placement? 1. Place the stethoscope over the stomach and listen for a swishing sound while inserting water into the tube. 2. Place the stethoscope over the stomach and listen for a swishing sound while inserting air into the tube. 3. Aspirate stomach contents and check the acidity using a pH test strip. 4. Connect the tube to suction and observe the contents. Answer: 3 Explanation: Aspirating stomach contents and checking the acidity using a pH test strip is the most reliable test to confirm tube placement. Page Ref: 958 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 12. Verbalize the steps used in: c. Managing gastrointestinal suction. MNL Learning Outcome: 3. Implement the steps for nursing procedures used in the care of patients during the preoperative, operative, and postoperative phases.
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20) The nurse is preparing a 6-year-old child for a tonsillectomy. Which strategy should the nurse use for teaching this client? 1. Pamphlets 2. Play 3. Books 4. Videotapes Answer: 2 Explanation: Play is an effective teaching tool with children. Page Ref: 939 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 6. Describe essential preoperative teaching, including pain assessment and management, moving, leg exercises, and deep-breathing and coughing exercises. MNL Learning Outcome: 3. Implement the steps for nursing procedures used in the care of patients during the preoperative, operative, and postoperative phases. 21) The nurse is planning care for a client during the postoperative period. What should the nurse identify as the goal of care for this client? 1. Provide necessary preoperative teaching. 2. Assist the client to achieve the most optimal health status possible. 3. Ensure client safety. 4. Maintain an aseptic environment. Answer: 2 Explanation: The goal of postoperative care is to assist the client to achieve the most optimal health status possible. Page Ref: 932 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 10. Demonstrate ongoing nursing assessments and interventions for the postoperative client. MNL Learning Outcome: 2. Plan care of patients during preoperative, operative, and postoperative phases, and determine delegation appropriate to each phase.
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22) The nurse is planning a perioperative client's needs upon discharge. What should be included when determining these needs? (Select all that apply.) 1. Client's abilities to provide self-care 2. Date of anticipated discharge 3. Physician performing the surgery 4. Financial resources 5. Need for home healthcare services Answer: 1, 4, 5 Page Ref: 960 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning/Teaching and Learning Learning Outcome: 6. Describe essential preoperative teaching, including pain assessment and management, moving, leg exercises, and deep-breathing and coughing exercises. MNL Learning Outcome: 2. Plan care of patients during preoperative, operative, and postoperative phases, and determine delegation appropriate to each phase. 23) The nurse has identified the goals of maintaining client safety and homeostasis during the intraoperative phase of client care. What nursing activities would support these goals? (Select all that apply.) 1. Maintain the sterile field. 2. Perform instrument counts. 3. Instruct in postoperative exercises. 4. Position the client appropriately for surgery. 5. Perform preoperative skin preparation. Answer: 1, 2, 4, 5 Page Ref: 947 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Identify nursing responsibilities in planning perioperative nursing care. MNL Learning Outcome: 2. Plan care of patients during preoperative, operative, and postoperative phases, and determine delegation appropriate to each phase.
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24) A client is anxious about receiving general anesthesia for a surgical procedure. What should the nurse explain are the advantages of having this type of anesthesia? (Select all that apply.) 1. The client remains conscious. 2. Respiratory rate can be regulated easily. 3. It is used for minor surgical procedures. 4. The anesthesia can be adjusted to the length of the operation. 5. It focuses on a single nerve or nerve group. Answer: 2, 4 Explanation: An advantage of general anesthesia is that the respiratory rate can be regulated easily. An advantage of general anesthesia is that the anesthesia can be adjusted to the length of the procedure. Page Ref: 945 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 8. Compare various types of anesthesia. MNL Learning Outcome: 3. Implement the steps for nursing procedures used in the care of patients during the preoperative, operative, and postoperative phases. 25) During the assessment of a client recovering from surgery, the nurse notes decreased breath sounds in both lower lobes bilaterally. What should the nurse do? 1. Coach the client to deep-breathe and cough. 2. Restrict fluids. 3. Remind the client to perform leg exercises. 4. Maintain on bed rest. Answer: 1 Explanation: The reduction of breath sounds could indicate the pooling of secretions in the lower lobes. The nurse should coach the client to deep-breathe and cough. Page Ref: 951 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 11. Identify potential postoperative complications and describe nursing interventions to prevent them. MNL Learning Outcome: 3. Implement the steps for nursing procedures used in the care of patients during the preoperative, operative, and postoperative phases. 13
26) The nurse is evaluating the effectiveness of preoperative instruction regarding leg exercises with a client recovering from surgery. Which observation indicates that the instructions were effective? 1. The lower extremity is swollen and hot to touch. 2. The vein feels hard. 3. There is no cramping or pain with ambulation. 4. There is pain in the calf with dorsiflexion. Answer: 3 Explanation: The absence of cramping or pain with ambulation indicates that leg exercises instructed prior to surgery were effective to prevent the onset of thrombophlebitis. Page Ref: 951 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation Learning Outcome: 13. Evaluate the effectiveness of perioperative nursing interventions. MNL Learning Outcome: 4. Implement the evaluation, documentation, and reporting of care of patients during preoperative, operative, and post-operative phases. 27) The nurse determines that interventions to prevent postoperative constipation have been effective in a client recovering from surgery. What did the nurse assess to make this clinical decision? 1. Abdominal distention present. 2. Gas pains present. 3. Client vomiting. 4. Bowel movement occurred 24 hours after resuming a normal diet. Answer: 4 Explanation: A bowel movement that occurs within 48 hours after resuming a normal diet is evidence that postoperative constipation has been prevented. Page Ref: 956-957 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation Learning Outcome: 13. Evaluate the effectiveness of perioperative nursing interventions. MNL Learning Outcome: 4. Implement the evaluation, documentation, and reporting of care of patients during preoperative, operative, and post-operative phases.
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28) The nurse is caring for a postoperative client with an abdominal wound and a drain. What can the nurse assign to assistive personnel (AP)? (Select all that apply.) 1. Clean the wound. 2. Assess the skin around the wound. 3. Determine the effectiveness of pain medication. 4. Report if the dressing is soiled. 5. Report if the dressing is loose. Answer: 4, 5 Page Ref: 953 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the health care team | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 14. Recognize when it is appropriate to assign perioperative skills to assistive personnel. MNL Learning Outcome: 2. Plan care of patients during preoperative, operative, and postoperative phases, and determine delegation appropriate to each phase. 29) The nurse is preparing to instruct a client on leg exercises to be used when recovering from abdominal surgery. What should the nurse determine before beginning this teaching? (Select all that apply.) 1. Type of surgery 2. Time of surgery 3. Postoperative diet 4. Preoperative orders 5. Name of the surgeon Answer: 1, 2, 4, 5 Page Ref: 937 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment/Teaching and Learning Learning Outcome: 12. Verbalize the steps used in: a. Teaching moving, leg exercises, deep breathing, and coughing. MNL Learning Outcome: 3. Implement the steps for nursing procedures used in the care of patients during the preoperative, operative, and postoperative phases.
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30) A client in the postanesthesia care unit is to have suction applied through a nasogastric tube. When documenting, the nurse should include which information? (Select all that apply.) 1. The time suction was started 2. Characteristics of wound drainage 3. Pressure on the suction 4. Integrity of the surgical dressing 5. Color and consistency of drainage Answer: 1, 3, 5 Page Ref: 960 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 15. Demonstrate appropriate documentation and reporting of perioperative skills. MNL Learning Outcome: 3. Implement the steps for nursing procedures used in the care of patients during the preoperative, operative, and postoperative phases.
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31) The nurse is completing a preoperative assessment with a client. What should this assessment include? (Select all that apply.) 1. Current health status 2. Allergies 3. Current medications 4. Mental status 5. Respiratory rate Answer: 1, 2, 3, 4 Explanation: When documenting the current health status, essential information includes general health status and the presence of any chronic diseases that might affect the client's response to surgery or anesthesia. When documenting allergies, the nurse should include allergies to prescription and nonprescription drugs, food allergies, and allergies to tape, latex, soaps, or antiseptic agents. All current medications should be listed. Herbal remedies and over-the-counter preparations are also a part of this assessment. The client's current mental status is a part of this assessment. Page Ref: 935 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify essential aspects of preoperative assessment. MNL Learning Outcome: 1. Assess patients during preoperative, operative, and post-operative phases.
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32) A client is scheduled for lung resection surgery. What should the nurse keep in mind when determining this client's degree of risk for this major surgical procedure? (Select all that apply.) 1. Age 2. Medications 3. General health 4. Blood pressure 5. Nutritional status Answer: 1, 2, 3, 5 Page Ref: 932-934 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Discuss various types of surgery according to the purpose, degree of urgency, and degree of risk. MNL Learning Outcome: 1. Assess patients during preoperative, operative, and post-operative phases. 33) A client is having a surgical procedure. At which time does the postoperative phase begin? 1. When healing is complete 2. When the decision to have surgery is made 3. With admission to the postanesthesia care unit 4. When the client is transferred to the operating table Answer: 3 Explanation: The postoperative phase begins with admission to the postanesthesia care unit. The postoperative phase ends when healing is complete. The preoperative phase begins when the decision to have surgery is made. The intraoperative phase begins when the client is transferred to the operating table. Page Ref: 931 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 2. Describe the phases of the perioperative period. MNL Learning Outcome: 2. Plan care of patients during preoperative, operative, and postoperative phases, and determine delegation appropriate to each phase.
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34) The surgical team conducts a final verification of the correct client, procedure, and site. In which way should the nurse document this validation? 1. SBAR 2. Time-out 3. SOAPIE note 4. Hand-off communication Answer: 2 Explanation: The Joint Commission established the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery in 2004. This protocol involves three steps. The third step is called "time-out." Before surgery begins the surgical team takes a time-out to conduct a final verification of the correct client, procedure, and site. SBAR is a form of communication. A SOAPIE note is a method of documenting client care. Hand-off communication occurs between shifts or when transferring a client. Page Ref: 943 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 7. Describe essential aspects of preparing a client for surgery. MNL Learning Outcome: 3. Implement the steps for nursing procedures used in the care of patients during the preoperative, operative, and postoperative phases.
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35) The nurse is concerned that an older client is developing a postoperative infection. What did the nurse assess to make this clinical determination? 1. Fever 2. Confusion 3. Tachycardia 4. Inflammation Answer: 2 Explanation: An older adult may not show the classic signs of infection such as fever, tachycardia, or inflammation. Instead, there may be an abrupt change in mental status. Page Ref: 950 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 10. Demonstrate ongoing nursing assessments and interventions for the postoperative client. MNL Learning Outcome: 2. Plan care of patients during preoperative, operative, and postoperative phases, and determine delegation appropriate to each phase. 36) Assistive personnel (AP) responds when a client recovering from surgery calls for help. Which should the AP do when the client has accidentally removed the nasogastric tube? 1. Reinsert the tube 2. Suction the client's mouth 3. Empty the suction cannister 4. Notify the nurse immediately Answer: 4 Explanation: The AP should report the dislodged nasogastric tube to the nurse. The AP is not to reinsert the tube. There is no reason to suction the client's mouth. Emptying the suction cannister is not a priority at this time. Page Ref: 958 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the health care team | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 14. Recognize when it is appropriate to assign perioperative skills to assistive personnel. MNL Learning Outcome: 2. Plan care of patients during preoperative, operative, and postoperative phases, and determine delegation appropriate to each phase.
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37) A client recovering from surgery has antiembolic stockings applied. Which should the nurse document about this procedure? 1. Type of surgery 2. Name of the surgeon 3. Orientation of the client 4. Time when the stockings were applied Answer: 4 Explanation: The time when the stockings were applied should be documented. Documentation does not need to include the type of surgery, the name of the surgeon, or the client's orientation. Page Ref: 945 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 15. Demonstrate appropriate documentation and reporting of perioperative skills. MNL Learning Outcome: 4. Implement the evaluation, documentation, and reporting of care of patients during preoperative, operative, and post-operative phases.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 38 Sensory Perception 1) During review of admission data, the nurse learns that the new client has impairment of kinesthetic sensation. Which nursing intervention should be planned for this client? 1. Use the clock face as a format for describing the position of food on meal trays. 2. Provide all teaching materials in very large font. 3. Ensure that the client has assistance when ambulating. 4. Use only nonirritating soaps for bathing. Answer: 3 Explanation: Kinesthetic sensation refers to the awareness of the position and movement of body parts. The client with impairment of this sensation may be prone to injury by falling and should be assisted when ambulating. Page Ref: 966 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 1. Discuss the components of the sensory-perception process. MNL Learning Outcome: 3. Plan care of patients with impaired sensory-perception function. 2) A client diagnosed with congestive heart failure has been treated for many years with intravenous furosemide (Lasix). What sensory impairment should the nurse assess in this client? 1. Loss of ability to taste 2. Hearing loss 3. Vision loss 4. Loss of ability to smell Answer: 2 Explanation: Furosemide (Lasix) can be ototoxic if taken over long periods of time. The nurse would monitor for hearing loss. Page Ref: 968 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Discuss factors that place a client at risk for sensory disturbances. MNL Learning Outcome: 2. Assess patients for normal and impaired sensory-perception function. 1
3) A client who has been treated for diabetes mellitus since childhood has a blood glucose reading of 180 mg/dl. For which sensory disturbance should the nurse assess in this client? 1. Loss of ability to taste 2. Hearing loss 3. Vision loss 4. Loss of ability to smell Answer: 3 Explanation: Uncontrolled diabetes mellitus is a leading cause of blindness in the United States. Page Ref: 968 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Discuss factors that place a client at risk for sensory disturbances. MNL Learning Outcome: 2. Assess patients for normal and impaired sensory-perception function. 4) The nurse suspects that the client has a hearing disorder; however, the client denies not being able to hear. What initial assessment technique should the nurse employ? 1. Use a Snellen chart to assess for hearing. 2. Observe the client's interaction with significant others. 3. Use an otoscope to visualize the inner ear. 4. Confront the client with the nurse's suspicion. Answer: 2 Explanation: The most telling of these options would be to observe the client's interactions with significant others. The nurse should assess for frequent requests to repeat, inattention to conversation, turning one ear to the conversation, and lip-reading. Page Ref: 970 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Describe essential components in assessing a client's sensory-perception function. MNL Learning Outcome: 2. Assess patients for normal and impaired sensory-perception function.
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5) The nurse is teaching the parents of a 7-month-old child who has just been diagnosed with a hearing loss. What guidance should the nurse provide? 1. Expect that the child will be enrolled in a special hearing intervention program immediately. 2. Keep your child in a quiet environment until additional testing is done. 3. Interventions to support hearing are not useful until the child is at least 9 months old. 4. Hearing loss is not serious until 1 year of age. Answer: 1 Explanation: The Centers for Disease Control and Prevention (CDC) expects that all infants identified with hearing loss will receive early intervention services prior to age 36 months. Page Ref: 972 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 7. Discuss nursing interventions to promote and maintain sensory function. MNL Learning Outcome: 4. Utilize nursing strategies for the care of patients with impaired sensory-perception function. 6) The odor from a hospitalized client's draining wound permeates the room and is very overwhelming and distracting to the client and the staff. What intervention would be most helpful? 1. Spray the room routinely with a floral room spray. 2. Instill a vinegar solution into the wound. 3. Keep the wound dressing dry and clean. 4. Burn a candle in the room. Answer: 3 Explanation: The best way to keep odors controlled is to keep the wound dressing dry and clean. Page Ref: 978 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Discuss nursing interventions to promote and maintain sensory function. MNL Learning Outcome: 4. Utilize nursing strategies for the care of patients with impaired sensory-perception function.
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7) The nurse is assisting a visually impaired client with ambulation. In which way should the nurse proceed with this intervention? 1. Walk slightly behind the client. 2. Walk 1 foot in front of the client. 3. Walk on the right side of the client. 4. Walk on the left side of the client. Answer: 2 Explanation: The nurse should walk about 1 foot in front of the client, offering the client an arm. Page Ref: 973 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Discuss nursing interventions to promote and maintain sensory function. MNL Learning Outcome: 4. Utilize nursing strategies for the care of patients with impaired sensory-perception function. 8) An older client has become very confused since being hospitalized however but has been able to maintain an independent lifestyle at home. In which way should the nurse document this mental state? 1. Reversible confusion 2. Sundown syndrome 3. Delirium 4. Dementia Answer: 3 Explanation: Delirium is acute confusion caused by illness, medication, or a change in environment and is the appropriate documentation for this client. Page Ref: 979 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment/Communication and Documentation Learning Outcome: 3. Identify clinical signs and symptoms of sensory deprivation and overload. MNL Learning Outcome: 2. Assess patients for normal and impaired sensory-perception function.
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9) The nurse is concerned that a client is not aware of being in the hospital. For what aspects of the sensory process should the nurse assess the client? (Select all that apply.) 1. Speech 2. Stimuli 3. Receptor 4. Perception 5. Impulse conduction Answer: 2, 3, 4, 5 Page Ref: 966 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Discuss the components of the sensory-perception process. MNL Learning Outcome: 1. Examine components of and factors that affect sensory-perception process and function. 10) A client can be aroused only with extreme or repeated stimuli. How should the nurse document this client's behavior? 1. Somnolent 2. Disoriented 3. Comatose 4. Semicomatose Answer: 4 Explanation: Because this client can be aroused with extreme stimuli or repeated stimuli, the correct description is semicomatose. Page Ref: 967 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment/Communication and Documentation Learning Outcome: 6. Develop nursing diagnoses and outcome criteria for clients with impaired sensory function. MNL Learning Outcome: 2. Assess patients for normal and impaired sensory-perception function.
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11) The nurse is planning care for a client who is experiencing dementia. What essential concept should the nurse consider for this planning? 1. Background noise such as music will keep this client calm. 2. Activities should be scheduled at the same time each day. 3. Pain mediation will increase dementia. 4. It is important to talk with the client throughout procedures. Answer: 2 Explanation: The client with dementia benefits from a routine schedule of activities. Page Ref: 980 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 8. Identify strategies to promote a therapeutic environment for the client with acute confusion or delirium. MNL Learning Outcome: 3. Plan care of patients with impaired sensory-perception function. 12) The client who has the medical diagnosis of Alzheimer disease is confused and has difficulty interpreting environmental stimuli. Which nursing diagnosis accurately describes this client's situation? 1. Acute Confusion 2. Altered Role Performance 3. Disturbed Sensory Perception 4. Disturbed Thought Processes Answer: 4 Explanation: Because this client has dementia, which interferes with the ability to interpret stimuli, the correct diagnosis problem statement is Disturbed Thought Processes. Page Ref: 971 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Diagnosis Learning Outcome: 6. Develop nursing diagnoses and outcome criteria for clients with impaired sensory function. MNL Learning Outcome: 3. Plan care of patients with impaired sensory-perception function.
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13) The nurse is caring for a client who has difficulty hearing conversation. What intervention should the nurse implement? 1. Use short phrases. 2. Overarticulate words. 3. Vary the volume of the voice. 4. Face the client during conversation. Answer: 4 Explanation: The best intervention is to face the client during conversation so that the client can employ any lip-reading skills. Page Ref: 976 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Discuss nursing interventions to promote and maintain sensory function. MNL Learning Outcome: 4. Utilize nursing strategies for the care of patients with impaired sensory-perception function. 14) A client is experiencing changes in taste. What can the nurse do to improve this client's gustatory sense? (Select all that apply.) 1. Suggest eating each food separately. 2. Offer foods with a variety of flavors. 3. Recommend eating foods that are cold. 4. Promote sips of water between eating different foods. 5. Encourage the client to consume foods of different textures. Answer: 1, 2, 4, 5 Page Ref: 975 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Discuss nursing interventions to promote and maintain sensory function. MNL Learning Outcome: 4. Utilize nursing strategies for the care of patients with impaired sensory-perception function.
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15) The family of a client in the hospital is concerned about the constant noise in the care area. Which healthcare professionals have the greatest control over the level of sensory input in the hospital? 1. Physicians 2. Administrators 3. Nurses 4. Planners Answer: 3 Explanation: Nurses have the greatest amount of control over the level of sensory input in the hospital. Nurses can decrease sensory overload by controlling lights, noise, odors, and pain. Nurses can also increase sensory input by stimulating the client as appropriate. Page Ref: 975, 978 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 2. Describe factors that influence sensory function. MNL Learning Outcome: 4. Utilize nursing strategies for the care of patients with impaired sensory-perception function. 16) The nurse documents that a client is fully conscious. What did the nurse assess in this client? (Select all that apply.) 1. Client responded to verbal stimuli. 2. Client responded to written words. 3. Client oriented to time, place, and person. 4. Client demonstrated poor memory. 5. Client alert. Answer: 1, 2, 3, 5 Page Ref: 967 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Describe essential components in assessing a client's sensory-perception function. MNL Learning Outcome: 2. Assess patients for normal and impaired sensory-perception function.
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17) A client asks the nurse to please close the door when entering or exiting the room because the noise is more than the client is used to because he lives alone. The nurse identifies the reason for this client's response to sensory stimuli as being due to which factor? 1. Lifestyle 2. Developmental stage 3. Culture 4. Illness Answer: 1 Explanation: Lifestyle influences the quality and quantity of stimulation to which an individual is accustomed. A client who lives alone is exposed to fewer, less diverse stimuli. Page Ref: 968 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Describe factors that influence sensory function. MNL Learning Outcome: 1. Examine components of and factors that affect sensory-perception process and function. 18) The nurse is concerned that a client is experiencing sensory deprivation. What did the nurse assess to make this clinical decision? (Select all that apply.) 1. Excessive sleeping 2. Confusion at night 3. Anger over minor issues 4. Easily distracted 5. Sitting quietly reading a book Answer: 1, 2, 3, 4 Page Ref: 969 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify clinical signs and symptoms of sensory deprivation and overload. MNL Learning Outcome: 2. Assess patients for normal and impaired sensory-perception function.
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19) The nurse suspects a client will develop sensory overload. What characteristics did the nurse observe in the client? (Select all that apply.) 1. Ongoing pain 2. Confusion at night 3. Inability to sleep 4. Easily angered 5. Worrying about upcoming diagnostic tests Answer: 1, 3, 5 Page Ref: 969 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify clinical signs and symptoms of sensory deprivation and overload. MNL Learning Outcome: 2. Assess patients for normal and impaired sensory-perception function. 20) A client who is hospitalized receives no telephone calls or visitors. The nurse should assess which aspect of the client's sensory-perception function? 1. Risk for sensory overload 2. Social support network 3. Mental status 4. Environment Answer: 2 Explanation: The degree of isolation a person feels is significantly influenced by the quality and quantity of support from family members and friends. The nurse should assess the client's living arrangements, visitors, and any signs indicating social deprivation, such as withdrawal from contact with others to avoid embarrassment or dependence on others, negative self-image, reports of lack of meaningful communication with others, and absence of opportunities to discuss fears or concerns that facilitate coping mechanisms. Page Ref: 969 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Discuss factors that place a client at risk for sensory disturbances. MNL Learning Outcome: 2. Assess patients for normal and impaired sensory-perception function. 10
21) The nurse is assessing a client for possible sensory deprivation. What findings would indicate the client is at risk for developing this sensory disorder? (Select all that apply.) 1. Client has severe pain. 2. Client has impaired vision. 3. Client is unable to ambulate. 4. Client is on medication that alters sensory perception. 5. Client has no family in the immediate area. Answer: 2, 3, 4, 5 Page Ref: 971 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify clinical signs and symptoms of sensory deprivation and overload. MNL Learning Outcome: 2. Assess patients for normal and impaired sensory-perception function. 22) The nurse is identifying diagnoses appropriate for a client recovering from cataract surgery who lives alone. Which diagnosis would be the priority for this client? 1. Social Isolation 2. Risk for Impaired Skin Integrity 3. Disturbed Sensory Perception 4. Risk for Injury Answer: 4 Explanation: Because the client lives alone and is recovering from cataract surgery, the client's risk for injury is great. Page Ref: 971 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Diagnosis Learning Outcome: 6. Develop nursing diagnoses and outcome criteria for clients with impaired sensory function. MNL Learning Outcome: 3. Plan care of patients with impaired sensory-perception function.
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23) The nurse is identifying outcome criteria for a client with a nursing diagnosis of Disturbed Sensory Perception, Auditory. What would indicate that interventions to address this diagnosis have been successful? 1. Client places hearing aid on bedside table when not in use. 2. Client does not respond appropriately to questions. 3. Client demonstrates use and care of hearing aid. 4. Client demonstrates difficulty with problem solving. Answer: 3 Explanation: Outcome criteria that indicate interventions to address Disturbed Sensory Perception, Auditory have been successful would include the client's demonstrating use and care of the hearing aid. Page Ref: 981 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation Learning Outcome: 8. Identify strategies to promote a therapeutic environment for the client with acute confusion or delirium. MNL Learning Outcome: 3. Plan care of patients with impaired sensory-perception function. 24) A client is experiencing acute confusion. What nursing actions would be appropriate for this client? (Select all that apply.) 1. Eliminate unnecessary noise. 2. Keep eyeglasses within reach. 3. Place a calendar in the room and identify each day. 4. Keep the room well-lit during waking hours. 5. Provide dark glasses. Answer: 1, 2, 3, 4 Page Ref: 980 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 8. Identify strategies to promote a therapeutic environment for the client with acute confusion or delirium. MNL Learning Outcome: 4. Utilize nursing strategies for the care of patients with impaired sensory-perception function.
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25) Which recent change, reported by a client's family, would indicate that the client's hearing ability is decreasing? (Select all that apply.) 1. Inability to follow directions 2. Mood swings 3. Decreased appetite 4. Complaints of dizziness 5. Answering questions incorrectly Answer: 1, 2, 4, 5 Page Ref: 970 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Discuss factors that place a client at risk for sensory disturbances. MNL Learning Outcome: 2. Assess patients for normal and impaired sensory-perception function. 26) The nurse is concerned that a hospitalized client is experiencing sensory overload. What did the nurse assess to come to this conclusion? (Select all that apply.) 1. Sleeplessness 2. Anxiety 3. Apathy 4. Racing thoughts 5. Somatic complaints Answer: 1, 2, 4 Page Ref: 969 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify clinical signs and symptoms of sensory deprivation and overload. MNL Learning Outcome: 2. Assess patients for normal and impaired sensory-perception function.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 39 Self-Concept 1) Which statement, made by the client, would indicate a "me-centered" self-concept? 1. "I couldn't stand to disappoint my parents." 2. "My sister is so much smarter than I am." 3. "My future is based on the decisions I make today." 4. "The world has always been against people like me." Answer: 3 Explanation: Individuals with a positive self-concept are me-centered and value how they perceive themselves over the opinions of others and have learned to depend on themselves. This is reflected in the statement, "My future is based on the decisions I make today." Page Ref: 986 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Summarize the development of self-concept and self-esteem, including the framework described by Erikson. MNL Learning Outcome: 1. Examine the formation of self-concept across the lifespan. 2) The staff development instructor planning self-concept development classes for staff nurses is going to include information to improve the nurses' self-concept along with information to use with clients. Why is the information for nurses important? 1. The nurse's self-concept is more important than the client's. 2. Poor self-concept is the number-one reason for nursing burnout. 3. Nurses with positive self-concept are better able to help clients. 4. Nurses with poor self-concept are more likely to make errors. Answer: 3 Explanation: Nurses who have positive self-concept are better prepared to assist clients with their own understanding of needs, desires, feelings, and conflicts. Page Ref: 986 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 2. Describe the dimensions and components of self-concept. MNL Learning Outcome: 2. Examine the components and formation of self-concept across the lifespan. 1
3) The nurse with 25 years' experience is overheard saying, "I learn something new about nursing every day." What does this indicate about the nurse's self-awareness? 1. This nurse is not very self-aware. 2. The nurse's self-awareness is behind normal development. 3. Because this nurse has been a nurse for so long, self-awareness is no longer an important issue. 4. Because self-awareness is never complete, this nurse is demonstrating desirable behavior. Answer: 4 Explanation: Self-awareness takes time and energy and is never completed. This nurse is demonstrating desirable behavior in that there is still intellectual humility and a desire to learn. Page Ref: 986 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Describe the dimensions and components of self-concept. MNL Learning Outcome: 2. Examine the components and formation of self-concept across the lifespan. 4) A nursing student has just received an evaluation that indicates difficulties with time management and prioritization in the care of clients. How should the student react to this input? 1. Take the feedback seriously and use it to guide personal growth. 2. Blame the student—faculty relationship as the basis of the evaluation. 3. Dismiss the evaluation as invalid. 4. Consider the feedback carefully but not change practice patterns. Answer: 1 Explanation: The student should take the feedback seriously and use it to guide personal growth. Issues with time management and prioritization are common with students and should be addressed. The student should introspectively look at the situation and use it for growth. Page Ref: 986 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 3. Identify common stressors affecting self-concept and coping strategies. MNL Learning Outcome: 2. Examine the components and formation of self-concept across the lifespan.
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5) The nurse is determining a client's level of psychosocial development according to Erikson's stages. Place the developmental tasks in order according to Erikson's stages of psychosocial development. 1. Expressing one's own opinion 2. Guiding others 3. Asserting independence 4. Working well with others Answer: 1, 4, 3, 2 Explanation: 1. Expressing one's own opinion is a behavior in the infancy stage of trust versus mistrust. 2. Guiding others is a behavior in the middle-aged adult stage of generativity versus stagnation. 3. Asserting independence is a behavior in the adolescence stage of identity versus role confusion. 4. Working well with others is a behavior in the early school years stage of industry versus inferiority. Page Ref: 987 Cognitive Level: Applying Client Need/Sub: Physiological Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Summarize the development of self-concept and self-esteem, including the framework described by Erikson. MNL Learning Outcome: 2. Examine the components and formation of self-concept across the lifespan.
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6) The adolescent male client who weighs 100 lbs. is considering taking "some herbal stuff" to increase muscle mass and strength. Which should the nurse realize this statement indicates about the client? 1. A strong need for admiration 2. Serious problems with logical thinking 3. Incongruence between reality and ideal self 4. The need for referral to a psychologist Answer: 3 Explanation: The nurse can determine that there is incongruence between reality and this client's ideal self. Page Ref: 988 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify common stressors affecting self-concept and coping strategies. MNL Learning Outcome: 3. Assess patients to determine potential or actual problems related to self-concept. 7) During an assessment, the nurse notes that a client frequently refers to his cultural heritage. In which way should the nurse identify the impact of the client's heritage? 1. Personal identity 2. Body image 3. Role performance 4. Self-esteem Answer: 1 Explanation: Self-concept consists of personal identity, body image, role performance, and selfesteem. Personal identity consists of name, sex, age, race, ethnic origin or culture, occupation or roles, talents, and other situational characteristics. Page Ref: 988 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Describe the dimensions and components of self-concept. MNL Learning Outcome: 2. Examine the components and formation of self-concept across the lifespan.
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8) A client who has recently lost 75 pounds continues to dress in loose, baggy clothing and frequently talks about being fat. Which should this indicate to the nurse? 1. Role confusion 2. Body image disturbance 3. Fear of success 4. Lack of education Answer: 2 Explanation: The most likely interpretation of this finding is that the client continues to see self as fat, which is a body image disturbance. Page Ref: 988 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify common stressors affecting self-concept and coping strategies. MNL Learning Outcome: 2. Examine the components and formation of self-concept across the lifespan. 9) An adolescent client with a rare malignancy would prefer to die than to have a leg amputated. What information should the nurse use to plan future interventions for this client? 1. The knowledge that adolescents are very concerned about body image 2. Concern about need for education regarding the danger of delaying surgery 3. The fact that the parents will have the ultimate decision about surgery 4. The ability of the adolescent to understand medical terminology Answer: 1 Explanation: Adolescents are very concerned about body image and will make decisions based on peer or media opinion even if it puts their health at risk. The nurse's further interventions should be planned with this thought in mind. Page Ref: 988-989 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 2. Describe the dimensions and components of self-concept. MNL Learning Outcome: 2. Examine the components and formation of self-concept across the lifespan.
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10) Which statement made by a new mother would indicate to the nurse that there is potential for lowered self-esteem due to role ambiguity? 1. "I don't know if I know how to be a mom." 2. "My husband will be a stay-at-home dad while I work." 3. "I'm so disappointed that this baby is not a girl." 4. "I haven't even finished the baby's room." Answer: 1 Explanation: Role ambiguity occurs when expectations are unclear or a person does not know how to fulfill the role. In this case, the clearest indication of role ambiguity is "I don't know if I know how to be a mom." Page Ref: 990 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify common stressors affecting self-concept and coping strategies. MNL Learning Outcome: 2. Examine the components and formation of self-concept across the lifespan. 11) The nurse suspects that a client is having difficulty with specific self-esteem. Which client statements caused the nurse to have this concern? (Select all that apply.) 1. "I hate my hair." 2. "Life is wonderful!" 3. "My hips are too big." 4. "I wish I had that nose job 2 years ago." 5. "It is awesome that I got that promotion at work." Answer: 1, 3, 4 Explanation: Specific self-esteem is how much one approves of a certain part of oneself. The client hating her hair, stating that her hips are too big, and wishing that a nose job was done 2 years ago demonstrate issues with specific self-esteem. Page Ref: 990 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Describe the dimensions and components of self-concept. MNL Learning Outcome: 2. Examine the components and formation of self-concept across the lifespan. 6
12) Which nursing intervention would be helpful when caring for a client who has negative selfesteem? 1. Find a way to praise the client during each encounter. 2. Design a series of "small successes" for the client. 3. Correct the client when negativity arises. 4. Tell the client how much easier life would be with positive self-esteem. Answer: 2 Explanation: Clients who have negative self-esteem may have a history of failures and disappointments. Designing a series of "small successes" for the client will help foster a more positive attitude. Page Ref: 991 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 6. Describe nursing interventions designed to achieve identified outcomes for clients with altered self-concept. MNL Learning Outcome: 4. Determine appropriate nursing diagnoses, interventions, and evaluation of patients with potential or actual altered self-concept. 13) The nurse is conducting a thorough psychosocial assessment of a client who reports fatigue, tearfulness, and relationship difficulties. What action by the nurse would support accurate assessment? 1. Take detailed notes to record client responses. 2. Ask as many questions as possible to explore all areas of concern. 3. Start the interview by asking a series of yes/no questions. 4. Investigate the client's culture prior to the interview. Answer: 4 Explanation: The nurse should consider how the client's behaviors are influenced by culture. In order to understand what is being said or seen, the nurse should investigate the client's culture prior to the interview. Page Ref: 992 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Describe the essential aspects of assessing role relationships. MNL Learning Outcome: 3. Assess patients to determine potential or actual problems related to self-concept. 7
14) Which statement should the nurse make first when assessing a client's self-concept? 1. "Describe yourself as a person." 2. "Tell me about your family." 3. "Describe what you do when you have free time." 4. "Tell me about the work you do." Answer: 1 Explanation: The first information the nurse gathers when assessing self-concept should focus on the client's personal identity ("Describe yourself as a person"). Page Ref: 993 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 6. Describe nursing interventions designed to achieve identified outcomes for clients with altered self-concept. MNL Learning Outcome: 3. Assess patients to determine potential or actual problems related to self-concept. 15) During the assessment interview, the client is quiet and answers questions only minimally. What action should the nurse take about the client's reluctance to share information? 1. Document that the client is not cooperative. 2. Consider any cultural implications of these actions. 3. Assume that the client has something to hide. 4. Ask another nurse to sit in on the next interview attempt. Answer: 2 Explanation: The nurse should always consider that there could be a cultural implication of behavior. Page Ref: 992 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 6. Describe nursing interventions designed to achieve identified outcomes for clients with altered self-concept. MNL Learning Outcome: 3. Assess patients to determine potential or actual problems related to self-concept.
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16) Which characteristic of self-esteem will make it difficult for the nurse to plan interventions for a client? 1. Low motivation to improve 2. A focus on problems 3. Expressed disinterest in working on improvement 4. Not satisfied with personal situation Answer: 2 Explanation: Clients with low self-esteem often have difficulty identifying strengths and focus more on their limitations and problems. Page Ref: 993 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 6. Describe nursing interventions designed to achieve identified outcomes for clients with altered self-concept. MNL Learning Outcome: 3. Assess patients to determine potential or actual problems related to self-concept. 17) The nurse is assisting a client in setting goals as a strategy to reinforce strengths. What intervention should the nurse employ? 1. Encourage the client to set attainable goals, even if small. 2. Help the client choose a significant goal, even if it is time-consuming. 3. Devise a set of goals from which the client can pick. 4. Advise the client to avoid goals that will require too much effort. Answer: 1 Explanation: When attempting to reinforce client strengths, it is important to help the client set attainable goals, even if the goals are small at first. Page Ref: 993 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 6. Describe nursing interventions designed to achieve identified outcomes for clients with altered self-concept. MNL Learning Outcome: 4. Determine appropriate nursing diagnoses, interventions, and evaluation of patients with potential or actual altered self-concept.
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18) A client had set the expected outcome: "At the next clinic visit, the client will report participation in three activities to increase self-esteem." Which action should the nurse take if the client is unable to meet the stated outcome? 1. Explore the possible reasons for not meeting the outcome. 2. Reevaluate the accuracy of the outcome statement. 3. Collaborate with the client to write a new expected outcome. 4. Identify new interventions to help the client achieve the outcome. Answer: 1 Explanation: The nurse's first action should be to explore possible reasons the outcome was not met. Page Ref: 994 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation Learning Outcome: 6. Describe nursing interventions designed to achieve identified outcomes for clients with altered self-concept. MNL Learning Outcome: 4. Determine appropriate nursing diagnoses, interventions, and evaluation of patients with potential or actual altered self-concept. 19) The spouse is concerned that a client is not making progress in developing a more positive self-esteem. What should the nurse respond to the spouse? 1. "Most clients make quicker progress." 2. "Self-esteem work takes time and is not easily evaluated." 3. "What have you done to help the client with this work?" 4. "Do you think that the client is really trying?" Answer: 2 Explanation: It would be appropriate to respond that self-esteem work takes time and that improvement is sometimes not easy to evaluate. Page Ref: 994 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 2. Describe the dimensions and components of self-concept. MNL Learning Outcome: 4. Determine appropriate nursing diagnoses, interventions, and evaluation of patients with potential or actual altered self-concept.
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20) The nurse is teaching a class for new parents about self-esteem development in infants. What information should be included? 1. If the baby awakens at night, let him cry for a few minutes before responding. 2. Keep the baby on a 3-hour feeding schedule, even if it means awakening him. 3. Respond to the baby's needs promptly and consistently. 4. Use firm, loving discipline with the baby from the beginning. Answer: 3 Explanation: In order to develop self-esteem in their baby, parents should be taught to respond to the baby's needs promptly and consistently. Page Ref: 995 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 7. Describe ways to enhance client self-esteem. MNL Learning Outcome: 4. Determine appropriate nursing diagnoses, interventions, and evaluation of patients with potential or actual altered self-concept. 21) The parents are concerned that day-care workers might think they are negligent because their preschooler demands to wear mismatched clothing. What should be the nurse's response to this concern? 1. "Don't worry, day-care workers are accustomed to that sort of thing." 2. "This is normal and the preschooler is just practicing skills needed later in life" 3. "I am glad you brought that to our attention. I will make a note for her pediatrician." 4. "You should have better control of the child now if you have any hope of controlling the child during the teenage years." Answer: 2 Explanation: The nurse should accept that the parents are concerned and then tell them that this is normal behavior at this age. Preschoolers often begin to exert independence and to "practice" picking out clothing, cooking with play toys, and parenting dolls. Page Ref: 995 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 1. Summarize the development of self-concept and self-esteem, including the framework described by Erikson. MNL Learning Outcome: 2. Examine the components and formation of self-concept across the lifespan. 11
22) An adolescent has recently gotten into trouble at school for cheating on an examination and has been barred from participating in a school trip as a consequence of that action. Which should the nurse respond when asked if the punishment is suitable? 1. "I think the punishment may be excessive. Have you talked with the school officials about the incident?" 2. "Because my expertise is in health, I really can't respond to your question." 3. "Honesty and respect for authorities is important. I am surprised that the punishment is not more extensive." 4. "Living with the consequences of your actions is a way to help the adolescent develop good self-esteem." Answer: 4 Explanation: One of the most important tasks of adolescence and a prime way to develop selfesteem is to take responsibility and to live with the consequences of actions. Page Ref: 995 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 7. Describe ways to enhance client self-esteem. MNL Learning Outcome: 2. Examine the components and formation of self-concept across the lifespan. 23) The nurse working in a long-term care facility notices that one of the residents has had a recent decline in self-esteem. What intervention would be appropriate for this resident? 1. Ask the resident for advice in setting up an activity in the dayroom. 2. Keep the resident too busy to dwell in the past. 3. Don't allow the resident to talk about minor concerns. 4. Meet with the social worker to plan all of the client's care. Answer: 1 Explanation: Asking the client for advice in setting up an activity in the dayroom validates the client's usefulness and worth. Page Ref: 996 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Describe ways to enhance client self-esteem. MNL Learning Outcome: 4. Determine appropriate nursing diagnoses, interventions, and evaluation of patients with potential or actual altered self-concept. 12
24) The nurse is planning to assess a client's family relationships. What questions should the nurse ask to obtain this information? (Select all that apply.) 1. "How do you spend your free time?" 2. "What is your home like?" 3. "Who is most important to you?" 4. "How well do you feel you accomplish what is expected of you?" 5. "Whom do you seek out for help?" Answer: 2, 4 Page Ref: 993 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Describe the essential aspects of assessing role relationships. MNL Learning Outcome: 3. Assess patients to determine potential or actual problems related to self-concept. 25) A client demonstrating fatigue and inadequacy states the expectation to to maintain the home and children as well as have a job to help with household expenses. The nurse identifies which nursing diagnosis as appropriate for the client at this time? 1. Chronic Low Self-Esteem 2. Ineffective Role Performance 3. Disturbed Body Image 4. Parental Role Conflict Answer: 2 Explanation: The client has many role expectations that could be in conflict. The client is expected to maintain the home, care for the family, and earn money. The client's symptoms of fatigue and inadequacy indicate Ineffective Role Performance. Page Ref: 993 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Diagnosis Learning Outcome: 5. Identify nursing diagnoses related to altered self-concept. MNL Learning Outcome: 4. Determine appropriate nursing diagnoses, interventions, and evaluation of patients with potential or actual altered self-concept.
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26) A client recovering from a lumpectomy for breast cancer tells the nurse that she "feels ugly." For which nursing diagnosis should the nurse plan interventions? 1. Powerlessness 2. Social Isolation 3. Grieving 4. Hopelessness Answer: 3 Explanation: The diagnosis Grieving is appropriate because the client is expressing a feeling related to a change in physical appearance. Page Ref: 993 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Diagnosis Learning Outcome: 5. Identify nursing diagnoses related to altered self-concept. MNL Learning Outcome: 4. Determine appropriate nursing diagnoses, interventions, and evaluation of patients with potential or actual altered self-concept.
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27) An adult client who has been a successful writer in the past has been experiencing low selfesteem over the last year. Which behaviors indicate that the client is attempting to make positive changes? (Select all that apply.) 1. The client joined a library book club. 2. The client counted the number of rejection letters received from publishers. 3. The client states no longer reading Facebook to compare personal life with her friends' lives. 4. The client works with the local Meals on Wheels to deliver meals once a week to older community members. 5. The client shared a letter from a magazine publisher that is going to print a short story in the next edition. Answer: 1, 3, 4, 5 Explanation: Joining a book club demonstrates spending time with positive supportive people. Avoiding comparisons with other people helps develop self-esteem. Helping others will help develop the client's self-esteem. Having success will help develop the client's self-esteem. Page Ref: 994 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation Learning Outcome: 7. Describe ways to enhance client self-esteem. MNL Learning Outcome: 4. Determine appropriate nursing diagnoses, interventions, and evaluation of patients with potential or actual altered self-concept.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 40 Sexuality 1) A client is concerned that an adult son who is homosexual will be going "to hell." Which should the nurse consider when responding to this client's comment? 1. Normal sexuality is described as whatever behaviors give pleasure and satisfaction to those adults involved. 2. Because alternative lifestyles are now so well accepted in society, this parent should not feel so much concern. 3. What constitutes normal sexual expression varies among cultures and religions. 4. Sexual development is genetically determined and not affected by environment. Answer: 3 Explanation: This nurse should remember that culture and religion have a big impact on what a person believes to be normal sexual behavior. Page Ref: 999 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Relationship-centered care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Planning Learning Outcome: 4. Give examples of how family, culture, religion, and personal expectations and ethics influence one's sexuality. MNL Learning Outcome: 1. Examine the development of sexuality across the lifespan.
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2) The parent of a 20-month-old is concerned because the baby touches the genital area during diaper changes. How should the nurse respond to this concern? 1. At 20 months this touching is not a sexual experience. 2. Masturbation to orgasm is common and normal at this age. 3. Genital stimulation should not be occurring until the age of 2½ or 3. 4. Babies are sexual beings, but this activity should be discouraged. Answer: 1 Explanation: At 20 months, exploration and touching of the genital area is no different than exploration and touching of fingers and toes. This touching is not considered a sexual experience. Page Ref: 999 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Relationship-centered care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Planning Learning Outcome: 1. Describe sexual development across the lifespan. MNL Learning Outcome: 1. Examine the development of sexuality across the lifespan. 3) The nurse is asked by a preadolescent client about using tampons for sanitary protection during menstruation. What advice should the nurse include? 1. Tampons should not be used until the menstrual cycle is well established, usually 2-3 years after the first period occurs. 2. Superabsorbent tampons should be used at night to protect from overflow accidents. 3. Tampons should be alternated with sanitary pads to help decrease risk for infection. 4. Tampons should be changed at least every 8 hours. Answer: 3 Explanation: The client should be instructed to alternate tampons with sanitary pads to decrease risk for infection. Page Ref: 1001 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 9. Recognize health promotion teaching related to reproductive structures. MNL Learning Outcome: 4. Utilize the nursing process in caring for patients in relation to sexuality.
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4) The nurse is developing strategies for the relief of menstrual cramping to teach a group of young clients. What should be the focus of these strategies? 1. Increase of blood flow to the uterine muscle 2. Avoidance of uterine contraction 3. Minimization of menstrual flow 4. Decrease in estrogen production Answer: 1 Explanation: Menstrual cramping is a result of the muscle ischemia that occurs when the client experiences powerful uterine contractions. Increase of blood flow to the uterine muscle through rest, some exercises, application of heat to the abdomen, and presence of milder uterine contractions (such as those associated with orgasm) can decrease pain and cramping. Page Ref: 1001 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 9. Recognize health promotion teaching related to reproductive structures. MNL Learning Outcome: 4. Utilize the nursing process in caring for patients in relation to sexuality. 5) During a routine physical, an 11-year-old tells the nurse that many students in school are "doing it." How should the nurse respond to this statement? 1. Tell the client to talk with parents about sexual matters. 2. Ask what "doing it" means to this client. 3. State that sexual activity is not appropriate at age 11. 4. Stay silent and wait for the client to continue the discussion. Answer: 2 Explanation: The nurse should ask what "doing it" means to this 11-year-old client. It is important that the nurse and the client are talking about the same thing before additional information is shared. Page Ref: 1001 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Identify basic sexual questions the nurse should ask during client assessment. MNL Learning Outcome: 1. Examine the development of sexuality across the lifespan.
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6) Which statement made by a postmenopausal client should the nurse evaluate as indicating the need for further assessment? 1. "For some reason, I have more sexual desire than ever." 2. "I use water-soluble lubricant to treat my vaginal dryness." 3. "I am so glad that I don't need to worry about sex anymore." 4. "Sex certainly takes longer than it used to, but I'm getting used to that." Answer: 3 Explanation: The nurse would further assess the client who made the statement, "I am so glad that I don't need to worry about sex anymore." This statement is unclear. Does it mean that the client is glad not to have to engage in sex anymore, or does it mean that she will not have to worry about getting pregnant anymore? Page Ref: 1014 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Describe sexual development across the lifespan. MNL Learning Outcome: 1. Examine the development of sexuality across the lifespan. 7) A research article the nurse is reading discusses the prevalence of androgyny in persons 20-30 years old. What should the nurse keep in mind when caring for clients who are androgynous? 1. They do not limit their behaviors to one gender over the other. 2. They are attracted to people of the same gender. 3. They often repress their sexual feelings. 4. They hold rigid stereotyped gender role expectations. Answer: 1 Explanation: Androgyny means flexibility in gender roles. Androgynous individuals do not limit their behaviors to one specific gender. Page Ref: 1004 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Discuss variations in sexual expression. MNL Learning Outcome: 2. Examine sexual health, varieties, and factors influencing sexuality.
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8) A client experienced female circumcision as a puberty ritual while living in Africa as a child. For which health problem should the nurse monitor the client as an adult? 1. Early menopause 2. Increased menstrual flow 3. Chronic urinary tract infection 4. Tendency for postpartum hemorrhage Answer: 3 Explanation: Female circumcision increases the possibility that the client will suffer chronic urinary tract infection. Page Ref: 1007 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Give examples of how family, culture, religion, and personal expectations and ethics influence one's sexuality. MNL Learning Outcome: 2. Examine sexual health, varieties, and factors influencing sexuality. 9) The 45-year-old married client reports having no interest in sex and has not had intercourse in 16 years. How should the nurse interpret this assessment data? 1. This couple is experiencing sexual dysfunction. 2. The lack of sexual desire has adversely affected the spouse. 3. If both partners share the same lack of desire, there is often not a problem. 4. This situation is so unnatural that some dysfunction is present. Answer: 3 Explanation: If both members of a couple have the same lack of desire and they are comfortable, there is likely no problem with the couple's sexuality. Page Ref: 1010 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 6. Identify the forms of altered sexual function. MNL Learning Outcome: 2. Examine sexual health, varieties, and factors influencing sexuality.
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10) A client who was recently unable to recently achieve an erection is concerned that a previous sexually transmitted infection will cause impotence. Which response should the nurse make? 1. Sexually transmitted infections may result in sexual problems in adults. 2. Erectile dysfunction is the correct term for the inability to achieve or sustain an erection. 3. An occasional incident like this is normal and common and there is no reason to be concerned. 4. The medical diagnosis of erectile dysfunction is not made until the man has erection difficulties in 25% or more of his interactions. Answer: 4 Explanation: The diagnosis of male erectile disorder is usually made when the male has erection problems during 25% or more of his sexual interactions. Page Ref: 1010 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 6. Identify the forms of altered sexual function. MNL Learning Outcome: 2. Examine sexual health, varieties, and factors influencing sexuality. 11) The nurse is preparing for a pelvic physical examination of a client with vaginismus. What equipment should the nurse obtain for this examination? 1. Culture tubes to assess expected vaginal infection 2. Extra cleaning supplies to remove thick external secretions 3. Smaller-than-normal vaginal speculums 4. Equipment for preexamination douche Answer: 3 Explanation: Clients with vaginismus experience involuntary spasm of the outer one-third of the vaginal muscles. This spasm makes internal examination, tampon use, and intercourse difficult. Use of smaller-than-normal vaginal speculums may make examination easier. Page Ref: 1011 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 8. Formulate nursing diagnoses and interventions for the client experiencing sexual problems. MNL Learning Outcome: 4. Utilize the nursing process in caring for patients in relation to sexuality.
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12) There is disagreement among the nursing unit staff regarding how much sexual history should be included in adult admission assessments. What standard is generally the most applicable? 1. A complete sexual history must be included in the admission history and physicals. 2. Sexual information should be pursued only if the client's chief complaint indicates possible sexual dysfunction. 3. Sexual assessment should be done by the physician and not repeated by the nurse. 4. The amount of sexual information taken will vary on a case-by-case basis. Answer: 4 Explanation: The amount of sexual information taken will vary on a case-by-case basis. The nurse can open the conversation by asking open-ended questions. Page Ref: 1012 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 7. Identify basic sexual questions the nurse should ask during client assessment. MNL Learning Outcome: 4. Utilize the nursing process in caring for patients in relation to sexuality. 13) A client who engages in collegiate sports asks why sexual activity must be avoided for two days before a sporting event. Which response should the nurse make? 1. As long as intercourse is not involved, there is no reason to avoid sexual activity. 2. Some residual physical weakness is common for up to 18 hours after sex. 3. This is a common myth among athletes, but there is no basis in fact. 4. In fact, sexual activity before intense physical exercise increases stamina and endurance. Answer: 3 Explanation: The idea that sexual activity weakens the person physically is a common misconception among athletes, but there is no evidence to support that idea. Page Ref: 1001 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 4. Give examples of how family, culture, religion, and personal expectations and ethics influence one's sexuality. MNL Learning Outcome: 2. Examine sexual health, varieties, and factors influencing sexuality.
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14) An adolescent reports stopping intercourse before orgasm to avoid getting pregnant. What teaching is necessary for this client? 1. Even though pregnancy is avoided, a sexually transmitted infection can still occur. 2. Intercourse until orgasm may actually reduce conception because the vaginal contractions help to expel sperm. 3. Conceiving is not related to whether the female partner experiences an orgasm. 4. As long as there is no ejaculation into the vagina, conception is unlikely. Answer: 3 Explanation: Conceiving is not related to experiencing female orgasm. Page Ref: 1001 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 9. Recognize health promotion teaching related to reproductive structures. MNL Learning Outcome: 4. Utilize the nursing process in caring for patients in relation to sexuality. 15) A high school student asks, "If alcohol causes erectile dysfunction, then why does pregnancy occur in events where alcohol is consumed?" The nurse should plan a response based on which concept? 1. Alcohol is a central nervous system depressant that affects judgment. 2. Erectile dysfunction only occurs after years of alcohol abuse. 3. Alcohol is a sexual stimulant. 4. Erectile dysfunction occurs only in men older than age 50. Answer: 1 Explanation: Alcohol is implicated in behaviors leading to undesired pregnancy because it is a central nervous system depressant and affects judgment. Page Ref: 1010 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 9. Recognize health promotion teaching related to reproductive structures. MNL Learning Outcome: 4. Utilize the nursing process in caring for patients in relation to sexuality.
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16) A female client being treated for candidiasis continues to have a white, cheesy discharge. What recommendation is necessary? 1. Referral to a surgeon for excision of infected tissue 2. Examination and treatment of sexual partner 3. Treatment with a stronger oral antibiotic 4. Routine douches with a topical antibiotic solution Answer: 2 Explanation: Candidiasis is a sexually transmitted infection. It may be that this client's sexual partner is also infected with candidiasis and that the couple is transmitting the infection between them. Page Ref: 1015 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 8. Formulate nursing diagnoses and interventions for the client experiencing sexual problems. MNL Learning Outcome: 4. Utilize the nursing process in caring for patients in relation to sexuality. 17) The nurse enters the room and finds the adult client masturbating. What action should the nurse take? 1. Tell the client that masturbation is harmful to sexual well-being. 2. Say "excuse me" and leave the room. 3. Request that the client stop so that care can be provided. 4. Ask the client if there are any sexual concerns that should be discussed. Answer: 2 Explanation: In this situation, the nurse should quickly and politely leave the room. Page Ref: 1007-1008 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 5. Deliver compassionate, patientcentered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 2. Define sexual health. MNL Learning Outcome: 2. Examine sexual health, varieties, and factors influencing sexuality.
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18) A nurse colleague learns that a grandchild's day-care center is planning a class on sexuality for 3- and 4-year-olds. Discussion of this plan should include what concept? 1. At this age, education regarding sexuality should come from parents. 2. Children are sexual beings from before birth. 3. Understanding the body and sexuality are a part of growth and development. 4. Sexual activity is beginning at earlier and earlier ages. Answer: 1 Explanation: Although all of these statements are true, the primary consideration is that early childhood education on sex should come primarily from parents. Page Ref: 1014 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 5. Deliver compassionate, patientcentered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning/Teaching and Learning Learning Outcome: 4. Give examples of how family, culture, religion, and personal expectations and ethics influence one's sexuality. MNL Learning Outcome: 2. Examine sexual health, varieties, and factors influencing sexuality. 19) In discussion with adolescents, the nurse chooses to use the term sexually transmitted infection rather than sexually transmitted disease. What is the rationale for this choice? 1. Infection is a much more precise term for the transmission that occurs. 2. The word disease may elicit guilt, shame, and fear in the client. 3. Sexually transmitted disease does not receive as much third-party reimbursement as does sexually transmitted infection. 4. These terms can be used interchangeably and there is no good rationale for using one over the other. Answer: 2 Explanation: The term sexually transmitted disease can elicit guilt, shame, and fear in the client. Page Ref: 1014-1015 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 5. Deliver compassionate, patientcentered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 9. Recognize health promotion teaching related to reproductive structures. MNL Learning Outcome: 4. Utilize the nursing process in caring for patients in relation to sexuality.
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20) The nurse uses the PLISSIT format in helping clients who have sexual dysfunction. Which action by the nurse best reflects the P section of this format? 1. Ask the physician for permission to discuss sexual topics with the client. 2. Obtain signed informed consent from both the client and the spouse or partner prior to providing them with sexual information. 3. Acknowledge the client's spoken and unspoken sexual concerns when providing care. 4. Document precertification for benefits from the client's insurance company regarding sexual teaching. Answer: 3 Explanation: The P section of this format reflects permission giving. This giving of permission refers to acknowledging the client's spoken and unspoken sexual concerns and giving the client permission to be a sexual being. Page Ref: 1016 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Identify basic sexual questions the nurse should ask during client assessment. MNL Learning Outcome: 4. Utilize the nursing process in caring for patients in relation to sexuality.
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21) The nurse uses the PLISSIT format in helping clients who have sexual dysfunction. Which action by the nurse best reflects the LI section of this format? 1. In order to avoid causing anxiety, limit the amount of information given to clients regarding adverse sexual side effects of treatments or medications. 2. Give the client accurate but concise information in regard to any sexual questions that might be asked. 3. State information using slang terms to refer to sexual body parts because the client is not likely to know the proper terms. 4. Review current research literature associated with the sexual concerns of the client and partner. Answer: 2 Explanation: LI represents limited information. The nurse should give accurate but concise information regarding sexual matters. Page Ref: 1016 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Identify basic sexual questions the nurse should ask during client assessment. MNL Learning Outcome: 4. Utilize the nursing process in caring for patients in relation to sexuality.
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22) The nurse uses the PLISSIT format in helping clients who have sexual dysfunction. Which action by the nurse best reflects the SS section of this format? 1. Use the nurse's knowledge about how disease affects sexuality to offer specific suggestions for the client. 2. Focus interventions on explaining the somatic sexual difficulties and their treatment. 3. Offer the client a list of expected sexual side effects of drugs or treatments. 4. Identify any concerns the client has regarding attraction to the same sex. Answer: 1 Explanation: SS represents specific suggestions. The nurse should use specialized knowledge and skill about how sexuality and functioning are affected by the disease process or therapy to offer specific suggestions for intervention. Page Ref: 1016-1017 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Identify basic sexual questions the nurse should ask during client assessment. MNL Learning Outcome: 4. Utilize the nursing process in caring for patients in relation to sexuality.
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23) The nurse uses the PLISSIT format in helping clients who have sexual dysfunction. Which action by the nurse best reflects the IT section of this format? 1. Use information technology such as the Internet to obtain guidance suggestions for the client. 2. Use the technique of informal therapeutic groups to assist the client and partner. 3. Evaluate previous interventions and treatment for success. 4. Recommend intensive therapy with a qualified sex therapist. Answer: 4 Explanation: IT represents intensive therapy. At this point in intervention, the nurse recognizes that the client requires therapy with a nurse who has specialized preparation and knowledge of sexual and gender identity disorders. Referral or recommendation for intensive therapy is required. Page Ref: 1016-1017 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Identify basic sexual questions the nurse should ask during client assessment. MNL Learning Outcome: 4. Utilize the nursing process in caring for patients in relation to sexuality.
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24) An older male client with an indwelling urinary catheter exposes the genitalia and fondles the penis. Which action should the nurse take? 1. Tell the client to stop touching the penis. 2. Assess the client's penis for irritation from the catheter. 3. Ask the client to keep the linens at waist level. 4. Collaborate with the physician regarding medications to control this behavior. Answer: 2 Explanation: The nurse should assess whether this client has irritation of the penis that is causing this action. The nurse needs to determine if there is a physical reason such as irritation that the client is trying to communicate. Page Ref: 1018 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 8. Formulate nursing diagnoses and interventions for the client experiencing sexual problems. MNL Learning Outcome: 4. Utilize the nursing process in caring for patients in relation to sexuality. 25) After an assessment, the nurse determines that a client has strong sexual health. What did the nurse assess in the client? (Select all that apply.) 1. Knowledge about sexual behavior 2. Reluctance to discuss sexual history 3. Utilization of birth control method that fits lifestyle 4. Statement that there are no issues with sexuality 5. Discussing sexual problems with healthcare provider Answer: 1, 3, 5 Explanation: Characteristics of sexual health include knowledge about sexuality and sexual behavior, the right to make free and responsible reproductive choices, and the ability to access sexual healthcare for sexual concerns, problems, and disorders. Page Ref: 1004 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Define sexual health. MNL Learning Outcome: 2. Examine sexual health, varieties, and factors influencing sexuality. 15
26) The nurse is preparing to assess a client's sexual health. What will the nurse include in this assessment? Select all that apply. 1. Sexual self-concept 2. Body image 3. Gender identity 4. Contraceptive choices 5. Employment Answer: 1, 2, 3 Explanation: Sexual self-concept, body image, and gender identity are components of sexual health. Page Ref: 1004 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 7. Identify basic sexual questions the nurse should ask during client assessment. MNL Learning Outcome: 4. Utilize the nursing process in caring for patients in relation to sexuality. 27) During an assessment, a client tells the nurse of a desire to wear clothing that is typically associated with the opposite sex. The nurse realizes this client is describing which gender identity? 1. Intersex 2. Transgenderism 3. Homosexuality 4. Cross-dressing Answer: 4 Explanation: Cross-dressing makes one's outward appearance consistent with the inner identity and gender role and increases comfort with themselves. Page Ref: 1006 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Discuss variations in sexual expression. MNL Learning Outcome: 3. Examine the sexual response cycle and altered sexual function.
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28) During a sexual assessment, a client tells the nurse about a preference for oral—genital sex. How should the nurse instruct this client? 1. Explain the need to follow safe sex practice. 2. Explain the need to use contraception. 3. Explain the importance of having an annual HIV test. 4. Explain that routine gynecologic examinations are not necessary. Answer: 1 Explanation: Oral—genital sex is not completely free of the potential for sexually transmitted illness transmission, and safe sex practices must be used. Page Ref: 1006 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 3. Discuss variations in sexual expression. MNL Learning Outcome: 3. Examine the sexual response cycle and altered sexual function. 29) The nurse is preparing an educational session on the sexual response cycle. What should be included when discussing the physiological changes in females during the excitement phase? (Select all that apply.) 1. The vagina dries. 2. The length of the vagina narrows and swells. 3. Erection of the clitoris occurs. 4. The breasts enlarge. 5. The uterus elevates. Answer: 3, 4, 5 Page Ref: 1008 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 5. Describe physiological changes during the sexual response cycle. MNL Learning Outcome: 3. Examine the sexual response cycle and altered sexual function.
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30) When discussing the orgasmic phase of the sexual response cycle, what should the nurse include as physiological changes that affect both sexes? (Select all that apply.) 1. The respiratory rate can increase up to 40 breaths per minute. 2. Involuntary muscle spasms occur throughout the body. 3. The heart rate decreases to 20 beats below normal. 4. Systolic blood pressure can increase 20-30 mm Hg above normal. 5. Diastolic blood pressure can decrease 20-50 mm Hg below normal. Answer: 1, 2, 4 Explanation: Physiological changes that affect both sexes during the orgasmic phase of the sexual response cycle include an increase in respiratory rate of up to 40 breaths per minute. Involuntary muscle spasms throughout the body, and an increase of systolic blood pressure of 20-30 mm Hg above normal. Page Ref: 1008 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 5. Describe physiological changes during the sexual response cycle. MNL Learning Outcome: 3. Examine the sexual response cycle and altered sexual function. 31) The nurse is discussing the resolution phase of the sexual response cycle with a group of students in a health education class. What should be included as a physiological change that affects males only? 1. Genitalia and breasts return to pre-excitement states. 2. There is a refractory period during which the body will not respond to sexual stimulation. 3. The heart rate returns to normal. 4. Possible sleepiness or intense relaxation may occur. Answer: 2 Explanation: During the resolution phase of the sexual response cycle, the physiological change that affects males only is a refractory period during which the body will not respond to sexual stimulation. Page Ref: 1008 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 5. Describe physiological changes during the sexual response cycle. MNL Learning Outcome: 3. Examine the sexual response cycle and altered sexual function. 18
32) The nurse is conducting a sexual health history with a client. What questions should the nurse ask during this history? (Select all that apply.) 1. "What are your erotic fantasies?" 2. "Are you currently sexually active?" 3. "Do you experience any pain with sexual interaction?" 4. "Do you have difficulty with sexual desire?" 5. "What do you like the best about having sex?" Answer: 2, 3, 4 Page Ref: 1012 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 7. Identify basic sexual questions the nurse should ask during client assessment. MNL Learning Outcome: 4. Utilize the nursing process in caring for patients in relation to sexuality. 33) The nurse is conducting a health history with an older client with arthritis and heart disease. When gathering the sexual history for this client, what question should the nurse ask? 1. "Do you have any difficulty with sexual desire and orgasm?" 2. "How often do you have sexual relations?" 3. "What type of contraception do you use?" 4. "Have there been any changes in your sexual functioning that might be related to your illness or the medications you take?" Answer: 4 Explanation: All nursing histories should at least include a question such as "Have there been any changes in your sexual functioning that might be related to your illness or the medications you take?" Page Ref: 1013 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 7. Identify basic sexual questions the nurse should ask during client assessment. MNL Learning Outcome: 4. Utilize the nursing process in caring for patients in relation to sexuality. 19
34) The nurse who is teaching a client breast self-examination describes inspection of the breasts before a mirror. Which findings should the nurse tell the client should be evaluated by a healthcare provider? (Select all that apply.) 1. Puckering of the skin 2. Flattening of the breast from the side view 3. Free movement of the breast over the chest wall 4. Symmetry of the nipples 5. Change in shape Answer: 1 Explanation: The client should be instructed to observe for puckering of the skin, flattening of the breast from the side view. Page Ref: 1015 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 9. Recognize health promotion teaching related to reproductive structures. MNL Learning Outcome: 4. Utilize the nursing process in caring for patients in relation to sexuality.
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35) While the nurse is measuring blood pressure, a male client lifts his hand and fondles the nurse's breast. What should the nurse do about this behavior? (Select all that apply.) 1. Ignore the fondling. 2. Move the client's hand away. 3. Refocus the client on appropriate behavior. 4. Tell the client to stop performing the behavior. 5. Communicate that the behavior is not acceptable. Answer: 2, 3, 4, 5 Explanation: The nurse needs to set firm limits and take the client's hand and move it away. The nurse needs to try to refocus the client from the inappropriate behavior to appropriate behavior. The nurse needs to set firm limits and tell the client to stop the behavior. The nurse needs to communicate that the behavior is not acceptable. This will set limits as to what is appropriate and not appropriate behavior with the client. Page Ref: 1017 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 8. Formulate nursing diagnoses and interventions for the client experiencing sexual problems. MNL Learning Outcome: 4. Utilize the nursing process in caring for patients in relation to sexuality.
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36) After reviewing a list of prescribed medications, the nurse plans to complete a sexual history with the client. Which medications in the client's list caused the nurse to make this clinical decision? (Select all that apply.) 1. Antibiotics 2. Antipyretics 3. Cardiotonics 4. Beta-blockers 5. Anticoagulants Answer: 3, 4 Page Ref: 1010 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 8. Formulate nursing diagnoses and interventions for the client experiencing sexual problems. MNL Learning Outcome: 4. Utilize the nursing process in caring for patients in relation to sexuality.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 41 Spirituality 1) As a part of care planning, the nurse considers the client's spiritual needs. What is the rationale for this concern? 1. Nurses are the only health professionals who provide this type of holistic care. 2. Meeting the client's spiritual needs can decrease suffering. 3. Until spiritual needs are met, physical needs cannot be healed. 4. It is important that the nurse's idea of spirituality matches the client's ideas. Answer: 2 Explanation: The nurse is concerned about the client's spiritual health because meeting spiritual needs can decrease suffering. Page Ref: 1021 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 18. Develop an awareness of patients as well as healthcare professionals' spiritual beliefs and values and how those beliefs and values impact healthcare | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 1. Describe the interconnection of spirituality and religion concepts as they relate to health and spiritually sensitive nursing care. MNL Learning Outcome: 1. Consider the components and development of spirituality across the lifespan. 2) The nurse assesses that a client is experiencing spiritual distress. What should be the nurse's primary intervention? 1. Establish a trusting nurse-client relationship. 2. Have the client describe the basic problem. 3. Ask the client what religion is practiced in the home. 4. Identify the client's belief in a Supreme Being. Answer: 1 Explanation: The first step in successfully working with a client with spiritual distress is establishing a trusting nurse-client relationship. Page Ref: 1028 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 18. Develop an awareness of patients as well as healthcare professionals' spiritual beliefs and values and how those beliefs and values impact healthcare | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 4. Describe methods to assess the spiritual and religious preferences, strengths, concerns, or distress of clients and plan appropriate nursing care. MNL Learning Outcome: 4. Implement interventions to support the spirituality of patients. 1
3) The nurse has identified that many of the clients in the long-term care facility have spiritual concerns and distress. What is the nurse's first step in becoming a competent provider for these clients? 1. The nurse must possess a healthy spiritual self-awareness. 2. The nurse must learn about diverse spiritual beliefs and practices. 3. The nurse should start going to church more often. 4. The nurse should establish regular religious services in the facility. Answer: 1 Explanation: The first step of becoming a competent provider for clients who have spiritual distress is for the nurse to possess a healthy spiritual self-awareness. Page Ref: 1035 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 18. Develop an awareness of patients as well as healthcare professionals' spiritual beliefs and values and how those beliefs and values impact healthcare | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 8. Describe strategies that can increase a nurse's own spiritual awareness. MNL Learning Outcome: 4. Implement interventions to support the spirituality of patients. 4) A client who is facing a final life-saving surgery asks the nurse to stay and pray until the surgery begins. In which ways should the nurse demonstrate presencing with this client? (Select all that apply.) 1. Adjusting the intravenous infusion 2. Talking with the client about the surgery 3. Sitting next to the client in the holding area 4. Praying with the client for divine intervention 5. Focusing on the client and fulfilling his needs Answer: 4, 5 Explanation: Praying with the client for divine intervention demonstrates transcendent presence because the nurse is spiritually present for the client. Focusing on the client and fulfilling his needs demonstrates full presence. Page Ref: 1027 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 18. Develop an awareness of patients as well as healthcare professionals' spiritual beliefs and values and how those beliefs and values impact healthcare | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 4. Describe methods to assess the spiritual and religious preferences, strengths, concerns, or distress of clients and plan appropriate nursing care. MNL Learning Outcome: 4. Implement interventions to support the spirituality of patients. 2
5) During assessment, the client tells the nurse, "I don't believe that the existence of God has been proven. I don't see the scientific evidence I need to be certain." How should the nurse document this finding? 1. The client demonstrates polytheism. 2. The client is an atheist. 3. The client has beliefs that support monotheism. 4. The client is agnostic. Answer: 4 Explanation: Agnostics are persons who doubt the existence of God or a Supreme Being or believe the existence of God has not been proven. Page Ref: 1022 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 18. Develop an awareness of patients as well as healthcare professionals' spiritual beliefs and values and how those beliefs and values impact healthcare | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 7. Describe the influence of spiritual and religious beliefs and practices that can have an impact on a client's healthcare: holy days, sacred texts, prayer and meditation, diet, healing, dress, birth, and death. MNL Learning Outcome: 3. Assess patient spiritual beliefs and practices.
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6) The 70-year-old client with terminal lung cancer tells the nurse, "I am dying because I sinned by smoking cigarettes." What is the nurse's best response to this dying client? 1. "You are correct, but it is too late to do anything about it now." 2. "When you started smoking cigarettes we didn't know about the problems they cause. It is not your fault." 3. "Why don't we call the hospital chaplain and you can pray about your sins." 4. "Smoking cigarettes isn't a sin. There are many worse habits you could have." Answer: 2 Explanation: This client is in distress and is seeking forgiveness. The nurse should offer this forgiveness and a reason the forgiveness is valid. Page Ref: 1021, 1023 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 18. Develop an awareness of patients as well as healthcare professionals' spiritual beliefs and values and how those beliefs and values impact healthcare | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 2. Compare and contrast spiritual needs, spiritual disruption, and spiritual health. MNL Learning Outcome: 2. Incorporate religious practices into the care of patients as appropriate. 7) During assessment, the client says that it has been "a long time" since she has thought very much about religion. The nurse caring for this client has a strong belief in God and the healing power of prayer. What action should be taken by the nurse? 1. Mention the nurse's belief and offer to pray with the client for forgiveness. 2. Tell the client that the nurse will pray for her often. 3. Ask the client if there are any spiritual needs with which the staff can assist. 4. Refer the client for spiritual counseling. Answer: 3 Explanation: The client can be asked general questions to elicit information about what beliefs and practices are important to the present healthcare situation, and what, if anything, the client would like from the healthcare team to support spiritual health. Page Ref: 1025 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 18. Develop an awareness of patients as well as healthcare professionals' spiritual beliefs and values and how those beliefs and values impact healthcare | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Describe nursing care/therapeutics to support religiosity and promote clients' spiritual health. MNL Learning Outcome: 3. Assess patient spiritual beliefs and practices. 4
8) The client being prepared for a procedure asks to be allowed to wear a religious medal. The client states, "I have worn this medal and have not removed it since I was a teenager." What action should the nurse take? 1. Tell the client that the medal must be removed, as it is policy to remove all jewelry for these procedures. 2. Tell the client that the medal can be worn. 3. Tell the client that the nurse will explain to the procedure staff about the medal and will request that they allow the client to wear it. 4. Remove the medal and place it on the head of the bed where the client will be able to see it during the procedure. Answer: 3 Explanation: The nurse should explain the significance of the medal to the procedure staff and request that the client be allowed to wear it during the procedure. Page Ref: 1032 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 18. Develop an awareness of patients as well as healthcare professionals' spiritual beliefs and values and how those beliefs and values impact healthcare | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Describe nursing care and therapeutics to support religiosity and promote clients' spiritual health. MNL Learning Outcome: 4. Implement interventions to support the spirituality of patients.
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9) The emergency department nurse contacts the admissions office to request a bed for a bedbound client who is a practicing Muslim. In acting as an advocate for the client, what request should the nurse make of the admission clerk? 1. Please try to find a private room. 2. A bed that faces east will be best. 3. Have the bed stripped, as the client will provide special sheets. 4. If the only available room is semi-private, the other client should be Muslim. Answer: 2 Explanation: Because this bed-bound client is a practicing Muslim and this religion has a sacred practice of five daily prayers performed while facing east, the logical bed assignment for this client is one that faces east. Page Ref: 1031 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 18. Develop an awareness of patients as well as healthcare professionals' spiritual beliefs and values and how those beliefs and values impact healthcare | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Describe nursing care and therapeutics to support religiosity and promote clients' spiritual health. MNL Learning Outcome: 2. Incorporate religious practices into the care of patients as appropriate. 10) A client who is devoutly Jewish is hospitalized during Yom Kippur and wants to fast. How should the nurse respond to this wish? 1. Support the client's desires to the extent possible. 2. Remind the client that most religions excuse persons who are ill from fasting. 3. Attempt to convince the client to ignore the tradition due to illness. 4. Tell the client that the physician must make this decision. Answer: 1 Explanation: The nurse should support the client's desires to the extent possible. Page Ref: 1033 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 18. Develop an awareness of patients as well as healthcare professionals' spiritual beliefs and values and how those beliefs and values impact healthcare | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Describe nursing care and therapeutics to support religiosity and promote clients' spiritual health. MNL Learning Outcome: 2. Incorporate religious practices into the care of patients as appropriate. 6
11) A female client who follows a religious order where clothing is worn that covers the arms and the knees is concerned that the body will be exposed during a scheduled cardiac catheterization. How should the nurse respond to this concern? 1. Tell the client that medical personnel have seen so many people's bodies that they don't even notice any longer. 2. Make a note in the client's chart that she is particularly modest. 3. Explain to the client that in order to perform the study, the body must be exposed. 4. Ask the cath lab charge nurse to come to the client's room to talk about the concerns. Answer: 4 Explanation: The best plan is to have the cath lab charge nurse talk to the client about concerns. The charge nurse can then assure the client that even though a small part of her body must be exposed, modesty will be protected. Page Ref: 1033-1034 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 18. Develop an awareness of patients as well as healthcare professionals' spiritual beliefs and values and how those beliefs and values impact healthcare | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Describe nursing care and therapeutics to support religiosity and promote clients' spiritual health. MNL Learning Outcome: 2. Incorporate religious practices into the care of patients as appropriate.
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12) During labor, it becomes apparent that the male infant will survive only a short time after birth. Because this baby's parents are Catholic, what planning should the nurse consider? 1. Arrange to have the baby circumcised immediately after birth. 2. Ask the hospital chaplain to be present in the delivery room. 3. Ask the nursing supervisor to find a Catholic nurse to attend the birth. 4. Consider emergency transport of the mother to a Catholic hospital. Answer: 2 Explanation: In this situation, the best choice is to have the hospital chaplain or a Catholic priest be present in the delivery room if the parents want the baby baptized immediately after birth. Page Ref: 1034 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 18. Develop an awareness of patients as well as healthcare professionals' spiritual beliefs and values and how those beliefs and values impact healthcare | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 7. Describe the influence of spiritual and religious beliefs and practices that can have an impact on a client's healthcare: holy days, sacred texts, prayer and meditation, diet, healing, dress, birth, and death. MNL Learning Outcome: 4. Implement interventions to support the spirituality of patients.
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13) The family of a dying client has informed the nurse that their religion requires that a ritual bath be given after death by members of the faith. In which way should the nurse respond to this request? 1. Notify the mortuary of the family's request. 2. Arrange for supplies and privacy for the family. 3. Tell the family that the bath will have to take place after the body is removed from the hospital. 4. Allow the family to give the bath but give a 1-hour deadline for completion. Answer: 2 Explanation: When a client is dying, much of the nursing care shifts from the client to support of the family. The nurse should allow this bath and should provide supplies and privacy for the family to complete the ritual. Page Ref: 1034 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 18. Develop an awareness of patients as well as healthcare professionals' spiritual beliefs and values and how those beliefs and values impact healthcare | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Describe the influence of spiritual and religious beliefs and practices that can have an impact on a client's healthcare: holy days, sacred texts, prayer and meditation, diet, healing, dress, birth, and death. MNL Learning Outcome: 4. Implement interventions to support the spirituality of patients. 14) After asking general assessment questions regarding spirituality, the nurse finds the client content and satisfied. How should the nurse conduct the rest of the assessment? 1. Specific questions regarding beliefs should be included. 2. The nurse should validate spiritual information with the client's family. 3. The assessment can now move on to physical assessment. 4. No further specific spiritual assessment is currently necessary. Answer: 4 Explanation: If the client is satisfied and content with current levels of spirituality, there is no further specific spiritual assessment necessary. Page Ref: 1025 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 18. Develop an awareness of patients as well as healthcare professionals' spiritual beliefs and values and how those beliefs and values impact healthcare | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Describe methods to assess the spiritual and religious preferences, strengths, concerns, or distress of clients and plan appropriate nursing care. MNL Learning Outcome: 3. Assess patient spiritual beliefs and practices. 9
15) A client says that a treatment plan is against religious beliefs. Which nursing diagnosis problem statement should the nurse identify as appropriate for this client? 1. Ineffective Coping 2. Decisional Conflict 3. Impaired Religiosity 4. Anxiety Answer: 2 Explanation: For this situation, the best nursing diagnosis problem statement is Decisional Conflict. This client will be called upon to make a decision between two highly regarded but conflicting plans. Page Ref: 1026 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 18. Develop an awareness of patients as well as healthcare professionals' spiritual beliefs and values and how those beliefs and values impact healthcare | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Diagnosis Learning Outcome: 5. Describe nursing care and therapeutics to support religiosity and promote clients' spiritual health. MNL Learning Outcome: 3. Assess patient spiritual beliefs and practices. 16) The nurse caring for wheelchair-dependent residents of a long-term care environment has developed a care plan that includes taking the clients outside and assisting them in planting and maintaining a garden. What is the best rationale for this plan? 1. Accreditation agencies require that the residents have regular outings. 2. Keeping in touch with nature is a form of spiritual care. 3. Fresh vegetables from the garden are good sources of nutritional fiber. 4. Sunshine helps activate vitamin D. Answer: 2 Explanation: Keeping in touch with nature is a form of spiritual care for these residents. Page Ref: 1027 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 18. Develop an awareness of patients as well as healthcare professionals' spiritual beliefs and values and how those beliefs and values impact healthcare | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 5. Describe nursing care and therapeutics to support religiosity and promote clients' spiritual health. MNL Learning Outcome: 4. Implement interventions to support the spirituality of patients.
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17) When arriving to a client's room to provide care, the client is praying with family. What action should the nurse take? 1. Stand quietly just inside the room door until the prayer is completed. 2. Come to the bedside and join in with the prayer. 3. Politely ask the client to allow care to proceed. 4. Quietly shut the door and wait in the hall until asked to enter. Answer: 4 Explanation: The nurse should wait in the hall until the prayer is over and the client or family give permission to enter the room. Page Ref: 1028 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 18. Develop an awareness of patients as well as healthcare professionals' spiritual beliefs and values and how those beliefs and values impact healthcare | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Describe the influence of spiritual and religious beliefs and practices that can have an impact on a client's healthcare: holy days, sacred texts, prayer and meditation, diet, healing, dress, birth, and death. MNL Learning Outcome: 4. Implement interventions to support the spirituality of patients. 18) The nurse has never been particularly religious or spiritual and is unaccustomed to praying but holds no strong feeling against prayer. Which action should the nurse take when asked to pray with a client and family? 1. Try to ensure assignment to clients who are unlikely to request prayer. 2. Arrange to have a coworker substitute for the nurse in these prayer situations. 3. Memorize two or three short, formal prayers to use when prayer is requested. 4. Just stand silently at the bedside and let others in the room do the praying. Answer: 3 Explanation: Because this nurse has no objection to praying with clients and families, the best plan is to have two or three short, formal prayers or verses memorized to use when prayer is suggested. Page Ref: 1028-1029 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 18. Develop an awareness of patients as well as healthcare professionals' spiritual beliefs and values and how those beliefs and values impact healthcare | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 5. Describe nursing care and therapeutics to support religiosity and promote clients' spiritual health. MNL Learning Outcome: 2. Incorporate religious practices into the care of patients as appropriate. 11
19) A client who needs multiple units of blood belongs to a religion where blood transfusions are prohibited. What action should the nurse take? 1. Use rapport to influence the client to accept the blood transfusions. 2. Explain the scientific reasons that blood transfusions are necessary and why refusal is dangerous. 3. Encourage the client, the physician, and the client's spiritual adviser to discuss this conflict and any possible alternative therapies. 4. Suggest to the client that as the illness progresses, the blood will probably be transfused despite religious objections. Answer: 3 Explanation: The best response is to support the discussion between client, physician, and spiritual adviser. At that point, the nurse must be prepared to support whatever decision the client makes, even if it is to not permit the transfusions. Page Ref: 1029 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 18. Develop an awareness of patients as well as healthcare professionals' spiritual beliefs and values and how those beliefs and values impact healthcare | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 6. Recognize the importance of providing ethical spiritual care. MNL Learning Outcome: 2. Incorporate religious practices into the care of patients as appropriate.
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20) The nurse is caring for a 5-year-old child. How can the nurse best support the spiritual development of this client? 1. Ask the child who God is. 2. Listen to the child's routine bedtime prayer. 3. Encourage the child to pray before each meal. 4. Bring a Bible storybook in to read to the child at bedtime. Answer: 2 Explanation: The nurse should support the routine spiritual practices encouraged by the family. If the client says routine bedtime prayers, the nurse can support this practice by listening to the prayer. Page Ref: 1024 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 18. Develop an awareness of patients as well as healthcare professionals' spiritual beliefs and values and how those beliefs and values impact healthcare | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 3. Appreciate spiritual development by describing spiritual developmental issues of childhood and aging in particular. MNL Learning Outcome: 3. Assess patient spiritual beliefs and practices. 21) During the morning bath, the client asks if the nurse is religious and believes in God. What would be most helpful for the nurse to consider in formulating a response to this question? 1. The nurse's personal life is none of the client's business. 2. Religion and politics are two subjects not discussed in polite interactions. 3. Will sharing this information positively contribute to the relationship? 4. What is the culture of the facility regarding self-disclosure? Answer: 3 Explanation: Practice guidelines regarding support of religious practices indicate that the nurse should first consider whether such self-disclosure will contribute to a therapeutic nurse-client relationship. Page Ref: 1029 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 18. Develop an awareness of patients as well as healthcare professionals' spiritual beliefs and values and how those beliefs and values impact healthcare | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 6. Recognize the importance of providing ethical spiritual care. MNL Learning Outcome: 4. Implement interventions to support the spirituality of patients.
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22) The nurse and client have spent several minutes praying together that the client's upcoming surgery will be successful. What action should the nurse take at this point? 1. Gently tell the client that the nurse must take care of other duties. 2. Smile and pat the client and silently leave the room. 3. Stay with the client until the emotion evoked by the prayer dissipates. 4. Ask the client if there is anything else the nurse can do. Answer: 3 Explanation: The nurse should stay with the client for a few minutes after the prayer has ended until the strong emotions that can be evoked by joint prayer dissipate. Page Ref: 1029 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 18. Develop an awareness of patients as well as healthcare professionals' spiritual beliefs and values and how those beliefs and values impact healthcare | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Describe the influence of spiritual and religious beliefs and practices that can have an impact on a client's healthcare: holy days, sacred texts, prayer and meditation, diet, healing, dress, birth, and death. MNL Learning Outcome: 4. Implement interventions to support the spirituality of patients. 23) A client with diabetes mellitus who develops diabetic ketoacidosis after a religious fast reports fasting every season and has no plans to stop now. Which action should the nurse take? 1. Tell the client that it is different now because of the diabetes. 2. Do some research into the meaning of fasting in this religion. 3. Ask family members of the same religion to discuss fasting with the client. 4. Request a consult from a diabetes educator. Answer: 4 Explanation: The diabetes educator should be contacted to work with the client on strategies that might allow the fasting to occur in a safe manner. Page Ref: 1033 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 18. Develop an awareness of patients as well as healthcare professionals' spiritual beliefs and values and how those beliefs and values impact healthcare | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Describe the influence of spiritual and religious beliefs and practices that can have an impact on a client's healthcare: holy days, sacred texts, prayer and meditation, diet, healing, dress, birth, and death. MNL Learning Outcome: 2. Incorporate religious practices into the care of patients as appropriate. 14
24) The nurse, who believes in God, is caring for a client that does not follow any particular religion. Which question should the nurse consider when responding to the client? 1. "Will I get into trouble if I say anything?" 2. "How much longer will I be caring for this client?" 3. "Am I meeting my needs or the client's?" 4. "How can I best make this client understand?" Answer: 3 Explanation: The nurse should first determine if it is the nurse's needs or the client's needs that would be met by a response. Only after that determination is made would the nurse move on to the other questions in formulating the response. Page Ref: 1031-1032 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 18. Develop an awareness of patients as well as healthcare professionals' spiritual beliefs and values and how those beliefs and values impact healthcare | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Describe nursing care and therapeutics to support religiosity and promote clients' spiritual health. MNL Learning Outcome: 4. Implement interventions to support the spirituality of patients. 25) The nurse is caring for an older client with end-stage renal disease. What actions should the nurse take to support this client's spiritual development? (Select all that apply.) 1. Support the client to have hope for a cure. 2. Suggest the client view losses as liberations. 3. Encourage the client to reminisce about life events. 4. Ask open-ended questions about the client's life purpose. 5. Remind the client that time is running out to make any life changes. Answer: 2, 3, 4 Page Ref: 1024 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 18. Develop an awareness of patients as well as healthcare professionals' spiritual beliefs and values and how those beliefs and values impact healthcare | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 3. Appreciate spiritual development by describing spiritual developmental issues of childhood and aging in particular. MNL Learning Outcome: 1. Consider the components and development of spirituality across the lifespan.
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26) The nurse is concerned that the spouse of a recently deceased client is experiencing spiritual distress. What did the nurse observe to come to this clinical decision? (Select all that apply.) 1. Expressing anger toward God 2. Crying softly in the client's room 3. Hugging family members 4. Talking with caregivers about the client's personal items 5. Refusing comfort from family Answer: 1, 5 Explanation: Defining characteristics of spiritual distress include expressing anger toward God and refusing comfort from family. Page Ref: 1022 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 18. Develop an awareness of patients as well as healthcare professionals' spiritual beliefs and values and how those beliefs and values impact healthcare | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Compare and contrast spiritual needs, spiritual disruption, and spiritual health. MNL Learning Outcome: 2. Incorporate religious practices into the care of patients as appropriate. 27) The nurse determines that a middle-aged client has developed spiritually. What client statement caused the nurse to come to this conclusion? 1. "I listen to and learn from others who talk about beliefs in God or a Supreme Being." 2. "The tales in the Bible are real to me." 3. "I attend service with my friends on most Sundays." 4. "I attend the same church as my parents and follow the customs of my culture." Answer: 1 Explanation: The client who listens and learns from others about God or a Supreme Being is demonstrating openness to others' truths, which is a characteristic of spiritual development in middle adulthood. Page Ref: 1024 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 18. Develop an awareness of patients as well as healthcare professionals' spiritual beliefs and values and how those beliefs and values impact healthcare | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation Learning Outcome: 3. Appreciate spiritual development by describing spiritual developmental issues of childhood and aging in particular. MNL Learning Outcome: 1. Consider the components and development of spirituality across the lifespan. 16
28) The nurse is determining whether interventions to address the diagnosis of Spiritual Distress for a client newly diagnosed with a chronic illness have been effective. What outcome would indicate that interventions have been effective for this client? 1. The client has talked with the church priest twice during the hospitalization. 2. The client states that there is nothing that can be done spiritually to improve her current outlook on life. 3. The client plans to make an appointment with a psychologist after discharge. 4. The client thanks the nurse for trying to help improve her feelings. Answer: 1 Explanation: Evidence that interventions to address the diagnosis of Spiritual Distress have been effective would be the client's talking with the church priest, as evidence of spiritual health is connecting with a spiritual leader. Page Ref: 1035 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 18. Develop an awareness of patients as well as healthcare professionals' spiritual beliefs and values and how those beliefs and values impact healthcare | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation Learning Outcome: 4. Describe methods to assess the spiritual and religious preferences, strengths, concerns, or distress of clients and plan appropriate nursing care. MNL Learning Outcome: 4. Implement interventions to support the spirituality of patients. 29) A client newly diagnosed with a terminal illness asks to talk with the hospital chaplain and requests a Bible to read. What do these client behaviors indicate to the nurse? 1. The client does not have any family members to discuss spiritual issues. 2. The client is searching for answers. 3. The client wants to talk with someone other than the nurse about spiritual concerns. 4. Interventions for Spiritual Distress have been effective. Answer: 4 Explanation: Requesting to talk with a spiritual counselor and desiring spiritual reading material indicate that interventions for the diagnosis of Spiritual Distress have been effective. Page Ref: 1035 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 18. Develop an awareness of patients as well as healthcare professionals' spiritual beliefs and values and how those beliefs and values impact healthcare | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation Learning Outcome: 2. Compare and contrast spiritual needs, spiritual disruption, and spiritual health. MNL Learning Outcome: 4. Implement interventions to support the spirituality of patients. 17
30) The nurse is planning to conduct a spiritual self-assessment. What questions would the nurse include in this assessment? (Select all that apply.) 1. "What makes me joyful?" 2. "What causes me to feel despair?" 3. "What possessions do I value the most?" 4. "What is my purpose in life?" 5. "What feeds my spirit?" Answer: 1, 2, 4, 5 Explanation: "What makes me joyful?", "What causes me to feel despair?", "What is my purpose in life?", and "What feeds my spirit?" are questions used for spiritual self-assessment. Page Ref: 1035 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 18. Develop an awareness of patients as well as healthcare professionals' spiritual beliefs and values and how those beliefs and values impact healthcare | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 8. Describe strategies that can increase a nurse's own spiritual awareness. MNL Learning Outcome: 3. Assess patient spiritual beliefs and practices. 31) The nurse is engaging in an activity to develop spiritual self-awareness. What activities can aid the nurse in achieving this goal? (Select all that apply.) 1. Write a will. 2. Complete an advance directives form. 3. Explore personal end-of-life issues. 4. Create a personal loss history. 5. List significant values. Answer: 3, 4, 5 Page Ref: 1035 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 18. Develop an awareness of patients as well as healthcare professionals' spiritual beliefs and values and how those beliefs and values impact healthcare | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 8. Describe strategies that can increase a nurse's own spiritual awareness. MNL Learning Outcome: 3. Assess patient spiritual beliefs and practices.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 42 Stress and Coping 1) The nurse elects to use a scale of stressful life events to assess the level of a newly admitted client's stress. How should the nurse explain the use of this scale to the client? 1. "We will consider only the negative life events that have happened to you recently." 2. "You should try to remember any stressful event that has occurred to you in the last 10 years to include in the scale." 3. "This scale will give us a definite stress level number that can be used to compare your stress to that of others your age." 4. "This scale will give us some idea about your stress related to both positive and negative recent events in your life." Answer: 4 Explanation: Stress scales are useful to give the client and others an idea of the amount of stress that both positive and negative recent life events have placed on the client. Page Ref: 1042 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 7. Identify essential aspects of assessing a client's stress and coping patterns. MNL Learning Outcome: 3. Assess patients' stress and coping patterns.
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2) The client has just received news of the death of a relative. Over the next few hours, what physiological response should the nurse attribute to the shock phase of the alarm reaction caused by the stress of this event? 1. Drop in blood pressure from 130/80 to 120/75 2. A more bounding pulse 3. Slight increase in urine output 4. Some decrease in oxygen saturation Answer: 2 Explanation: During this shock phase, the sympathetic nervous system is stimulated, resulting in increased myocardial contractility, which would be reflected in the client as a bounding pulse. Page Ref: 1042 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify physiological, psychological, and cognitive indicators of stress. MNL Learning Outcome: 2. Examine indicators of stress. 3) The nurse admits to being mildly anxious about an upcoming exam in graduate school. What is the likely result of this level of anxiety? 1. The nurse's perception and learning is enhanced. 2. The nurse's attention is focused solely on studying for the examination. 3. The nurse's only topic of conversation is the examination. 4. The nurse cannot talk about the examination without crying. Answer: 1 Explanation: With mild anxiety, the student's perception and learning will be enhanced. Page Ref: 1045 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify physiological, psychological, and cognitive indicators of stress. MNL Learning Outcome: 2. Examine indicators of stress.
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4) While attempting to choose a nursing diagnosis, the nurse must decide whether the client is experiencing anxiety or fear. What key point would help the nurse make this decision? 1. Anxiety is a milder form of fear. 2. Fear results in a physiological response, whereas anxiety is psychological. 3. The source of fear is identifiable, but anxiety may be vague. 4. Anxiety is generally based in reality, fear is not. Answer: 3 Explanation: The source of fear is identifiable, but anxiety is vague. Page Ref: 1045 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Diagnosis Learning Outcome: 4. Differentiate four levels of anxiety. MNL Learning Outcome: 2. Examine indicators of stress. 5) The new nurse feels overwhelmed by the demands of working on a busy acute care unit and maintaining a growing family. What strategy should this nurse employ to lessen this stress? 1. Spend the lunch hour completing documentation while eating a sandwich. 2. Set the alarm earlier in order to get to work early. 3. Focus on work instead of on family until more familiar with the environment. 4. Differentiate between "have to do" and "nice to do" at work. Answer: 4 Explanation: This nurse should differentiate between what is essential care at work and what is nice to do but can be eliminated on days when stress is high and resources are limited. Page Ref: 1051 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 6. Discuss types of coping and coping strategies. MNL Learning Outcome: 4. Implement interventions to minimize stress and support coping strategies.
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6) The parent of a critically ill child becomes distraught and begins to cry loudly while stroking the child's face. What is the nurse's best response to this occurrence? 1. Tell the parent to exercise self-control for the benefit of the child. 2. Distract the parent. 3. Explain all procedures. 4. Take the parent out of the room and provide comfort. Answer: 4 Explanation: In this situation, the nurse must analyze which of the available options would be best for this parent and child. At this level of emotion, the nurse should remove the parent from the room and provide comfort. Page Ref: 1051 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Identify essential aspects of assessing a client's stress and coping patterns. MNL Learning Outcome: 4. Implement interventions to minimize stress and support coping strategies. 7) A client is angry about not being permitted to smoke and throws the breakfast tray at the nurse. What should the nurse do in response to this outburst? 1. Call the charge nurse and refuse to take care of this client. 2. Apologize to the client for the unit rules but state they must be followed. 3. Tell the client that it is understandable about being upset but the no-smoking rule is not negotiable. 4. Tell the client to stop acting like a child and that such behavior will not be tolerated. Answer: 3 Explanation: Telling the client that it is understandable about being upset serves to show that the nurse accepts the client's right to be angry, but that the anger is the client's. Page Ref: 1051 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 9. Describe interventions to help clients minimize and manage stress. MNL Learning Outcome: 4. Implement interventions to minimize stress and support coping strategies.
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8) A client tells the nurse about being laid off from work, the spouse wanting a divorce, and being ill with a chest cold for a month. What statement should the nurse make that reflects understanding of a client in crisis? 1. "Once you reach the crisis state, you may remain there for several months until you recover." 2. "People generally find it easier to work through a crisis if someone is working with them." 3. "Men often handle crisis better individually, whereas women do better with a counselor." 4. "Experiencing a crisis is never positive, so we must work to relieve your anxiety as soon as possible." Answer: 2 Explanation: In general, people are more successful in working through a crisis if they have someone to help them. Page Ref: 1052 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Identify essential aspects of assessing a client's stress and coping patterns. MNL Learning Outcome: 3. Assess patients' stress and coping patterns. 9) The nurse manager suspects the nursing staff is experiencing burnout because of complaints and an increase in absenteeism. The nurses also appear tired and anxious. What can the manager do to help reduce this burnout? 1. Ask the physician staff to take over some of the tasks they routinely ask the nurses to do. 2. Make certain that the nurses are well prepared for their responsibilities. 3. Assign each nurse to spend 30 minutes with the hospital psychologist daily. 4. Ask administration to require 30 minutes of exercise at the end of each shift. Answer: 2 Explanation: In this situation, the best alternative is to be certain that the nurses are well prepared for the responsibilities of their jobs, as the frustration of being unprepared leads to burnout. Page Ref: 1052 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 9. Describe interventions to help clients minimize and manage stress. MNL Learning Outcome: 4. Implement interventions to minimize stress and support coping strategies. 10) The nurse identifies that a client has not met the expected outcome established for the 5
nursing diagnosis Ineffective Individual Coping. What should the nurse do first? 1. Revise the nursing diagnosis. 2. Reassess the patient, looking for previously unknown stressors. 3. Rewrite the interventions used to address the problem. 4. Explore reasons why the outcome was not achieved. Answer: 4 Explanation: When the expected outcome is not met, the nurse, client, and support persons must explore reasons why before modifying the remaining portions of the care plan. Page Ref: 1053 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation Learning Outcome: 9. Describe interventions to help clients minimize and manage stress. MNL Learning Outcome: 4. Implement interventions to minimize stress and support coping strategies. 11) The client who has been experiencing slight anxiety is now communicating in a manner that makes it difficult for the nurse to understand the client's needs. The nurse suspects the client hasprogressed to which anxiety level? 1. Mild 2. Moderate 3. Severe 4. Panic Answer: 3 Explanation: At severe levels of anxiety, communication is difficult to understand. Page Ref: 1045 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Describe the three stages of Selye's general adaptation syndrome. MNL Learning Outcome: 1. Examine the models of stress.
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12) The physician has just told the client that the results of a biopsy performed yesterday reveal no malignancy. During discharge teaching, the nurse finds the client to be easily distractible and unable to focus. What is the nurse's best interpretation of this situation? 1. The client did not understand that there is no malignancy. 2. Anxiety can result from both positive and negative stimuli. 3. Because there is no malignancy present, the client feels there is no need for teaching. 4. These findings reflect mild anxiety, but the client should retain information taught despite this distractibility. Answer: 2 Explanation: Anxiety can be the result of both positive and negative stimuli. Page Ref: 1045 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Differentiate four levels of anxiety. MNL Learning Outcome: 2. Examine indicators of stress. 13) A client diagnosed with a myocardial infarction is overheard telling family about having food poisoning. What defense mechanism is this client exhibiting? 1. Compensation 2. Denial 3. Displacement 4. Identification Answer: 2 Explanation: Denial is an attempt to ignore unacceptable realities by refusing to acknowledge them. Page Ref: 1047 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Identify behaviors related to specific ego defense mechanisms. MNL Learning Outcome: 3. Assess patients' stress and coping patterns.
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14) The client tells the nurse that she does not wish to see her mother-in-law during this hospitalization because she does not like her. When the client's husband and her mother-in-law visit, the client is very cordial and acts happy to see both visitors. The nurse recognizes that this client may be using which defense mechanism? 1. Reaction formation 2. Rationalization 3. Regression 4. Reparation Answer: 1 Explanation: Reaction formation is a mechanism that causes people to act exactly opposite to the way they feel. Page Ref: 1047 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Identify behaviors related to specific ego defense mechanisms. MNL Learning Outcome: 3. Assess patients' stress and coping patterns. 15) The parents of a school-age client who was sexually abused by a minister want to know why someone who is sexually attracted to children would choose to go into the ministry. The nurse explains that the displacement of sexual drives into socially acceptable activities is which type of defense mechanism? 1. Repression 2. Sublimation 3. Substitution 4. Undoing Answer: 2 Explanation: Sublimation is displacement of sexual drives into more socially acceptable activities. Page Ref: 1047 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Identify behaviors related to specific ego defense mechanisms. MNL Learning Outcome: 3. Assess patients' stress and coping patterns.
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16) The assessment of a client undergoing testing for an anxiety disorder reveals an increased heart rate, an increased respiratory rate, a low-normal hematocrit, and a low blood sugar. Which finding is contrary to what could be explained by a normal response to anxiety? 1. The heart rate 2. The respiratory rate 3. The hematocrit 4. The blood sugar Answer: 4 Explanation: The blood sugar generally increases because of the release of glucocorticoids and gluconeogenesis. Page Ref: 1045 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify physiological, psychological, and cognitive indicators of stress. MNL Learning Outcome: 2. Examine indicators of stress. 17) A newly hospitalized client is demonstrating anxiety and stress. What intervention can the nurse plan to help this client? 1. Explain all procedures in detail before performing them. 2. Let the client make the majority of decisions about the plan of care. 3. Control the environment of healing. 4. Demonstrate staff competence by using multiple nurses for care. Answer: 3 Explanation: The nurse is in charge of the environment of healing and should take responsibility for limiting noise, dimming lights at night, using minimal numbers of nurses to care for one client, and keeping the area clean and comfortable. Page Ref: 1051 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 9. Describe interventions to help clients minimize and manage stress. MNL Learning Outcome: 4. Implement interventions to minimize stress and support coping strategies.
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18) The parents of an adolescent who has a history of depression are concerned because the physician has prescribed an SSRI antidepressant for their child. What information should the nurse use to formulate a response to these parents' concerns? 1. These medications are addictive and difficult to discontinue when the depressive incident is past. 2. It is difficult for adolescents to manage the dosage regimen for many of these drugs because they must be taken with a full meal. 3. There is an FDA warning regarding antidepressant use in adolescents and the increased risk of suicide. 4. Most of the SSRI antidepressant medications will deliver a marked improvement in depression within 3-4 days of the first dose. Answer: 3 Explanation: The major concern regarding use of antidepressants and teenagers is the increased risk for suicide. Page Ref: 1053 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 9. Describe interventions to help clients minimize and manage stress. MNL Learning Outcome: 4. Implement interventions to minimize stress and support coping strategies.
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19) A 2-year-old client, who has had multiple hospitalizations for treatment of a congenital disorder, is lying curled in bed holding a stuffed animal and will not interact with the parents. What should the nurse identify as causing this client's behavior? 1. The parents may have been abusing this child. 2. The child is probably developmentally delayed secondary to multiple hospitalizations. 3. The child is reacting as a normal 2-year-old. 4. The child could be suffering from a clinical depression. Answer: 3 Explanation: Toddlers and preschool children often react to anxiety by either withdrawing or acting out. This child is behaving in a normal manner. Page Ref: 1054 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify physiological, psychological, and cognitive indicators of stress. MNL Learning Outcome: 2. Examine indicators of stress. 20) During an assessment, the nurse learns that a client has been having periodic upper respiratory infections since experiencing the death of a close family member. Which should the nurse identify as this client's response to stress? 1. Stimulus 2. Response 3. Transaction 4. Negotiation Answer: 1 Explanation: Stress is defined as a stimulus, a life event, or a set of circumstances that arouses physiological and/or psychological reactions that can increase the individual's vulnerability to illness. Page Ref: 1041 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Differentiate the concepts of stress as a stimulus, as a response, and as a transaction. MNL Learning Outcome: 1. Examine the models of stress.
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21) After hearing the diagnosis of cancer, a client becomes withdrawn and refuses to talk with friends or family. The nurse realizes this client is demonstrating which type of reaction to stress? 1. Stimulus 2. Response 3. Combination 4. Transaction Answer: 4 Explanation: Stress that is a transaction refers to any event in which environmental demands, internal demands, or both tax or exceed the adaptive resources of an individual, social system, or tissue system. The individual responds to perceived environmental changes with adaptive or coping responses such as being withdrawn. Page Ref: 1044 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Differentiate the concepts of stress as a stimulus, as a response, and as a transaction. MNL Learning Outcome: 1. Examine the models of stress. 22) The nurse identifies that a client is experiencing the resistance stage of general adaption syndrome. What did the nurse assess to make this clinical decision? 1. The client is unable to focus on activities and events. 2. The client is exhausted and spends time sleeping. 3. There is localized swelling and inflammation of the client's leg wound. 4. The client's capillary blood glucose level is 180 mg/dL. Answer: 3 Explanation: In the second stage in general adaption syndrome, the stage of resistance is when the body's adaption takes place. The body attempts to cope with the stressor and to limit the stressor to the smallest area of the body that can deal with it, such as with localized swelling and inflammation of a leg wound. Page Ref: 1043 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Describe the three stages of Selye's general adaptation syndrome. MNL Learning Outcome: 1. Examine the models of stress. 12
23) A client is experiencing the shock phase within general adaption syndrome. The nurse realizes that this phase affects which hormones? (Select all that apply.) 1. Epinephrine 2. Estrogen 3. Norepinephrine 4. Corticotropin-releasing 5. Progesterone Answer: 1, 3, 4 Explanation: In the alarm phase of general adaption syndrome, epinephrine secretion is increased, which affects heart rate, breathing, and blood-clotting mechanisms. In the alarm phase of general adaption syndrome, norepinephrine secretion is increased, which decreases blood flow to the kidney and increases renin release. The hypothalamus releases corticotropin-releasing hormone, which stimulates the anterior pituitary gland to release adrenocorticotropic hormone. This causes increased fat mobilization to make energy available and to synthesize other compounds needed by the body. Page Ref: 1042 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Describe the three stages of Selye's general adaptation syndrome. MNL Learning Outcome: 1. Examine the models of stress.
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24) A client newly diagnosed with colon cancer finishes dinner and turns on the nightly news. The nurse suspects the client is experiencing which cognitive indicator of stress? 1. Problem solving 2. Self-control 3. Structuring 4. Daydreaming Answer: 2 Explanation: Self-control is assuming a manner and facial expression that convey a sense of being in control or in charge. When self-control prevents panic and harmful or nonproductive actions in a threatening situation, it is a helpful response that conveys strength. Self-control carried to an extreme, however, can delay problem solving and prevent a person from receiving the support of others, who might perceive the person as handling the situation well, as cold, or as unconcerned. Page Ref: 1046 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify physiological, psychological, and cognitive indicators of stress. MNL Learning Outcome: 2. Examine indicators of stress.
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25) A client is informed of the need for surgery to correct a potentially life-threatening health problem. Afterward, the nurse determines that the client is experiencing physiological indicators of stress. What did the nurse assess to make this determination? (Select all that apply.) 1. Dilated pupils 2. Diaphoretic 3. Tachycardia 4. Flaccid muscle tone 5. Excessive oral secretions Answer: 1, 2, 3 Explanation: Pupils dilate to increase visual perception when serious threats to the body arise. Sweat production or diaphoresis increases to control elevated body heat due to increased metabolism. The heart rate increases to transport nutrients and by-products of metabolism more efficiently. Page Ref: 1045 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify physiological, psychological, and cognitive indicators of stress. MNL Learning Outcome: 2. Examine indicators of stress.
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26) The nurse is concerned that a client diagnosed with a chronic illness is experiencing depression. What did the nurse assess in this client? (Select all that apply.) 1. Weight gain 2. Irritability 3. No appetite 4. Constipation 5. Complaints of headache and dizziness Answer: 2, 3, 4, 5 Explanation: Behavioral signs of depression include irritability. Physical signs of depression include loss of appetite. Physical signs of depression include constipation. Physical signs of depression include headache and dizziness. Page Ref: 1046 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify physiological, psychological, and cognitive indicators of stress. MNL Learning Outcome: 2. Examine indicators of stress. 27) While assessing a client's ability to cope after being diagnosed with a chronic illness, the client admits to an increase in drinking and smoking. The nurse recognizes the client is utilizing which type of coping strategy? 1. Short term 2. Long term 3. Adaptive 4. Effective Answer: 1 Explanation: Short-term coping strategies can reduce stress to a tolerable limit temporarily but are ineffective ways to deal with reality permanently. They can even have a destructive or detrimental effect on the person. An example of short-term strategies is using alcoholic beverages or drugs. Page Ref: 1048 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 6. Discuss types of coping and coping strategies. MNL Learning Outcome: 3. Assess patients' stress and coping patterns. 16
28) The adult daughter of an older client, who provides and pays for the client's care and needs, tells the nurse that her time is limited because of work responsibilities. The client complains that all the daughter ever does is work. What basic need is being affected by the daughter's stress? 1. Love and belonging 2. Self-actualization 3. Physiological 4. Self-esteem Answer: 4 Explanation: The effects of stress on the basic need of self-esteem include becoming a workaholic. Page Ref: 1048 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 7. Identify essential aspects of assessing a client's stress and coping patterns. MNL Learning Outcome: 3. Assess patients' stress and coping patterns.
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29) The nurse asks a client what strategies are used to cope with stress. The client does not respond. What should the nurse do? (Select all that apply.) 1. Document that the client has no stress. 2. Move on with the assessment. 3. Ask the client whether crying occurs. 4. Suggest that the client use humor or exercise. 5. Question the use of anger. Answer: 3, 4, 5 Explanation: If the client does not adequately describe how stressful situations are handled, the nurse should prompt by asking the client whether crying occurs. If the client does not adequately describe how stressful situations are handled, the nurse should prompt by suggesting the client use humor or exercise. If the client does not adequately describe how stressful situations are handled, the nurse should ask the client about using anger or being angry. Page Ref: 1049 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 6. Discuss types of coping and coping strategies. MNL Learning Outcome: 3. Assess patients' stress and coping patterns. 30) During a health interview, the nurse decides to focus the assessment questions on the middleaged client's amount of stress. What information did the nurse use to make this clinical decision? (Select all that apply.) 1. Caring for aging parents 2. Needing to wear glasses to read 3. Newly married 4. Choosing a career 5. Not having the same amount of stamina and energy Answer: 1, 2, 5 Page Ref: 1054 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 7. Identify essential aspects of assessing a client's stress and coping patterns. MNL Learning Outcome: 3. Assess patients' stress and coping patterns. 18
31) The nurse is preparing to assess a client's stress and coping patterns. What will be included in this assessment? (Select all that apply.) 1. Client's perception of stressors 2. Manifestations of stress 3. Employment status 4. Coping strategies 5. Weight changes Answer: 1, 2, 4, 5 Page Ref: 1048-1049 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 7. Identify essential aspects of assessing a client's stress and coping patterns. MNL Learning Outcome: 3. Assess patients' stress and coping patterns. 32) A client diagnosed with a chronic illness tells the nurse that the spouse is not helping the client with household activities, which is causing stress. Which diagnosis should the nurse identify as being appropriate for the client at this time? 1. Defensive Coping 2. Disabled Family Coping 3. Compromised Family Coping 4. Ineffective Coping Answer: 3 Explanation: The diagnosis of Compromised Family Coping is applicable if a usually supportive primary person provides insufficient, ineffective, or compromised support, comfort, assistance, or encouragement that might be needed by the client to manage or master adaptive tasks related to the health challenge. Page Ref: 1049 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Diagnosis Learning Outcome: 8. Identify nursing diagnoses related to stress. MNL Learning Outcome: 3. Assess patients' stress and coping patterns.
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33) A client repeatedly tells the nurse that "all will be well" and "I'm fine" in response to learning of a health problem that requires immediate surgery. The nurse realizes that which diagnosis is appropriate for the client at this time? 1. Compromised Family Coping 2. Ineffective Coping 3. Disabled Family Coping 4. Defensive Coping Answer: 4 Explanation: Defensive coping is the repeated projection of falsely positive self-evaluation based on a self-protective pattern that defends against underlying perceived threats to positive self-regard. Page Ref: 1049 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Diagnosis Learning Outcome: 8. Identify nursing diagnoses related to stress. MNL Learning Outcome: 3. Assess patients' stress and coping patterns. 34) A client asks what changes can be made to dietary intake to reduce the effects of stress. What changes should the nurse encourage the client to make? (Select all that apply.) 1. Reduce sugar intake. 2. Eliminate excess salt. 3. Reduce caffeine intake. 4. Avoid vitamin supplements. 5. Follow a low-fat eating plan. Answer: 1, 2, 3, 5 Page Ref: 1050 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 9. Describe interventions to help clients minimize and manage stress. MNL Learning Outcome: 4. Implement interventions to minimize stress and support coping strategies.
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35) After dealing with a variety of physical stressors, a client is entering the stage of exhaustion. The nurse should recognize that the end of this stage will depend on which factors? (Select all that apply.) 1. Release of hormones 2. Severity of the stressor 3. Reversal of body changes 4. External resources provided 5. Energy resources of the client Answer: 2, 4, 5 Page Ref: 1043 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Describe the three stages of Selye's general adaptation syndrome. MNL Learning Outcome: 1. Examine the models of stress.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 43 Loss, Grieving, and Death 1) During a home visit, an older male client tells the nurse that his wife died 3 years ago. What did the nurse observe as an indication that this client is experiencing complicated grief? 1. The client has an album of photographs of his wife open on the living room table. 2. He tells the nurse that his wife was an awful cook and that he has eaten better meals since she died. 3. He indicates that he sends his laundry out to be done because he had never figured out how the washer works. 4. He shows the nurse his wife's craft room that remains just as she left it before she died. Answer: 4 Explanation: Leaving the deceased wife's craft room and belongings intact for over 3 years is considered outside the normal limits of the grief process. Page Ref: 1061 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Describe types and sources of losses. MNL Learning Outcome: 1. Examine factors related to loss and grief across the lifespan. 2) The nurse is caring for the family of a terminally ill client. The family members have been tearful and sad since the diagnosis was given. What is the best nursing diagnosis problem statement for this family? 1. Anticipatory Grieving 2. Dysfunctional Grieving 3. Hopelessness 4. Caregiver Role Strain Answer: 1 Explanation: Grieving prior to the actual loss is termed anticipatory grieving. Page Ref: 1061 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Diagnosis Learning Outcome: 1. Describe types and sources of losses. MNL Learning Outcome: 1. Examine factors related to loss and grief across the lifespan. 1
3) The nurse is counseling a family in which a member is terminally ill. The family has children of varying ages. What should the nurse teach the family about the reactions of children to death? 1. Toddlers perceive death as irreversible and unnatural. 2. Preschool children view death as a spiritual release. 3. At about age 9, children begin to understand that death is inevitable. 4. Adolescents tend to have better outcomes than adults after a loss. Answer: 3 Explanation: At about age 9, children's concept of death matures and most understand that death is an inevitable part of life. Page Ref: 1067 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 4. Discuss factors affecting a grief response. MNL Learning Outcome: 1. Examine factors related to loss and grief across the lifespan. 4) The nurse is assigning support personnel to assist the families of clients who have died in dealing with the stress related to the loss of their family members. For which client should the nurse screen the family as being at the highest risk for complicated grief? 1. Client died after a long battle against cancer. 2. Client died after developing diabetes-induced renal failure. 3. Client was killed in the robbery of a bank. 4. Client died from chronic heart disease. Answer: 3 Explanation: Although all families are different and all families can respond to grief differently, research supports a greater potential for complicated grief in families whose loved one died suddenly, violently, or unexpectedly. Of the options given, the client who was murdered best fits all three situations. Page Ref: 1061 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Discuss factors affecting a grief response. MNL Learning Outcome: 1. Examine factors related to loss and grief across the lifespan.
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5) The nurse critically evaluates various models of grief used for terminally ill clients and their families. What should the nurse recognize when applying these models to individual cases? 1. The Kübler-Ross model is primarily used to describe anticipatory grief. 2. No clear timetables exist, nor are there clear-cut stages of grief. 3. The models serve as clear and definitive predictors of grief behaviors. 4. There is strong research proving that these models are not useful for many dying clients. Answer: 2 Explanation: Although the models of grief are useful in guiding nursing care of clients who are experiencing loss, there are no clear-cut stages of grief, nor are there exact timetables. Page Ref: 1061-1062 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Identify measures that facilitate the grieving process. MNL Learning Outcome: 2. Examine the various theories of the stages of grief. 6) A client hospitalized for injuries from a motor-vehicle crash is diagnosed with higher brain death. What findings support this client's diagnosis? (Select all that apply.) 1. Episodic coughing 2. No cephalic reflexes 3. Not breathing spontaneously 4. Inconsistent cardiac function on the heart monitor 5. Electroencephalogram showed no activity for 30 minutes Answer: 2, 3, 5 Explanation: Evidence of higher brain death includes absence of cephalic reflexes. Evidence of higher brain death includes apnea. Evidence of higher brain death includes absence of cephalic reflexes, apnea, and an isoelectric electroencephalogram for at least 30 minutes. Page Ref: 1068 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 6. List clinical signs of impending and actual death. MNL Learning Outcome: 3. Assess the psychological and physiological needs of dying patients and their families.
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7) A client is diagnosed with a terminal illness and is demonstrating anxiety. What intervention can the nurse use to help the client at this time? 1. Explore the client's history with other stressful life events and how successful coping was at that time. 2. Teach the family that while talking with the client about death and dying is permissible, they should not allow the client to dwell on death. 3. Supply information about the client's disease process and the expected trajectory of death only on a need-to-know basis. 4. Encourage early pharmaceutical intervention with antianxiety and sedative medications. Answer: 1 Explanation: It is most helpful for the nurse to know how the client has dealt with previous stressful life events so that support of positive coping mechanisms can occur. The client who has received a terminal diagnosis needs to discuss the future and the implications of the diagnosis. Page Ref: 1065 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Identify measures that facilitate the grieving process. MNL Learning Outcome: 3. Assess the psychological and physiological needs of dying patients and their families.
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8) A client who has AIDS tells the nurse, "I don't know why I should even keep trying. This disease is so horrible and so many people die from it. It will get me, too." In which way should the nurse characterize this client's statement? 1. An indication of hopelessness that should be further evaluated for treatment. 2. A simple statement of the facts regarding AIDS. 3. Common and expected in those facing the end of life. 4. Proof that the client is accepting the facts of the illness and impending death. Answer: 1 Explanation: This statement reflects hopelessness. Hopelessness is not an expected feeling at end of life and can and should be treated. Despite the inevitability of death, the goal is for the client to continue to express hope of some nature. This hope might take the form of short-term completion of goals prior to death, for peacefulness at the time of death, or for attainment of the individual's personal belief about the afterlife. Page Ref: 1067, 1071 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Diagnosis Learning Outcome: 3. Identify clinical symptoms of grief. MNL Learning Outcome: 3. Assess the psychological and physiological needs of dying patients and their families. 9) A client who was having an affair is upset and cannot sleep since learning of her partner's death. The nurse recognizes that the sleeping difficulty is most likely a result of which type of grief? 1. Abbreviated 2. Chronic 3. Disenfranchised 4. External Answer: 3 Explanation: This client is unable to grieve openly for her lost relationship, as extramarital affairs are not socially sanctioned. Page Ref: 1060 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify clinical symptoms of grief. MNL Learning Outcome: 1. Examine factors related to loss and grief across the lifespan. 5
10) A recently widowed father has three children who are doing poorly in school however the father because he is having difficulty keeping up with household expectations because of having to work a second job. Which nursing diagnoses should the nurse consider in planning care for this family? (Select all that apply.) 1. Anticipatory Grieving 2. Impaired Family Processes 3. Impaired Adjustment 4. Caregiver Role Strain 5. Hopelessness Answer: 2, 3, 4, 5 Page Ref: 1065 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Diagnosis Learning Outcome: 3. Identify clinical symptoms of grief. MNL Learning Outcome: 1. Examine factors related to loss and grief across the lifespan. 11) During a bath, the client suddenly says, "I am not going to get well. I think I am going to die." What response given by the nurse is most appropriate? 1. "Let's think of something more cheerful." 2. "You are doing so well; don't talk like that." 3. "What makes you think you are dying?" 4. "Whatever is meant to be will happen." Answer: 3 Explanation: The nurse should ask what it is that makes the client think about dying. This allows the nurse to collect and evaluate data before making a further response. Page Ref: 1070 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Describe the process of helping clients die with dignity. MNL Learning Outcome: 4. Implement interventions to help the patient die with dignity, facilitate grieving for the family and caregivers, and care for the body after death.
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12) The client with an advance healthcare directive that indicates that no resuscitative measures should be employed in the event of a respiratory or cardiac arrest asks for help when dyspnea and air hunger occurs. What action should be taken by the nurse? 1. Offer the client comfort measures until death occurs. 2. Call the client's physician for direction. 3. Initiate resuscitative measures. 4. Check the medical record to ascertain the terms of the directive. Answer: 3 Explanation: This client has the right to change decisions about resuscitation and has asked for help. The nurse should initiate resuscitative measures. Page Ref: 1073-1074 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 6. List clinical signs of impending and actual death. MNL Learning Outcome: 4. Implement interventions to help the patient die with dignity, facilitate grieving for the family and caregivers, and care for the body after death. 13) A client with end-stage renal disease refuses to talk about dying with the spouse, who also refuses to discuss death with the client. What will be the outcomes of this situation? (Select all that apply.) 1. Client has dignity 2. Client has privacy 3. Client can finalize affairs 4. Client can plan own funeral 5. Client burdened with no one to confide in Answer: 1, 2, 5 Page Ref: 1070 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 7. Describe the process of helping clients die with dignity. MNL Learning Outcome: 4. Implement interventions to help the patient die with dignity, facilitate grieving for the family and caregivers, and care for the body after death.
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14) The family of a young adult client who has recently been diagnosed with a rapidly progressing terminal illness does not believe the diagnosis and that there must have been a mistake with testing. What should be the nurse's first step in assisting this family? 1. Provide structure and continuity to promote feelings of security. 2. Examine the nurse's own feelings to ensure denial is not shared. 3. Offer spiritual support. 4. Allow the family to express sadness. Answer: 2 Explanation: The nurse must first self-examine feelings to ensure that personal behaviors do not demonstrate denial of the situation. Page Ref: 1061 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 8. Describe the role of the nurse in working with families or caregivers of dying clients. MNL Learning Outcome: 3. Assess the psychological and physiological needs of dying patients and their families. 15) A client who has just been diagnosed with a slowly progressive terminal illness asks the nurse about the availability of hospice services. What information should the nurse share with this client? 1. When clients are designated as terminally ill, they are automatically assigned to hospice care. 2. Hospice services are generally reserved for those who have a life expectancy of 6 months or less. 3. Only those clients with private insurance can receive hospice benefits. 4. Provision of hospice services is reserved only for those who refuse other palliative treatments. Answer: 2 Explanation: Hospice services are generally provided only to those who are expected to live less than 6 months. Those clients whose conditions improve after receiving hospice care may be removed from those services. Page Ref: 1072 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Describe the process of helping clients die with dignity. MNL Learning Outcome: 4. Implement interventions to help the patient die with dignity, facilitate grieving for the family and caregivers, and care for the body after death. 8
16) The nurse is caring for a child who is dying. What is the most important communication strategy for the nurse to use at this time? 1. Talk to the child at the appropriate level of understanding. 2. Be totally open and honest with the child. 3. Avoid discussing death with the child. 4. Encourage the family to talk with the child about the impending death. Answer: 1 Explanation: Although it is very important to be open and honest with the child and may be appropriate to encourage the family to talk with the child about impending death, the most important strategy is to talk with the child at the appropriate level of understanding. Without recognition of this concept, none of the other options will be effective. The nurse should not avoid discussing death with the child if the child brings up the subject. Page Ref: 1067 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Identify measures that facilitate the grieving process. MNL Learning Outcome: 4. Implement interventions to help the patient die with dignity, facilitate grieving for the family and caregivers, and care for the body after death.
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17) The nurse is caring for a client whose family does not want to tell him that he is dying. What is the nurse's best action according to these wishes? 1. Arrange an encounter with the client and tell him the truth. 2. Change the subject when the client asks about his impending death. 3. Tell the family that the patient has the right to know that he is dying. 4. Talk to the family about the situation and their concerns. Answer: 4 Explanation: In this situation, the best and first thing the nurse should do is talk with the family about what is happening and what their concerns are. The nurse should investigate religious, cultural, and family traditions regarding telling the client about impending death. Page Ref: 1070 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 8. Describe the role of the nurse in working with families or caregivers of dying clients. MNL Learning Outcome: 4. Implement interventions to help the patient die with dignity, facilitate grieving for the family and caregivers, and care for the body after death. 18) The nurse who is providing postmortem care sees that the client is wearing a ring. What is the most important action regarding this observation? 1. Remove the ring and give it to the family. 2. Call the presence of the ring to the attention of the funeral director. 3. Tape the ring to the client's finger. 4. Document fully whatever action is taken. Answer: 4 Explanation: Depending on the circumstances and what kind of ring it is, the nurse might take any of these actions. The most important action is to document what occurred. Page Ref: 1075 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 9. Describe nursing measures for care of the body after death. MNL Learning Outcome: 4. Implement interventions to help the patient die with dignity, facilitate grieving for the family and caregivers, and care for the body after death.
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19) A client recovering from back surgery is upset after learning of the future inability to perform certain sports, activities, and employment types because of the surgery. The nurse interprets this client's reaction as a response to which type of loss? 1. Situational loss 2. Anticipatory loss 3. Psychological loss 4. Developmental loss Answer: 1 Explanation: The loss of functional ability because of acute illness or injury is a situational loss. Page Ref: 1060 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Describe types and sources of losses. MNL Learning Outcome: 1. Examine factors related to loss and grief across the lifespan. 20) An older client who has just relocated from home to an assisted living facility is withdrawn and is crying periodically throughout the day. What type of loss is this client demonstrating? 1. External objects 2. Familiar environment 3. Loved ones 4. Psychological Answer: 2 Explanation: Separation from an environment and people who provide security can result in a sense of loss, such as in the client who has relocated from home to an assisted living facility. Page Ref: 1060 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Describe types and sources of losses. MNL Learning Outcome: 1. Examine factors related to loss and grief across the lifespan.
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21) A client with terminal lung cancer complains of being short of breath with bilateral crackles and wheezes, despite oxygen at 4 L via nasal cannula and diuretic therapy. What nursing interventions are appropriate for this client? (Select all that apply.) 1. Move the client to a room closer to the nurse's desk for closer observation. 2. Help the client assume a position lying on the right side. 3. Place a fan in the room to move air around the client. 4. Change the client's oxygen therapy to a nonrebreathing mask. 5. Elevate the head of the client's bed to a Fowler position. 6. Consider use of a p.r.n. morphine sulfate order. Answer: 3, 5, 6 Explanation: Placement of a fan to circulate air might relieve shortness of breath. Elevating the head of the bed might relieve shortness of breath. Use of morphine sulfate might relieve shortness of breath. Page Ref: 1073 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Describe the process of helping clients die with dignity. MNL Learning Outcome: 4. Implement interventions to help the patient die with dignity, facilitate grieving for the family and caregivers, and care for the body after death.
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22) The nurse is providing postmortem care for a client whose family would like to view the body before it is transported to the morgue. What interventions are necessary for this preparation? (Select all that apply.) 1. Provide a total bed bath. 2. Place absorbent pads beneath the body. 3. Remove dentures. 4. Dress the client in street clothes. 5. Place a pillow under the head. 6. Tape the eyelids closed. Answer: 1, 2, 5 Explanation: A total bed bath is not necessary. The nurse should place absorbent pads beneath the body. A pillow should be placed under the head. Page Ref: 1075 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 9. Describe nursing measures for care of the body after death. MNL Learning Outcome: 4. Implement interventions to help the patient die with dignity, facilitate grieving for the family and caregivers, and care for the body after death.
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23) The spouse of a deceased client is working through the stages of grief. If the nurse applies Kübler-Ross's stages of grief to this situation, the spouse would progress through the stages in which order? 1. Depression 2. Anger 3. Acceptance 4. Bargaining 5. Denial Answer: 4, 2, 5, 3, 1 Explanation: Kübler-Ross's stages of grief are: (1) denial, (2) anger, (3) bargaining, (4) depression, and (5) acceptance. Page Ref: 1061 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Discuss selected frameworks for identifying stages of grieving. MNL Learning Outcome: 2. Examine the various theories of the stages of grief. 24) The nurse determines that a client, after learning of the death of a close family member, is demonstrating normal signs of grief. What did the nurse assess in this client? (Select all that apply.) 1. Crying 2. Weakness 3. Inability to sleep 4. No appetite 5. Inability to concentrate on conversations Answer: 1, 3, 4, 5 Page Ref: 1062 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify clinical symptoms of grief. MNL Learning Outcome: 1. Examine factors related to loss and grief across the lifespan.
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25) The nurse is concerned that a client is experiencing complicated grieving after the unexpected death of a son. The nurse most likely assessed which of the following? (Select all that apply.) 1. The client's denying the son's death 2. Depression 3. Sudden weight loss because of not eating 4. Crying 5. Verbalizing the desire to not live anymore Answer: 1, 2, 3, 5 Page Ref: 1061 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify clinical symptoms of grief. MNL Learning Outcome: 1. Examine factors related to loss and grief across the lifespan. 26) When observing an older client's response upon learning of the death of a close family friend, the nurse realizes that the significance of the loss to the client is dependent upon which factors? (Select all that apply.) 1. Importance of the person to the client 2. Amount of changes that will occur because of the loss 3. The client's beliefs 4. The client's values 5. The client's socioeconomic status Answer: 1, 2, 3, 4 Page Ref: 1064 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Discuss factors affecting a grief response. MNL Learning Outcome: 1. Examine factors related to loss and grief across the lifespan.
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27) The nurse is planning care to help a client work through the grieving process. What would be appropriate to include in this plan of care? (Select all that apply.) 1. Listen to the client. 2. Clarify and reflect the client's feelings. 3. Reassure the client that all will be well. 4. Be silent. 5. Provide advice to the client. Answer: 1, 2, 4 Page Ref: 1066 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 5. Identify measures that facilitate the grieving process. MNL Learning Outcome: 3. Assess the psychological and physiological needs of dying patients and their families. 28) The nurse is providing emotional support to a client who just learned the outcome of a biopsy. What actions will be the best for the nurse to provide at this time? (Select all that apply.) 1. Encourage the client to resume normal activities. 2. Use therapeutic communication techniques. 3. Offer choices that promote client autonomy. 4. Provide information about community resources or support groups. 5. Acknowledge the grief of the client. Answer: 2, 3, 4, 5 Explanation: Therapeutic communication techniques let the client know that the nurse acknowledges the client's feelings. Offering choices that promote autonomy helps the client have a sense of some control at a time when much control might not be possible. Providing information about community resources or support groups provides the client with sources of additional information. Acknowledging the grief of the client is helpful when providing emotional support. Page Ref: 1066 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Identify measures that facilitate the grieving process. MNL Learning Outcome: 3. Assess the psychological and physiological needs of dying patients and their families. 16
29) A terminally ill client is demonstrating gurgling respirations. Which should the nurse realize is occurring with this client? 1. Status is improving 2. Increase in pain 3. Attempting to talk 4. Nearing death Answer: 4 Explanation: A clinical manifestation of impending death is noisy breathing. This is often referred to as the death rattle and is due to collecting of mucus in the throat. Page Ref: 1070 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 6. List clinical signs of impending and actual death. MNL Learning Outcome: 4. Implement interventions to help the patient die with dignity, facilitate grieving for the family and caregivers, and care for the body after death. 30) The nurse determines that a terminally ill client is nearing death. What did the nurse assess to make this clinical decision? (Select all that apply.) 1. Diarrhea 2. Muscle spasms 3. Slow, weak pulse 4. Decreased blood pressure 5. Cyanosis of the extremities Answer: 3, 4, 5 Page Ref: 1070 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 6. List clinical signs of impending and actual death. MNL Learning Outcome: 4. Implement interventions to help the patient die with dignity, facilitate grieving for the family and caregivers, and care for the body after death.
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31) While caring for a client who is approaching death, the nurse notices the client's facial expression of extreme sadness. What should the nurse do? 1. Leave the client alone. 2. Provide physical care to increase comfort. 3. Acknowledge the client's expression and ask whether the client would like to talk about her feelings. 4. Offer to provide pain medication. Answer: 3 Explanation: The nurse should establish a communication relationship that shows concern for and commitment to the client. Communication strategies include describing observations and asking whether the client would like to talk about feelings. Page Ref: 1071 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Identify measures that facilitate the grieving process. MNL Learning Outcome: 4. Implement interventions to help the patient die with dignity, facilitate grieving for the family and caregivers, and care for the body after death.
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32) The spouse of a dying client is sitting quietly in the client's room, looking at the floor. What can the nurse do to help the client and spouse during this time? (Select all that apply.) 1. Encourage the spouse to move closer to the client, if desired. 2. Permit the spouse to sit alone. 3. Leave the spouse and client in the room alone together as much as possible. 4. Recommend that the spouse return home to get some rest. 5. Suggest the spouse read to the client, if desired. Answer: 1, 3, 5 Explanation: The dying and the family must be allowed as much privacy as they desire in order to meet their needs for physical and emotional intimacy. The dying client and the family must be allowed as much privacy as they desire in order to meet their needs for physical and emotional intimacy. Family members should be encouraged to participate in the physical care of the dying person as much as they wish to and are able. The nurse can suggest they assist with bathing, speak or read to the client, and hold hands. Page Ref: 1074 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Identify measures that facilitate the grieving process. MNL Learning Outcome: 4. Implement interventions to help the patient die with dignity, facilitate grieving for the family and caregivers, and care for the body after death.
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33) The family members of a client who has just died want to spend time with the client. What should the nurse do to prepare the client for the family? (Select all that apply.) 1. Check the client's religion to make sure care is in compliance with religious expectations. 2. Remove equipment from the room. 3. Permit the family to view the client before postmortem care is done. 4. Change the linens. 5. Place the client in a natural body position. Answer: 1, 2, 4, 5 Explanation: Because care of the body can be influenced by religious law, the nurse should check the client's religion and make every attempt to comply. It is important to make the environment as clean and pleasant as possible, so equipment should be removed from the room. It is important to make the environment as clean and pleasant as possible, so the linens should be changed. It is important to make the environment as clean and pleasant as possible, so the client's position should appear natural and comfortable. Page Ref: 1074-1075 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 8. Describe the role of the nurse in working with families or caregivers of dying clients. MNL Learning Outcome: 4. Implement interventions to help the patient die with dignity, facilitate grieving for the family and caregivers, and care for the body after death.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 44 Activity and Exercise 1) The nurse is assisting in logrolling a client recovering from spinal surgery. Why should the nurse place a pillow between the client's legs when turning? (Select all that apply.) 1. Stabilizes the spine 2. Prevents hip contractures 3. Supports the upper leg 4. Keeps the legs parallel and aligned 5. Prevents adduction of the upper leg Answer: 3, 4, 5 Page Ref: 1114-1115 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 10. Verbalize the steps used in: c. Logrolling a client. MNL Learning Outcome: 3. Implement the steps for nursing procedures used in the care of patients with activity, exercise, and mobility problems.
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2) During a prenatal visit, the nurse is instructing a newly pregnant client in regard to exercise. What advice is best for the nurse to give this client? 1. Pregnant clients can exercise if exercise was a part of their life prior to pregnancy. 2. Due to the stress of a growing fetus, exercise should be limited to no more than 10 minutes per day. 3. Healthy pregnant women should exercise at least 30 minutes on most if not all days. 4. The pregnant woman's exercise should actually increase above normal recommended levels to prevent water weight gain. Answer: 3 Explanation: The current recommendation of the American College of Obstetricians and Gynecologists is for healthy pregnant women to get as much exercise as the general population (30 minutes on most if not all days). This is a change from the previous recommendation that pregnant women can exercise. Page Ref: 1089 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 3. Compare the effects of exercise and immobility on body systems. MNL Learning Outcome: 2. Plan care of patients with activity, exercise, and mobility problems.
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3) The nurse is caring for a client diagnosed with early osteoporosis. Which intervention is most applicable for this client? 1. Institute an exercise plan that includes weight-bearing activities. 2. Increase the amount of calcium in the client's diet. 3. Protect the client's bones with strict bed rest. 4. Provide the client with assisted range-of-motion exercising twice daily. Answer: 1 Explanation: Osteoporosis is a demineralization of the bone in which calcium leaves the bone matrix. One causative factor is lack of weight-bearing activity. Weight bearing helps to move calcium back into the bones, thereby strengthening them. A standard intervention for those attempting to prevent or reverse osteoporosis is beginning an exercise plan that includes weightbearing activities. Page Ref: 1091 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 2. Differentiate isotonic, isometric, isokinetic, aerobic, and anaerobic exercise. MNL Learning Outcome: 3. Implement the steps for nursing procedures used in the care of patients with activity, exercise, and mobility problems.
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4) The newly admitted client has contractures of both lower extremities. What nursing intervention should be included in this client's plan of care? 1. Frequent position changes to reverse the contractures 2. Exercises to strengthen flexor muscles 3. Range-of-motion exercises to prevent worsening of contractures 4. Weight-bearing activities to stimulate joint relaxation Answer: 3 Explanation: Once contractures occur they are irreversible except by surgical intervention. The best nursing intervention is to keep the contractures from getting tighter (or worse) by providing range-of-motion exercises. Page Ref: 1123 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Assess activity-exercise pattern, body alignment, gait, appearance and movement of joints, mobility capabilities and limitations, muscle mass and strength, activity tolerance, and problems related to immobility. MNL Learning Outcome: 2. Plan care of patients with activity, exercise, and mobility problems.
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5) The nurse has documented that the client has orthostatic hypotension. Which assessment finding would support this assessment? 1. Decrease in blood pressure when moving from supine to standing 2. Decrease in heart rate when moving from supine to sitting 3. Pale color in the legs when lying in bed 4. Complaints of dizziness when first sitting up Answer: 1 Explanation: Orthostatic hypotension occurs when the normal vasoconstriction reflex in the legs is dormant and the client's central blood pressure drops when moving from supine to sitting or to standing. Page Ref: 1093 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Identify factors influencing a client's body alignment and activity. MNL Learning Outcome: 1. Assess activity-exercise pattern, body alignment, gait, appearance and movement of joints, mobility capabilities and limitations, muscle mass and strength, activity tolerance, and problems related to immobility for patients.
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6) The nurse is considering using the NANDA nursing diagnosis Impaired Physical Mobility in the care plan of a newly admitted client. In order to make this problem statement more individual, the nurse should take which action? 1. Include what mobility is impaired. 2. Explain the effects of immobility. 3. Describe what happens when the client attempts mobility. 4. Add strength assessment data. Answer: 1 Explanation: In order to make this broad nursing diagnosis more specific to the client, the nurse should include what mobility is impaired. For example, if the client cannot transfer from bed to chair, a more specific nursing diagnosis is Impaired Transfer Mobility. Page Ref: 1101 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Diagnosis Learning Outcome: 6. Develop nursing diagnoses and outcomes related to activity, exercise, and mobility problems. MNL Learning Outcome: 2. Plan care of patients with activity, exercise, and mobility problems.
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7) The nurse is working on a hospital committee focused on preventing back injury in nurses. Which recommendation by this committee is most likely to result in a decrease in back injuries if followed? 1. Nurses must wear back belts when lifting clients. 2. All nursing personnel must attend annual body mechanics education. 3. In order to prevent injury, nurses must strive to become physically fit. 4. No solo lifting of clients is permitted in the facility. Answer: 4 Explanation: The only option that has any influence on frequency of back injury is a practice prohibiting solo lifting. Page Ref: 1104 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 7. Use safe practices when positioning, moving, transferring, and ambulating clients. MNL Learning Outcome: 3. Implement the steps for nursing procedures used in the care of patients with activity, exercise, and mobility problems. 8) The nurse must lift a 15-pound box of supplies from a low shelf on the supply cart to a table. Which technique should the nurse use to protect the back? 1. Place the feet together to provide a strong base of support. 2. Flex the knees to lower the center of gravity. 3. Face the box, pick it up, and rotate the upper body toward the table. 4. Hold the box as close to the body as possible. Answer: 4 Explanation: In order to pick up this box as safely as possible, the nurse should hold the box as close to the body as possible. Page Ref: 1105 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Use safe practices when positioning, moving, transferring, and ambulating clients. MNL Learning Outcome: 3. Implement the steps for nursing procedures used in the care of patients with activity, exercise, and mobility problems. 7
9) The nurse is caring for a client experiencing dyspnea. In which position should the nurse place this client? 1. High Fowler position with two pillows behind the head 2. Orthopneic position across the overbed table 3. Prone position with knees flexed and arms extended 4. Sims position with both legs flexed Answer: 2 Explanation: The orthopneic position across the overbed table facilitates respiration by allowing maximum chest expansion. Page Ref: 1108 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Assess activity-exercise pattern, body alignment, gait, appearance and movement of joints, mobility capabilities and limitations, muscle mass and strength, activity tolerance, and problems related to immobility. MNL Learning Outcome: 3. Implement the steps for nursing procedures used in the care of patients with activity, exercise, and mobility problems. 10) While assisting the client with a bath, the nurse encourages full range of motion in all the client's joints. Which activity would best support range of motion in the hand and arm? 1. Give the client a washcloth to wash the face. 2. Move the wash basin farther toward the foot of the bed so the client must reach for it. 3. Have the client brush the hair and teeth. 4. Move each of the client's hand and arm joints through passive range of motion. Answer: 3 Explanation: Brushing the hair and teeth includes more of the joints of the hands and the arms than does washing the face. Page Ref: 1122 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 8. Compare and contrast active, passive, and active-assistive range-ofmotion (ROM) exercises. MNL Learning Outcome: 3. Implement the steps for nursing procedures used in the care of patients with activity, exercise, and mobility problems. 8
11) A client who is bed-bound complains of pain and burning in the right calf area. What action should be taken by the nurse? 1. Deeply palpate the area for rebound tenderness. 2. Percuss over the area for change in tone. 3. Measure the calf and compare to the opposite calf. 4. Medicate the client for pain and reassess in 30 minutes. Answer: 3 Explanation: The nurse should measure the calf and compare it to the opposite calf. The client may be developing a deep vein thrombosis or thrombophlebitis. Page Ref: 1101 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Assess activity-exercise pattern, body alignment, gait, appearance and movement of joints, mobility capabilities and limitations, muscle mass and strength, activity tolerance, and problems related to immobility. MNL Learning Outcome: 1. Assess activity-exercise pattern, body alignment, gait, appearance and movement of joints, mobility capabilities and limitations, muscle mass and strength, activity tolerance, and problems related to immobility for patients.
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12) The client who is bed-bound complains of abdominal pain. Bowel sounds are present. What action should be taken by the nurse? 1. Percuss for flatness over the liver. 2. Palpate for bladder fullness. 3. Use the p.r.n. order to medicate the client with an antacid. 4. Inspect the sacral area for edema. Answer: 2 Explanation: The nurse should palpate for bladder fullness that could cause this discomfort. Page Ref: 1101 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Assess activity-exercise pattern, body alignment, gait, appearance and movement of joints, mobility capabilities and limitations, muscle mass and strength, activity tolerance, and problems related to immobility. MNL Learning Outcome: 1. Assess activity-exercise pattern, body alignment, gait, appearance and movement of joints, mobility capabilities and limitations, muscle mass and strength, activity tolerance, and problems related to immobility for patients. 13) The client who is unconscious is developing foot drop. What nursing action is indicated? 1. Place high-topped shoes on the client while in bed. 2. Keep the linens on the end of the bed turned back to expose the feet. 3. Use only the prone and Sims positions for client positioning. 4. Use a device to elevate the linens off the feet. Answer: 1 Explanation: High-topped shoes will place the client's feet in the anatomical position of dorsal flexion. Page Ref: 1108 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Assess activity-exercise pattern, body alignment, gait, appearance and movement of joints, mobility capabilities and limitations, muscle mass and strength, activity tolerance, and problems related to immobility. MNL Learning Outcome: 3. Implement the steps for nursing procedures used in the care of patients with activity, exercise, and mobility problems. 10
14) The nurse is planning care for a client who has limited bed mobility. What instruction should be given to the assistive personnel who will be caring for this client? (Select all that apply.) 1. Place a turn sheet on the bed. 2. Always use two personnel to move the client. 3. Stand at the head of the bed to pull the client up. 4. Slide the client toward the head of the bed. 5. Encourage the client to assist as possible. Answer: 1, 2, 5 Explanation: Placing a turn sheet on the bed will help overcome inertia and friction during moving. Using two personnel will allow a "lift and move" rather than pulling or sliding the client over linens. Encouraging the client to assist as much as possible will lighten the workload. Page Ref: 1106 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the health care team | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 11. Recognize when it is appropriate to assign aspects of moving, transferring, and ambulating a client to assistive personnel. MNL Learning Outcome: 3. Implement the steps for nursing procedures used in the care of patients with activity, exercise, and mobility problems.
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15) The nurse is preparing to assist a client to a lateral position to position a bedpan. What action should the nurse take first? 1. Perform hand hygiene. 2. Move the client to the side of the bed. 3. Place the client's arm over the chest. 4. Raise the opposite side rail. Answer: 1 Explanation: Even though the intervention being performed is placing the client on a bedpan, the nurse should first perform hand hygiene. This prevents cross-transmission of infection from one client to another. Performing this hygiene in front of the client also increases the client's perception of the quality of care being provided and the nurse's concern about infection control. Page Ref: 1113 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Use safe practices when positioning, moving, transferring, and ambulating clients. MNL Learning Outcome: 3. Implement the steps for nursing procedures used in the care of patients with activity, exercise, and mobility problems. 16) When planning care, the nurse should identify which client as needing logrolling for position changes? 1. A client with documented pneumonia 2. The client who has had abdominal surgery 3. The client who fell from a house, sustaining fractured vertebrae 4. A client who has a severe headache from hypertensive crisis Answer: 3 Explanation: The logrolling technique is used in moving any client who may have sustained a spinal injury. Of these clients, the most concern is for the client who fell from a house. Page Ref: 1114 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 7. Use safe practices when positioning, moving, transferring, and ambulating clients. MNL Learning Outcome: 3. Implement the steps for nursing procedures used in the care of patients with activity, exercise, and mobility problems. 12
17) The nurse is assisting the client to dangle on the bedside. After raising the head of the bed, in which position should the nurse face? 1. Toward the nearest corner of the head of the bed 2. Toward the side of the bed 3. Toward the far corner of the foot of the bed 4. Directly toward the client Answer: 3 Explanation: The nurse should face the far corner of the foot of the bed because this is the direction in which movement will occur. Page Ref: 1126 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 10. Verbalize the steps used in: d. Assisting a client to sit on the side of the bed. MNL Learning Outcome: 3. Implement the steps for nursing procedures used in the care of patients with activity, exercise, and mobility problems. 18) What is the priority action of the nurse prior to transferring a client from bed to wheelchair? 1. Place the bed in its lowest position. 2. Place the wheelchair parallel to the bed. 3. Lock the brakes on the bed. 4. Place a transfer belt on the client. Answer: 3 Explanation: Although all of these activities address important safety issues, the most important is to lock the wheels on the bed. If the wheels are not locked and the bed moves out from under the client, none of the other safety actions will likely prevent a fall or near fall. Page Ref: 1118-1119 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 10. Verbalize the steps used in: e. Transferring between bed and chair. MNL Learning Outcome: 3. Implement the steps for nursing procedures used in the care of patients with activity, exercise, and mobility problems.
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19) The nurse is preparing to transfer a client from the bed to a stretcher. At which height should the bed be placed for this transfer? 1. Slightly higher 2. Slightly lower 3. At the same height 4. At least 2 inches lower Answer: 1 Explanation: When transferring a client from bed to gurney, the bed should be parallel to the stretcher and slightly higher. It is easier for the client to move down a slant to the new surface than to move up to a higher surface or to an even surface. Page Ref: 1121 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 10. Verbalize the steps used in: f. Transferring between bed and stretcher. MNL Learning Outcome: 3. Implement the steps for nursing procedures used in the care of patients with activity, exercise, and mobility problems. 20) The postoperative client is preparing to ambulate for the first time since surgery. Which staff member should ambulate this client? 1. The AP 2. A licensed practical (vocational) nurse 3. A registered nurse 4. It makes no difference Answer: 3 Explanation: Because this is the first time this client has ambulated, the best choice is for the registered nurse to ambulate the client. The registered nurse must assess and evaluate the client's response to the ambulation. Once the client has successfully ambulated, any nursing staff member can assist. The registered nurse should make assistive personnel aware of potential untoward effects of ambulation and of what to report to the nurse. Page Ref: 1126 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the health care team | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 11. Recognize when it is appropriate to assign aspects of moving, transferring, and ambulating a client to assistive personnel. MNL Learning Outcome: 3. Implement the steps for nursing procedures used in the care of patients with activity, exercise, and mobility problems. 14
21) A client who is ambulating complains of light-headedness and begins to faint. What is the nurse's most important action? 1. Ensure for the client's modesty. 2. Be certain the client does not hit the head on anything. 3. Call for immediate assistance. 4. Check the vital signs. Answer: 2 Explanation: The priority is ensuring the client does not strike the head on anything when falling. The nurse should ease the client down while supporting the body against the nurse, protecting the head and laying it gently on the floor. Page Ref: 1127 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 10. Verbalize the steps used in: g. Assisting a client to ambulate. MNL Learning Outcome: 3. Implement the steps for nursing procedures used in the care of patients with activity, exercise, and mobility problems. 22) The nurse is providing range-of-motion exercising to the client's elbow when the client complains of pain. What action should the nurse take? 1. Stop immediately and report the pain to the client's physician. 2. Discontinue the treatment and document the results in the medical record. 3. Reduce the movement of the joint just until the point of slight resistance. 4. Continue to exercise the joint as before to loosen the stiffness. Answer: 3 Explanation: Range-of-motion exercising should never cause discomfort. In this case, the best action is to reduce the movement of the joint just until the point of slight resistance is felt and evaluate the pain response at that level. If there is no pain, the exercise can be continued. Page Ref: 1123 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 8. Compare and contrast active, passive, and active-assistive range-ofmotion (ROM) exercises. MNL Learning Outcome: 3. Implement the steps for nursing procedures used in the care of patients with activity, exercise, and mobility problems. 15
23) A client has a history of orthostatic hypotension. Which activities should the nurse advise this client as likely to cause orthostatic hypotension? (Select all that apply.) 1. Hot baths 2. Heavy meals 3. Use of a rocking chair 4. Moving in bed 5. Bending down to the floor Answer: 1, 2, 5 Explanation: Hot baths can cause venous pooling in the lower extremities. Heavy meals divert blood to the gastrointestinal organs. Bending to the floor can cause rapid changes in blood pressure upon standing up again. Page Ref: 1125 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 5. Assess activity-exercise pattern, body alignment, gait, appearance and movement of joints, mobility capabilities and limitations, muscle mass and strength, activity tolerance, and problems related to immobility. MNL Learning Outcome: 3. Implement the steps for nursing procedures used in the care of patients with activity, exercise, and mobility problems.
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24) The nurse is teaching a client on the use of a cane. What should the nurse include in this teaching? (Select all that apply.) 1. Hold the cane on the weaker side of the body. 2. Move the cane forward while the body weight is between both legs. 3. The length of the cane should permit the elbow to be fully extended. 4. Move the weaker leg forward while the weight is between the cane and the stronger leg. 5. Move the stronger leg forward while the weight is between the cane and the weaker leg. Answer: 2, 4, 5 Explanation: The cane should be moved forward while the body weight is borne by both legs. The weaker leg is moved forward while the weight is borne by the cane and stronger leg. The stronger leg is moved forward while the weight is borne by the cane and weak leg. Page Ref: 1127-1128 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 9. Describe client teaching for clients who use mechanical aids for walking. MNL Learning Outcome: 3. Implement the steps for nursing procedures used in the care of patients with activity, exercise, and mobility problems.
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25) The nurse observes a client walking down the hall. Which element of body movement should the nurse assess in this client? (Select all that apply.) 1. Posture 2. Balance 3. Joint mobility 4. Range of motion 5. Coordinated movement Answer: 1, 2, 3, 5 Explanation: Posture, balance, joint mobility, and coordinated movement are elements of body movement. Balance is an element of body movement. Joint mobility is an element of body movement. Coordinated movement is an element of body movement. Page Ref: 1083 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Describe four basic elements of normal movement. MNL Learning Outcome: 1. Assess activity-exercise pattern, body alignment, gait, appearance and movement of joints, mobility capabilities and limitations, muscle mass and strength, activity tolerance, and problems related to immobility for patients.
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26) A client recovering from surgery is turned and repositioned in bed. Which should the nurse document about this positioning? (Select all that apply.) 1. Skin status 2. Type of surgery 3. Time of position change 4. Use of supportive devices 5. Client response to the move Answer: 1, 3, 4, 5 Explanation: The client's skin status, time of position change, use of any supportive devices, and client's response to the move should be documented. The time of position change should be documented. The use of any supportive devices should be documented. The client's response to the move should be documented. Page Ref: 1114 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 12. Demonstrate appropriate documentation and reporting of moving, transferring, and ambulating a client. MNL Learning Outcome: 4. Implement the evaluation, documentation, and reporting of care of patients with activity, exercise, and mobility problems.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 45 Sleep 1) The mother of a newborn is concerned because the baby's eyes dart around the eyelids and twitching and irregular breathing occurs during sleep. What advice should the nurse give this mother? 1. Please bring your baby in immediately for a checkup. 2. These are common behaviors in newborns and are normal. 3. You should ask the physician about these symptoms at your next checkup. 4. If your baby does this again, take her to the emergency department. Answer: 2 Explanation: These are indications of normal REM sleep in the newborn. The mother should be reassured that this is normal. Page Ref: 1139-1140 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 3. Describe variations in sleep patterns throughout the lifespan. MNL Learning Outcome: 1. Examine the physiology of sleep and normal sleep patterns across the lifespan.
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2) The parents of a 6-month-old are exhausted because the baby wakes up several times every night. What advice should the nurse give these parents? 1. Be certain that the baby is truly awake before providing a feeding. 2. Let the baby "cry it out" for a few nights until able to sleep through the night. 3. Continue to respond to the baby whenever restlessness occurs during the night. 4. Bring the baby in for a possible sleep study to check for sleeping disorders. Answer: 1 Explanation: Babies often move and make noises while sleeping that do not indicate wakefulness. The parents should be certain the baby is awake before feeding, changing, or comforting. Page Ref: 1140 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 3. Describe variations in sleep patterns throughout the lifespan. MNL Learning Outcome: 1. Examine the physiology of sleep and normal sleep patterns across the lifespan. 3) An older client reports going to sleep easily but waking up a few hours later and unable to go back to sleep. What nursing action would help promote rest and sleep in this client? 1. Have the client develop a bedtime ritual of quiet music and a glass of wine. 2. Encourage the client to avoid taking pain medication prior to sleep. 3. Evaluate if the client perceives sleeplessness to be a serious problem. 4. Have the client perform moderate exercises before bedtime. Answer: 3 Explanation: The first intervention is to determine what the pattern of sleeplessness means to the client. Many older clients will "nap" off and on through the day and night and spend wakeful times engaged in activity, even if the active times are not during traditional active hours. Page Ref: 1143 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 8. Describe interventions that promote sleep. MNL Learning Outcome: 2. Examine factors that affect sleep.
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4) A client complains of not being able to stay awake during the day even after sleeping throughout the night. What should the nurse suggestion to this client? 1. Go to your physician for a physical examination. 2. Go to a mental health professional for evaluation of possible depression. 3. Purchase an over-the-counter sleep aid to deepen nighttime sleep. 4. Drink more caffeinated beverages in the daytime to stay awake. Answer: 1 Explanation: Daytime hypersomnia is often due to medical conditions such as kidney, liver, or metabolic disturbances. The nurse should suggest that the client be evaluated by a physician. Page Ref: 1146 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Describe common sleep disorders. MNL Learning Outcome: 2. Examine factors that affect sleep. 5) The nurse is developing a plan of care for a client diagnosed with narcolepsy. Which intervention should the nurse include in this plan of care? 1. Encourage the client to take an over-the-counter medication to improve nighttime sleep. 2. Be certain the client has the prescription for modafinil (Provigil) filled. 3. Have the client purchase sodium oxybate (Xyrem) over-the-counter to prevent daytime drowsiness. 4. Be certain the client obtains antihistamines to control nasal stuffiness. Answer: 2 Explanation: The medication modafinil (Provigil) is prescribed to control the daytime drowsiness associated with narcolepsy. Sodium oxybate is not sold over-the-counter. Page Ref: 1146 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 5. Describe common sleep disorders. MNL Learning Outcome: 2. Examine factors that affect sleep.
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6) A client is being treated with a nasal continuous positive airway pressure device (CPAP) for sleep apnea. What finding indicates that this treatment has been helpful to the client? 1. The client has lost 7 pounds since treatment began. 2. The client sleeps so soundly that he snores. 3. The client's diabetes is now under control. 4. The client reports a decrease in morning headache. Answer: 4 Explanation: The fact that the client experiences a decrease in morning headache indicates the client is sleeping better. Page Ref: 1146 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation Learning Outcome: 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems. MNL Learning Outcome: 4. Implement nursing interventions to promote sleep. 7) The nurse is admitting a critically ill client to the intensive care unit. What question should the nurse ask regarding this client's sleep history? 1. No questions should be asked. 2. "When do you usually go to sleep?" 3. "Do you have any problems with sleeping?" 4. "What are your bedtime rituals?" Answer: 1 Explanation: When the client is critically ill or being admitted for an outpatient procedure, sleep history can be omitted or deferred. Page Ref: 1148 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 6. Identify the components of a sleep pattern assessment. MNL Learning Outcome: 3. Assess the sleep patterns of patients.
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8) A client with sleep apnea reports falling asleep while driving, almost being involved in an accident, and frequent episodes of sleepwalking. What nursing diagnosis should be a priority for this client? 1. Disturbed Sleep Pattern related to difficulty staying asleep 2. Risk for Impaired Gas Exchange related to sleep apnea 3. Disturbed Thought Processes related to chronic insomnia 4. Risk for Injury related to somnambulism Answer: 4 Explanation: The priority is Risk for Injury related to somnambulism because it reflects the most dangerous situation for the client. Page Ref: 1149 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems. MNL Learning Outcome: 4. Implement nursing interventions to promote sleep. 9) A client has the nursing diagnosis Disturbed Sleep Pattern, difficulty staying asleep related to anxiety secondary to multiple life stressors. Which expected outcome would be most applicable to this client's situation? 1. The client will sleep at least 8 hours each night. 2. The client will list three positive coping mechanisms for anxiety relief. 3. The client will report getting sufficient sleep to provide energy for daily activities. 4. The client will manifest less anxiety after taking prescribed medications. Answer: 3 Explanation: The best outcome statement for this client is to report getting sufficient sleep to provide energy for daily activities. Page Ref: 1149 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems. MNL Learning Outcome: 4. Implement nursing interventions to promote sleep.
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10) The nurse is planning interventions for a client who has difficulty falling asleep. Which intervention regarding sleep times would be most helpful? 1. Maintain a regular bedtime and wake-up time for all days of the week. 2. If bedtime is delayed on one night, go to bed that much earlier the next night. 3. If daytime drowsiness occurs, go to bed earlier that night. 4. Sleep at least 1 hour later on mornings you don't have to go to work. Answer: 1 Explanation: The best intervention is to have the client establish and maintain a regular bedtime and wake-up time for all days of the week. Page Ref: 1150 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems. MNL Learning Outcome: 4. Implement nursing interventions to promote sleep. 11) A client reports difficulty sleeping. Which environmental intervention should the nurse recommend? 1. Play soft music throughout the night. 2. Keep a television on in the bedroom. 3. Provide white noise with a fan. 4. Play a talk radio station. Answer: 3 Explanation: Noise should be kept to a minimum. Extraneous noise can be blocked by white noise from a fan, air conditioner, or white noise machine. Page Ref: 1150 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems. MNL Learning Outcome: 4. Implement nursing interventions to promote sleep.
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12) A client reports difficulty sleeping and awakening several times during the night. What intervention should the nurse recommend for the client when unable to sleep? 1. Get out of bed, go into another room, and pursue some relaxing activity until drowsy. 2. Get out of bed, go into another room, and exercise until tired before trying to go back to sleep. 3. Sit in bed and watch the bedroom television until drowsy. 4. Stay in bed with eyes closed and do some mental arithmetic until sleepy. Answer: 1 Explanation: The bed should be used only for sleep or sexual activity, so it is associated with sleep. The client should get up, go into a different room, and pursue some relaxing activity until drowsiness returns. Page Ref: 1150 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems. MNL Learning Outcome: 4. Implement nursing interventions to promote sleep. 13) A hospitalized client requests a bedtime snack. Which food should the nurse offer this client? 1. Hot chocolate 2. Tea and crackers 3. Cereal with milk 4. Chips and salsa Answer: 3 Explanation: The nurse should offer the client a light carbohydrate (cereal) and milk. Page Ref: 1150 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 8. Describe interventions that promote sleep. MNL Learning Outcome: 4. Implement nursing interventions to promote sleep.
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14) A client has been prescribed zolpidem (Ambien) for the short-term management of insomnia. What information should the nurse include when teaching the client about this medication? 1. For best results, take the medication just prior to bedtime. 2. Take the medication at dinnertime to avoid gastric upset. 3. Do not take the medication with any liquid that contains calcium. 4. Drink an entire glass of water with the dose to avoid kidney stones. Answer: 1 Explanation: Zolpidem (Ambien) has a rapid onset of action, so for best results and decreased sedation while awake, the client should take the medication just prior to bedtime. Page Ref: 1153 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems. MNL Learning Outcome: 4. Implement nursing interventions to promote sleep. 15) A client who has obstructive sleep apnea is being treated with a nasal continuous positive airway pressure (CPAP) device but has just been prescribed modafinil (Provigil). What client statement indicates that teaching about these therapies has been effective? 1. "I am so glad that I won't have to sleep in this machine anymore." 2. "Once I get regulated on the Provigil, I will wean myself off the CPAP." 3. "I will continue using my CPAP machine at night." 4. "I can turn down the pressure on my CPAP machine in about 1 week." Answer: 3 Explanation: Provigil is a medication that is for the treatment of narcolepsy, not sleep apnea. It will not prevent sleep apnea, so the client must continue to use the CPAP machine as it was used prior to the Provigil. Page Ref: 1153 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation/Teaching and Learning Learning Outcome: 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems. MNL Learning Outcome: 4. Implement nursing interventions to promote sleep.
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16) A client questions why a medication that is used to treat Parkinson disease has been prescribed for the diagnosis of periodic limb movement disorder (PLMD). What should the nurse do? 1. Contact the physician. 2. Assure the client that medications used to treat Parkinson disease are also used to treat PLMD. 3. Tell the client not to take the medication because there is most likely an error. 4. Check with the pharmacy to make sure the correct medication has been provided to the client. Answer: 2 Explanation: Medications that are commonly prescribed for the treatment of Parkinson disease are also prescribed for the treatment of PLMD. Page Ref: 1147 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems. MNL Learning Outcome: 4. Implement nursing interventions to promote sleep. 17) A client with stiffness and muscle tension in the back declines the offer of a back rub. What action should the nurse take? 1. Encourage the client to accept the back rub, saying how much it will relax the back muscles. 2. Document that the client is noncompliant with the nursing plan of care. 3. Accept the declination but tell the client to call if one is desired later. 4. Instruct assistive personnel to rub the client's back while assisting to change into a clean gown. Answer: 3 Explanation: Some clients are eager to have a back rub, but others are not comfortable with the close physical contact this intervention requires. Respect the client's decision but keep the offer open if one is desired later. Page Ref: 1151 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 8. Describe interventions that promote sleep. MNL Learning Outcome: 4. Implement nursing interventions to promote sleep.
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18) A 5-year-old client has recurrent night terrors. What nursing intervention should the nurse use to help alleviate this problem? 1. Have the child walk around in the room when night terrors occur. 2. The next morning, ask the child to describe the event. 3. Have the child empty the bladder prior to going to bed. 4. Use an additional pillow behind the child's head at night. Answer: 3 Explanation: Night terrors are partial awakenings that are sometimes related to excessive tiredness or a full bladder. Having the child empty the bladder before going to bed might be helpful. Page Ref: 1143 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems. MNL Learning Outcome: 4. Implement nursing interventions to promote sleep. 19) A client is diagnosed with obstructive sleep apnea. Which findings should the nurse expect when assessing this client? (Select all that apply.) 1. Reddened uvula 2. Large soft palate 3. Obesity 4. Short neck 5. Deviated septum Answer: 1, 2, 3 Page Ref: 1149 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Describe common sleep disorders. MNL Learning Outcome: 2. Examine factors that affect sleep.
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20) A hospital committee is tasked with reducing environmental distractions to sleep within the hospital. Which recommendations by the committee would be helpful? (Select all that apply.) 1. Turn off all overhead lights on the unit and use nightlights and flashlights. 2. Establish a time at which radios and televisions should be turned off or down. 3. Discontinue use of the paging system after 2100. 4. Conduct nursing reports in the hallway. 5. Open curtains between beds in semiprivate rooms. Answer: 2, 3 Explanation: Establishing a time at which radios and televisions should be turned off or down will reduce the amount of disturbance to clients. Discontinuing use of the paging system at 2100 will also reduce noise. Page Ref: 1151 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 8. Describe interventions that promote sleep. MNL Learning Outcome: 4. Implement nursing interventions to promote sleep. 21) A client tells the nurse that because of work and life responsibilities, sleep has "become optional." What is the best response the nurse should make to this client? 1. "Be sure to get extra sleep when you can." 2. "A lack of sleep can affect hormone levels and bodily functions." 3. "Everyone has different needs for sleep in order to function." 4. "You must be very productive." Answer: 2 Explanation: Different biological functions occur during sleep that become altered with the lack of sleep. The nurse should explain what is affected by a lack of sleep. Page Ref: 1142 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 1. Explain the physiology and the functions of sleep. MNL Learning Outcome: 1. Examine the physiology of sleep and normal sleep patterns across the lifespan.
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22) The nurse is assessing a client in the intensive care unit who is asleep. What physiological changes will the nurse observe in this client? (Select all that apply.) 1. Lower respiratory rate 2. Increased muscle tension 3. Increased lower-extremity edema 4. Lower blood pressure 5. Lower heart rate Answer: 4, 5 Explanation: One physiological change that occurs during sleep is a drop in arterial blood pressure. One physiological change that occurs during sleep is a decrease in heart rate. Page Ref: 1139 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Identify the characteristics of the NREM and REM sleep states. MNL Learning Outcome: 1. Examine the physiology of sleep and normal sleep patterns across the lifespan.
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23) A client with diabetes asks why the blood glucose level is higher on days when less sleep is obtained. What should the nurse explain to the client? 1. During sleep, the hormone cortisol is inhibited. If sleep is interrupted, cortisol levels will remain elevated, impacting blood glucose. 2. Because the client is awake more, it is likely the client is eating more, which is impacting the blood glucose level. 3. There is no relationship between sleep and blood glucose levels. 4. The body needs cortisol for the extra energy created by the lack of sleep. Answer: 1 Explanation: The cortisol level falls during sleep. With waking, the cortisol level peaks. If the client with diabetes is not getting sufficient rest, the cortisol level will stay elevated, which will impact the control of blood glucose. Page Ref: 1138 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 1. Explain the physiology and the functions of sleep. MNL Learning Outcome: 1. Examine the physiology of sleep and normal sleep patterns across the lifespan. 24) A hospitalized client is being awakened every hour during the night for care and procedures. The nurse realizes that the lack of NREM sleep can have which physiological effect? 1. Decrease urine output 2. Increase thirst 3. Increase susceptibility to infection 4. Decrease heart rate Answer: 3 Explanation: The loss of NREM sleep causes immunosuppression, slows tissue repair, lowers pain tolerance, triggers profound fatigue, and increases susceptibility to infection. Page Ref: 1139 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Explain the physiology and the functions of sleep. MNL Learning Outcome: 1. Examine the physiology of sleep and normal sleep patterns across the lifespan. 13
25) A client has not had uninterrupted sleep for several nights and is irritable. What other assessment findings should the nurse associate with the client's lack of REM sleep? (Select all that apply.) 1. Depression 2. Confusion 3. Disorientation 4. Impaired memory 5. Muscle weakness Answer: 1, 2, 3, 4 Page Ref: 1143 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Explain the physiology and the functions of sleep. MNL Learning Outcome: 1. Examine the physiology of sleep and normal sleep patterns across the lifespan. 26) A client who appeared to be asleep denies sleeping and wants the television to remain on. Which stage of NREM sleep is the client demonstrating? 1. 4 2. 3 3. 2 4. 1 Answer: 4 Explanation: Stage 1 is the stage of very light sleep and lasts only a few minutes. During this stage, the person feels drowsy and relaxed, the eyes roll from side to side, and the heart and respiratory rates drop slightly. The sleeper can be readily awakened and might deny that she was sleeping. Page Ref: 1139 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Identify the characteristics of the NREM and REM sleep states. MNL Learning Outcome: 1. Examine the physiology of sleep and normal sleep patterns across the lifespan.
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27) The parent of a preschool-age child asks the nurse what can be done to reduce the number of nightmares the child experiences. What should the nurse suggest to this parent? 1. Provide hot chocolate prior to bedtime. 2. Limit or eliminate television. 3. Engage in a physical activity before bedtime. 4. Play a computer game before bedtime. Answer: 2 Explanation: Preschool children wake up frequently at night, and they might be afraid of the dark or experience night terrors or nightmares. Often, limiting or eliminating TV will reduce the number of nightmares. Page Ref: 1141 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems. MNL Learning Outcome: 4. Implement nursing interventions to promote sleep. 28) A client reports the need to urinate during the night and then not being able to fall back asleep. The nurse should document this assessment finding as which factor that influences sleep? 1. Illness 2. Stimulant 3. Diet 4. Lifestyle Answer: 1 Explanation: The need to urinate during the night disrupts sleep, and people who awaken at night to urinate sometimes have difficulty getting back to sleep. Page Ref: 1142-1143 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems. MNL Learning Outcome: 3. Assess the sleep patterns of patients.
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29) A client is working two jobs, caring for aged parents, and maintaining a household for the family. The nurse realizes that this emotional stress will have what impact on the client's sleep? 1. More REM sleep 2. Less Stage 1 and Stage II NREM sleep 3. More NREM sleep 4. Less deep sleep and more awakenings during the night Answer: 4 Explanation: Stress is considered by most sleep experts to be the number one cause of shortterm sleeping difficulties. A person preoccupied with personal problems might be unable to relax sufficiently to get to sleep. Anxiety increases the norepinephrine blood levels through stimulation of the sympathetic nervous system. This chemical change results in less deep and REM sleep and more stage changes and awakenings. Page Ref: 1144 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Identify factors that affect sleep. MNL Learning Outcome: 2. Examine factors that affect sleep. 30) A client who smokes cigarettes reports being a light sleeper and awakens easily. What should the nurse suggest to help this client sleep? 1. Smoke no cigarettes 1 hour before sleep. 2. Smoke no cigarettes after the evening meal. 3. Limit the number of cigarettes smoked during the day. 4. Adjust to the lack of sleep because those who smoke do not get sufficient sleep. Answer: 2 Explanation: Nicotine has a stimulating effect on the body, and smokers often have more difficulty falling asleep than nonsmokers do. Smokers are usually easily aroused, and often describe themselves as light sleepers. When refraining from smoking after the evening meal, the person usually sleeps better. Page Ref: 1144 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems. MNL Learning Outcome: 4. Implement nursing interventions to promote sleep. 16
31) A client reports having problems falling and staying asleep. What should the nurse ask the client to gain more information about this client problem? (Select all that apply.) 1. "How often does this happen?" 2. "How much coffee do you drink each day?" 3. "How do you feel when you wake up in the morning?" 4. "When do you eat your evening meal?" 5. "What have you done to deal with this sleeping problem?" Answer: 1, 2, 3, 5 Page Ref: 1148 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 6. Identify the components of a sleep pattern assessment. MNL Learning Outcome: 3. Assess the sleep patterns of patients. 32) After an assessment, the nurse is concerned that an older client is experiencing changes in sleep. What findings did the nurse use to make this clinical decision? (Select all that apply.) 1. Is wide awake around 3:00 AM 2. Takes a nap after lunch every day 3. Returns to sleep after using the bathroom 4. Goes to sleep before 9:00 PM most evenings 5. Wakes up and looks at the clock every hour Answer: 1, 2, 4, 5 Explanation: A hallmark change with age is a tendency toward earlier wake times. Many older adults report daytime napping, which may contribute to reduced nocturnal sleep. A hallmark change with age is a tendency toward earlier bedtime. Older adults may awaken an average of six times during the night. Page Ref: 1142 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Describe variations in sleep patterns throughout the lifespan. MNL Learning Outcome: 1. Examine the physiology of sleep and normal sleep patterns across the lifespan.
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33) The nurse suspects that an adult is not getting an adequate amount of nightly sleep. What information caused the nurse to have this suspicion? (Select all that apply.) 1. Enrolled in online classes 2. Raising two children ages 4 and 8 3. Experiences chronic pain from sciatica 4. Attends religious services every Sunday and Wednesday 5. Works one steady job at night and another part time in the late afternoon Answer: 1, 2, 3, 5 Explanation: Certain adults, such as students, are vulnerable for not getting enough sleep. A woman's sleep pattern is more commonly affected by the birth of a child. However, both parents of infants and young children experience fatigue related to interrupted sleep or sleep deprivation. Certain adults, such as those experiencing chronic pain, are vulnerable for not getting enough sleep. Certain adults, such as shift workers, are vulnerable for not getting enough sleep. Adults working long hours or multiple jobs may find their sleep less refreshing. Page Ref: 1142 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Identify factors that affect sleep. MNL Learning Outcome: 2. Examine factors that affect sleep.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 46 Nutrition 1) The parent of a newborn infant reports that the baby wakes up every 2 hours and only takes about 2 ounces of formula before going back to sleep. What instruction should the nurse give this parent? 1. Make the baby wait at least 3 hours between feedings. 2. Continue to feed the baby with this on-demand schedule. 3. When the baby gets sleepy during feeding, use techniques such as moving around and tickling to encourage wakefulness. 4. Offer the baby less formula to prevent waste. Answer: 2 Explanation: Newborns are often fed following an on-demand schedule. This might include feedings every 2 hours at first. Page Ref: 1167 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 4. Identify nutritional variations throughout the life cycle. MNL Learning Outcome: 1. Assess the nutritional status of patients across the lifespan. 2) What criteria should the nurse use to evaluate to determine if an infant's regurgitation, or spitting up, should be further investigated? 1. How often the baby spits up 2. How much the baby spits up at a time 3. If the baby is gaining weight adequately 4. The consistency of the regurgitated matter Answer: 3 Explanation: As long as the baby is gaining weight adequately, it is not abnormal for regurgitation or spitting up to occur. Page Ref: 1167 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Identify nutritional variations throughout the life cycle. MNL Learning Outcome: 1. Assess the nutritional status of patients across the lifespan. 1
3) The parents of a 7-month-old child have started offering solid foods to their baby. The baby has enjoyed and tolerated rice cereal, applesauce, and other fruits. Which food should the nurse recommend to be introduced next? 1. Strained beef 2. Green beans 3. Squash 4. Strained chicken Answer: 3 Explanation: As the baby develops, foods are offered in the sequence in which they are generally best tolerated. Most experts recommend introducing cereals, fruits, yellow vegetables (e.g., squash), green vegetables (e.g., green beans), and then meats. Page Ref: 1167 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 4. Identify nutritional variations throughout the life cycle. MNL Learning Outcome: 1. Assess the nutritional status of patients across the lifespan. 4) The nurse completes triceps skinfold measurement on a client. In order to obtain the most meaningful data, how soon should the nurse repeat this measurement? 1. 2 days 2. 10 days to 2 weeks 3. 1 month 4. 1 year Answer: 4 Explanation: Anthropometric measurements such as triceps skinfold measurement provide the most meaningful data when monitored over longer periods of time, such as several months to years. Page Ref: 1178 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 9. Discuss nursing interventions to treat clients with nutritional problems. MNL Learning Outcome: 1. Assess the nutritional status of patients across the lifespan.
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5) The client's lab studies reveal a normal serum albumin with a prealbumin of 10. How should the nurse interpret the significance of these readings? 1. The client has had recent protein malnutrition. 2. The client is now relatively well nourished with malnutrition 6-8 months ago. 3. The client is at risk for development of malabsorption syndromes. 4. Carbohydrate malnutrition has occurred over the last 6 months. Answer: 1 Explanation: Prealbumin is the most responsive serum protein to rapid changes in nutritional status. A level below 11 indicates that aggressive nutritional intervention is necessary. Page Ref: 1179 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation Learning Outcome: 9. Discuss nursing interventions to treat clients with nutritional problems. MNL Learning Outcome: 4. Implement the evaluation, documentation, and reporting of care for patients with nutritional problems. 6) A client reports following the "food pyramid" to guide nutritional intake. How should the nurse evaluate this information? 1. Because this food pyramid is produced by the U.S. Department of Agriculture, the client is likely consuming necessary levels of all essential nutrients. 2. The food pyramid is most useful when applied to the nutritional intake of children. 3. The food pyramid is not very useful because it does not take fluid intake and combination foods into consideration. 4. The food pyramid has been replaced with MyPlate to be used as a guide for dietary intake. Answer: 4 Explanation: Various daily food guides have been developed to help healthy individuals meet the daily requirements of essential nutrients and to facilitate meal planning. MyPlate has replaced the food pyramid as an overall guide. Page Ref: 1173 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation Learning Outcome: 5. Evaluate a diet using a food guide pyramid. MNL Learning Outcome: 2. Plan care for patients with nutritional problems.
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7) The nurse has instructed an overweight client to follow a 2,000-calorie diet by substituting foods considered low in calories for those higher in calories. How should the client interpret the food label to decide if a food is moderate in calories? 1. The product label will state "lighter" or "reduced calories." 2. The Nutrition Facts label will have the letter "L" located in the lower right corner. 3. Nutritional labeling on the product will indicate 100 calories per serving. 4. The product will contain no more than 11% fat. Answer: 3 Explanation: In order to qualify as a low-calorie food in a 2,000-calorie diet, the food must have 100 calories per serving. Page Ref: 1174 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation/Teaching and Learning Learning Outcome: 9. Discuss nursing interventions to treat clients with nutritional problems. MNL Learning Outcome: 4. Implement the evaluation, documentation, and reporting of care for patients with nutritional problems. 8) Nitrogen balance testing is planned for a client. What instruction to the staff caring for this client is essential? 1. Remove the client's oxygen cannula 10 minutes prior to the test. 2. Accurate measurement of food intake is very important. 3. All urine output should be collected for 48 hours. 4. Keep the client NPO beginning at midnight before the test. Answer: 2 Explanation: Nitrogen balance is determined by comparing the grams of protein taken in to the urinary nitrogen output for 24 hours. Accurate food intake is essential. Page Ref: 1179 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 9. Discuss nursing interventions to treat clients with nutritional problems. MNL Learning Outcome: 2. Plan care for patients with nutritional problems.
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9) A client who has undergone gastrointestinal surgery is permitted to have a clear liquid diet on the second postoperative day. Which fluid should the nurse order from the diet kitchen for this client? 1. Apricot nectar 2. Cranberry juice 3. Chicken broth 4. Cherry ice pop Answer: 3 Explanation: Chicken broth is the only liquid listed that is clear and not red. Page Ref: 1182-1183 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 9. Discuss nursing interventions to treat clients with nutritional problems. MNL Learning Outcome: 2. Plan care for patients with nutritional problems. 10) Assistive personnel are assigned the task of feeding breakfast to older clients with alterations in mobility and orientation. What instruction should the nurse include in this delegation? 1. Breakfast should be completed quickly so that baths may begin. 2. Give fluids before and after each bite of solid foods. 3. Stand to the left of right-handed clients during feeding. 4. Engage the client in conversation during the meal. Answer: 4 Explanation: Of the options given, the best answer is to engage the client in conversation during the meal. This makes the mealtime pleasant and encourages socialization as well as appetite. Page Ref: 1185 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the health care team | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 9. Discuss nursing interventions to treat clients with nutritional problems. MNL Learning Outcome: 2. Plan care for patients with nutritional problems.
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11) The nurse is preparing to insert a nasogastric tube into a client. In what order will the nurse conduct the following steps? 1. Ask the client to tilt the head forward. 2. Insert the tube with its natural curve toward the client. 3. Ask the client to hyperextend the neck. 4. Have the client swallow a small amount of liquid. 5. Employ a slight twisting motion on the tube. Answer: 2, 3, 5, 1, 4 Explanation: 1. At this time, have the client tilt the head forward to facilitate passage of the tube into the posterior pharynx and esophagus. 2. The tube should first be inserted with its natural curve toward the client. 3. At this time, having the client hyperextend the neck will reduce the curvature of the nasopharyngeal junction. 4. The client should then be asked to swallow to move the epiglottis over the opening of the larynx, directing the tube toward the esophagus. 5. A slight twisting motion may help pass the tube into the nasopharynx. Page Ref: 1187-1189 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 10. Verbalize the steps used in: a. Inserting a nasogastric tube. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients requiring tube feeding.
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12) The nurse has assigned administration of tube feeding to a specially trained assistive personnel (AP). What action should be taken by the nurse in regard to this delegation? 1. Order the equipment to give the feeding. 2. Check the tube for placement. 3. Set up the equipment and mix the feeding. 4. Regulate the rate of the feeding. Answer: 2 Explanation: The nurse is responsible to assess tube placement and to determine that the tube is patent. Page Ref: 1193 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the health care team | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 11. Recognize when it is appropriate to assign aspects of feeding clients to assistive personnel. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients requiring tube feeding. 13) The nurse notices that the client's continuous open-system tube-feeding set is almost empty. What action should the nurse take? 1. Add tube feeding to the set. 2. Discontinue the feeding and hang a closed system bag. 3. Wash out the set and add new feeding. 4. Flush the set with clear carbonated soda and discontinue. Answer: 3 Explanation: The open set should be taken down, washed well, and rehung with new feeding. Page Ref: 1194 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 10. Verbalize the steps used in: c. Administering a tube feeding. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients requiring tube feeding.
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14) As the nasogastric tube is passed into the oropharynx, the client begins to gag and cough. What is the correct nursing action? 1. Remove the tube and attempt reinsertion. 2. Give the client a few sips of water. 3. Use firm pressure to pass the tube through the glottis. 4. Have the client tilt the head back to open the passage. Answer: 2 Explanation: Swallowing ice or water may help calm the gag reflex and also facilitate the "swallowing" of the tube. Page Ref: 1188 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 10. Verbalize the steps used in: a. Inserting a nasogastric tube. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients requiring tube feeding. 15) The nurse notes that the tube-fed client has shallow breathing and dusky color. The feeding is running at the prescribed rate. What should the nurse do first? 1. Place the client in high Fowler position. 2. Turn off the tube feeding. 3. Assess the client's lung sounds. 4. Assess the client's bowel sounds. Answer: 2 Explanation: These findings indicate possible aspiration of the feeding. The priority action is to discontinue the feeding to eliminate the amount of material going into the client's lungs. This should be done before any further assessment or client position change is attempted. If it is discovered that there is no aspiration, the tube feeding can be restarted. Page Ref: 1192 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 12. Plan, implement, and evaluate nursing care associated with nursing diagnoses related to nutritional problems. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients requiring tube feeding. 8
16) The client has a body mass index (BMI) of 18. How should the nurse interpret this finding? 1. The client is malnourished. 2. The client is underweight. 3. The client is normal. 4. The client is overweight. Answer: 2 Explanation: A BMI of 18 falls within the category of being underweight (16-19). Page Ref: 1164 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 7. Identify risk factors for and clinical signs of malnutrition. MNL Learning Outcome: 1. Assess the nutritional status of patients across the lifespan. 17) On admission, the client weighs 165 lb (75 kg). The client reports that this is a weight loss from 180 lb (82 kg). What is this client's percent weight loss? 1. 4.5% 2. 6.25% 3. 8.3% 4. 10.0% Answer: 3 Explanation: To calculate the percent weight loss, subtract the current weight (165 lb) from the usual weight (180 lb). Divide the result by the usual weight and multiply that result by 100. In this case, the loss is 8.3%. Page Ref: 1175 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 6. Discuss essential components and purposes of nutritional assessment and nutritional screening. MNL Learning Outcome: 1. Assess the nutritional status of patients across the lifespan.
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18) The client is weighed each month while residing in the long-term care facility. This month the client weighs 110 lb (50 kg). The nurse compares this weight to the last 3 months' results and discovers the client has lost 22 lb (10 kg). There has been no attempt to lose this weight. How should the nurse interpret this weight loss? 1. No malnutrition 2. Mild malnutrition 3. Moderate malnutrition 4. Severe malnutrition Answer: 2 Explanation: To calculate the level of nutritional deficit, the nurse first figures the current percentage of usual body weight and then compares that result to nutritional standards. To calculate the percent of usual body weight, divide the current weight by the usual body weight and multiply by 100. In this case, the client is at 91% of usual body weight. Mild malnutrition is 85-90%, moderate malnutrition is 75-84%, and severe malnutrition is less than 74%. This calculation is particularly important in an unintentional weight loss. Page Ref: 1180 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 12. Plan, implement, and evaluate nursing care associated with nursing diagnoses related to nutritional problems. MNL Learning Outcome: 1. Assess the nutritional status of patients across the lifespan.
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19) A client reports that an adolescent family member has started a vegan diet. Which additions to meals should the nurse recommend to help ensure that the adolescent does not become deficient in calcium? (Select all that apply.) 1. Tofu 2. Soybeans 3. Brewer's yeast 4. Raisins 5. Okra Answer: 1, 2, 4 Explanation: Calcium deficiency is a concern for strict vegetarians. It can be prevented by including in the diet tofu (soybean curd) fortified with calcium. Calcium deficiency is a concern for strict vegetarians. It can be prevented by including in the diet soybean milk. Raisins are a good source of iron. Page Ref: 1174 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 8. Describe nursing interventions to promote optimal nutrition. MNL Learning Outcome: 2. Plan care for patients with nutritional problems. 20) The nurse is providing diet teaching to a client with diabetes. Which should the nurse instruct is the most prevalent monosaccharide? 1. Fructose 2. Galactose 3. Corn syrup 4. Glucose Answer: 4 Explanation: Of the three monosaccharides–glucose, fructose, and galactose–glucose is by far the most abundant simple sugar. Page Ref: 1160 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 1. Identify essential nutrients and their dietary sources. MNL Learning Outcome: 2. Plan care for patients with nutritional problems. 11
21) The nurse is instructing a client on foods that are considered complete proteins. What will the nurse include in these instructions? (Select all that apply.) 1. Meat 2. Gelatin 3. Eggs 4. Chicken 5. Fish Answer: 1, 3, 4, 5 Explanation: Complete proteins contain all of the essential amino acids plus many nonessential ones. Most animal proteins, including meats, are complete proteins. Complete proteins contain all of the essential amino acids plus many nonessential ones. Most animal proteins, including eggs, are complete proteins. Complete proteins contain all of the essential amino acids plus many nonessential ones. Most animal proteins, including poultry, are complete proteins. Complete proteins contain all of the essential amino acids plus many nonessential ones. Most animal proteins, including fish, are complete proteins. Page Ref: 1160 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 1. Identify essential nutrients and their dietary sources. MNL Learning Outcome: 2. Plan care for patients with nutritional problems. 22) A client is diagnosed with an elevated cholesterol level. What should the nurse instruct the client regarding foods to avoid? (Select all that apply.) 1. Fish 2. Milk 3. Liver 4. Chicken 5. Egg yolk Answer: 2, 3, 5 Page Ref: 1161 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 1. Identify essential nutrients and their dietary sources. MNL Learning Outcome: 2. Plan care for patients with nutritional problems. 12
23) The nurse is planning an educational program for community members on ways to improve nutritional intake. What information should the nurse include about carbohydrate digestion and metabolism? (Select all that apply.) 1. Enzymes are needed to digest carbohydrates. 2. The breakdown of carbohydrates results in simple sugars. 3. Carbohydrates are a major source of body energy. 4. The simple sugar glucose provides a readily available source of energy. 5. Pancreatic amylase enhances the use of glucose by the body cells. Answer: 1, 2, 3, 4 Explanation: Major enzymes of carbohydrate digestion speed up chemical reactions. The desired end products of carbohydrate digestion are monosaccharides. Some simple sugars are already monosaccharides and require no digestion. Carbohydrate metabolism is a major source of body energy. After the body breaks carbohydrates down into glucose, some glucose continues to circulate in the blood to maintain blood levels and to provide a readily available source of energy. Page Ref: 1160 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning/Teaching and Learning Learning Outcome: 2. Describe normal digestion, absorption, and metabolism of carbohydrates, proteins, and lipids. MNL Learning Outcome: 2. Plan care for patients with nutritional problems.
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24) A client is diagnosed as having a negative nitrogen balance. What should the nurse instruct the client about this finding? 1. Discuss ways to reduce protein in the diet. 2. Review how to limit carbohydrates in the diet. 3. Discuss ways to increase protein in the diet. 4. Analyze reasons why fats should be limited in the diet. Answer: 3 Explanation: Nitrogen balance means the amounts of protein anabolism and protein catabolism are equal. In negative nitrogen balance, there is an excessive amount of protein catabolism or a decrease in the amount of protein ingested in the diet. Page Ref: 1161 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 2. Describe normal digestion, absorption, and metabolism of carbohydrates, proteins, and lipids. MNL Learning Outcome: 2. Plan care for patients with nutritional problems. 25) A client diagnosed with negative nitrogen balance abstains from all food for several days at a time. What should the nurse discuss with the client regarding this practice? 1. The amount of weight the client will lose during the fasts 2. The need to ingest some carbohydrates for body functions 3. The amount of calories the client will need to ingest after fasting for several days 4. The importance of the practice to the client Answer: 2 Explanation: A person who fasts will obtain most calories from fat metabolism, but some of the body's carbohydrate and protein stores must be used to support brain, nerve, and red blood cell function. The nurse should discuss with the client reasons to ingest carbohydrates to preserve the client's protein stores while fasting. Page Ref: 1161 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 2. Describe normal digestion, absorption, and metabolism of carbohydrates, proteins, and lipids. MNL Learning Outcome: 2. Plan care for patients with nutritional problems. 14
26) A client asks the nurse for help in selecting foods, as some are "good" and others are "bad." How should the nurse respond to the client? (Select all that apply.) 1. "Eat a wide variety of foods to furnish adequate nutrients." 2. "Avoid starchy foods." 3. "Limit foods with high-fructose corn syrup." 4. "Eat three meals a day to reduce calories." 5. "Eat moderately to maintain correct body weight." Answer: 1, 5 Explanation: Nurses should not use a "good food, bad food" approach, but rather should realize that variations of intake are acceptable under different circumstances. The only "universally" accepted guidelines are to eat a wide variety of foods to furnish adequate nutrients. Nurses should not use a "good food, bad food" approach, but rather should realize that variations of intake are acceptable under different circumstances. The only "universally" accepted guidelines are to eat moderately to maintain correct body weight. Page Ref: 1164 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 3. Identify factors influencing nutrition. MNL Learning Outcome: 2. Plan care for patients with nutritional problems.
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27) A client tells the nurse that fresh fruit should be eaten only on an empty stomach, as it will cause other foods to ferment in the stomach. Which should the nurse identify as influencing this client's nutritional status? 1. Lifestyle 2. Culture 3. Beliefs about food 4. Religious practices Answer: 3 Explanation: Beliefs about the effects of foods on health and well-being can affect food choices. Many people acquire their beliefs about food from television, magazines, and other media. Food fads that involve nontraditional food Practice-Know-Hows are relatively common. Page Ref: 1164 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify factors influencing nutrition. MNL Learning Outcome: 2. Plan care for patients with nutritional problems. 28) The nurse is planning instruction for a client who is underweight. What should be included in this teaching? (Select all that apply.) 1. Discuss factors contributing to inadequate nutrition and weight loss. 2. Discuss ways to manage, minimize, or alter the factors contributing to malnourishment. 3. Discuss principles of a well-balanced diet and high-and low-calorie foods. 4. Provide information about community agencies that can assist in providing food. 5. Provide information about ways to increase calorie intake. Answer: 1, 2, 4, 5 Page Ref: 1172 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 5. Evaluate a diet using a food guide pyramid. MNL Learning Outcome: 2. Plan care for patients with nutritional problems.
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29) The nurse is planning interventions for a client to improve the appetite. What actions would be appropriate for this client? (Select all that apply.) 1. Select small portions. 2. Avoid unpleasant treatments immediately before or after a meal. 3. Ensure a clean environment free of unpleasant sights and odors. 4. Encourage oral hygiene before a meal. 5. Provide medication for pain or other symptoms after a meal. Answer: 1, 2, 3, 4 Page Ref: 1185 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 9. Discuss nursing interventions to treat clients with nutritional problems. MNL Learning Outcome: 2. Plan care for patients with nutritional problems. 30) A client's nasogastric tube has been discontinued and needs to be removed. Place in order the steps the nurse will perform to remove this tube. 1. Place the tube in a plastic bag. 2. Ask the client to take a deep breath and to hold it. 3. Smoothly withdraw the tube. 4. Pinch the tube with the gloved hand. 5. Observe the intactness of the tube. 6. Apply clean gloves. Answer: 6, 2, 4, 3, 1, 5 Explanation: When removing a nasogastric tube, the nurse should (1) apply clean gloves; (2) ask the client to take a deep breath and to hold it; (3) pinch the tube with the gloved hand; (4) smoothly withdraw the tube; (5) place the tube in a plastic bag; and (6) observe the intactness of the tube. Page Ref: 1198-1199 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 10. Verbalize the steps used in: b. Removing a nasogastric tube. MNL Learning Outcome: 4. Implement the evaluation, documentation, and reporting of care for patients with nutritional problems.
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31) The nurse is preparing to administer a feeding to a client with a gastrostomy tube. What should the nurse do before providing this feeding? 1. Assess tube placement. 2. Measure vital signs. 3. Assist the client to a prone position. 4. Lower the head of the bed. Answer: 1 Explanation: Prior to administering a feeding through a gastrostomy tube, the nurse should assess for tube placement. Page Ref: 1196 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 10. Verbalize the steps used in: d. Administering a gastrostomy or jejunostomy tube feeding. MNL Learning Outcome: 4. Implement the evaluation, documentation, and reporting of care for patients with nutritional problems. 32) The nurse has finished providing a tube feeding to a client. What should the nurse document about this procedure? (Select all that apply.) 1. Name of physician prescribing the feedings 2. Solution provided 3. Amount of fluid 4. Duration of the feeding 5. Client tolerance of the feeding Answer: 2, 3, 4, 5 Page Ref: 1196 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 13. Demonstrate appropriate documentation and reporting of nutritional therapy. MNL Learning Outcome: 4. Implement the evaluation, documentation, and reporting of care for patients with nutritional problems.
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33) A client receives several tube feedings each day. After documenting the client's tolerance of the feedings and assessments in the medical record, where should the nurse also document the amount of feeding provided? 1. Graphic sheet 2. Dietary consultation notes 3. Vital signs record 4. Intake and output record Answer: 4 Explanation: The amount of fluid as feeding provided to the client should be recorded on the intake and output record. Page Ref: 1196 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 13. Demonstrate appropriate documentation and reporting of nutritional therapy. MNL Learning Outcome: 4. Implement the evaluation, documentation, and reporting of care for patients with nutritional problems. 34) A client is prescribed a 1,600-calorie diet. Of this diet, 30% of the intake should be protein, 20% fat, and 50% carbohydrates. How many grams of carbohydrates should the client ingest every day? Calculate to the nearest whole number. Answer: 200 grams Explanation: First determine the number of calories for carbohydrates by multiplying the total number of calories by the percentage; 1600 calories × 50% = 800 calories. Then divide the total calories by calories/gram. For carbohydrates, this would be 800 calories/4 = 200 grams. The client should eat 200 grams of carbohydrates each day. Page Ref: 1173 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 6. Discuss essential components and purposes of nutritional assessment and nutritional screening. MNL Learning Outcome: 2. Plan care for patients with nutritional problems.
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35) The nurse is assigning feedings of an older client who is at risk for aspiration to assistive personnel (AP). What feeding techniques should the nurse instruct the AP to use? (Select all that apply.) 1. Thicken all fluids. 2. Use the chin-tuck method. 3. Place the client in a seated position. 4. Focus on food preferences. 5. Keep the head of the bed at a 30-degree angle. Answer: 1, 2, 3, 4 Explanation: Safety should always be a priority concern, with attention paid to preventing aspiration. Techniques to reduce this risk include thickening fluids. Many older adults can swallow foods with thicker consistency more easily than thin liquids. Safety should always be a priority concern, with attention paid to preventing aspiration. Techniques to reduce this risk include using the chin-tuck method. Flexing the head toward the chest when swallowing decreases the risk of aspiration into the lungs. Safety should always be a priority concern, with attention paid to preventing aspiration. Techniques to reduce this risk include eating in a seated position. Safety should always be a priority concern, with attention paid to preventing aspiration. Techniques to reduce this risk include focusing on food preferences. Page Ref: 1184-1185 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 11. Recognize when it is appropriate to assign aspects of feeding clients to assistive personnel. MNL Learning Outcome: 2. Plan care for patients with nutritional problems.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 47 Urinary Elimination 1) The nurse is assessing a client's urinary elimination. Which factor should the nurse keep in mind as influencing this elimination? 1. Age 2. Body image 3. Knowledge 4. Socioeconomic status Answer: 1 Explanation: Development factors such as how old the client is influence urinary elimination. Page Ref: 1209 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Identify factors that influence urinary elimination. MNL Learning Outcome: 1. Assess the urinary function of patients. 2) The nurse realizes that which client is at risk for difficulty in urinary elimination? 1. A client who had bladder cancer and now has a newly created ileal conduit 2. A 25-year-old female client with low self-esteem 3. An 80-year-old male reporting frequent urination at night 4. The client with hypertension who takes a diuretic every day for blood pressure Answer: 3 Explanation: The client who is 80 years old with frequent urination at night is having problems with his prostate. Older male adults experience urinary retention due to prostate enlargement causing an alteration in urinary elimination. Page Ref: 1209 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify common causes of selected urinary problems. MNL Learning Outcome: 1. Assess the urinary function of patients.
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3) A client tells the nurse about the need to get up several times throughout the night to void. The nurse suspects the client is experiencing nocturia due to which factor? 1. Decrease in bladder tone 2. Decrease in blood supply 3. Decrease in number of nephrons 4. Decrease in cardiac output Answer: 1 Explanation: Nocturia is voiding frequently at night. An increased intake of fluid causes some increase in the frequency of voiding. Conditions such as urinary tract infection, stress, and pregnancy can cause frequent voiding of small quantities of urine. Total fluid intake and output may be normal. Page Ref: 1211 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify common causes of selected urinary problems. MNL Learning Outcome: 1. Assess the urinary function of patients. 4) Which intervention would the nurse plan to help a client prevent a urinary tract infection? 1. Encourage the use of bubble baths. 2. Have the client increase sugar in the diet. 3. Instruct the client to empty the bladder completely. 4. Wipe from back to front. Answer: 3 Explanation: Completely emptying the bladder prevents stasis of urine, which would contribute to a urinary tract infection. Page Ref: 1217 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Describe nursing interventions to maintain normal urinary elimination, prevent urinary tract infection, and manage urinary incontinence. MNL Learning Outcome: 2. Plan care for patients to maintain normal urinary elimination, prevent urinary tract infection, and manage urinary incontinence.
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5) The nurse should incorporate which instructions into the teaching plan for a client with a urinary diversion? 1. Change the appliance several times a day. 2. Increase fluid intake. 3. Notify the physician if the stoma is deep pink and shiny. 4. Strands of blood may appear in the urine. Answer: 2 Explanation: Increasing the fluid intake helps to flush out sediment and mucus and prevents clogging of the stoma. Page Ref: 1217 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning/Teaching and Learning Learning Outcome: 9. Explain the care of clients with retention catheters or urinary diversions. MNL Learning Outcome: 2. Plan care for patients to maintain normal urinary elimination, prevent urinary tract infection, and manage urinary incontinence. 6) Which nursing intervention is appropriate when caring for a client with an indwelling urinary catheter? 1. Don sterile gloves. 2. Gently retract the labia majora away from the urinary meatus. 3. Observe urine in the drainage bag. 4. Retape the catheter to the thigh. Answer: 4 Explanation: Retaping the catheter to the thigh after care is given prevents trauma and pain from tension and pulling. Page Ref: 1228 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 9. Explain the care of clients with indwelling catheters or urinary diversions. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients with urinary incontinence or requiring bladder irrigation.
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7) Which nursing diagnosis would be appropriate for a client who has a retention catheter if the drainage bag is found lying on the floor? 1. Risk for Impaired Skin Integrity related to catheter placement 2. Risk for Infection related to improper handling 3. Self-Care Deficit related to presence of a retention catheter 4. Risk for Incontinence related to an obstruction Answer: 2 Explanation: The floor is the dirtiest place, so the drainage device should never be placed on the floor. Page Ref: 1215 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Diagnosis Learning Outcome: 6. Develop nursing diagnoses and desired outcomes related to urinary elimination. MNL Learning Outcome: 2. Plan care for patients to maintain normal urinary elimination, prevent urinary tract infection, and manage urinary incontinence. 8) The nurse is identifying outcomes for a client with the nursing diagnosis Stress Urinary Incontinence. Which outcome would be related to sphincter incompetence? 1. The client will empty the bladder with each void. 2. The client will improve incontinence within 1 month. 3. The client will perform eight squeezes three times a day. 4. The client will stop the flow of urine when voiding. Answer: 3 Explanation: Performing eight squeezes three times a day is the goal when teaching a client Kegel exercises, which are used for stress and urge incontinence. Page Ref: 1220 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 6. Develop nursing diagnoses and desired outcomes related to urinary elimination. MNL Learning Outcome: 2. Plan care for patients to maintain normal urinary elimination, prevent urinary tract infection, and manage urinary incontinence.
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9) Which goal should the nurse identify as appropriate for a client with the nursing diagnosis Urinary Pattern Alteration related to an enlarged prostate? 1. The client will avoid bladder distention. 2. The client will maintain fluid imbalance. 3. The client will remain free of skin breakdown. 4. The client will voice increased discomfort. Answer: 1 Explanation: Avoiding bladder distention will help eliminate stasis of urine in the bladder, which contributes to urinary tract infections, a possible complication of urine flow being obstructed from an enlarged prostate. Page Ref: 1220 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 6. Develop nursing diagnoses and desired outcomes related to urinary elimination. MNL Learning Outcome: 2. Plan care for patients to maintain normal urinary elimination, prevent urinary tract infection, and manage urinary incontinence. 10) A client is diagnosed with a urinary disorder. Which physical assessment techniques should the nurse use in assessing this client's urinary system? 1. Auscultation and inspection 2. Inspection and percussion 3. Observation and auscultation 4. Palpation and percussion Answer: 4 Explanation: Palpation and percussion are used to assess the bladder. Page Ref: 1213 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Describe nursing assessment of urinary function, including subjective and objective data. MNL Learning Outcome: 1. Assess the urinary function of patients.
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11) A client has been admitted with incontinence. What should the nurse expect to assess in this client? 1. Client is wearing cotton undergarments. 2. Leakage of urine occurs when client laughs. 3. Leakage of urine occurs when talking with the client. 4. The skin of the client is clear without discoloration. Answer: 2 Explanation: Incontinence involves a small leakage of urine when a client laughs. Page Ref: 1211 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Describe nursing assessment of urinary function, including subjective and objective data. MNL Learning Outcome: 1. Assess the urinary function of patients. 12) A client is rushed to the emergency department with what the physicians suspect to be necrosis of the urinary diversion stoma. What evidence presented by the client leads to this conclusion? 1. Black with sloughing 2. Moist stoma 3. Pink and shiny 4. Slight bleeding from stoma Answer: 1 Explanation: Black color to the stoma and sloughing are signs of necrosis of the stoma. Page Ref: 1235 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Describe nursing assessment of urinary function, including subjective and objective data. MNL Learning Outcome: 1. Assess the urinary function of patients.
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13) A client's results from a urinalysis are as follows: pH 5.2, gross cloudiness, WBC 10-15, glucose negative, specific gravity 1.012, and protein negative. How should the nurse interpret the results? 1. Dehydration 2. Diabetic ketoacidosis 3. Trauma 4. Urinary tract infection Answer: 4 Explanation: The pH, glucose, specific gravity, and protein are all within normal limits. Urine is usually clear to slightly cloudy, and WBC count can be from 0 to 4. Therefore, the gross cloudiness and WBC count of 10-15 are not normal, indicating a urinary tract infection. Page Ref: 1214 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Identify normal and abnormal characteristics and constituents of urine. MNL Learning Outcome: 2. Plan care for patients to maintain normal urinary elimination, prevent urinary tract infection, and manage urinary incontinence. 14) A client's urinalysis is reported as being normal. What were the client's results? 1. Blood present and no ketones 2. Dark amber color and output less than 500 cc in 24 hours 3. pH 6 and no glucose present 4. Specific gravity 1.035 and faint aromatic odor Answer: 3 Explanation: Normal pH is 4.5 to 8, so a pH of 6 and no glucose present are two normal characteristics of urine. Page Ref: 1214 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Identify normal and abnormal characteristics and constituents of urine. MNL Learning Outcome: 2. Plan care for patients to maintain normal urinary elimination, prevent urinary tract infection, and manage urinary incontinence.
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15) A client is prescribed propranolol (Inderal). What should the nurse instruct the client about this medication? 1. The medication should be discontinued abruptly. 2. Notify the physician if you experience urinary retention. 3. Take a laxative every day. 4. Take the medication on an empty stomach. Answer: 2 Explanation: A beta-adrenergic blocker such as propranolol can cause urinary retention; therefore, it would be of the utmost importance to notify the physician. Page Ref: 1210 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 7. Describe nursing interventions to maintain normal urinary elimination, prevent urinary tract infection, and manage urinary incontinence. MNL Learning Outcome: 2. Plan care for patients to maintain normal urinary elimination, prevent urinary tract infection, and manage urinary incontinence. 16) A client is having issues with urinary elimination. What should the nurse instruct this client to help with this problem? 1. Don't interrupt your day by going to the bathroom; wait until you're at a good stopping place. 2. Drink 8-10 glasses of water daily. 3. Urine color changes are not important. 4. Wash with soap and water every other day. Answer: 2 Explanation: Drinking 8-10 glasses of water daily will encourage the need for bladder emptying, keeping the system flushed. Page Ref: 1217 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 7. Describe nursing interventions to maintain normal urinary elimination, prevent urinary tract infection, and manage urinary incontinence. MNL Learning Outcome: 2. Plan care for patients to maintain normal urinary elimination, prevent urinary tract infection, and manage urinary incontinence.
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17) A client recovering from a transurethral resection of the prostate with a three-way indwelling catheter expresses the need to urinate. Which action should the nurse take to help this client? 1. Deflate and then reinflate the balloon. 2. Irrigate the catheter. 3. Reposition the catheter. 4. Retape the catheter to the abdomen. Answer: 2 Explanation: Blood clots give the client the sensation to urinate when they obstruct the urine outflow; therefore, irrigation will have to remedy the problem. Page Ref: 1231 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Describe nursing interventions to maintain normal urinary elimination, prevent urinary tract infection, and manage urinary incontinence. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients with urinary incontinence or requiring bladder irrigation.
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18) The nurse is caring for a client with a urinary diversion. For which type of diversion should the nurse plan care for this client?
1. Incontinent urinary diversion 2. The kock pouch 3. Neobladder 4. Nephrostomy Answer: 1 Explanation: This is an incontinent urinary diversion (ileal conduit). Page Ref: 1235 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 2. Identify factors that influence urinary elimination. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients with urinary incontinence or requiring bladder irrigation.
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19) A client has a spinal cord injury at the cervical spine area. The nurse realizes that this injury will affect which aspect of urinary elimination in the client? 1. Elimination of urine from the bladder 2. Ability of the kidneys to absorb solutes 3. Ureteral function 4. Urethra function Answer: 1 Explanation: The bladder contains the detrusor muscle, which is responsible for expulsion of urine from the bladder. If the client has a cervical spine injury, muscle function will be affected below the level of the injury, resulting in an impaired ability to eliminate urine from the bladder. Page Ref: 1207 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Identify factors that influence urinary elimination. MNL Learning Outcome: 1. Assess the urinary function of patients. 20) A client is complaining of pain with urination. The nurse realizes that the client needs to be assessed for which health problems? (Select all that apply.) 1. Urethral stricture 2. Renal failure 3. Urethral injury 4. Bladder injury 5. Urinary infection Answer: 1, 3, 4, 5 Page Ref: 1211 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify common causes of selected urinary problems. MNL Learning Outcome: 1. Assess the urinary function of patients.
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21) A client needs a test to determine the amount of residual urine. The nurse realizes that this assessment is used for which reason(s)? (Select all that apply.) 1. Evaluate the glomerular filtration rate 2. Determine the extent of renal failure 3. Determine the amount of retained urine after voiding 4. Determine the need for medications 5. Evaluate fluid volume status Answer: 3, 4 Page Ref: 1215 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Describe nursing assessment of urinary function, including subjective and objective data. MNL Learning Outcome: 2. Plan care for patients to maintain normal urinary elimination, prevent urinary tract infection, and manage urinary incontinence. 22) A client's urine pH is 8.0. What further assessments would be indicated for this client? (Select all that apply.) 1. Intake of fruits and vegetables 2. Intake of cranberries 3. Intake of high-protein foods 4. Symptoms of diarrhea 5. Symptoms of a urinary tract infection Answer: 1, 5 Explanation: Alkaline urine might indicate a diet high in fruits and vegetables. Alkaline urine might indicate a urinary tract infection. Page Ref: 1214 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Describe nursing assessment of urinary function, including subjective and objective data. MNL Learning Outcome: 1. Assess the urinary function of patients.
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23) The nurse is instructing a client on ways to manage stress urinary incontinence. What should be included in this client's teaching? (Select all that apply.) 1. Limit intake of caffeine. 2. Limit intake of alcohol. 3. Increase intake of citrus juices. 4. Limit evening fluid intake. 5. Increase intake of beverages with artificial sweeteners. Answer: 1, 2, 4 Page Ref: 1217 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 7. Describe nursing interventions to maintain normal urinary elimination, prevent urinary tract infection, and manage urinary incontinence. MNL Learning Outcome: 2. Plan care for patients to maintain normal urinary elimination, prevent urinary tract infection, and manage urinary incontinence. 24) The nurse is concerned that a client is at risk for the development of urinary tract infections. What did the nurse assess to come to this conclusion? 1. The client is wearing tight clothing. 2. The client is employed as a computer operator. 3. The client drinks 8 to 10 8-ounce glasses of water and low-calorie beverages each day. 4. The client exercises for 30-60 minutes most days of the week. Answer: 1 Explanation: Tight-fitting pants or other clothing can cause irritation to the urethra and prevent ventilation of the perineal area, leading to an infection. Page Ref: 1219 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify common causes of selected urinary problems. MNL Learning Outcome: 1. Assess the urinary function of patients.
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25) The nurse is concerned that an older client with an indwelling urinary catheter is developing a urinary tract infection. What assessment finding caused this concern? 1. Elevated blood pressure 2. Elevated heart rate 3. Confusion 4. Leg pain Answer: 3 Explanation: In the older client, confusion can be an early sign of urinary tract infection. Page Ref: 1217 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Describe nursing assessment of urinary function, including subjective and objective data. MNL Learning Outcome: 1. Assess the urinary function of patients. 26) The nurse is applying an external urinary device to a client. Before attaching the device to the drainage bag, what should the nurse do? 1. Perform hand hygiene. 2. Document the client's tolerance of the procedure. 3. Instruct the client about the drainage system. 4. Ensure that the condom is not twisted. Answer: 4 Explanation: The nurse should make sure that the tip of the penis is not touching the condom and that the condom is not twisted because a twisted condom could obstruct the flow of urine. Page Ref: 1221 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 10. Verbalize the steps used in: a. Applying an external urinary device. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients with urinary incontinence or requiring bladder irrigation.
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27) The nurse is performing urinary catheterization for a client. After using the nondominant hand to separate the client's labia for cleansing, in which way should the nurse treat this hand? 1. Sterile 2. Contaminated 3. Able to evaluate the effectiveness of the catheter balloon 4. Clean Answer: 2 Explanation: When performing urinary catheterization, the nondominant hand is considered contaminated once it touches the client's skin. Page Ref: 1227 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 10. Verbalize the steps used in: b. Performing urinary catheterization. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients with urinary incontinence or requiring bladder irrigation. 28) The nurse wants to delegate the application of a condom catheter to assistive personnel (AP). What must the nurse assess prior to delegating this task? 1. Assess whether the client has unique needs. 2. Measure the client's intake. 3. Assist the client out of bed to a chair. 4. Assess changes in the client's mobility status. Answer: 1 Explanation: Applying a condom catheter may be delegated to AP. However, the nurse must determine whether the specific client has unique needs, such as impaired circulation or latex allergy, that would require special training of the AP in the use of the condom catheter. Page Ref: 1221 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the health care team | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 11. Recognize when it is appropriate to assign aspects of urinary elimination to assistive personnel. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients with urinary incontinence or requiring bladder irrigation.
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29) The nurse is determining tasks to assign to AP. Which task should the nurse question before assigning to this level of healthcare provider? 1. Measuring intake and output 2. Assessing vital signs for clients who are clinically stable 3. Performing complete morning care for a client recovering from a stroke 4. Inserting a urinary catheter into a client Answer: 4 Explanation: Due to the need for sterile technique and detailed knowledge of anatomy, insertion of a urinary catheter is not delegated to AP. Page Ref: 1225 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the health care team | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 11. Recognize when it is appropriate to assign aspects of urinary elimination to assistive personnel. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients with urinary incontinence or requiring bladder irrigation. 30) The nurse is documenting the insertion of an indwelling urinary catheter for a client. What should be included in this documentation? (Select all that apply.) 1. Catheter size 2. Location of the drainage bag 3. Amount of urine that drained after insertion 4. Name of the physician who prescribed the insertion of the catheter 5. Client tolerance of the procedure Answer: 1, 3, 5 Page Ref: 1229 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 12. Demonstrate appropriate documentation and reporting of application of an external catheter, performing urethral urinary catheterization, and performing bladder irrigation. MNL Learning Outcome: 4. Implement the evaluation, documentation, and reporting of care for patients with urinary problems.
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31) Assistive personnel (AP) has applied a condom catheter to a client. The nurse should document what information about this procedure? (Select all that apply.) 1. Number of mL of fluid used to inflate the balloon 2. Location of the drainage bag 3. Name of the AP who applied the device 4. Time and date that the condom catheter was applied 5. Integrity of the penis Answer: 4, 5 Explanation: The nurse should document the application of the condom, including the time. The nurse should document any pertinent observations, such as the integrity of the penis. Page Ref: 1222 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 12. Demonstrate appropriate documentation and reporting of application of an external catheter, performing urethral urinary catheterization, and performing bladder irrigation. MNL Learning Outcome: 4. Implement the evaluation, documentation, and reporting of care for patients with urinary problems. 32) The nurse has completed closed irrigation of a client's retention catheter. What specific information should the nurse document about this procedure? 1. Number of mL of solution used to inflate the balloon of the catheter 2. Abnormal drainage, such as blood clots, pus, or mucous shreds 3. Location of the draining bag 4. Technique used to conduct the irrigation Answer: 2 Explanation: The nurse should note any abnormal constituents, such as blood clots, pus, or mucous shreds. Page Ref: 1233 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 12. Demonstrate appropriate documentation and reporting of application of an external catheter, performing urethral urinary catheterization, and performing bladder irrigation. MNL Learning Outcome: 4. Implement the evaluation, documentation, and reporting of care for patients with urinary problems. 17
33) A client with an indwelling urinary catheter is prescribed to receive sterile normal saline bladder irrigation at 100 mL/hr. After an 8-hour shift the nurse measures the client's output as being 1425 mL. What is the client's urine output for the 8-hour shift? Calculate to the nearest whole number. Answer: 625 mL Explanation: The client is to receive 800 mL of bladder irrigant for the 8-hour shift. The nurse needs to subtract the bladder irrigant total from the total output, or 1425-800=625 mL. This is the client's urine output for the 8-hour shift. Page Ref: 1233 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 10. Verbalize the steps used in: c. Performing bladder irrigation. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients with urinary incontinence or requiring bladder irrigation. 34) An older female client with a history of urinary tract infections has an indwelling urinary catheter. What should the nurse do to reduce this client's risk of developing an infection because of the catheter? (Select all that apply.) 1. Maintain a sterile closed drainage system. 2. Clean the peri-urethral area with antiseptics. 3. Ensure the catheter and tubing are not kinked. 4. Wash hands before manipulating the catheter. 5. Keep the collection bag below the level of the bladder. Answer: 1, 3, 4, 5 Page Ref: 1223 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 8. Delineate ways to prevent urinary infection. MNL Learning Outcome: 2. Plan care for patients to maintain normal urinary elimination, prevent urinary tract infection, and manage urinary incontinence.
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35) The nurse is explaining the process of urine formation. Which should the nurse explain occurs with urine after it is formed in the kidneys? 1. Enters the bladder 2. Filters metabolic wastes 3. Moves through the urethra 4. Moves into the renal pelvis Answer: 4 Explanation: Once urine is formed it moves into the renal pelvis. It enters the bladder through the ureters. It moves through the urethra upon urination. The kidneys filter metabolic wastes. Page Ref: 1207 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching and Learning Learning Outcome: 1. Describe the process of urination, from urine formation through micturition. MNL Learning Outcome: 1. Assess the urinary function of patients. 36) During an assessment a client states the urgent need to void urine. Which should the nurse identify as the reason for the client to use the bathroom? 1. Burning of the urethra 2. Relaxation of the trigone 3. Activation of stretch receptors 4. Contraction of bladder ligaments Answer: 3 Explanation: Urine collects in the bladder until pressure stimulates special sensory nerve endings in the bladder wall called stretch receptors. Urethral burning indicates an infection. The trigone is an area of the bladder where the ureters enter. Bladder ligaments do not contract when the bladder is full. Page Ref: 1208 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies| Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Describe the process of urination, from urine formation through micturition. MNL Learning Outcome: 1. Assess the urinary function of patients. 19
37) The nurse needs to insert an indwelling urinary catheter into a client. For which reason should the nurse ask assistive personnel to help with the procedure? 1. Distracts the client 2. Improves visualization 3. Evaluates the nurse's skill level 4. Ensures sterile technique is followed Answer: 2 Explanation: Having assistance with the insertion of an indwelling urinary catheter improves visualization. Assistance is not used to distract the client, evaluate the nurse's skill level, or ensure that sterile technique is followed. Page Ref: 1223 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 8. Delineate ways to prevent urinary infection. MNL Learning Outcome: 2. Plan care for patients to maintain normal urinary elimination, prevent urinary tract infection, and manage urinary incontinence.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 48 Fecal Elimination 1) A client asks why it is more difficult to use a bedpan for defecating than sitting on the toilet. Which would be the nurse's best response? 1. The sitting position decreases the contractions of the muscles of the pelvic floor. 2. The sitting position increases the downward pressure on the rectum, making it easier to pass stool. 3. The sitting position increases the pressure within the abdomen. 4. The sitting position inhibits the urge to urinate, allowing one to defecate. Answer: 2 Explanation: Normal defecation is facilitated by thigh flexion, which increases the pressure within the abdomen, and a sitting position, which increases the downward pressure on the rectum. Page Ref: 1244 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 1. Describe the physiology of defecation. MNL Learning Outcome: 1. Assess the fecal elimination patterns of patients. 2) A client asks why expelled flatus is foul-smelling. What should the nurse respond? 1. The actions of microorganisms within the gastrointestinal tract are responsible for the odor. 2. The client's emotions are causing the gas formation. 3. The sensory nerves in the rectum are being stimulated. 4. The client has swallowed too much air while eating. Answer: 1 Explanation: The actions of the microorganisms are responsible for the odor produced and also the color of the feces. Page Ref: 1244 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 1. Describe the physiology of defecation. MNL Learning Outcome: 1. Assess the fecal elimination patterns of patients.
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3) The home care nurse is reviewing a list of clients prior to making visits. For which client should the nurse plan interventions to decrease the risk of developing constipation? 1. An adult who is on bed rest 2. An infant who is breast-fed 3. A school-age child at recess 4. A toddler who is now walking Answer: 1 Explanation: Activity stimulates peristalsis, thus facilitating the movement of chyme along the colon. Weak abdominal and pelvic muscles are often ineffective in increasing the intraabdominal pressure during defecation or in controlling defecation. Weak muscles can result from lack of exercise, immobility, or impaired neurological functioning. Clients confined to bed are often constipated. Page Ref: 1245 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 4. Identify common causes and effects of selected fecal elimination problems. MNL Learning Outcome: 1. Assess the fecal elimination patterns of patients.
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4) A client reports ignoring the urge to defecate when at work. Which response should the nurse make to explain why this practice should be changed? 1. "If you continue to ignore the urge to defecate, the urge is ultimately lost." 2. "It is best to suppress the urge rather than suffer embarrassment at work." 3. "This is a common practice, and it will strengthen the reflex later." 4. "You will get the urge later; don't worry." Answer: 1 Explanation: When the normal defecation reflexes are inhibited, these conditioned reflexes tend to be progressively weakened. When the urge to defecate is ignored, water continues to be reabsorbed, making the feces hard and difficult to expel. Ignoring the urge repeatedly will eventually cause the urge to be lost. Page Ref: 1245 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 4. Identify common causes and effects of selected fecal elimination problems. MNL Learning Outcome: 1. Assess the fecal elimination patterns of patients. 5) The nurse is preparing to assess a client's fecal elimination status. Which activity will the nurse complete during this assessment? 1. Obtain a nursing history. 2. Interpret results of diagnostic tests. 3. Perform a physical examination. 4. Set goals with the client. Answer: 1 Explanation: Assessment of fecal elimination includes a nursing history and also a review of any data from the client's records. Page Ref: 1250 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Describe methods used to assess fecal elimination. MNL Learning Outcome: 1. Assess the fecal elimination patterns of patients.
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6) The nurse determines that an adult client's feces are normal. What did the nurse assess to come to this conclusion? 1. Black in color 2. Cylindrical in shape 3. Pungent in odor 4. Yellow in color Answer: 2 Explanation: Cylindrical in contour is a normal characteristic of feces because it takes the shape of the rectum. Page Ref: 1244 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Distinguish normal from abnormal characteristics and constituents of feces. MNL Learning Outcome: 1. Assess the fecal elimination patterns of patients. 7) The nurse is caring for a client who experiences frequent bouts of diarrhea. What should the nurse instruct the client to do? 1. Change the daily routine. 2. Decrease fluid consumption. 3. Increase fiber in the diet. 4. Note the precipitating event. Answer: 4 Explanation: Psychological stress such as anxiety, medications, food allergies, and certain diseases can cause diarrhea. Noting the event can help identify and stop the cause. Page Ref: 1248 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 3. Identify factors that influence fecal elimination and patterns of defecation. MNL Learning Outcome: 1. Assess the fecal elimination patterns of patients.
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8) The nurse is caring for a client who is experiencing constipation. Which client behavior indicates that teaching was effective? 1. The client continues to ask for his pain medication. 2. The client decreases his fluid consumption. 3. The client refuses to eat the bran flakes on his tray. 4. The client walks around the unit several times a day. Answer: 4 Explanation: Increased activity such as walking promotes gastric motility, which increases bowel function. Page Ref: 1252 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation/Teaching and Learning Learning Outcome: 6. Identify examples of nursing diagnoses, outcomes, and interventions for clients with elimination problems. MNL Learning Outcome: 4. Implement the evaluation, documentation, and reporting of care for patients with fecal elimination problems. 9) A client has a bowel movement of hard, dry, but formed stool. With which health problem should the nurse associate these characteristics? 1. Bowel incontinence 2. Constipation 3. Diarrhea 4. Fecal impaction Answer: 2 Explanation: Hard, dry, formed stool is characteristic of constipation. Page Ref: 1246 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Identify common causes and effects of selected fecal elimination problems. MNL Learning Outcome: 1. Assess the fecal elimination patterns of patients.
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10) What nursing diagnosis should the nurse select as appropriate to address bowel evacuation for a client who is on bed rest? 1. Bowel Incontinence 2. Constipation 3. Diarrhea 4. Disturbed Body Image Answer: 2 Explanation: Lack of activity, as in bed rest, is a major contributor to constipation. Lack of movement slows bowel movements. Page Ref: 1246, 1250 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Diagnosis Learning Outcome: 6. Identify examples of nursing diagnoses, outcomes, and interventions for clients with elimination problems. MNL Learning Outcome: 2. Plan care for patients to maintain normal fecal elimination and manage altered patterns of fecal elimination. 11) The nurse is identifying goals for a client experiencing diarrhea. What goal should the nurse select for this client? 1. Client will defecate regularly. 2. Client will increase the amount of sugar in the diet. 3. Client will limit fluid intake. 4. Client will regain normal stool consistency. Answer: 4 Explanation: Because this client is experiencing diarrhea, the goal would be to regain normal stool consistency, which would be less water in the stool and a more formed consistency. Page Ref: 1251 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 6. Identify examples of nursing diagnoses, outcomes, and interventions for clients with elimination problems. MNL Learning Outcome: 2. Plan care for patients to maintain normal fecal elimination and manage altered patterns of fecal elimination. 6
12) The nurse is instructing a client on ostomy care. What should be included in this teaching? 1. Change the drainage pouch daily. 2. Clothing of a special style will be needed now that a pouch is worn. 3. Stick a pin into the drainage pouch to relieve any gas buildup. 4. Secure the faceplate to the drainage pouch so no skin around the stoma is exposed. Answer: 4 Explanation: The skin around a stoma is very susceptible to irritation and breakdown. To avoid skin irritation, the faceplate to the drainage pouch needs to fit close enough to the stoma so as not to expose any other skin. Page Ref: 1267 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 11. Verbalize the steps used in: b. Changing a bowel diversion ostomy appliance. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients with a colostomy or requiring an enema. 13) Which assessment technique will the nurse use first when examining a client with a fecal elimination problem? 1. Auscultation 2. Inspection 3. Palpation 4. Percussion Answer: 2 Explanation: The nurse will first inspect the client's abdominal region. Page Ref: 1250 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Describe methods used to assess fecal elimination. MNL Learning Outcome: 1. Assess the fecal elimination patterns of patients.
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14) The nurse suspects that a client is experiencing compromised gastrointestinal function. What assessment data did the nurse use to make this clinical decision? 1. Bowel sounds active in all four quadrants 2. Clay-colored stool 3. Increased appetite 4. Semisolid and moist stool Answer: 2 Explanation: Clay-colored stools would be an indication of a problem in the GI tract. Clay color is a sign of the absence of bile pigment (bile obstruction). Page Ref: 1244 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Identify common causes and effects of selected fecal elimination problems. MNL Learning Outcome: 1. Assess the fecal elimination patterns of patients. 15) A client has a history of an inconsistent fecal elimination pattern. What should the nurse instruct this client to improve this health problem? 1. Drink two to four glasses of water daily. 2. Include more spicy foods and sugar in the diet. 3. Include more whole grains in the diet. 4. Use enemas as desired. Answer: 3 Explanation: Eating more whole grains will increase fiber in the diet, which increases bulk and volume. Page Ref: 1252 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 7. Identify measures that maintain normal fecal elimination patterns. MNL Learning Outcome: 2. Plan care for patients to maintain normal fecal elimination and manage altered patterns of fecal elimination.
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16) The nurse is caring for the stoma of a client who has a colostomy. Which action is the most appropriate? 1. Apply pressure over the stoma. 2. Clean the stoma and pat dry. 3. Dilate the stoma. 4. Scrub the stoma. Answer: 2 Explanation: Stoma care includes cleaning the area and patting it dry. Excess rubbing can abrade the skin and stoma tissue. Page Ref: 1266 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 9. Describe essentials of fecal stoma care for clients with an ostomy. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients with a colostomy or requiring an enema. 17) A client is prescribed to receive a cleansing enema. What should the nurse instruct the client prior to administering this enema? 1. Hold the solution for a short time. 2. Lie in the left lateral position. 3. Lie in the right lateral position. 4. Take fast breaths through the nose. Answer: 2 Explanation: The client lies in the left lateral position in order to clean the rectum and sigmoid. Page Ref: 1257 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 8. Describe the purpose and action of commonly used enema solutions. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients with a colostomy or requiring an enema.
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18) A client is prescribed a saline enema. Because this solution is hypertonic, the nurse would expect the enema to cause which action? 1. Exerts osmotic pressure and draws fluid from the interstitial space into the colon 2. Exerts a lower osmotic pressure than the surrounding interstitial fluid 3. Exerts the same osmotic pressure as the interstitial fluid surrounding the colon 4. Stimulates peristalsis by increasing the volume in the colon and irritating the colon Answer: 1 Explanation: A hypertonic solution exerts osmotic pressure and draws fluid from the interstitial space into the colon. Page Ref: 1255 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 8. Describe the purpose and action of commonly used enema solutions. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients with a colostomy or requiring an enema. 19) After eating dinner, a client asks for help to get to the bathroom because of an extreme urge to defecate. The nurse realizes that the client has experienced which physiological function of the colon? 1. Flatus 2. Gastrocolic reflex 3. Haustral churning 4. Peristalsis Answer: 2 Explanation: Many individuals defecate after eating due to the gastrocolic reflex (increased peristalsis of the colon after food has entered the stomach). Page Ref: 1245 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify factors that influence fecal elimination and patterns of defecation. MNL Learning Outcome: 1. Assess the fecal elimination patterns of patients.
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20) The nurse determines that a client's fecal elimination is pale in color. This finding supports which client behavior obtained during the health history? 1. The client rarely eats animal protein and ingests milk and cheese at several meals each day. 2. The client rarely eats fruits or vegetables. 3. The client uses laxatives routinely. 4. The client drinks 8 to 10 8-ounce glasses of water each day. Answer: 1 Explanation: Stool that is pale in color is seen in those who ingest a diet high in milk and milk products and low in meat. Page Ref: 1244 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Distinguish normal from abnormal characteristics and constituents of feces. MNL Learning Outcome: 1. Assess the fecal elimination patterns of patients.
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21) An older client tells the nurse that in order to have a daily bowel movement, the client uses laxatives most days of the week. What should the nurse tell this client? (Select all that apply.) 1. Normal patterns of elimination are different for everyone. 2. Increase fiber intake to 20-35 grams a day. 3. Engage in enjoyable exercise. 4. Ignore the urge to have a bowel movement. 5. Drink six to eight glasses of fluid daily. Answer: 1, 2, 3, 5 Explanation: Older adults should be advised that normal patterns of bowel elimination vary considerably. For some, a normal pattern might be every other day; for others, twice a day. Constipation can be relieved by increasing the fiber intake to 20-35 grams per day. Adequate exercise is a preventative measure for constipation. Daily fluid intake of six to eight glasses is an essential preventive measure for constipation. Page Ref: 1244-1246, 1249 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 3. Identify factors that influence fecal elimination and patterns of defecation. MNL Learning Outcome: 2. Plan care for patients to maintain normal fecal elimination and manage altered patterns of fecal elimination.
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22) A client recovering from abdominal surgery is demonstrating abdominal distention from trapped flatus. What can the nurse do to help this client? 1. Assist the client to move in bed. 2. Restrict fluids. 3. Obtain an order for a rectal tube. 4. Provide a diet rich in foods that create flatulence. Answer: 3 Explanation: If excessive gas cannot be expelled through the anus, it might be necessary to insert a rectal tube to remove it. Page Ref: 1249 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 4. Identify common causes and effects of selected fecal elimination problems. MNL Learning Outcome: 2. Plan care for patients to maintain normal fecal elimination and manage altered patterns of fecal elimination. 23) A client with an upper gastrointestinal disorder is experiencing seeping of liquid stool, anorexia, abdominal distention, and nausea and vomiting. Which should the nurse suspect the client is experiencing? 1. Constipation 2. Diarrhea 3. Trapped flatus 4. Fecal impaction Answer: 4 Explanation: A client who has a fecal impaction will experience the passage of liquid fecal seepage and no normal stool. The liquid portion of the feces seeps out around the impacted mass. Symptoms include anorexia, abdominal distention, and nausea and vomiting. Page Ref: 1247 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Identify common causes and effects of selected fecal elimination problems. MNL Learning Outcome: 1. Assess the fecal elimination patterns of patients. 13
24) A client has occasional bouts of constipation and asks the nurse what can be done to prevent these episodes in the future. What should the nurse instruct the client to do? (Select all that apply.) 1. Establish a regular exercise regimen. 2. Include high-fiber foods, such as vegetables, fruits, and whole grains, in the diet. 3. Maintain fluid intake of 2000-3000 mL a day. 4. Do not ignore the urge to defecate. 5. Use over-the-counter medications to treat constipation. Answer: 1, 2, 3, 4 Page Ref: 1252 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 7. Identify measures that maintain normal fecal elimination patterns. MNL Learning Outcome: 2. Plan care for patients to maintain normal fecal elimination and manage altered patterns of fecal elimination. 25) A hospitalized client tells the nurse of the inability to have a bowel movement because "too many people are around." What should the nurse do to promote normal fecal elimination for this client? 1. Provide a laxative. 2. Assist the client to the bathroom to ensure privacy. 3. Restrict fluids. 4. Assist the client with ambulation. Answer: 2 Explanation: Privacy during defecation is extremely important to many people. The nurse should therefore provide as much privacy as possible for such clients but might need to stay with those who are too weak to be left alone. Page Ref: 1252 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 7. Identify measures that maintain normal fecal elimination patterns. MNL Learning Outcome: 2. Plan care for patients to maintain normal fecal elimination and manage altered patterns of fecal elimination.
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26) A client has received an oil retention enema. At which time should the nurse instruct the client that the enema will take effect? 1. 1-3 hours 2. 10-20 minutes 3. 5-10 minutes 4. 10-15 minutes Answer: 1 Explanation: Oil retention enemas take effect within 1-3 hours. Page Ref: 1256 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 8. Describe the purpose and action of commonly used enema solutions. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients with a colostomy or requiring an enema. 27) A client experiencing hard, dry feces is scheduled for an enema. The nurse recognizes that what type of solution would be best for the client? (Select all that apply.) 1. Hypertonic 2. Hypotonic 3. Soapsuds 4. Oil retention 5. Isotonic Answer: 2, 5 Page Ref: 1256 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 8. Describe the purpose and action of commonly used enema solutions. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients with a colostomy or requiring an enema.
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28) The nurse is discussing different types of ostomy appliances with a client with a new ostomy. During this discussion, the nurse should keep in mind that an ostomy appliance should do which of the following? (Select all that apply.) 1. Be changed daily 2. Protect the skin 3. Collect stool 4. Control odor 5. Be open, so the client can empty it sporadically throughout the day Answer: 2, 3, 4 Page Ref: 1263 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 9. Describe essentials of fecal stoma care for clients with an ostomy. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients with a colostomy or requiring an enema. 29) The nurse is assigning activities regarding fecal elimination to assistive personnel (AP). Which activity can AP safely perform to meet a client's fecal elimination needs? 1. Provide a fracture pan to a client on bed rest. 2. Provide a client who has a fecal impaction and prolapsed rectum with a cleansing enema. 3. Change a client's ostomy device. 4. Irrigate a client's ostomy. Answer: 1 Explanation: Providing a client who is on bed rest with a fracture pan is within the skill level of AP. Page Ref: 1253-1254 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the health care team | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 10. Recognize when it is appropriate to assign assistance with fecal elimination to assistive personnel. MNL Learning Outcome: 2. Plan care for patients to maintain normal fecal elimination and manage altered patterns of fecal elimination.
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30) During morning care, assistive personnel (SAP) notes that thick green drainage is seeping around the appliance of a client's new ostomy. What should the AP have been instructed to do? 1. Clean around the drainage. 2. Remove the ostomy appliance and cover the stoma with toilet tissue. 3. Perform complete ostomy care. 4. Report the drainage to the nurse. Answer: 4 Explanation: Care of a new ostomy is not delegated to AP. However, aspects of ostomy function are observed during usual care, and may be recorded by persons other than the nurse. Abnormal findings must be validated and interpreted by the nurse. Page Ref: 1266 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the health care team | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation Learning Outcome: 10. Recognize when it is appropriate to assign assistance with fecal elimination to assistive personnel. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients with a colostomy or requiring an enema.
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31) The nurse is performing ostomy care for a client. Place in order the steps the nurse will perform to do this care. 1. Clean and dry the peristomal skin and stoma. 2. Prepare and apply the skin barrier. 3. Empty the pouch and remove the ostomy barrier. 4. Assess the stoma and peristomal skin. 5. Apply the pouch. 6. Place a piece of tissue or gauze over the stoma and change it as needed. Answer: 3, 1, 4, 6, 2, 5 Explanation: When caring for a client with an ostomy, the nurse should (1) empty the pouch and remove the ostomy barrier; (2) clean and dry the peristomal skin and stoma; (3) assess the stoma and peristomal skin; (4) place a piece of tissue or gauze over the stoma and change it as needed; (5) prepare and apply the skin barrier; and (6) apply the pouch. Page Ref: 1265-1267 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 11. Verbalize the steps used in: b. Changing a bowel diversion ostomy appliance. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients with a colostomy or requiring an enema.
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32) While administering an enema, the client complains of abdominal cramping. What should the nurse do? 1. Raise the height of the solution container. 2. Clamp the flow for 30 seconds, and restart at a slower rate. 3. Discontinue the enema infusion. 4. Assist the client to a supine position. Answer: 2 Explanation: If the client complains of fullness or pain, lower the container or use the clamp to stop the flow for 30 seconds, and then restart the flow at a slower rate. Administering the enema slowly and stopping the flow momentarily decreases the likelihood of intestinal spasm and premature ejection of the solution. Page Ref: 1258 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 11. Verbalize the steps used in: a. Administering an enema. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients with a colostomy or requiring an enema. 33) A client has received a return-flow enema. What should the nurse document about this procedure? (Select all that apply.) 1. Number of times the solution was changed. 2. Type of solution. 3. Length of time the solution was retained. 4. The amount, color, and consistency of the return. 5. Client relief of flatus and abdominal distention. Answer: 2, 3, 4, 5 Page Ref: 1258 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patientcentered care | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 12. Demonstrate appropriate documentation and reporting related to fecal elimination. MNL Learning Outcome: 4. Implement the evaluation, documentation, and reporting of care for patients with fecal elimination problems.
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34) The nurse has completed care with a client who has a new ostomy. What should the nurse document about the care provided? (Select all that apply.) 1. Any change in stoma size 2. Condition of the skin around the stoma 3. Amount and type of drainage 4. Client's response to the procedure 5. Degree of bowel sounds after care provided Answer: 1, 2, 3, 4 Page Ref: 1267 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 12. Demonstrate appropriate documentation and reporting related to fecal elimination. MNL Learning Outcome: 4. Implement the evaluation, documentation, and reporting of care for patients with fecal elimination problems. 35) During an assessment, the nurse notes that a client's stool is black. Which medication should the nurse consider as causing this client's change in stool color? 1. Iron 2. Aspirin 3. Antacids 4. Antibiotics Answer: 1 Explanation: Iron salts lead to black stool because of the oxidation of the iron. Page Ref: 1246 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify factors that influence fecal elimination and patterns of defecation. MNL Learning Outcome: 1. Assess the fecal elimination patterns of patients.
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36) The nurse is caring for a client with a fecal incontinence pouch. What should the nurse do when caring for this client? (Select all that apply.) 1. Assess perianal skin. 2. Irrigate the pouch every shift. 3. Maintain the drainage system. 4. Change the bag every 72 hours. 5. Explain the purpose of the system to the client. Answer: 1, 3, 4, 5 Page Ref: 1260 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 6. Identify examples of nursing diagnoses, outcomes, and interventions for clients with elimination problems. MNL Learning Outcome: 2. Plan care for patients to maintain normal fecal elimination and manage altered patterns of fecal elimination.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 49 Oxygenation 1) The nurse is caring for a client with a tracheostomy. For what protective mechanism will the nurse monitor in the client? 1. The ability to cough 2. Filtration and humidification of inspired air 3. The sneeze reflex initiated by irritants in the nasal passages 4. Decrease in oxygen-carrying capacity of the trachea Answer: 2 Explanation: When the nasal passages are bypassed as they would be in the case of a client with a tracheostomy, the filtration, humidification, and warming of the nasal passages is also bypassed. Page Ref: 1276 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Outline the structure and function of the respiratory system. MNL Learning Outcome: 1. Assess the oxygen status of patients.
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2) The client complains of difficulty breathing. Which assessment findings should the nurse associate with that complaint? (Select all that apply.) 1. Use of accessory muscles 2. Increased respiratory depth 3. Increased respiratory rate 4. Decreased respiratory depth 5. Decreased respiratory rate Answer: 1, 2, 3, 4 Explanation: Use of accessory muscles often is an assessment finding indicating difficulty breathing. Depth is often assessed when determining difficulty breathing. The depth of respirations can be deeper (tidal volume greater than 500 mL of air) or shallower if partial obstruction is present. Rate is assessed when determining difficulty breathing. Rate is generally increased. The depth of respirations can be deeper (tidal volume greater than 500 mL of air) or shallower if partial obstruction is present. Page Ref: 1283 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 7. Describe nursing assessments for oxygenation status. MNL Learning Outcome: 1. Assess the oxygen status of patients.
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3) The client has been admitted with complaints of shortness of breath of 2 weeks duration and has received the nursing diagnosis Impaired Gas Exchange. Which admission laboratory result would support the choice of this diagnosis? 1. Increased hematocrit 2. Decreased BUN 3. Increased blood sugar 4. Increased sedimentation rate Answer: 1 Explanation: Hematocrit is the percentage of the blood that is erythrocytes, which contain the hemoglobin that carries oxygen. Long-term hypoxia may result in the body's attempt to increase oxygen-carrying capacity by increasing erythrocyte production. Page Ref: 1279 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 6. Identify four major types of conditions that can alter respiratory function. MNL Learning Outcome: 1. Assess the oxygen status of patients. 4) A client diagnosed with chronic obstructive lung disease who is receiving oxygen at 1.5 liters per minute via nasal cannula is complaining of shortness of breath. What action should the nurse take? 1. Increase the oxygen to 3 liters per minute via nasal cannula. 2. Lower the head of the client's bed to the semi-Fowler position. 3. Have the client breathe through pursed lips. 4. Encourage the client to breathe more rapidly. Answer: 3 Explanation: The client should be taught to breathe out against pursed lips to increase the time it takes to exhale and to help keep airways open. Page Ref: 1286 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 8. Describe nursing measures to promote respiratory function and oxygenation. MNL Learning Outcome: 2. Plan care for patients to maintain oxygenation and manage altered patterns of oxygenation. 3
5) After learning of a terminal illness and life expectancy, the client begins to hyperventilate and complains of being light-headed with the fingers, toes, and mouth tingling. What action should be taken by the nurse? 1. Prepare to resuscitate the client. 2. Have the client concentrate on slowing down respirations. 3. Place the client in Trendelenburg position and ask him to cough forcefully. 4. Administer 25 mg of meperidine (Demerol) according to the prn pain order. Answer: 2 Explanation: This client is hyperventilating and should be assisted to slow down respirations. Techniques to slow respirations include counting respirations or having the client match respirations with the nurse, who then slows down the respiratory rate. Page Ref: 1281 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 8. Describe nursing measures to promote respiratory function and oxygenation. MNL Learning Outcome: 2. Plan care for patients to maintain oxygenation and manage altered patterns of oxygenation. 6) Upon assessment, the nurse notes that a client has dyspnea, crackles in both lung bases, and tires easily upon exertion. Which nursing diagnosis is best supported by these assessment details? 1. Ineffective Breathing Pattern 2. Anxiety 3. Ineffective Airway Clearance 4. Impaired Gas Exchange Answer: 3 Explanation: The data given for this client best support the nursing diagnosis of Ineffective Airway Clearance. The most supportive finding for this diagnosis is crackles in both lung bases. Page Ref: 1283 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Diagnosis Learning Outcome: 6. Identify four major types of conditions that can alter respiratory function. MNL Learning Outcome: 2. Plan care for patients to maintain oxygenation and manage altered patterns of oxygenation. 4
7) The nurse encourages the client to expectorate sputum rather than swallowing it. What is the rationale for this direction? 1. Sputum contains bacteria that should be expectorated. 2. Swallowing sputum is dangerous to the system. 3. The nurse should view the sputum for quality and quantity. 4. The client is likely to aspirate the sputum while attempting to swallow it. Answer: 3 Explanation: There is no good rationale for having the client expectorate the sputum except for the nurse to view it for quality and quantity. Page Ref: 1282 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 8. Describe nursing measures to promote respiratory function and oxygenation. MNL Learning Outcome: 1. Assess the oxygen status of patients. 8) The nurse is planning a time schedule for a client's twice-daily postural drainage. Which time schedule would be best? 1. 0800 and 1100 2. 1200 and 1800 3. 0700 and 2000 4. 0900 and 2100 Answer: 3 Explanation: Postural drainage should be scheduled to avoid hours shortly after meals because the treatment may induce vomiting and can be very tiring for the client. Of the options offered, the one that takes into consideration when the meal schedule is most widely distributed is 0700 and 2000. Page Ref: 1289 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Planning Learning Outcome: 8. Describe nursing measures to promote respiratory function and oxygenation. MNL Learning Outcome: 2. Plan care for patients to maintain oxygenation and manage altered patterns of oxygenation. 5
9) A client is receiving oxygen by nonrebreather mask, but the bag is deflating on inspiration. What action should be taken by the nurse? 1. Turn the client to the left side. 2. Increase the percentage of oxygen being delivered. 3. Check for an airtight seal between the client's face and the mask. 4. Increase the liter flow of oxygen being delivered. Answer: 4 Explanation: To prevent carbon dioxide buildup, the nonrebreather bag must not totally deflate during inspiration. If it does, the nurse can correct this problem by increasing the liter flow of oxygen. Page Ref: 1295 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation Learning Outcome: 9. Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients requiring supplemental oxygen, suctioning, or tracheostomy care. 10) The nurse has placed an oropharyngeal airway in a client. What action should the nurse take at this time? 1. Tape the airway in place. 2. Suction the client. 3. Turn the client's head to the side. 4. Insert a nasal trumpet. Answer: 3 Explanation: The nurse should turn the client's head to the side to allow drainage of oral secretions. Page Ref: 1298 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation Learning Outcome: 9. Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients requiring supplemental oxygen, suctioning, or tracheostomy care. 6
11) A client has a newly created tracheostomy for mechanical ventilation after a surgical procedure. What action should the nurse plan for this client? 1. Deflate the cuff of the tracheostomy tube every 2 hours for 5 minutes. 2. Remove the tracheostomy ties and replace them with an elastic bandage. 3. Remove the tracheostomy inner cannula. 4. Tape the tracheostomy obturator to the head of the bed. Answer: 4 Explanation: The obturator should be taped to the head of the bed so that it will be readily available if the client tracheostomy tube should become dislodged. Page Ref: 1299 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation Learning Outcome: 9. Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients requiring supplemental oxygen, suctioning, or tracheostomy care. 12) The nurse needs to hyperinflate a client prior to suctioning. How should the nurse proceed with this requirement? 1. Turn the suction level up to 60 cm prior to inserting the catheter. 2. Increase the oxygen flow to the client by 20% prior to suctioning. 3. Provide two to three breaths at 1.5 times the tidal volume prior to suction. 4. Instruct the client to cough forcefully from the abdomen prior to suction. Answer: 3 Explanation: The nurse should provide two to three breaths at 1.5 times the client's normal tidal volume prior to and after insertion of the suction catheter. Page Ref: 1307 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation Learning Outcome: 11. Verbalize the steps used in: b. Oropharyngeal, nasopharyngeal, and nasotracheal suctioning. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients requiring supplemental oxygen, suctioning, or tracheostomy care.
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13) The nurse who is assessing a client's chest tube insertion site notices a fine crackling sound and feeling upon palpating the area. What action should the nurse take? 1. Discontinue the chest tube suction. 2. Collaborate with the client's physician. 3. Mark the area involved and remove the tube. 4. Reinforce the chest tube dressing. Answer: 2 Explanation: Subcutaneous emphysema, which is air in the subcutaneous tissues, can result from a poor seal at the chest tube insertion site. The nurse should collaborate with the client's physician regarding this finding. Page Ref: 1314 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation Learning Outcome: 11. Verbalize the steps used in: b. Oropharyngeal, nasopharyngeal, and nasotracheal suctioning. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients requiring supplemental oxygen, suctioning, or tracheostomy care. 14) The nurse is preparing to assist with the removal of a chest tube that is a simple insertion without a purse-string suture. What materials should the nurse gather for this procedure? 1. An occlusive dressing 2. A 4 × 4 gauze 3. An adhesive gauze pad dressing 4. A nonadherent gauze dressing Answer: 1 Explanation: Because this chest tube was put in without a purse-string suture, there is nothing to pull the tissue together once the tube is removed. In order to prevent leakage of air into the chest cavity, an occlusive dressing must be used. Page Ref: 1315 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation Learning Outcome: 9. Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients requiring supplemental oxygen, suctioning, or tracheostomy care. 8
15) The nurse has completed discharge teaching for a client who will be going home on oxygen therapy. What statement made by the client would indicate that this client needs further instruction? 1. "I will replace my cotton blankets with polyester ones." 2. "My son will not be able to smoke when I am around." 3. "I will have my electrical appliance checked for grounding." 4. "I will buy a fire extinguisher for my bedroom." Answer: 1 Explanation: Polyester blankets and fabrics tend to produce static electricity, which can cause sparks and can cause oxygen-saturated fabrics to burn more readily. Page Ref: 1291 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Evaluation/Teaching and Learning Learning Outcome: 9. Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function. MNL Learning Outcome: 4. Implement the evaluation, documentation, and reporting of care for patients requiring oxygen therapy, suctioning, and tracheostomy care.
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16) A client with a nasotracheal tube in place has been restless and pulling at the tube. How should the nurse assess if the tube is still in place? 1. Count the client's respirations. 2. Assess the depth of the client's respirations. 3. Auscultate for bilateral breath sounds. 4. Deflate the cuff and listen for minimal leak. Answer: 3 Explanation: The end of the endotracheal tube should sit just above the bifurcation of the trachea into the two mainstem bronchi. If the tube is in the correct position, the nurse should be able to hear equal bilateral breath sounds. Page Ref: 1298 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 9. Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients requiring supplemental oxygen, suctioning, or tracheostomy care. 17) The nurse has just initiated oxygen by nasal cannula for a client with the medical diagnosis of chronic obstructive pulmonary disease. What is the nurse's next action? 1. Fill the humidifier with normal saline. 2. Pad the tubing where it contacts the client's ears. 3. Set the oxygen delivery to 5 liters. 4. Secure the cannula with ties around the client's head. Answer: 2 Explanation: It is necessary to pad the cannula where it contacts the client's ears, as pressure irritation may occur. Page Ref: 1293 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation Learning Outcome: 11. Verbalize the steps used in: a. Administering oxygen by cannula, face mask, or face tent. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients requiring supplemental oxygen, suctioning, or tracheostomy care. 10
18) The nurse who is performing care for a client with a new tracheostomy needs to change the ties. What is the best method for changing these ties? 1. Remove the old ties, clean the area well, and then put on new ties. 2. Attach the new tape and tie with a square knot behind the client's neck. 3. Have an assistant hold the tracheostomy tube in place, remove the soiled ties, and replace the ties. 4. Remove the outer cannula, replace the soiled ties, and reinsert. Answer: 3 Explanation: Because these ties are soiled, it is likely that they must be removed before new ties are attached. The safest way to perform this intervention is to have an assistant hold the tracheostomy tube flange in place while the nurse removes the old ties and replaces them. Page Ref: 1310 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation Learning Outcome: 11. Verbalize the steps used in: d. Providing tracheostomy care. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients requiring supplemental oxygen, suctioning, or tracheostomy care. 19) The nurse is planning the care of a client who has the need for frequent suctioning. What should the nurse delegate to the assistive personnel (AP)? 1. Both oral and tracheal suctioning 2. Only oral suctioning 3. Only tracheal suctioning 4. Neither oral nor tracheal suctioning Answer: 2 Explanation: The suctioning of the oral cavity is a nonsterile procedure and can be delegated to the AP. Page Ref: 1269 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the health care team | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation Learning Outcome: 12. Recognize when it is appropriate to delegate aspects of oxygen therapy, suctioning, and tracheostomy care. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients requiring supplemental oxygen, suctioning, or tracheostomy care.
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20) During tracheal suctioning, the nurse notes that the client' heart rate has increased from 80 to 100 bpm. Based on this assessment, what action should the nurse take? 1. Immediately discontinue suctioning. 2. Prepare to resuscitate the client. 3. Continue to suction until the airway is clear. 4. Complete the suction episode as quickly as possible. Answer: 4 Explanation: An increase in heart rate from 80 to 100 is not an unusual finding during suctioning but does indicate increased stress on the client. The nurse should complete the suctioning episode as quickly as possible. Page Ref: 1307 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation Learning Outcome: 11. Verbalize the steps used in: c. Suctioning a tracheostomy or endotracheal tube. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients requiring supplemental oxygen, suctioning, or tracheostomy care. 21) A client who is being mechanically ventilated has copious amounts of secretions ranging from thick and tenacious to frothy. In preparing to suction this client, the nurse should take which action? 1. Hyperventilate the client using the settings on the mechanical ventilator. 2. Hyperventilate the client using a manual resuscitator. 3. Avoid hyperventilation but instill normal saline into the endotracheal tube. 4. Avoid hyperventilation and increase the oxygen to 100% for several breaths. Answer: 4 Explanation: The nurse should avoid hyperventilation and should increase the oxygen to 100% for several breaths prior to initiating suction. Hyperventilating a client who has copious secretions can force the secretions deeper into the respiratory tract. Page Ref: 1307 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation Learning Outcome: 11. Verbalize the steps used in: c. Suctioning a tracheostomy or endotracheal tube. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients requiring supplemental oxygen, suctioning, or tracheostomy care. 12
22) A client has been prescribed both a bronchodilator and a steroid medication that is delivered by inhaler. What information is essential to teach this client in regard to these medications? 1. The medications cannot be used on the same day. 2. The steroid inhaler should be used when immediate effects are necessary. 3. The bronchodilator should be used only when absolutely necessary and only after the steroid inhaler. 4. Both medications have the possible side effect of increased heart rate. Answer: 4 Explanation: Both of these medications have the possible side effect of increased heart rate. Page Ref: 1288 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 9. Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients requiring supplemental oxygen, suctioning, or tracheostomy care. 23) A client who was a victim of a house fire is coughing. Which should the nurse realize is the purpose of the client's cough? 1. Improve oxygenation 2. Remove irritants from the nasal passages 3. Remove irritants from the trachea or bronchi 4. Close the glottis Answer: 3 Explanation: The trachea and bronchi are lined with mucosal epithelium. These cells produce a thin layer of mucus that traps pathogens and microscopic particulate matter. These foreign particles are then swept upward toward the larynx and throat by cilia. The cough reflex is triggered by irritants in the larynx, trachea, or bronchi. Page Ref: 1277 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Explain the role and function of the respiratory system in transporting oxygen and carbon dioxide to and from body tissues. MNL Learning Outcome: 1. Assess the oxygen status of patients. 13
24) A client is experiencing atelectasis. The nurse anticipates that this client will have an alteration in which part of the respiratory system? 1. Ventilation 2. Alveolar gas exchange 3. Transportation of oxygen and carbon dioxide 4. Systemic diffusion Answer: 1 Explanation: Atelectasis affects lung compliance, which is a condition that needs to be present for adequate ventilation. Page Ref: 1277 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Describe the processes of breathing (ventilation) and gas exchange (respiration). MNL Learning Outcome: 1. Assess the oxygen status of patients. 25) A client is demonstrating signs of hypoxia. What laboratory value will help the nurse determine the client's degree of effective gas exchange? 1. Blood glucose 2. Serum potassium 3. Serum sodium 4. Arterial blood gas Answer: 4 Explanation: Blood for partial pressures or blood gases is usually obtained from arterial blood. Page Ref: 1283 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 7. Describe nursing assessments for oxygenation status. MNL Learning Outcome: 1. Assess the oxygen status of patients.
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26) The nurse is determining a client's ability to transport oxygen from the lungs to body tissues. What factors will influence this ability? (Select all that apply.) 1. Cardiac output 2. Exercise 3. Diet 4. Erythrocyte count 5. Hematocrit Answer: 1, 2, 4, 5 Page Ref: 1279 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Identify factors influencing respiratory function. MNL Learning Outcome: 1. Assess the oxygen status of patients. 27) A client's blood gas analysis results show an increase in carbon dioxide level. What will the nurse most likely assess in this client? 1. Decreased respiration rate 2. Increased respiration rate 3. Increased blood pressure 4. Decreased bowel sounds Answer: 2 Explanation: Of the three blood gases–hydrogen, oxygen, and carbon dioxide–that can trigger chemoreceptors, increased carbon dioxide concentration normally has the strongest effect on stimulating respiration. Page Ref: 1279 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 7. Describe nursing assessments for oxygenation status. MNL Learning Outcome: 1. Assess the oxygen status of patients.
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28) A client's blood gas results reveal a low oxygen level. The nurse realizes that which area of the body will respond to this level and influence respirations? 1. Alveoli 2. Trachea 3. Bronchioles 4. Carotid bodies Answer: 4 Explanation: Special neural receptors sensitive to decreases in O 2 concentration are located outside the central nervous system in the carotid bodies, just above the bifurcation of the common carotid arteries, and aortic bodies located above and below the aortic arch. Decreases in arterial oxygen concentrations stimulate these chemoreceptors, and they in turn stimulate the respiratory center to increase ventilation. Page Ref: 1279 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Describe the processes of breathing (ventilation) and gas exchange (respiration). MNL Learning Outcome: 1. Assess the oxygen status of patients.
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29) An older client is prescribed diazepam (Valium). What should the nurse monitor in this client? 1. Respirations 2. Urine output 3. Muscle tone 4. Appetite Answer: 1 Explanation: Medications such as diazepam (Valium) can decrease the rate and depth of respirations. Older clients are at high risk of respiratory depression. The nurse must carefully monitor respiratory status in this client. Page Ref: 1280 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 9. Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function. MNL Learning Outcome: 2. Plan care for patients to maintain oxygenation and manage altered patterns of oxygenation. 30) The nurse is assessing the respiratory status of an older client. What effects of aging should the nurse keep in mind during this assessment? (Select all that apply.) 1. Decreased cough reflex 2. Stiffening of blood vessels 3. Alteration in protein synthesis 4. Dry mucous membranes 5. Increased risk of aspiration Answer: 1, 4, 5 Explanation: The cough reflex decreases during aging. Mucous membranes are drier with aging. Increased risk of aspiration occurs in aging because of gastroesophageal reflux disease. Page Ref: 1280 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Identify factors influencing respiratory function. MNL Learning Outcome: 1. Assess the oxygen status of patients. 17
31) A client is diagnosed with congestive heart failure. The nurse should assess the client for which conditions that can alter this client's respiratory function? 1. Conditions that affect the airway. 2. Conditions that affect transport. 3. Conditions that affect the movement of air. 4. Conditions that affect diffusion. Answer: 2 Explanation: Once oxygen moves into the lungs and diffuses into the capillaries, the cardiovascular system transports the oxygen to all body tissues, and transports CO2 from the cells back to the lungs, where it can be exhaled from the body. Conditions that decrease cardiac output, such as congestive heart failure or hypovolemia, affect tissue oxygenation and also the body's ability to compensate for hypoxemia. Page Ref: 1279 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Identify factors influencing respiratory function. MNL Learning Outcome: 1. Assess the oxygen status of patients. 32) The nurse is conducting a health history for a client with a respiratory disorder. What should the nurse include in this assessment? (Select all that apply.) 1. Lifestyle 2. Presence of cough 3. Sputum production 4. Pain 5. Diet Answer: 1, 2, 3, 4 Page Ref: 1282 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 7. Describe nursing assessments for oxygenation status. MNL Learning Outcome: 1. Assess the oxygen status of patients.
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33) A client is concerned about maintaining a healthy respiratory system. What should the nurse instruct the client to do to promote a healthy respiratory status? (Select all that apply.) 1. Use pursed-lip breathing. 2. Exercise regularly. 3. Do not smoke. 4. Breathe through the nose. 5. Breathe through the mouth. Answer: 2, 3, 4 Page Ref: 1285 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 8. Describe nursing measures to promote respiratory function and oxygenation. MNL Learning Outcome: 2. Plan care for patients to maintain oxygenation and manage altered patterns of oxygenation. 34) Which client statement indicates to the nurse that instruction about the use of a humidifier has been effective? 1. "A humidifier takes moisture out of the air." 2. "A humidifier tightens secretions." 3. "A humidifier prevents my lungs from getting too dry." 4. "A humidifier replaces the use of oxygen." Answer: 3 Explanation: The purposes of humidifiers are to prevent mucous membranes from drying and becoming irritated and to loosen secretions for easier expectoration. Page Ref: 1287 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Evaluation/Teaching and Learning Learning Outcome: 10. State outcome criteria for evaluating client responses to measures that promote adequate oxygenation. MNL Learning Outcome: 4. Implement the evaluation, documentation, and reporting of care for patients requiring oxygen therapy, suctioning, and tracheostomy care.
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35) The nurse documents that a prescribed expectorant has been effective for a client. What did the nurse evaluate in this client? 1. Respiratory rate 24 and labored 2. Audible wheeze upon auscultation 3. High-pitched cough present 4. Presence of a productive cough Answer: 4 Explanation: Expectorants break up mucus, making it more liquid and easier to cough out. Page Ref: 1287 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Evaluation Learning Outcome: 10. State outcome criteria for evaluating client responses to measures that promote adequate oxygenation. MNL Learning Outcome: 4. Implement the evaluation, documentation, and reporting of care for patients requiring oxygen therapy, suctioning, and tracheostomy care. 36) The nurse is performing nasotracheal suctioning of a client. What should the nurse do when suctioning this client? 1. Apply suction for 5-10 seconds. 2. Plan to suction for 10 minutes. 3. Apply suction while inserting the catheter. 4. Apply suction for 20-30 seconds. Answer: 1 Explanation: When conducting nasotracheal suctioning, the nurse should apply suction for 5-10 seconds. Page Ref: 1303 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation Learning Outcome: 11. Verbalize the steps used in: b. Oropharyngeal, nasopharyngeal, and nasotracheal suctioning. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients requiring supplemental oxygen, suctioning, or tracheostomy care.
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37) The nurse wants to delegate the Yankauer suctioning of a client to assistive personnel (AP). What will the nurse ensure that AP know before delegating this activity? 1. How to apply suction during the insertion of the catheter 2. Not to apply suction during the insertion of the catheter 3. How to maintain sterile technique 4. How to listen for lung sounds Answer: 2 Explanation: Oral suctioning using a Yankauer suction tube can be delegated to AP, as this is not a sterile procedure. The nurse needs to review the procedure and important points, such as not applying suction during insertion of the tube to avoid trauma to the mucous membrane. Page Ref: 1302 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the health care team | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Planning Learning Outcome: 12. Recognize when it is appropriate to delegate aspects of oxygen therapy, suctioning, and tracheostomy care. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients requiring supplemental oxygen, suctioning, or tracheostomy care. 38) The nurse has completed nasopharyngeal suctioning of a client. What should the nurse document about this procedure? (Select all that apply.) 1. Amount, consistency, color, and odor of sputum 2. Amount of sterile solution used to flush the catheter 3. Lung sounds before the procedure 4. Lung sounds after the procedure 5. Oxygen saturation after the procedure Answer: 1, 3, 4, 5 Page Ref: 1304 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 13. Demonstrate appropriate documentation and reporting of oxygen therapy, suctioning, and tracheostomy care. MNL Learning Outcome: 4. Implement the evaluation, documentation, and reporting of care for patients requiring oxygen therapy, suctioning, and tracheostomy care.
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39) The nurse is documenting the completion of tracheostomy suctioning and tracheostomy care in a client's medical record. What should this documentation include? (Select all that apply.) 1. Lung sounds before and after suctioning 2. Characteristics of suctioned sputum 3. Integrity of the skin around the stoma 4. Side on which the tracheostomy tie knot is located 5. Flow rate of oxygen Answer: 1, 2, 3 Page Ref: 1308 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 13. Demonstrate appropriate documentation and reporting of oxygen therapy, suctioning, and tracheostomy care. MNL Learning Outcome: 4. Implement the evaluation, documentation, and reporting of care for patients requiring oxygen therapy, suctioning, and tracheostomy care. 40) The nurse is planning care for a client who was admitted after having a myocardial infarction. Based on this history, the nurse's greatest concern is that this client might develop which health problem? 1. Chronic renal failure 2. A gastric ulcer 3. Hypoxemia 4. A cerebral vascular accident Answer: 3 Explanation: Although injury to the heart muscle might affect any or all of the body systems, at this point the nurse is most concerned that the client will develop hypoxemia. The status of the respiratory system is closely linked to and dependent upon the cardiovascular system. Page Ref: 1281 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Outline the structure and function of the respiratory system. MNL Learning Outcome: 1. Assess the oxygen status of patients.
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41) Before administering the prescribed medication propranolol (Inderal) to a client, the nurse contacts the healthcare provider to question the order. What health problems did the client have that caused the nurse to question the medication order? (Select all that apply.) 1. COPD 2. Asthma 3. Arthritis 4. Gastritis 5. Heart failure Answer: 1, 2 Explanation: Beta-adrenergic blocking agents such as propranolol affect the sympathetic nervous system to reduce the workload of the heart. These drugs can negatively affect people with COPD because they may constrict airways by blocking beta-2 adrenergic receptors. Beta-adrenergic blocking agents such as propranolol affect the sympathetic nervous system to reduce the workload of the heart. These drugs can negatively affect people with asthma because they may constrict airways by blocking beta-2 adrenergic receptors. Page Ref: 1287 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 9. Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients requiring supplemental oxygen, suctioning, or tracheostomy care.
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42) The nurse is planning care for a client with an oral endotracheal tube. Which interventions should be included in this client's plan of care? (Select all that apply.) 1. Insert an oropharyngeal airway. 2. Provide nasal care every 2-4 hours. 3. Provide oral hygiene every 2-4 hours. 4. Adjust non-humidified airflow as prescribed. 5. Move the tube to opposite sides of the mouth every 8 hours. Answer: 1, 2, 3, 5 Explanation: For an oral endotracheal tube, use an oropharyngeal airway to prevent the client from biting down on the oral endotracheal tube. For an oral endotracheal tube, provide nasal care every 2-4 hours. For an oral endotracheal tube, provide oral hygiene every 2-4 hours. For an oral endotracheal tube, move the tube to the opposite side of the mouth every 8 hours or per agency protocol, taking care to maintain the position of the tube in the trachea. This prevents irritation to the oral mucosa. Page Ref: 1296 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Implementation Learning Outcome: 9. Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients requiring supplemental oxygen, suctioning, or tracheostomy care.
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43) A male client has a hematocrit level of 58%. Which should the nurse expect to assess in this client? 1. Slow heart rate 2. Slow respiratory rate 3. Reduced blood pressure 4. Poor oxygenation of tissues Answer: 4 Explanation: Excessive increases in the blood hematocrit raise the blood viscosity, reducing the cardiac output and therefore reducing oxygen transport. An elevated hematocrit level will not cause a slow heart rate, slow respiratory rate, or reduced blood pressure. Page Ref: 1279 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Explain the role and function of the respiratory system in transporting oxygen and carbon dioxide to and from body tissues. MNL Learning Outcome: 1. Assess the oxygen status of patients. 44) The nurse notes that a client has a slow respiratory rate. Which should the nurse consider as having the greatest influence on the client's carotid bodies to affect the rate? 1. Water 2. Oxygen 3. Hydrogen 4. Carbon dioxide Answer: 4 Explanation: Of the three blood gases to include hydrogen, oxygen, and carbon dioxide that can trigger chemoreceptors, increased carbon dioxide concentration normally has the strongest effect on stimulating respiration. Water level does not stimulate respiratory rate. Page Ref: 1279 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Describe the mechanisms for respiratory regulation. MNL Learning Outcome: 1. Assess the oxygen status of patients.
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45) The nurse is caring for a client with emphysema. Which should the nurse consider that is regulating this client's respirations? 1. Oxygen concentration 2. Carbohydrate metabolism 3. Hydrogen ion concentration 4. Carbon dioxide concentration Answer: 1 Explanation: In clients with emphysema, oxygen concentrations, not carbon dioxide concentrations, play a major role in regulating respiration. For some clients, decreased oxygen concentrations are the main stimuli for respiration because the chronically elevated carbon dioxide levels that occur with emphysema "desensitize" the central chemoreceptors. This is sometimes called the hypoxic drive. Increasing the concentration of oxygen depresses the respiratory rate. Carbohydrate metabolism and hydrogen ion concentration do not play a role in regulating the respiratory rate in a client with emphysema. Page Ref: 1277 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge; Evidence and best practices for nursing | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Describe the mechanisms for respiratory regulation. MNL Learning Outcome: 1. Assess the oxygen status of patients.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 50 Circulation 1) After a cardiac catheterization, an infant is diagnosed with a malformation of the mitral valve. For which problem should the nurse monitor the client? 1. Oxygenated blood to the body 2. Deoxygenated blood to the lung 3. Oxygenated blood to the right atrium 4. Deoxygenated blood to the left ventricle Answer: 1 Explanation: The mitral valve separates the left ventricle from the left atrium. Problems with this valve will impede the flow of oxygenated blood from the left atrium into the left ventricle for delivery to the body. Page Ref: 1321 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Describe three major alterations in cardiovascular function. MNL Learning Outcome: 2. Examine alterations in cardiovascular function. 2) During assessment, the nurse notes a cardiac murmur that occurs between S1 and S2. Which type of murmur should the nurse document for this client? 1. Diastolic 2. Holosystolic 3. Systolic 4. Pansystolic Answer: 3 Explanation: The period of the cardiac cycle between S1 and S2 is ventricular systole. Any extra heart sounds heard during this period of time would be documented as systolic. The period of time between S2 and the next S1 is diastole. Page Ref: 1322 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Outline the structure and physiology of the cardiovascular system. MNL Learning Outcome: 2. Examine alterations in cardiovascular function. 1
3) The nurse is planning teaching for a client that focuses on Healthy People 2020 objectives for cardiovascular health. Which modifiable risk factors should the nurse include in this teaching? (Select all that apply.) 1. Age 2. Gender 3. Obesity 4. Smoking 5. Hypertension Answer: 3, 4, 5 Page Ref: 1294 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 2. Identify major risk factors for the development of cardiovascular disease and related health-promotion objectives from Healthy People 2020. MNL Learning Outcome: 2. Examine alterations in cardiovascular function. 4) A client has experienced a myocardial infarction with damage to the inferior portion of the heart. Due to this history, the nurse monitors the client for the development of rhythm disturbances that are most directly based on which factor? 1. The resultant change in blood sugar 2. Electrolyte disturbances from tissue damage 3. The automaticity of cardiac cells 4. Decreased blood flow to the liver Answer: 3 Explanation: Each cardiac cell can generate its own electrical impulse. Myocardial infarction interferes with the flow of blood to these cells, and the resultant ischemia makes the cells more irritable and more likely to generate an impulse. These uncontrolled impulses result in rhythm disturbances. The most likely cause of rhythm disturbance following myocardial infarction is insult to the cells, causing them to be irritable. Page Ref: 1322 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Describe three major alterations in cardiovascular function. MNL Learning Outcome: 2. Examine alterations in cardiovascular function. 2
5) A client has a heart rate of 170 beats per minute. For what will the nurse assess next in this client? 1. Increased cardiac output 2. Increased preload 3. Decreased afterload 4. Decreased cardiac output Answer: 4 Explanation: Cardiac output equals stroke volume × heart rate. Because this client has a sustained rapid heart rate, the ventricles are most likely not having sufficient time to relax and refill between contractions, so the stroke volume will decrease. At the rate of 170, the compensatory increase in heart rate is no longer helpful in increasing cardiac output. This leads to a decrease in cardiac output. Page Ref: 1323 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Outline the structure and physiology of the cardiovascular system. MNL Learning Outcome: 2. Examine alterations in cardiovascular function. 6) The client has complaints of being tired, listless, and unable to tolerate activity at usual levels. Which laboratory value should the nurse review first while assessing this complaint? 1. Blood urea nitrogen 2. Hemoglobin and hematocrit 3. Blood sugar 4. Serum potassium Answer: 2 Explanation: Hemoglobin is the oxygen-carrying portion of the blood, and anemia (decrease in hemoglobin and hematocrit) is often associated with client complaints of being tired, listless, and unable to tolerate normal activities. Page Ref: 1326 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease. MNL Learning Outcome: 3. Assess the cardiovascular status of patients.
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7) The nurse assessing a 1-day-old infant discovers the heart rate is 140 and irregular. What action should the nurse take? 1. Immediately contact the infant's physician. 2. Prepare to resuscitate the infant. 3. Note this normal finding in the infant's medical record. 4. Stimulate the infant gently. Answer: 3 Explanation: An irregular heart rate of 140 is common and normal in an infant of this age. The finding should be recorded in the medical record. Page Ref: 1326 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease. MNL Learning Outcome: 3. Assess the cardiovascular status of patients. 8) A client who is postmenopausal asks about the use of estrogen replacement therapy to protect the heart. In which way should the nurse respond? 1. "This therapy is well proven to protect the heart in postmenopausal women." 2. "Estrogen replacement therapy is helpful to reduce the sleep disturbances and hot flashes associated with menopause but does not protect the heart." 3. "Estrogen replacement therapy has been proven to have no effect on any postmenopausal symptoms and is not protective of the heart." 4. "The use of estrogen replacement therapy is complex and requires a thoughtful review of the balance between possible benefits and possible risks." Answer: 4 Explanation: There is some concern about the risk of administering this therapy and the development of other health problems such as cancers. The choice to use this therapy should be made only after careful consideration of these benefits and risks. Page Ref: 1334 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease. MNL Learning Outcome: 4. Implement interventions to promote optimal cardiovascular function and manage cardiovascular disease. 4
9) A client recovering from a myocardial infarction asks about returning to exercise. What information should the nurse give this client? 1. It is better to exercise when it is cold. 2. Environmental temperatures have little impact on cardiac function. 3. Avoid exercise when the weather is hot or cold. 4. Hot temperatures increase peripheral blood vessel contraction. Answer: 3 Explanation: The nurse should advise the client to avoid exercise in hot or cold weather, as these extremes of temperature increase the workload on the heart. Cold temperatures increase peripheral blood vessel contraction and therefore peripheral vascular resistance, making it more difficult for the heart to circulate blood. Hot temperatures decrease systemic vascular resistance by dilating peripheral vessels. This decrease makes the heart rate increase, thereby increasing the heart's workload. Page Ref: 1334 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease. MNL Learning Outcome: 4. Implement interventions to promote optimal cardiovascular function and manage cardiovascular disease. 10) What dietary teaching should the nurse provide to the client who has homocysteine elevation? 1. Reduce salt intake. 2. Take a B-complex vitamin supplement daily. 3. Increase fluid intake to 2,000 mL per day. 4. Avoid alcohol intake. Answer: 2 Explanation: Supplementation with a vitamin that provides folate, vitamin B6, vitamin B12, and riboflavin can reduce homocysteine levels, although results can vary. Page Ref: 1329 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease. MNL Learning Outcome: 4. Implement interventions to promote optimal cardiovascular function and manage cardiovascular disease. 5
11) A client has a history of recurrent transient ischemic attack. Based on this history, which health problem should the nurse be most concerned about? 1. Renal failure 2. Gangrene 3. Myocardial infarction 4. Stroke Answer: 4 Explanation: Transient ischemic attacks may result from atherosclerosis of the cerebral vessels. Continued development of this atherosclerosis may result in stroke. Page Ref: 1330 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Describe three major alterations in cardiovascular function. MNL Learning Outcome: 2. Examine alterations in cardiovascular function. 12) The nurse is assessing a newly admitted client for the presence of impaired peripheral arterial circulation. Which finding would be significant to this health problem? 1. Ruddy skin color over legs 2. Bounding pedal pulses 3. Hot spots on the feet and legs 4. Decreased hair on the legs Answer: 4 Explanation: When peripheral arterial blood flow is reduced, the amount of oxygen to support hair growth is decreased and there is a reduction of hair distribution on the legs. Page Ref: 13308 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease. MNL Learning Outcome: 3. Assess the cardiovascular status of patients.
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13) The client is admitted with a possible deep vein thrombosis. Nursing interventions should be designed to prevent which complication? 1. Myocardial infarction 2. Renal failure 3. Pulmonary embolism 4. Pneumonia Answer: 3 Explanation: The presence of a deep vein thrombosis is a risk factor for the development of a pulmonary embolism. The nurse should design interventions to help prevent that development. Page Ref: 1334 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease. MNL Learning Outcome: 4. Implement interventions to promote optimal cardiovascular function and manage cardiovascular disease. 14) The nurse is collecting equipment to assess a client's ankle brachial index. What equipment should be taken to the client's bedside? 1. Blood pressure cuff and a Doppler ultrasound device 2. None, as no special equipment is needed 3. Stethoscope and penlight 4. Reflex hammer and tuning fork Answer: 1 Explanation: The nurse should take a blood pressure cuff and a Doppler ultrasound device to the bedside for this measurement. Page Ref: 1332 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease. MNL Learning Outcome: 3. Assess the cardiovascular status of patients.
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15) The nurse notes a widely bizarre pattern on the client's cardiac monitor. What is the nurse's priority action? 1. Call a code blue. 2. Check the client's pulse. 3. Immediately defibrillate the client. 4. Check the rhythm in a different lead. Answer: 2 Explanation: The nurse should always remember to verify any changes on the cardiac monitor by assessing the client (in this case, checking the pulse). The cardiac monitor reports electrical activity that may not directly reflect the mechanical activity occurring in the heart. Page Ref: 1333 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease. MNL Learning Outcome: 3. Assess the cardiovascular status of patients. 16) The nurse is reviewing the laboratory results of a client who is being observed for possible myocardial infarction. Which laboratory result would be most important for the nurse to discuss with the physician? 1. Increased hemoglobin 2. Decreased creatine kinase 3. Increased troponin 4. High normal potassium Answer: 3 Explanation: Of these options, the most important finding to discuss with the physician is the increase in troponin, which may help diagnose myocardial infarction. Page Ref: 1333 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease. MNL Learning Outcome: 3. Assess the cardiovascular status of patients.
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17) A client exhibits confusion, decreased capillary refill time, low oxygen saturation readings, and decreased renal output. What nursing diagnosis problem statement should the nurse choose for this client? 1. Ineffective Tissue Perfusion 2. Decreased Cardiac Output 3. Activity Intolerance 4. Risk for Injury Answer: 1 Explanation: Ineffective Tissue Perfusion is the diagnosis assigned when there is a decrease in oxygenation from failure to nourish tissues at the capillary level. Page Ref: 1333 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Diagnosis Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease. MNL Learning Outcome: 4. Implement interventions to promote optimal cardiovascular function and manage cardiovascular disease. 18) A client is on strict bed rest following hip surgery. What nursing intervention would support vascular health? 1. Place pillows under the unaffected knee for support. 2. Position the bed to flex the knees at least 20 degrees. 3. Have the client alternately flex and extend the feet several times a day. 4. Keep the client in a prone position for at least 20 minutes twice a day. Answer: 3 Explanation: Alternating flexion and extension of the feet will help keep clots from forming in the extremities. Active contraction and relaxation of the calf muscles is also used for this purpose. Page Ref: 1333 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease. MNL Learning Outcome: 4. Implement interventions to promote optimal cardiovascular function and manage cardiovascular disease.
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19) The nurse finds a client pulseless and breathless. The client's skin is pale and cool, but not cyanotic. Because of this finding, what should the nurse suspect? 1. Respiratory arrest occurred prior to cardiac arrest. 2. Cardiac arrest occurred prior to respiratory arrest. 3. The client cannot be resuscitated. 4. Arrest was caused by airway obstruction. Answer: 2 Explanation: In the absence of cyanosis, the logical sequence of events would be cardiac arrest followed by respiratory arrest. Page Ref: 1337 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Describe the critical nature of cardiopulmonary resuscitation. MNL Learning Outcome: 3. Assess the cardiovascular status of patients. 20) A client has a long history of hypertension and has developed heart failure. The nurse should anticipate giving medications for which purpose? 1. Increase preload 2. Decrease afterload 3. Decrease contractility 4. Decrease cardiac output Answer: 2 Explanation: The client likely has developed heart failure secondary to the hypertension, which is an increase in afterload. The nurse would anticipate giving medication to decrease afterload. Page Ref: 1324 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease. MNL Learning Outcome: 4. Implement interventions to promote optimal cardiovascular function and manage cardiovascular disease.
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21) The nurse is preparing to apply sequential compression devices to a client. In which order should the nurse apply these devices? 1. Place in the dorsal recumbent or semi-Fowler position. 2. Place a sleeve under each leg with the opening at the knee. 3. Wrap the sleeve securely around the leg, securing the Velcro tabs. 4. Turn on the control unit and adjust the alarms and pressures as needed. 5. Connect the sleeves to the control unit and adjust the pressure as needed. Answer: 1, 2, 3, 5, 4 Explanation: 1. When applying sequential compression devices, the nurse should first place the client in the dorsal recumbent or semi-Fowler position. 2. The second step is to place a sleeve under each leg with the opening at the knee. 3. The third step is to wrap the sleeve securely around the leg, securing the Velcro tabs. 4. The fifth step is to turn on the control unit and adjust the alarms and pressures as needed. 5. The fourth step is to connect the sleeves to the control unit and adjust the pressure as needed. Page Ref: 1336 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 6. Verbalize the steps used in: A. Applying a sequential compression device. MNL Learning Outcome: 4. Implement interventions to promote optimal cardiovascular function and manage cardiovascular disease.
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22) The nurse is planning morning care for a client who has sequential compression devices in place. In which way should the nurse instruct the AP who will be giving the bath? 1. "Come get me when it is time to remove the devices because that must be done by a nurse." 2. "You may remove the devices, but standards require that only a nurse put them back on the client." 3. "You may leave the devices off until the client's legs air dry." 4. "Put the devices on as quickly as possible after the bath." Answer: 4 Explanation: The nurse should remind the AP that the devices are being used to support circulation and should be off the client for as short a period of time as possible. The AP who knows the correct removal and application process may remove and apply these devices. Page Ref: 1336 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the health care team | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 7. Recognize when it is appropriate to assign aspects of applying a sequential compression device to assistive personnel. MNL Learning Outcome: 4. Implement interventions to promote optimal cardiovascular function and manage cardiovascular disease. 23) The nurse is assessing the vital signs of a 5-year-old client. Should the nurse measure this child's blood pressure? 1. Yes, blood pressure is measured for all children over the age of 3 years. 2. No, blood pressure measurements are not required until age 13. 3. Only if the child complains of headache or has an elevated pulse rate. 4. Yes, but the measurement must be taken in the child's thigh. Answer: 1 Explanation: Blood pressure measurements should be included for all children over the age of 3 years. Page Ref: 1326 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease. MNL Learning Outcome: 3. Assess the cardiovascular status of patients.
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24) A client is diagnosed with anemia. What will the nurse most likely assess in this client as evidence of an alteration in cardiovascular functioning? (Select all that apply.) 1. Chronic fatigue 2. Lower-extremity edema 3. Pallor 4. Shortness of breath 5. Hypotension Answer: 1, 3, 4, 5 Explanation: A lack of red blood cells to transport oxygen to tissues can lead to chronic fatigue. A lack of red blood cells within tissues can cause skin pallor. A lack of red blood cells to transport oxygen to tissues can cause shortness of breath. A lack of red blood cells to transport oxygen to tissues can cause hypotension. Page Ref: 1331 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease. MNL Learning Outcome: 3. Assess the cardiovascular status of patients. 25) The nurse seeing a client stop breathing realizes that there is how much time before the onset of permanent damage? 1. 3 minutes 2. 2 minutes 3. 4-6 minutes 4. 20-40 minutes Answer: 3 Explanation: After 4-6 minutes, the lack of oxygen supply to the brain causes permanent and extensive damage. Page Ref: 1337 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 5. Describe the critical nature of cardiopulmonary resuscitation. MNL Learning Outcome: 4. Implement interventions to promote optimal cardiovascular function and manage cardiovascular disease.
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26) A client with a terminal illness without an advance directive stops breathing and does not have a heartbeat. What should the nurse do? 1. Call a "slow code." 2. Call a partial code. 3. Call the physician. 4. Call a code. Answer: 4 Explanation: If there is no do-not-resuscitate order, all clients who arrest will have resuscitation efforts begun. Page Ref: 1337 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 5. Describe the critical nature of cardiopulmonary resuscitation. MNL Learning Outcome: 4. Implement interventions to promote optimal cardiovascular function and manage cardiovascular disease. 27) A client asks why sequential compression devices have been prescribed. How should the nurse respond to the client? 1. "They stimulate the blood return that would occur with walking." 2. "They prevent lymph drainage buildup in the tissues." 3. "They exercise the muscles of the leg." 4. "They are used instead of getting out of bed." Answer: 1 Explanation: Sequential compression devices simulate the blood flow that results from walking. Page Ref: 1336 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease. MNL Learning Outcome: 4. Implement interventions to promote optimal cardiovascular function and manage cardiovascular disease.
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28) The nurse determines that AP can apply sequential compression devices to a client when what is observed? 1. The devices are left off for 1 hour after morning care. 2. The alarm is turned off. 3. The tubing is not kinked. 4. Ankle pressure is set at 100 mm Hg. Answer: 3 Explanation: The tubing should not be kinked. Page Ref: 1336 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the health care team | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation Learning Outcome: 7. Recognize when it is appropriate to assign aspects of applying a sequential compression device to assistive personnel. MNL Learning Outcome: 4. Implement interventions to promote optimal cardiovascular function and manage cardiovascular disease. 29) The nurse is documenting the use of sequential compression devices in a client's medical record. What should be included in this documentation? (Select all that apply.) 1. Calf circumference 2. Skin integrity 3. Peripheral vascular status 4. Neurovascular status 5. Control unit settings Answer: 2, 3, 4, 5 Page Ref: 1336 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 8. Demonstrate appropriate documentation and reporting when applying a sequential compression device. MNL Learning Outcome: 4. Implement interventions to promote optimal cardiovascular function and manage cardiovascular disease.
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30) After an assessment, the nurse determines that a client's sequential compression devices need to be removed. What should the nurse document about this client's status in the medical record? 1. Client ambulating without assistance. 2. Client complains of numbness, tingling, and leg pain with the sequential compression devices. 3. Client requested devices to be removed. 4. Client to wear sequential compression devices during sleep. Answer: 2 Explanation: The nurse should remove the devices if the client complains of numbness, tingling, or leg pain. Page Ref: 1336 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 8. Demonstrate appropriate documentation and reporting when applying a sequential compression device. MNL Learning Outcome: 4. Implement interventions to promote optimal cardiovascular function and manage cardiovascular disease.
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Fundamentals of Nursing, 11e (Berman/Snyder) Chapter 51 Fluid, Electrolyte, and Acid-Base Balance 1) The 154-pound adult client has had vomiting and diarrhea for 4 days secondary to a viral infection. What hourly urine measurement would indicate that efforts to rehydrate this client have been unsuccessful and should continue? 1. 35 mL per hour 2. 80 mL per hour 3. 50 mL per hour 4. 30 mL per hour Answer: 4 Explanation: Normal urine output for adult clients is at least 0.5 mL/kg/hour. This client weighs 70 kg, so adequate urine output would be 35 mL/hour. A urine output of 30/mL/hr indicates that efforts at rehydration have not been successful. Page Ref: 1345 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation Learning Outcome: 1. Discuss the function, distribution, composition, movement, and regulation of fluids and electrolytes in the body. MNL Learning Outcome: 1. Assess the fluid, electrolyte, and acid-base balance status of patients.
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2) The nurse suspects that a client's body is attempting to correct an acid-base imbalance. How will this imbalance be corrected? 1. Slow but efficient respiratory regulation will occur. 2. Primary regulation is through GI system losses. 3. Kidney regulation is powerfully effective. 4. The cardiovascular system is the major buffer. Answer: 3 Explanation: Renal regulation is slower, but powerfully effective. Page Ref: 1349 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Describe the regulation of acid-base balance in the body, including the roles of buffers, the lungs, and the kidneys. MNL Learning Outcome: 1. Assess the fluid, electrolyte, and acid-base balance status of patients. 3) The nurse is caring for a client who is recovering from surgery. Which intervention should the nurse implement to decrease the client's possibility of developing hypercalcemia? 1. Measure vital signs every 4 hours. 2. Assist the client to turn, cough, and deep-breathe every 2 hours. 3. Assist the client to ambulate around the room at least three times daily. 4. Irrigate the client's nasogastric tube every 2 hours. Answer: 3 Explanation: Hypercalcemia can occur from immobility. Ambulation of the client helps to prevent leaching of calcium from the bones into the serum. Page Ref: 1355 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 8. Implement measures to correct imbalances of fluids, electrolytes, acids, and bases, such as enteral or parenteral replacements and blood transfusions. MNL Learning Outcome: 2. Plan care for patients to maintain fluid, electrolyte, and acid-base balance and manage altered fluid, electrolyte, and acid-base balance.
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4) The client is admitted to the acute care unit with a phosphorus level of 2.3 mg/dL. Which nursing intervention would support this client's homeostasis? 1. Encourage consumption of milk and yogurt. 2. Enforce strict isolation protocols. 3. Encourage consumption of a high-calorie carbohydrate diet. 4. Strain all urine. Answer: 1 Explanation: A phosphorus level of 2.3 is low and the client needs additional phosphorus. Provision of phosphorus-rich foods such as milk and yogurt is a good way to provide that additional phosphorus. Page Ref: 1364 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 8. Implement measures to correct imbalances of fluids, electrolytes, acids, and bases, such as enteral or parenteral replacements and blood transfusions. MNL Learning Outcome: 2. Plan care for patients to maintain fluid, electrolyte, and acid-base balance and manage altered fluid, electrolyte, and acid-base balance. 5) The mother of a 1-month-old infant is concerned because the infant has had vomiting and diarrhea for 2 days. What instruction should the nurse give this infant's mother? 1. Have the infant be seen by a physician. 2. Give the infant at least 2 ounces of juice every 2 hours. 3. Measure the infant's urine output for 24 hours. 4. Provide the infant with 50 mL of glucose water. Answer: 1 Explanation: Parents and caregivers need to be taught the seriousness of vomiting or diarrhea in infants due to rapid fluid loss that can occur in this age group. They should also be taught the importance of bringing an infant in this situation to healthcare providers for evaluation. Page Ref: 1350 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 8. Implement measures to correct imbalances of fluids, electrolytes, acids, and bases, such as enteral or parenteral replacements and blood transfusions. MNL Learning Outcome: 2. Plan care for patients to maintain fluid, electrolyte, and acid-base balance and manage altered fluid, electrolyte, and acid-base balance. 3
6) A client has had a subclavian central venous catheter inserted. What should the nurse assess as a priority for this client's care? 1. Presence of bibasilar crackles 2. Tachycardia 3. Decreased pedal pulses 4. Headache Answer: 2 Explanation: Because insertion of a subclavian central venous catheter may result in hemothorax, pneumothorax, cardiac perforation, thrombosis, or infection, the priority finding for planning care is tachycardia. Page Ref: 1372 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Collect assessment data related to clients' fluid, electrolyte, and acid-base balances. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients requiring intravenous infusion or blood transfusions.
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7) The nurse is caring for a client who is receiving intravenous fluids that are not regulated on an electronic controller. In order to calculate the rate of the IV flow in drops per minute, the nurse must know the number of drops per milliliter of fluid the tubing delivers. Where should the nurse look for this information? 1. On the packaging of the tubing 2. In the charting from the nurse who started the infusion 3. In the drug reference book 4. On the roller clamp of the tubing Answer: 1 Explanation: The drop factor (number of drops per milliliter of fluid) of tubing is located on the packaging. Page Ref: 1375 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 10. Verbalize the steps used in: b. Monitoring an intravenous infusion. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients requiring intravenous infusion or blood transfusions. 8) The physician has ordered 50 mL of an IV solution to infuse over the next 20 minutes. In order to accurately infuse this solution, the nurse should set the electronic controller to deliver how many mL/hr? Record your answer, rounding to the nearest whole number. Answer: 150 mL/hr Explanation: 50 mL/20 minutes = × mL/60 minutes. 3000/20 = 150 mL/hr Page Ref: 1382-1383 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 10. Verbalize the steps used in: b. Monitoring an intravenous infusion. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients requiring intravenous infusion or blood transfusions.
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9) The nurse is to administer 75 mL of an antibiotic solution by IV over the next 30 minutes. The tubing has a drop factor of 20. How many drops per minute should the nurse set the controller to deliver? Record your answer, rounding to the nearest whole number. Answer: 50 drops per minute Explanation: 75 mL/1 hour × 20 drops/30 minutes = 50 drops per minute. Page Ref: 1383 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 10. Verbalize the steps used in: b. Monitoring an intravenous infusion. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients requiring intravenous infusion or blood transfusions. 10) The nurse is caring for a client who is receiving IV therapy at a rate of 10 mL/hour. The 500mL IV bottle was hung at 0900 Monday morning when the IV catheter was initiated. It is now 0900 on Tuesday morning. What nursing action should be taken? 1. Refigure the rate of the IV. 2. Infuse the remaining IV fluid before hanging a new bag. 3. Discard the remaining IV fluid and hang a new bag. 4. Discontinue the IV site and restart an IV in the opposite hand. Answer: 3 Explanation: The remaining IV fluid should be discarded and a new bag hung. IV fluid should be changed every 24 hours, regardless of how much solution remains. This helps to minimize the risk of contamination. Page Ref: 1387 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 10. Verbalize the steps used in: c. Changing an intravenous container and tubing. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients requiring intravenous infusion or blood transfusions.
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11) A client tells the nurse about passing out after following a fasting diet for 5 days. Which acid-base imbalance should the nurse expect to assess in this client? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis Answer: 3 Explanation: A client who is fasting is at risk for development of metabolic acidosis. The body recognizes fasting as starvation and begins to metabolize its own proteins into ketones, which are metabolic acids. Page Ref: 1358 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Discuss risk factors for, and causes and effects of, fluid, electrolyte, and acid-base imbalances. MNL Learning Outcome: 1. Assess the fluid, electrolyte, and acid-base balance status of patients.
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12) A client is admitted to the hospital after vomiting for 3 days. Which arterial blood gas results should the nurse expect to find in this client? 1. pH 7.30; PaCO2 50; HCO3 27 2. pH 7.47; PaCO2 43; HCO3 28 3. pH 7.43; PaCO2 50; HCO3 28 4. pH 7.47; PaCO2 30; HCO3 23 Answer: 2 Explanation: The nurse would expect that this client is alkalotic because stomach acids have been lost, so the pH would be above 7.45. This is a metabolic problem, so the PaCO2 is likely normal. The HCO3 will likely be high (above 26). The only option that includes all of these parameters is pH 7.47; PaCO2 43; HCO3 28. Page Ref: 1359 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify factors affecting normal body fluid, electrolyte, and acid-base balance. MNL Learning Outcome: 1. Assess the fluid, electrolyte, and acid-base balance status of patients.
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13) The client's arterial blood gas report reveals a pH of 6.58. In which way should the nurse evaluate this value? 1. There is a slight elevation. 2. This value is incompatible with life. 3. This is a low normal value. 4. This value is extremely elevated. Answer: 2 Explanation: The body's pH range is normally 7.35 to 7.45. Values lower than 6.8 or higher than 7.8 are generally considered incompatible with life. If the nurse assesses that this client is physiologically more stable than would be expected with this pH, the possibility of a lab error should be considered. Page Ref: 1348 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation Learning Outcome: 3. Identify factors affecting normal body fluid, electrolyte, and acid-base balance. MNL Learning Outcome: 1. Assess the fluid, electrolyte, and acid-base balance status of patients. 14) A client has experienced a narcotic overdose. What acid-base imbalance should the nurse expect to observe in this client? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis Answer: 1 Explanation: Because narcotics generally act to decrease or suppress respirations, this client is probably hypoventilating. The expected acid-base imbalance would be respiratory acidosis. Page Ref: 1357 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Identify factors affecting normal body fluid, electrolyte, and acid-base balance. MNL Learning Outcome: 1. Assess the fluid, electrolyte, and acid-base balance status of patients. 9
15) Ten minutes after the transfusion of a unit of packed red blood cells was initiated, the client experiences a headache, shortness of breath, and a fever. What action by the nurse is priority? 1. Notify the client's physician. 2. Discontinue the transfusion. 3. Slow the rate of the transfusion. 4. Prepare to resuscitate the client. Answer: 2 Explanation: The priority intervention is to discontinue the transfusion. If this client is having a transfusion reaction, it will be better to limit the amount of blood transfused. The nurse would also contact the physician to collaborate on further treatment, but this action should be after the transfusion is discontinued. Page Ref: 1394 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 8. Implement measures to correct imbalances of fluids, electrolytes, acids, and bases, such as enteral or parenteral replacements and blood transfusions. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients requiring intravenous infusion or blood transfusions. 16) A client on diuretic therapy has a serum potassium level of 3.4 mg/dL. Which food should the nurse encourage this client to choose from the dinner menu? 1. Baked chicken 2. Green beans 3. Cantaloupe 4. Iced tea Answer: 3 Explanation: A potassium level of 3.4 is low, so the client should be encouraged to consume potassium-rich foods. Of the foods listed, the highest in potassium is cantaloupe. Page Ref: 1347 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 7. Teach clients measures to maintain fluid and electrolyte balance. MNL Learning Outcome: 2. Plan care for patients to maintain fluid, electrolyte, and acid-base balance and manage altered fluid, electrolyte, and acid-base balance. 10
17) A client needs an IV for medication to start in several hours however but assistive personnel (AP) are preparing to bathe the client. Which action should the nurse take? 1. Instruct the AP to wait until the IV is started to bathe the client. 2. Let the AP start the bath on the opposite side of where the nurse will be starting the IV. 3. Tell the AP to notify the nurse as soon as the bath is completed. 4. Give the AP permission to skip the client's bath for today. Answer: 3 Explanation: Because this IV is being initiated to support the administration of IV antibiotic therapy that is not scheduled to start until noon, the nurse should let the AP give the bath and then start the IV. This will protect the IV site from movement during the bath. Page Ref: 1377-1378 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 10. Verbalize the steps used in: a. Inserting a short peripheral catheter. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients requiring intravenous infusion or blood transfusions. 18) The nurse is preparing to start an IV in the hand of a client who has very small veins. Which actions would be useful in dilating the veins? (Select all that apply.) 1. Position the hand at heart level. 2. Stroke the vein. 3. Have the client clench and unclench the fist. 4. Slap the back of the client's hand. 5. Massage the vein. Answer: 2, 3, 5 Explanation: Stroking the vein helps to dilate the vein. Having the client clench and unclench the fist is a strategy used to help dilate a vein. Massaging the vein helps with vein dilation. Page Ref: 1379-1380 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 10. Verbalize the steps used in: a. Inserting a short peripheral catheter. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients requiring intravenous infusion or blood transfusions. 11
19) The client complains of burning along the vein in which a medicated IV is infusing. Upon assessment, the nurse finds the IV site is slightly reddened, but not warmer than the surrounding skin, and without swelling. What action should be taken by the nurse? 1. Slow the IV infusion and reassess the area in 15 minutes. 2. Apply ice over the IV site and vein. 3. Discontinue the IV and place a warm pack on the area. 4. Call the physician for direction. Answer: 3 Explanation: This assessment likely indicates the beginning of phlebitis. The nurse should discontinue the IV and place either a warm or cool pack on the area. Page Ref: 1386 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 10. Verbalize the steps used in: b. Monitoring an intravenous infusion. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients requiring intravenous infusion or blood transfusions. 20) The client who has an IV with an intermittent infusion lock in place wishes to shower. What action should be taken by the nurse? 1. Have the AP discontinue the lock. 2. Cover the lock with an occlusive dressing. 3. Place a piece of cloth tape under the lock, wrapping the top in a U shape. 4. Tell the client that a bed bath is necessary until the IV is discontinued. Answer: 2 Explanation: The client can shower if the lock is covered with an occlusive dressing. Page Ref: 1374 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 10. Verbalize the steps used in: e. Changing a short peripheral catheter access to an intermittent infusion device. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients requiring intravenous infusion or blood transfusions.
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21) The nurse is collecting equipment to administer a unit of packed red blood cells. Which IV fluid should be used to initiate the IV for this transfusion? 1. 1,000 mL of lactated Ringer's solution 2. 250 mL of normal saline 3. 500 mL of 5% dextrose and water 4. 100 mL of 5% dextrose and 1/2 normal saline Answer: 2 Explanation: Blood and blood products should only be administered with normal saline. Other IV fluids may cause damage to the cells being administered. Page Ref: 1395 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 10. Verbalize the steps used in: f. Initiating, maintaining, and terminating a blood transfusion using a Y-set. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients requiring intravenous infusion or blood transfusions.
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22) After obtaining a unit of packed red blood cells for a client, the nurse learns the client needed to leave the care area for an emergency x-ray. What action should the nurse take? 1. Set up the blood with the IV fluid and y-tubing and place it on the IV stand in the client's room to initiate immediately after the client returns. 2. Place the blood in the unit refrigerator until the client returns. 3. Return the blood to the laboratory blood bank until the client returns. 4. Set up the blood with the IV fluid and y-tubing and place it in the unit medication room to initiate immediately after the client returns. Answer: 3 Explanation: Blood should not be held at room temperature for more than 30 minutes before the transfusion is initiated. The unit must be returned to the laboratory blood bank until the client has returned from x-ray. Page Ref: 1397 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 10. Verbalize the steps used in: f. Initiating, maintaining, and terminating a blood transfusion using a Y-set. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients requiring intravenous infusion or blood transfusions.
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23) The nurse initiates a blood transfusion for a client. What action should the nurse take next? 1. Stay with the client and closely observe him for the first 5-10 minutes of the transfusion. 2. Assign assistive personnel to sit with the client for 15 minutes. 3. Advise the client to notify the nurse if he experiences any chilling, nausea, flushing, or rapid heart rate. 4. Return to the room and take a set of vital signs in 15 minutes. Answer: 1 Explanation: The nurse should stay with the client and closely observe him for the first 5-10 minutes of the transfusion. Page Ref: 1397 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 10. Verbalize the steps used in: f. Initiating, maintaining, and terminating a blood transfusion using a Y-set. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients requiring intravenous infusion or blood transfusions. 24) The nurse is providing discharge instructions to a client who has been started on furosemide (Lasix) once daily. What information is essential to include in this information? 1. Take the medication at bedtime. 2. Avoid high-potassium foods. 3. Stand up slowly from a sitting position. 4. Do not take this medication on the days you take digitalis (Lanoxin). Answer: 3 Explanation: Clients who are taking diuretics must make position changes slowly in order to minimize dizziness from orthostatic hypotension. Page Ref: 1356 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 7. Teach clients measures to maintain fluid and electrolyte balance. MNL Learning Outcome: 2. Plan care for patients to maintain fluid, electrolyte, and acid-base balance and manage altered fluid, electrolyte, and acid-base balance.
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25) The nurse is reviewing orders for parenteral potassium. Which order is safe for the nurse to implement? 1. Add 20 mEq of KCL to 1,000 mL of IV fluid 2. 10 mEq KCL IV over 1-2 minutes 3. Dilute 20 mEq KCL in 3 mL of NS and give IV push 4. 10 mEq KCL SQ Answer: 1 Explanation: Parenteral potassium should be well diluted and given intravenously. Page Ref: 1354 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 8. Implement measures to correct imbalances of fluids, electrolytes, acids, and bases, such as enteral or parenteral replacements and blood transfusions. MNL Learning Outcome: 2. Plan care for patients to maintain fluid, electrolyte, and acid-base balance and manage altered fluid, electrolyte, and acid-base balance. 26) The client has been placed on a 1200-mL oral fluid restriction. In which way should the nurse plan for this restriction? 1. Allow 600 mL from 7:00-3:00, 400 mL from 3:00-11:00, and 200 mL from 11:00-7:00. 2. Instruct the client that the 1200 mL of fluid placed in the bedside pitcher must last until tomorrow. 3. Offer the client softer, cold foods such as sherbet and custard. 4. Remove fluids from diet trays and offer them only between meals. Answer: 1 Explanation: The amount of fluid allowed should be divided between the three major times of the day (7:00-3:00, 3:00-11:00, 11:00-7:00). This helps by taking into consideration meals and medication administration. Page Ref: 1368 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 8. Implement measures to correct imbalances of fluids, electrolytes, acids, and bases, such as enteral or parenteral replacements and blood transfusions. MNL Learning Outcome: 2. Plan care for patients to maintain fluid, electrolyte, and acid-base balance and manage altered fluid, electrolyte, and acid-base balance. 16
27) An older client with heart failure has edema, orthopnea, and confusion. Which nursing diagnosis is most appropriate for this client? 1. Heart Failure related to edema, as evidenced by confusion 2. Fluid Volume Deficit related to loss of fluids, as evidenced by edema 3. Excess Fluid Volume related to retention of fluids, as evidenced by edema and orthopnea 4. Excess Fluid Volume related to congestive heart failure, as evidenced by edema and confusion Answer: 3 Explanation: Edema and orthopnea are assessment findings associated with excess fluid volume. Page Ref: 1352 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Diagnosis Learning Outcome: 6. Identify examples of nursing diagnoses, outcomes, and interventions for clients with altered fluid, electrolyte, or acid-base balance. MNL Learning Outcome: 2. Plan care for patients to maintain fluid, electrolyte, and acid-base balance and manage altered fluid, electrolyte, and acid-base balance. 28) The nurse wants to assess a client for orthostatic hypotension. What action should the nurse take? 1. Assess the client for dependent edema and then raise the legs to the level of the heart and reassess for edema. 2. Measure the client's heart rate and blood pressure in both the sitting and standing position. 3. Measure the client's blood pressure before, during, and after administration of a normal saline fluid challenge. 4. Raise the client's legs above heart level and measure the blood pressure. Answer: 2 Explanation: The nurse should measure the client's blood pressure and heart rate in the sitting position and then again in the standing position. Page Ref: 1360 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 5. Collect assessment data related to clients' fluid, electrolyte, and acid-base balances. MNL Learning Outcome: 1. Assess the fluid, electrolyte, and acid-base balance status of patients. 17
29) A client being mechanically ventilated has an arterial blood gas analysis that indicates respiratory acidosis. Which change in ventilator settings should the nurse anticipate? 1. Decrease in oxygen delivery 2. Decreased tidal volume of each breath 3. Increased respiratory rate 4. Increase in humidification of inspired air Answer: 3 Explanation: This client needs to "blow off" more CO2, therefore the respiratory rate would be increased. Page Ref: 1357 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 8. Implement measures to correct imbalances of fluids, electrolytes, acids, and bases, such as enteral or parenteral replacements and blood transfusions. MNL Learning Outcome: 2. Plan care for patients to maintain fluid, electrolyte, and acid-base balance and manage altered fluid, electrolyte, and acid-base balance. 30) An older client receiving intravenous fluids at 175 mL/hr is demonstrating crackles, shortness of breath, and distended neck veins. Which complication of intravenous fluid therapy is this client experiencing? 1. An allergic reaction to the antibiotics in the fluid 2. Fluid volume excess 3. Pulmonary embolism 4. Speed shock Answer: 2 Explanation: Fluid volume excess may occur if clients, especially the very young or elderly, receive IV fluid rapidly. Page Ref: 1352 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 9. Evaluate the effect of nursing and collaborative interventions on clients' fluid, electrolyte, or acid-base balance. MNL Learning Outcome: 1. Assess the fluid, electrolyte, and acid-base balance status of patients. 18
31) A client with a significant loss of blood after a motor-vehicle accident has a low urine output. Which hormones should the nurse suspect are influencing the client's fluid balance? (Select all that apply.) 1. Aldosterone 2. Angiotensin 3. Antidiuretic hormone 4. Estrogen 5. Progesterone Answer: 1, 2, 3 Explanation: Aldosterone promotes sodium retention in the distal nephron, reducing urine output. Angiotensin acts directly on the nephrons to promote sodium and water retention. When serum osmolality rises, antidiuretic hormone is produced, causing the collecting ducts to become more permeable to water. This increased permeability allows more water to be reabsorbed into the blood. As more water is reabsorbed, urine output falls and serum osmolality decreases because the water dilutes body fluids. Page Ref: 1345 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Discuss the function, distribution, composition, movement, and regulation of fluids and electrolytes in the body. MNL Learning Outcome: 1. Assess the fluid, electrolyte, and acid-base balance status of patients.
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32) A client reports rarely feeling thirsty. Which parameter should be evaluated in this client? (Select all that apply.) 1. Status of osmotic pressure 2. Vascular volume 3. Presence of angiotensin 4. Urine output 5. Body weight Answer: 1, 2, 3 Page Ref: 1345 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 1. Discuss the function, distribution, composition, movement, and regulation of fluids and electrolytes in the body. MNL Learning Outcome: 1. Assess the fluid, electrolyte, and acid-base balance status of patients. 33) The nurse is preparing to discontinue a client's intravenous infusion. Which actions should the nurse take when removing the catheter from the vein? (Select all that apply.) 1. Pull the catheter out in line with the vein. 2. Apply pressure to the site while removing the catheter. 3. Pull the catheter out at an angle perpendicular to the vein. 4. Bend the client's elbow if bleeding at the site persists after removal. 5. Apply pressure to the site after the catheter is removed for a minimum of 30 seconds. Answer: 1, 5 Explanation: When removing an intravenous catheter, the nurse should pull the catheter out in line with the vein. This avoids injury to the vein. After removing the catheter, immediately apply firm pressure to the site, using sterile gauze, for a minimum of 30 seconds. Pressure helps stop the bleeding and prevents hematoma formation. Page Ref: 1389 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 10. Verbalize the steps used in: d. Discontinuing an intravenous infusion and removing a short peripheral catheter. MNL Learning Outcome: 3. Implement the steps for nursing procedures used for patients requiring intravenous infusion or blood transfusions. 20
34) A client is receiving a continuous intravenous infusion. What should the nurse document in the medical record about this infusion? (Select all that apply.) 1. Latest body temperature 2. Type of solution and flow rate 3. Total intravenous intake for the shift 4. Status of the intravenous catheter site 5. Results of blood pressure measurement Answer: 2, 3, 4 Explanation: The type of solution and flow rate should be documented. Total intravenous intake for the shift should be documented according to agency policy. The status of the intravenous insertion site should be documented. Page Ref: 1387 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 12. Demonstrate appropriate documentation and reporting of fluid, electrolyte, and acid-base balance activities. MNL Learning Outcome: 4. Implement the evaluation, documentation, and reporting of care of patients requiring fluid, electrolyte, acid-base balance, intravenous infusion, and blood transfusion care.
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35) A client reports taking multiple doses of antacids every day. For which health problem should this client be assessed? 1. Acidosis 2. Alkalosis 3. Hyperkalemia 4. Hyponatremia Answer: 2 Explanation: An overabundance of a base such as antacids depletes carbonic acid in the body, causes the pH to increase, and leads to alkalosis. Acidosis is a overabundance of carbonic acid in the body. Antacids do not affect potassium or sodium levels. Page Ref: 1349 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Describe the regulation of acid-base balance in the body, including the roles of buffers, the lungs, and the kidneys. MNL Learning Outcome: 1. Assess the fluid, electrolyte, and acid-base balance status of patients.
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36) The nurse is reviewing information received during hand-off communication. Which client should the nurse assess for a potential fluid or electrolyte imbalance? 1. Older client unable to self-feed 2. School-age child with pneumonia 3. Adolescent client having an appendectomy 4. Middle-aged client scheduled for a colonoscopy Answer: 1 Explanation: Factors that can lead to a fluid or electrolyte imbalance include a client with a decrease in food and fluid intake because of physical limitations such as the older client who is unable to self-feed. The school-age child is not at risk because will most likely be receiving fluids. The adolescent having an appendectomy will be able to ingest food and fluids after the surgery. The client having a colonoscopy would have had a restriction in intake and laxatives for a short period of time. Page Ref: 1350 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment Learning Outcome: 4. Discuss risk factors for, and causes and effects of, fluid, electrolyte, and acid-base imbalances. MNL Learning Outcome: 1. Assess the fluid, electrolyte, and acid-base balance status of patients.
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37) A client is diagnosed with hypernatremia. Which should the nurse include in the client's plan of care? 1. Enforce a fluid restriction 2. Provide a low-sodium diet 3. Administer diuretics as prescribed 4. Encourage foods high in potassium Answer: 2 Explanation: Hypernatremia is an elevated sodium level. Because of this, the client should be on a low-sodium diet. A fluid restriction would be appropriate for hyponatremia. Diuretics would cause dehydration and worsen the hypernatremia. Foods high in potassium would not help with an elevated sodium level. Page Ref: 1354 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning Learning Outcome: 6. Identify examples of nursing diagnoses, outcomes, and interventions for clients with altered fluid, electrolyte, or acid-base balance. MNL Learning Outcome: 2. Plan care for patients to maintain fluid, electrolyte, and acid-base balance and manage altered fluid, electrolyte, and acid-base balance.
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38) A client has been treated for hypokalemia. Which assessment finding indicates that treatment has been effective? 1. Lethargic 2. Muscle weakness 3. Normal bowel sounds 4. Irregular heart rhythm Answer: 3 Explanation: Normal bowel sounds indicates that treatment for hypokalemia has been effective. Lethargy, muscle weakness, and an irregular heart rhythm all indicate that treatment has not been effective. Page Ref: 1354 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation Learning Outcome: 9. Evaluate the effect of nursing and collaborative interventions on clients' fluid, electrolyte, or acid-base balance. MNL Learning Outcome: 4. Implement the evaluation, documentation, and reporting of care of patients requiring fluid, electrolyte, acid-base balance, intravenous infusion, and blood transfusion care. 39) The nurse assigns assistive personnel (AP) morning care for a client with an intravenous infusion. Which finding should the nurse remind the AP to report to the nurse? 1. Client's breath sounds 2. Rate of the intravenous infusion 3. Leaking of fluid around the catheter site 4. Amount of fluid remaining in the infusion bag Answer: 3 Explanation: The AP should be asked to report any leaking of fluid around the catheter site. The nurse is responsible for assessing breath sounds and monitoring the drip rate and amount of fluid remaining in the infusion bag. Page Ref: 1378 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the health care team | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 11. Recognize when it is appropriate to assign aspects of fluid, electrolyte, and acid-base balance to assistive personnel. MNL Learning Outcome: 1. Assess the fluid, electrolyte, and acid-base balance status of patients. 25
40) Assistive personnel (AP) is caring for a client with an intravenous infusion. Which action should the nurse take if the AP reports that the infusion bag is empty? 1. Direct the AP to cap the infusion 2. Ask the AP to turn the infusion off 3. Provide a new intravenous infusion bag 4. Provide the AP with a new infusion bag Answer: 3 Explanation: The nurse is responsible for changing the intravenous fluid container. The AP is not licensed or trained to cap the infusion, regulate the infusion, or change the infusion container. Page Ref: 1387 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the health care team | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 11. Recognize when it is appropriate to assign aspects of fluid, electrolyte, and acid-base balance to assistive personnel. MNL Learning Outcome: 1. Assess the fluid, electrolyte, and acid-base balance status of patients.
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41) A client is prescribed an intravenous infusion to be started. Which should the nurse ensure is included when documenting the starting of this infusion? 1. Type, length, and gauge of the catheter 2. Questions the client asked about the infusion 3. Length of time the current infusion bag will last 4. Medications that are to be changed to the intravenous route Answer: 1 Explanation: Documentation after beginning an intravenous infusion should include the type, length, and gauge of the catheter. It is not essential to document the client's questions, the length of time the infusion will last, or medications that will be changed to the intravenous route. Page Ref: 1382 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Practice-Know-How; Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 12. Demonstrate appropriate documentation and reporting of fluid, electrolyte, and acid-base balance activities. MNL Learning Outcome: 4. Implement the evaluation, documentation, and reporting of care of patients requiring fluid, electrolyte, acid-base balance, intravenous infusion, and blood transfusion care.
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